|Year : 2015 | Volume
| Issue : 1 | Page : 3-7
Israeli breast care nurses as a learning organization
Ilana Kadmon1, Livia Kislev2
1 Hadassah-Hebrew University School of Nursing, Hadassah Medical Organization, Jerusalem, Israel
2 Israel Cancer Association, Givatayim, Israel
|Date of Submission||03-Jun-2014|
|Date of Acceptance||30-Sep-2014|
|Date of Web Publication||2-Mar-2015|
Hadassah-Hebrew University School of Nursing, Hadassah Medical Organization, Jerusalem
Source of Support: None, Conflict of Interest: None
This article will look at the theory of a Learning Organization as described by Senge and the Israeli Breast Care Nurses as an example. A description of the theory of a Learning Organization, the role of the Breast Care Nurses in Israel and the relation between the two will be described. Since 1996, the role of the Breast Care Nurse was founded in Israel. At that time, the role with its importance was very hard to be recognized by the health care team and other professionals of the multidisciplinary team for breast cancer patients. Since the role was initiated, it had been developing all over Israel through the support given by the Israel Cancer Association. As a learning organization, the Breast Care Nurses have a few goals: To learn to give patients the most updated and relevant information; to be a part and be seen as equal as the other members of the multidisciplinary team for breast cancer patients; to have knowledge which empowers them as a working group; to enable to teach students, mainly nursing students, in basic and further education and to help continually teach a new generation of nurses. This learning organization involves some formal and informal education. Although oncology nurses do much of the ideas we have described, we suggest using a strict model to help in implementing a Learning Organization. Future research can examine the outcomes of a Learning Organization on oncology nursing.
Keywords: Breast neoplasms, education, nursing
|How to cite this article:|
Kadmon I, Kislev L. Israeli breast care nurses as a learning organization. Asia Pac J Oncol Nurs 2015;2:3-7
| Introduction|| |
This article aims to relate the theory of learning organization to the Israeli breast care nurses (BCNs) by using Senge's criteria.  This article describes Peter Senge's theory and the role of BCNs in Israel, as well as the relation between the two.
Learning organization is a concept established by Peter Michael Senge (born 1947), an American scientist and director of the Center for Organizational Learning at the Massachusetts Institute of Technology Sloan School of Management. Senge is also the founding chair of the Society for Organizational Learning. His areas of special interest focus on decentralizing the role of leadership in organizations to enhance the capacity of all people to work productively toward common goals. He is known as the author of the book, "The Fifth Discipline: The Art and Practice of the Learning organization" from 1990 (new edition 2006).  According to Senge, learning organizations are "organizations where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together." ( http://infed.org/mobi/peter-senge-and-the-learning-organization/ )
In his famous book, The Fifth Discipline , Senge asked the following question: Are we "prisoners of the system or prisoners of our own thinking?" He encouraged people to be independent thinkers and to have mastery over their own ideas. His ideas are related to business and organizations. Wen  noted that Senge, in his book, talks about disciplines in the routes of his learning organization theory:
- The ability to inspire or aspire;
- The ability to start reflecting on conversation and
- The ability to understand complexity.
These ideas can be gathered in a unique way to the healthcare system in general and to the Israeli BCNs in particular. Senge's criteria for a learning organization will also be presented in relation to the Israeli BCNs.
In 1996, some years after Senge wrote his book, the role of the BCNs was established in Israel. The Hadassah Ein Kerem Medical Center is the first to establish this profession, and Dr. Ilana Kadmon, who was appointed to the BCN role in 1996, still holds this position to date. At that time, lack of support had been given to women with breast cancer. This role was hardly recognized by the health care team and its importance took some years to attain recognition from the whole multidisciplinary team. Originally, BCNs mainly provided practical advice to women. Throughout the years, BCNs learned to implement more psychosocial interventions. Since 1996, the BCN role has continued to develop all over Israel through the support given by the Israel Cancer Association. 
Today, at least 40 BCNs are working in different centers in Israel. These nurses created a network among themselves. When a woman is diagnosed at a specific center and decides to undergo a part of her treatment in a different institution, BCNs from both centers communicate effectively. An advertisement about this network was presented at an international conference in Germany in 2004.  Majority of the hospitals implement the BCN role within their institution. Some institutions have more than one BCN, such as in some centers where BCNs provide service throughout the treatment trajectory, i.e., from diagnosis to rehabilitation and metastatic stage. In other institutions, some BCNs are dedicated to follow women at the surgical stage or mainly at the oncological stage. Some centers also have BCNs with more specific roles, such as those for genetic carriers or in coordinating care in the imaging institute.
This unique working group of BCNs meets every few weeks in the Israel Cancer Association led by the head nurse. These regular meetings are particularly designed to train the group, discuss common concerns, enable a forum to include consultation with each other, develop some new ideas and facilitate social gatherings. This design is similar to that of the learning organization described by Senge.
BCN Group as a learning organization
Senge developed the concept of learning organization in general, but he did not relate it to the healthcare system and nursing. Rishel  dealt with the same field of ongoing learning related to oncology nursing. She states that in 2012, the Oncology Nursing Society (ONS) published a position paper on lifelong learning for oncology nurses in the Oncology Nursing Forum (ONF) embracing the institute of medicine ([IOM], 2010) report. The ONS stated that nurses must engage in "continuous professional development, advanced nursing education and the development of interpersonal models of care."  The ONS recognized that although the basic principles of oncology nursing remain unchanged, new and improved trends in models of care delivery, the rapid changing science and technology of cancer care and published data from nursing research and clinical trials created knowledge domains that demanded that oncology nurses remain current to provide patient care. ,
As a learning organization, the BCN group has the following goals:
- To provide patients with the most updated and relevant information.
- To belong to a multidisciplinary team that promotes equality among members.
- To attain knowledge that empowers the working group.
- To enable BCNs to teach students, mainly nursing students, and help them in basic and further education.
- To help BCNs continue and develop a new generation of nurses.
In Israel, all BCNs have attained an academic degree. Most BCNs have also obtained a certificate in post-basic course in general oncology nursing. This post-basic curriculum includes a module focusing on chronic diseases and another specifically focusing on oncology care, which mostly includes topics related to breast cancer. The oncology module consists of many hours of theoretical study and as many hours of clinical practice. This curriculum has contents related to breast cancer, such as pathology, types of treatments, genetics, breast reconstruction, lymphedema and psychosocial issues.
Most BCNs in Israel have no formal education specific to breast cancer nursing. We are currently working on the curriculum for formally training BCNs. This formal training is well developed through the European Oncology Nursing Society (EONS). BCNs begin with such formal training by obtaining support from the Nursing Division of the Israeli Ministry of Health for implementation of this curriculum that was provided to the BCN group. Completion of this course will be one of the criteria to assess the role of BCN. A small team of BCNs is working on this process, but all the nurses are allowed to comment at every stage of the process and express their opinion.
Considering that no formal education specific to breast care nursing is provided in Israel, we have conducted several informal trainings for BCNs. These programs can also be regarded as part of our learning organization. Most Israeli BCNs nationwide have attended these activities.
- Invited speakers on various topics (innovations in treatments for breast cancer, neuropathy, breast reconstruction, fertility, and so on). Many BCNs have attended these lectures.
- Workshops on various topics (couples coping with cancer, who handles the therapist?, decision making, nurses coping with advanced breast cancer patients and guidelines for nausea and vomiting). One of the workshops was based on the involvement of BCNs in decisions regarding treatment. We all learned together about decision making in breast cancer care from a specialist in this area through lectures and role playing. This workshop provided an opportunity for understanding the various stages related to decision making, such as discourse regarding preferences and counseling with other specialists, to determine the optimal decision related to oneself. The group developed other ideas about conducting studies in this area.
- Another workshop was conducted by a social worker regarding caring for "difficult" women. Some of those women are in their advanced stage, and others have personality disorders.
- Participation in meetings and study days were organized by the Israel Society for Mastology. More clinical meetings were conducted, and these gatherings included subjects such as treatment of young women, ductal carcinoma in situ (DCIS), women with advanced breast cancer and many more.
- Attending courses on various topics within the Israel Cancer Association (aspects involving psych-oncology and sexuality). A wide course (60 h) about sexuality garnered much interest from the BCNs who deal with this issue on a daily basis. This course included different subjects, such as implications of treatment on sexuality, models for interventions and partners.
- Journal clubs related to cancer in general and breast cancer in particular were conducted. These journal clubs discussed various topics on a specific article.
- Study days within the activities of the Israel Oncology Nursing Society were included. These study days included topics such as psychosocial aspects of cancer (facilitated by the Israel Cancer Association and the local psycho-oncology society), genetic carriers, ethical issues and fertility. One important example is a study day led by a survivor who discussed reconstruction of the areola and the nipple using a new technique.
- Seminars and courses on various topics within the activities of the Israel Oncology Nursing Society (leadership, management, good clinical practice, geriatric oncology) were conducted. A special course about geriatric oncology was offered, which many of the BCNs attended. This course involved many aspects of caring for elderly women, such as pharmacology for older women, psycho-geriatrics, symptomatology, geriatric assessment and ethical issues. This course was concluded by professional actors (playback theater) who played aspects of dealing with geriatric patients in a general discussion.
- Conducting research was one of the group's major roles (as mentioned in this article).
- Learning through training of nurses from other countries. The BCN group has contact with other international groups, such as those from Russia, Cyprus, United Kingdom and China. This coordination involves hosting trainings as well as teaching in other countries.
- Learning to create presentations for conferences.
- Learning through preparation of lectures for the healthy population in the community, which are focused on prevention and early detection of breast cancer.
Why is the Israeli BCN Group a Learning Organization?
According to Senge's theory, the Israeli BCNs can comprise an active learning organization because they meet all the criteria described by him.  These criteria are as follows:
- Leadership. The BCNs have their own leader and coordinator in the person of the head nurse of the Israel Cancer Association. One of the aims of the organization is to develop leadership skills among the BCNs.
- Promoting personal learning and mastery. We must contently learn to observe reality and understand the truth. Such is done by looking at our actions to plan the future in establishing our mission.
- Double-loop learning. These criteria aim to create a profound way of thinking and achieving spiritual transformation. Such goals can be regarded as a spiral way of thinking and reflecting on actions and work. The group practices this approach by courses (such as geriatric oncology), workshops (on nausea and vomiting, for example) and personal facilitations.
- Developing organizational capacity and learning through dialogue. Our regular meetings include dialogue, brainstorming, role playing and discourse to solve common problems and other issues.
- Enhancing effectiveness of learning. The group continuously learns through seminars, workshops, study days and courses. Such learning is focused on relating knowledge and evidence-based data to everyday practice.
- Assessing for promoting the process. The BCNs constantly evaluate their roles and have recently conducted a research on job assessment and evaluation. This research was conducted to view the perception of women toward BCNs. 
Outcomes of the Israeli BCN group as a learning organization
The outcome of this process can be observed in the multicentric study being conducted by the group in the past few years  and funded by the Israel Cancer Association. This study examined women's perceptions of the BCN role. Overwhelming results suggest that most women diagnosed with breast cancer have met a BCN, who reported that this role is very important to them for managing the whole treatment trajectory and coping with all the different areas related to managing this process. For example, the results showed that most of the women (about 88%) thought that the amount of information they received from the BCNs was adequate (internal reliability of questions related to knowledge was Cronbach alfa 0.93). Another example is related to the BCN provision of psychological support. The BCNs were helpful in terms of coping with the diagnosis (78%) and encouraging expression and management of feelings (67%). Notably, 55.2% of the women received help from the nurses regarding family concerns and 61% received guidance in making decisions regarding treatment (internal reliability of the psychosocial questions was Cronbach alfa 0.92).
Another important qualitative study was published by Adami et al.,  who described a specific BCN in Israel and the letter she received from her patients. Similar to the previous research, this study shows the important roles of BCNs in the following three areas: Instrumental, cognitive and emotional.
Those studies provide proof and encouragement for the BCNs to continuously improve themselves in all areas needed in the learning process.
The outcomes can also be observed through a few qualitative data provided by the BCNs themselves. The roles of the BCNs in a learning group are as follows:
"When we started our role, we had no model to base our work on. We also came from other professional backgrounds, and the issue of breast health was not necessarily familiar to us. Thus, communication between us was mainly on sharing information. For example, we developed some written information and shared with one another. We continue this learning among ourselves and other health professionals. We participated in many study days of the Israeli Society for Breast Health, and we continue to learn and share this information with others. We also participated in a few research projects, and we are now models for other nursing groups. We also serve as educators for nursing schools and for other nurses internationally. Through the years, we had dealt with hardships, and we became not only more of a learning organization but also an organization that teaches and encourages others."
"As a learning organization, we continue to educate ourselves with new areas and studies. We learned about new technologies by attending local and international conferences and workshops. We learned from visiting other BCNs in other institutions. We also learned from the network we have built between ourselves. This network provides an informal forum for consultation and support for one another. We also conduct research. Thus, a learning organization facilitates continuity of learning and education."
"A learning organization involves sharing of professional problems and ways of dealing with them. We use simulation to learn and establish solutions. We have a few models on the same role which we share with one another. We learn through lectures on various topics."
"I started my role as a BCN in 1997 after learning and training for this job. As part of the establishing group, we formed the role in the country. As part of this group, we deal with a large target population from young to elderly women. Women diagnosed with breast cancer undergo a long process from diagnosis to rehabilitation and involves the whole multidisciplinary caring team. As nurses, we are part of this team, and such role requires us to learn from the media and professional medical knowledge that is constantly updated."
Based on the above response, this group of Israeli BCNs certainly invests much thought and motivations for updating their knowledge and continually learning about different methods and functions of a learning organization. A working group of European oncology nurses has already developed trainings for BCNs through the EONS.  However, in Israel, we still require a formal curriculum specific for BCNs. A working group of BCNs has already initiated this important process to achieve a formal recognition as clinical nurse specialists.
The concept of the BCN group as a learning organization in Israel is both innovative and unique, and may be applied to other countries and other professional settings. This concept may be important for future oncology nurses in their clinical work, teaching and research. Both the American model of the ONS and the European guidance of the EONS are good examples that need further study and application. Definitely, many of these aspects are already applied by oncology nurses, but not all applications are very systematic methods according to these specific models.
| Summary and recommendations|| |
According to Senge, "Through learning we re-create ourselves. Through learning we become able to do something we never were able to do. Through learning we extend our capacity to create, to be part of the generative process of life." ( http://infed.org/mobi/peter-senge-and-the-learning-organization/ )
The Israeli BCNs, who independently work with each other in their institution, have established and formed a unique, active and motivated group that can be regarded as a learning organization.
Although oncology nurses perform much of the ideas we have described, we suggest the use of a strict model to implement a learning organization. Future research can examine the outcomes of a learning organization on oncology nursing.
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