Oncology Data Advisor: In this month of May dedicated to nurses, we have a very inspiring nurse practitioner with us today at Oncology Data Advisor: Dr. Lauren Ghazal, a Family Nurse Practitioner and a Post-Doctoral Research Fellow at the University of Michigan. Her research on work-related challenges and financial toxicity in adolescent and young adult cancer survivors is funded by the National Cancer Institute. Lauren is a cancer survivor, and she is the author of editorial articles featured on CNN, including the article detailing why a nurse needed to be added to the COVID Task Force named by President Biden, which resulted in Jane Hopkins being added to the Task Force. Hi, Dr. Ghazal.

Lauren Ghazal, PhD, FNP-BC: Thank you for having me. I will say it was not just that one CNN article; there was a big push from the nursing community. But yes, a lot of people were like, "Two weeks after that, guess what? Jane Hopkins was added."

Oncology Data Advisor: What do nurses need right now to help themselves and the cause of nursing?

Dr. Ghazal: Yes, great question, and I have multiple responses to this. I will say, one of the most important resources that we as nurses need right now is institutional buy-in, institutional support, and workplace support. We know that the work environment is vital to nursing sustainability, to nurse retention, and to decreasing moral distress and burnout and turnover. But it's really hard to address those challenges for a single nurse, for one nurse on a unit or one nurse in an organization.

For that, we need nurses in leadership. We need nurses being not only invited to the table, but leading those table discussions. We need nurses overall to feel supported and valued, to have the ability and feel like they have the ability to grow as a nurse, as a nurse leader, as a nurse researcher, or wherever they want their careers to grow, feeling like they have those opportunities.

Then it's also important that nurses have mental health support. We know that there were issues around nursing sustainability well before the pandemic, but the pandemic has just highlighted that. Nurses have higher rates of suicide than the general population. They were the workforce hit the most with deaths related to COVID because of the pandemic. They've seen a lot of death, and they've seen a lot of illness. When they are in those positions, they have to kind of power through and continue. We're seeing a lot of that now.

It's even kind of similar to cancer survivors and what I felt during the pandemic, where you're going through treatment and you're kind of just in this survival mode. You're just getting through day-to-day, and that's what we saw with nurses. They were just getting through the day-to-day at the height of the pandemic. Now, even though the pandemic is still ongoing, as restrictions are loosening up and as our government is changing this as a global pandemic, we do see that nurses are dealing with those feelings of either post-traumatic stress or just a lot of the burnout from the pandemic and dealing with so much care as it related to patients and so much death.

So, I felt there were parallels in cancer survivorship to the nurses' role and the health care providers' role throughout the pandemic as well—having to feel like okay, they can sit up and breathe now, but then now they're dealing with this mental health fallout. Those are two big things.

Oncology Data Advisor: Those are great things, and nurses are amazing caregivers to others, but I feel that sometimes they're not the best caregivers to themselves. Is there anything that the team at the hospital can do to specifically help nurses take care of themselves?

Dr. Ghazal: Yes, yes. So, they can offer ample paid time off, ample vacation time, employee benefits, and mental health support, so they're not feeling scared to access that mental health support. We also saw from some early work during the pandemic, if you were seeking mental health support and you had to call into your employer or call into a nurse's support line, that detachment or that ability to reach out for help but not automatically being brought back to your institution, that could actually help. Definitely, definitely, mental health support is important.

We know it's hard. From personal experience, it's hard to even get access to a mental health clinician right now, whether that's a clinical psychologist, a psychiatric nurse practitioner, or a licensed clinical social worker. We know that there's a shortage in our mental health workforce, too. That access can be brought to us as a workforce, and perhaps even the human resources (HR) departments or employers saying, "We've partnered with Zencare as a supplier of mental health support, and you can access this way." Or, "We know that we carry this insurance for our employees, and these are mental health providers in the area that are accepting clients and that you can reach out to based on the insurance." Just eliminating those barriers to entry into mental health support could be really strong in bridging that gap to mental health support.

I felt this too as a patient when I transitioned, going from being on the other side of the bed and the examining table and being the patient. Nurses, I felt, definitely made the worst patients. You want to be on top of your care. Cancer is so different, too, because you want to control everything and you realize you don't have control. Letting that go can be really, really hard as a nurse when you take pride in caring for your patients and being able to say, "This is what I can do to help you better navigate your illness, your recovery, whatever you're going through in your care setting."

So, there's a lot that the environment can do and the institution can do. And yes, there's a lot that nurses themselves can do as well. But we want solutions to this. Based on the Mara Mogensen Flaherty discussion around nursing sustainability, we don't want the onus just to be on the nurse and the individual to say, "I know I'm getting burned out. I need to go do this," or "I'm experiencing moral distress in this way. This is what I need to do." We know that those aren't sustainable solutions.

Oncology Data Advisor: Is there anything that the population of the US, say, or we as patients who need our nurses can do to help advocate for nurses?

Dr. Ghazal: Yes, that's a great question. I remember being asked this January of 2021 when I was on CNN, and that was an incredible experience. The reporter asked, "What can we do for nurses right now?" Then, it was, "get vaccinated, continue to mask up, and donate blood," because there was a huge blood shortage at that time. I think in line with that, keeping yourself healthy ultimately does decrease the workload on nurses. There are less folks becoming sick. We know that when patients are entering the hospital, it's more complex care being provided. I think there is a way of preventative health where you can help in this long-term view.

But then also acutely too, you can support nurses through policy work and advocacy. It's National Nurses Week, right? There are a lot of organizations that travel to Capitol Hill. The Oncology Nursing Society is one, and Alec Stone, the Head of Advocacy, leads those efforts. So, we work on advocating. If there are specific bills in review in session that directly impact the nurse workforce or our patients, we will speak to our congresswomen and men about that.

And the general public, too—I think asking more about nurses beyond, "How are you doing?" but also, "Tell me about what a workday is like for you." One thing I've learned in my relatively short career in nursing is that the general public still has a lot of gaps in knowledge as to what we do. Under this umbrella of nursing, there are so many different careers, and there are so many different types of care and types of work that one can provide. I've been having more of those conversations with my friends who are not in health care at all. I'm just like, "What do you think I do?" And also, "What are your big questions about nursing where we can have a conversation together?"

I think that's why, especially during the pandemic, there was a big focus and a spotlight on several different media outlets following some nurses around in the intensive care unit (ICU), where there was a lot more coverage on nursing and nurses' experiences. We really had not been hearing their voices before. So, how can we as a public continue to amplify those voices? I feel like any career can incorporate a nurse. I just had a conversation earlier this morning with a friend of mine who I went to Boston College with for undergrad, and she works in the business world. We were talking about how we can brainstorm on a conference presentation or an abstract. A lot of her work is on supporting LGBTQ leaders and researchers, so how can we put our heads together and submit something to a conference to continue these discussions?

I think my biggest takeaway for the public is to bring in nurses when they can to discussions. I know this is an aside, but I was at the STAT Breakthrough Science Summit last week in San Francisco, and I talked to one leader of a startup. She said, "Nurses should just be inventing everything. The innovation that they have and the input that they bring to teams is so underappreciated and undervalued right now." I think that we're at a really pivotal time as a public to look at the nursing profession and ask, "What are we going to do?" from folks outside of nursing, from the general public as you just asked. "Are we going to continue to amplify their voices, amplify their experiences?" Or is it going to be, "Okay, this is a 'them' problem and we don't know what's going on, but we'll just continue to do what we're doing." And we know that's not working.

So, a long-winded way to say, we definitely need public involvement and public investment in our health and in the care that we give to patients, because you're going to in interact and encounter nurses throughout your life. I know that our profession touches every life, and we provide the most care to patients.

Oncology Data Advisor: You bring up an important point, that nurses are very good researchers too, and you are a researcher as well as a nurse. Could you talk a little bit about your research?

Dr. Ghazal: Yes, so I will start by saying that I am a second-degree nurse. I don't know the exact statistics on our current workforce and what percentage makes up the workforce from the second-degree programs, but my first degree was a bachelor's degree in economics, and then I came to nursing. I say that because that view of health economics and more of a business side to things has definitely influenced my research and my work.

I was in the first year of my PhD program while also working as a family nurse practitioner when I was diagnosed, very surprisingly, with stage II Hodgkin lymphoma. At first, I ran from any research related to cancer survivorship. I did not want that to be my entire life. I didn't want to switch or pivot my focus in research. That was early on in my diagnosis. Again, I was in the first year of my PhD program, so I'm going through rigorous chemotherapy treatment and doctor's appointments alongside learning "What is research? How do we implement theory into this work" and taking a design and methods course and biostats. I was sitting in the treatment chair doing work when I realized, oh, I have all these questions. Part of that is a result of learning about how to do research while you're living this life-changing experience.

I learned very quickly that there was this growing body of research around adolescent and young adult (AYA) cancer survivorship. I learned that there was an emerging body of work, too, around financial hardship and financial toxicity in younger cancer survivors. That's when I was immediately drawn to this is and wanted to contribute. This is where I can bring all my unique experiences and really work to improve the health and quality of life of AYAs with cancer.

We know that finances and money drive a lot of decision making, so that's where I pivoted my work. As I am as an early career nurse scientist, I'm also learning how to embrace these essentially two lines of research, one around the global nurse workforce where I initially started in the PhD program and then the other around AYA cancer survivorship. I had this incredible opportunity of being awarded the Mara Mogensen Flaherty Memorial Lectureship alongside Suzanne Boyle and Amy Rettig, and I had the opportunity to talk about merging those two paths.

I am really excited about future research. I'm currently finishing up a postdoc at the University of Michigan, where I've continued to be a part of a training in cancer care delivery research and working with leading experts like Dr. Brad Zebrak, being a part of interdisciplinary teams across economics, social work, psychology, medicine, and nursing, which I'm very excited about. Then I'll be transitioning over to a tenured track position to continue my research around these issues in AYAs with cancer.

Oncology Data Advisor: Congratulations, that's an amazing achievement. I can't wait to follow your career as a an exciting leading nurse scientist researcher. I look forward to seeing what you do.

Dr. Ghazal: Thank you. And I guess I will end with saying, something I've been talking about is this question of how can we inspire more folks to pursue a career in nursing. That's this million-dollar question now that a lot of people are grappling with, not only with our clinical nurse workforce, but also in research. We know that we're graduating fewer and fewer PhD-prepared nurse scientists, so there is this push to kind of reexamine. The National Institutes of Health (NIH) put out a call for comments on how can we re-examine the postdoc for not only nurse scientists but others in scientific research.

Also, the bigger thing that I reflect on with that question of inspiring more folks to pursue a career in nursing is really, really understanding the generational differences within our workforce, knowing that there are generational differences in perhaps work fulfillment or one's relationship with work. My mom just recently retired from her career in nursing and I shared at the Mara that we did our doctorates around the same time—her DNP, my PhD—and very different points in our careers. But she entered nursing after nursing school as, "I'm going to stay in this position for my entire career."

We know that's not the case now for younger nurses. We know that travel nursing is a big area that these early-career, younger nurses have focused on—not being tied down with families or perhaps wanting to not only explore the world and reap the benefits of increased pay, but then also have this travel component that's intriguing for many folks my age. They want to be able to balance their life and have left environments where they didn't feel supported or where they didn't feel like they could deliver safe and high-quality care because of a lack of nurses.

So, how can we inspire more people? I firmly, firmly believe we have to reimagine not only models of health care delivery, but then workplace settings too—incorporating these different perspectives and knowing that early-career, younger nurses have more to contribute to our workforce than just being good at the computer and technology. They have other unique experiences. We have to be able to show potential nurses that nursing is a sustainable career. We know pizza parties aren't the solution. We know that this change has to come from within institutions, and it has to come from the work environments where one works, where one's providing that care.

The final thing I'll say is that we can also show that there are many different pathways into nursing, and there are very many pathways after too. I think amplifying these different roles as a nurse—after you receive a BSN degree or your diploma degree or an associate's degree in nursing—shows where you can take your education and training along with other interests and skills that you have to shape the career that you want. Once you're fulfilled with your career, once you feel valued, you're more prone to stay at that place and also contribute more to your work, your workplace, and your work environment.

So, that's me putting on my economics hat and my nursing hat to show that we do have to get more nurses inspired, feeling more valued about their work, and knowing that they matter. We hope that was a good takeaway from Mara with our panel that we brought together. But I'll end there, thank you for asking that.

Oncology Data Advisor: No, thank you. I think that's a great takeaway, and very inspiring.

About Dr. Ghazal

Lauren Ghazal, PhD, FNP-BC, is a Family Nurse Practitioner and a Post-Doctoral Research Fellow at the University of Michigan–Ann Arbor, including at the Center for Improving Patient and Population Health at the School of Nursing and the Rogel Cancer Center. Her research focuses on nursing work-related challenges and financial toxicity experienced by adolescent and young adult cancer survivors, incorporating economic, clinical, and personal experiences to address survivorship disparities.

For More Information

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.