Why Ring the Bell When Well?

WORKING RESEARCHERS Prince George nurses Ava Hatcher, Grace Cole and Dustin Mackay make up one of five funded research teams in BC Cancer's practice-based research challenge inaugural 2019 cohort. They are completing their research on cancer patients' bell this year. Photo: Giles Palmer

Dustin Mackay is used to hearing cancer patients ring the bell at BC Cancer's Centre for the North. Patients at the Prince George facility, like those in many other hospitals and clinics in Canada, can choose to ring the bell to mark the end of chemotherapy or radiation treatment.

However, not every cancer patient sees the bell as a celebration. According to Mackay, three years ago some patients expressed concerns about the bell's location in the systemic therapy unit, an area that's accessible to other patients being treated. He recalls that requests to move the bell away from treatment areas had brought up a lot of feelings from patients and staff.

Mackay then had the idea of researching the experiences of people undergoing cancer treatment and who witness other patients ringing the bell. But, like most nurses working in BC's stretched health-care system, he had little time and few resources to engage in any formal investigation that would help answer his questions.

Fortunately, his employer had recently launched a practice-based research program that encourages and supports nurses and other health-care workers who wish to investigate an area of professional interest.

Mackay is a systemic therapy nurse and radiation therapy nurse. His work involves the planning and provision of comprehensive care to patients and their families receiving chemotherapy and biotherapy drugs. He wasted no time exploring this new learning opportunity.

Practice-based research is focused on answering every day clinical practice questions for the improvement of  patient care. It has been well established that point-of-care clinicians like Mackay are ideally positioned to engage in this research. That's important, given that so much evidence is presently generated by academic researchers who are removed from care environments.

BC Cancer's Practice-based Research Challenge is working to build connections between clinical practice and research by letting teams identify clinical issues and find evidence-based answers through research projects related to day-to-day work.

Each year interested BC Cancer employees across the province are encouraged to form teams and submit a letter of intent. After receiving initial acceptance, the teams spend the first half of the year in the training stage, where they learn about literature reviews, refining a research question, developing the research topic and submitting the research proposal to a research ethics board for review. They also learn about different types of research methodologies, and how to find mentors and patient partners to support development of the research project. The teams submit their research proposals to a review committee and five funded projects are selected to proceed. An ethics application process takes another six months, and the research is then conducted over the course of the following year.

Mackay, along with fellow RN and co-worker Grace Cole and RN Ava Hatcher, who's presently lead for professional practice nursing at Northern Health, formed a team in 2018. They were among the first employees to submit their letter of intent and were part of the inaugural 2019 cohort.

The team completed a literature review on the topic of the bells use in cancer care. They found there were some opinion articles and stories of patients who had shared their experiences with the bell, but there was no research in this area.  As point-of-care nurses, Mackay, and Cole knew there was value for patients who wanted to ring the bell, but they were curious about how patients on treatment were impacted when watching others ring it. They also wondered how the patients' experience could inform the way clinicians provide education for staff and patients about the use of the bell.

They then developed a research proposal that involved examining the experiences of people undergoing cancer treatment who observe other patients ringing the bell. The three were selected as one of the five teams in 2019 and were awarded $5,000 to help fund their research.

"It's not looking at the patients who are ringing the bell but patients who are actively sitting in a chair or a waiting room," Mackay says of the research. "They hear the bell being rung. What kind of emotions does that bring up?"

The COVID-19 pandemic led to a delay in data collection and participant interviews, but the team is now working on their final paper and plan to submit it to nursing journals for publication. In the meantime, they had the opportunity to make a presentation at last year's BC Cancer Summit and will be presenting their research at the Canadian Association of Nursing and Oncology conference this October in Victoria.

Some of the research findings the team shared described how patients were affected emotionally when witnessing others ring the bell, describing emotions for themselves and the other patients. The emotions for self were positive and joyful while those for others were described as being more complex, and involved happiness and worry or concern.

The bell at Prince George's cancer centre remains in a public area located near the main entrance to the building. The team's research goal is not to have the bell relocated, but to learn more about the patient experience and share their research within oncology communities. The team hopes their research will encourage other facilities to think about how the bell is used and explained to patients.

As their project reaches the end of its journey, the team is praising the research challenge for encouraging nursing staff to think about research that could make a tangible difference in the lives of their patients while allowing them to hone their nursing research skills as they work. "The value of this program is in the way it highlights the importance of nursing knowledge, and it makes space and time for that," Hatcher says.

Mackay, Cole and Hatcher are also grateful for the support they've received from program staff as they completed their research. "It has been very step-by-step. They've helped us along the way to get to those steps," says Cole.

The three speak highly of their mentors who were always available to advise and reassure them when they had concerns about the research process.

Cole and Mackay are planning to continue to use the skills they have gained through participation in the research challenge, and both are exploring entering master's programs.

They also encourage other nurses to consider the research challenge.

"My advice would be to just talk with your peers and talk with your leadership team because that's essentially the route that I took," says Mackay. "Figure out if there are other nurses who might be interested in a similar topic or even just doing research in general."

Cole suggests reaching out to other teams from previous years to talk about the experience and workload.

To date, BC Cancer's practice-based research challenge has provided training on the various stages of the research process to 28 nurses and 34 allied health professionals. The program is currently funding 10 teams, three of which are led by registered nurses.

BCNU began supporting members participating in the research challenge in 2020, with an annual contribution of $5,000 that's available to be awarded to teams that include nurses. The union has been funding a similar initiative at Providence Health Care since 2010. By providing funding to both organizations, BCNU is continuing to work toward its goal of expanding research collaborations. •

UPDATE (Fall 2022)