MAUREEN H. QUICK, DNP, RN, OCN DOCTOR OF NURSING PRACTICE SYSTEM CHANGE PROJECT ST. CATHERINE UNIVERSITY ST. PAUL, MINNESOTA Engaging Oncology Nurses in a Primary Prevention Program on Radon: Outcome Analysis and Implications for Practice

Radon Education Project (REP) Agenda Review of the Oncology Nursing Society (ONS) REP objectives/overview Review of REP findings and potential implications for practice White paper review developed from the REP Current issues/problem statement with radon education in clinical practice Potential new avenues to improve outcomes

Oncology Nursing Society National organization of oncology nurses Mission is dedicated to promoting excellence in oncology nursing and quality cancer care The national organization was founded in 1975 and has grown to over 35,000 members, 231 chapters The Metro MN Chapter is located in the Minneapolis, MN area and is the largest chapter in the State ONS supports the role of oncology nursing in primary prevention

REP Objectives To increase oncology nurses knowledge of the association between radon exposure and lung cancer through an educational program as evaluated by an online survey To identify how primary prevention strategies related to radon exposure can be incorporated into clinical practice as recommended by participants in follow up focus groups. The final output was the development of a white paper as a guide for oncology nurses in clinical practice

Radon Education Project (REP) Radon Education Project used a mixed methods design to explore knowledge and perceptions of oncology nurses and educate them about radon exposure and lung cancer. Project objectives were developed in collaboration with the Minnesota Department of Health (MDH) Indoor Air Unit. This is the first documented initiative where oncology nurses have partnered with a state department of health in a formalized, programmatic approach to radon education.

Radon in the United States

Radon Education Project (REP) The REP was designed in three phases Phase I: An educational program was developed and presented at the local ONS meeting. 66 people attended the educational program. Attendees were offered free radon test kits 41 Metro MN ONS members signed consent forms indicating interest in participating in the next phase of the REP 33 completed the online survey

REP Participants Oncology nurses from five health care institutions within a large metropolitan area in the Midwest Majority of nurses had a Bachelor of Science in Nursing (BSN) degree Worked for more than 20 years in oncology nursing.

Phase I –Online Survey Results 46% tested their home for radon prior to the educational program 94% shared the information on radon and lung cancer 100% stated that the information was relevant to them personally Majority identified applicability to practice

Phase I –Radon Test Kit Results Test Kits Used Prior Testing Inevaluable Tests Test Level Range % Above EPA Action Level % MN Homes Above EPA Action Level 49 (74%) 46%6 (12%)0.7 – %40% Prior testing is high compared to one cross sectional study where testing rate was seen in 9.7% and 15.5% and in another study where patients had a radon testing rate at baseline of 24.7% Nissen, et al. (2012). Radon testing and mitigation: An intervention in a primary care setting. Journal of Cancer Education Larsson et.al. (2009). Householder Status and Residence type as correlates of Radon Awareness and Testing Behavior Public Health Nursing

Radon Education Project: Phase II Phase II Focus groups were designed and offered to individuals who attended the Phase I educational program. Three focus groups were held in the fall of 2012 with 15 members attending Open ended questions were utilized to elicit possible ways that radon education might be incorporated into clinical practice Data were captured using a transcript-based analysis

ONS Member Comments “I don’t know if it is a community or state or federal requirement or if it is just widely considered best practice. The radon thing could be, at least in MN, considered best practice to be addressed by all health care providers. Focus Group Participant, Metro MN Member, 2012 “Lung cancer due to radon is a preventable disease. Our mission should be that we disseminate information about that.” Focus Group Participant, Metro MN Member, 2012 “I think it is great that we as a chapter have something specific that we sort of stand for or have a goal for or can present as part of as to why we are in existence” Focus Group Participant, Metro MN Member, 2012

Phase II –Focus Groups Five themes were identified Theme one: Education. They identified education of oncology nurses and physicians as important so health care professionals could be knowledgeable on the topic of radon and lung cancer when speaking with patients Theme two: Access. Data on radon and lung cancer should be accessible and have contact information/websites Theme three: Timing. It was suggested that the timing of this education should be individualized to the patient. Theme four: The role of ONS. Was recognized as important endorsement for this work. Theme five: Barriers. Cost of testing and mitigation was identified as a potential barrier to education.

Radon Education Project: Phase III Phase III- White Paper for ONS The nurses suggested that a document that provided educational information and web links for additional resources would be most beneficial A prescriptive outline of data, information and references was developed The white paper was adopted, without changes to format or content, by a unanimous vote by the Metro MN ONS board on September 10, 2013 Metro MN ONS Home

Current Issue/Problem Statement Radon is a major health concern in MN and globally The REP data demonstrates that health care professionals' knowledge of radon is limited The health care professionals (HCP) are the primary source of health information to the public, yet there is no systematic process for dissemination of radon information to HCPs Racial and Economic Disparity Issue Treating the patient does not treat the “Toxic Home”

Potential New Avenues to Improve Outcomes The biology of alpha radiation DNA damage is compelling, but the data is confusing to practitioners Need to package a scientific message that is meaningful to practitioners Focus of HCP is on tertiary care, but the ACA is focused on prevention. This new paradigm shift is a perfect time to address this issue Develop standards for education with health care professionals and study the impact

Potential Partnerships Institute of Medicine report calls for partnerships between public health and health care delivery organizations Partner with knowledgeable HCPs to consult on effective development and implementation of health care education and standards Partner with the scientific community to develop a “clinically meaningful” message to health care providers Partner with industry toward innovation in testing Partner with insurers and legislators to educate and pay for mitigation for the economically disadvantaged Partner with NGOs to incorporate an anti-radon message into their anti-smoking campaign Institute of Medicine of the National Academes. (2012). Best care at a lower cost: The path to continuously learning health care in America

Acknowledgments Andrew Gilbert and Jim Kelly, Site Mentors at the MDH Dr. Roberta Hunt at St. Catherine University Joshua Kerber and Dan Tranter from the MDH Indoor Air Unit The Minnesota Department of Health (MDH) The Minnesota Cancer Alliance (MCA) Bill Field, University of Iowa for scientific consultation