Cancer is the second most common cause of death for men and women after coronary heart disease (Department of Health, 1996). But the problems of the disease go beyond the morbidity and mortality statistics. A diagnosis of cancer elicits feelings of dread and terror.
Mandy Howell, BSc, RN, OND, DPSN, DMS
Matron, Sunderland Royal Hospital, City Hospitals Sunderland NHS Trust
Alongside the psychological symptoms of worry, fear, irritability and sadness arising from cancer, people can experience lack of energy, pain, drowsiness, dry mouth, nausea, anorexia, and difficulty sleeping and concentrating (Twycross, 1997; Twycross et al, 1996). An alteration in body image may occur as the result of surgery, insertion of a Hickman line, or side-effects such as weight loss.
People living with cancer not only have to deal with the symptoms. They have to manage healthcare regimens, adjust to body image changes and live with uncertainty. They may have to revise personal, social and occupational goals by a process of re-evaluation, transformation and redefinition (Burnet and Robinson, 2000). To face the prospect of dying from cancer is one of life’s ultimate painful emotional events (Singer, 1984).
Education is a critical influence in the continuing development of cancer nurses and nursing practice. But does the level of education on offer facilitate the changes in practice we need? Above all, does it make a difference to the patient experience?
This paper reports on a study that explored whether cancer nurse education has influenced the planning of care in several acute general medical wards within a large general hospital.
The Calman Hine report (1995) set out a number of principles governing the provision and delivery of cancer services. Equal access for all patients to uniform high-quality care, regardless of their geographical location, was a priority.
Establishing site-specific specialist nurses was highlighted, and the report said that patients should have access to nurses with appropriate experience and skill. The Royal College of Nursing (RCN, 1996) has identified that, within the field of oncology and palliative care, nurses deliver 80% of direct care to patients. Yet fewer than 1% have specialist training (Corner, 1996).
Calman Hine also recommended that nursing care in wards and departments of cancer centres should be planned and delivered by nurses with post-registration cancer qualifications (1995).
In response, the RCN proposed all nurses in cancer centres and units reach academic level two National Board award in Cancer Nursing, and that specialists working in any environment should hold a first or higher degree (RCN, 1996).
Evidence suggests nurses who have undertaken specialist post-registration education in cancer care are more able to identify patient problems and improve outcomes (RCN, 1996). However, Corner (1996) pointed out that very few nurses meet the RCN proposed standard.
Training needs analysis shows that in Sunderland these recommendations are being achieved, and that wards and departments have staff with a post-registration qualification. Examples include: ENB 237 Oncology Nursing, ENB 931 Care of the Dying, or ENB N59 Chemotherapy Nursing.
Preparing the study
One researcher had protected research time, which was used to organise focus groups. The other two participated during private study time.
A literature review was conducted, with searches of the Cinahl, Medline, Cochrane and National Research Register databases, and in hospital and university libraries. Information was also gathered by networking with the local Cancer Collaborative Forum. Ethics committee approval was not required, since the study involved only staff. But permission was sought from the business managers and senior nurses in those areas invited to participate in the focus groups.
The unique speciality of cancer nursing has had its profile raised by the need for specialist knowledge and educational programmes (Kremar, 2000).
Yasko (1991) suggests that specialist cancer nursing came of age when it was recognised that clinical experience alone was not enough and that formal education was necessary. Providing better care, being able to practise within the context of medical and technological advances, and attaining high-quality practice all require formal education.
Few studies consider the effectiveness of cancer education (Corner and Wilson-Barnett, 1992) in relation to improved service delivery, as opposed to individual development.
Traditional methods of evaluating nursing education focus on end-of-session feedback or testing related to the learning experience (Dickerson, 1990). Other ways to evaluate educational value in practice include pre- and post-education tests; observation of clinical skills; and assessment of skills capability through showing competency of technical procedures. These are valuable but short-term measures, which do not provide information about the student’s ability to provide quality care. There seems to be little long-term follow-up of education’s effectiveness (Langton et al, 1999).
The research question was: ‘Is there evidence that cancer nursing education influences the planning of care in patients with cancer?’
The researchers organised focus groups of nurses working at different levels with a variety of cancer patients. The aim was to assess staff attitudes towards applying new skills and knowledge when planning care. An audit of nursing documentation in these staff areas was carried out to see if evidence supported the focus group information.
Morgan (1997) defines focus groups as ‘a research technique that collects data through group interaction on a topic determined by the researcher …it is the researcher’s interest that provides the focus, whereas the data themselves come from the group interaction’. Focus groups are said to allow for maximum participant involvement in the stimulating exchange of ideas, experiences and attitudes about a specific topic (Kooker et al, 1998).
Trained nursing staff who worked with or came into regular contact with cancer patients were invited to participate in one of three focus groups, divided by staff grade. Group 1 included only D-grade nurses; Group 2 E- and F-grade nurses; and Group 3 G and H specialist nurses. Each group was asked the same set of questions, with the group discussions taped for later transcription and analysis.
After each session the facilitator and the other research observer sought feedback from each other about the process and evolving themes. The data were then transcribed and analysed using thematic and immersion approaches. Box 1 shows the detailed findings of the focus groups.
The overall finding from the groups was that education is not seen as the only factor to enhance practice. Experience, knowledge, beliefs and values, competency, personality, desire and interest, learning environment and organisational culture are other factors they see as important.
Common themes arising from all groups were:
- The importance of learning from and applying experience
- The issue of role clarification/confidence: whose job is it, therefore who gets the experience?
- Education: recognition of the need to learn and apply new skills.
The audit tool
We designed a simple audit tool around the Sunderland Cancer Unit’s Palliative Care Guidelines - produced by City Hospitals Sunderland and Priority Healthcare Wearside and distributed to all wards and departments during 2001. Twenty patient records were audited across six wards. Their cancers included lung, breast, prostate, bowel, brain, pancreas and leukaemia.
The six areas audited were pain, constipation/diarrhoea, oral care, nausea and vomiting, dying and discharge.
Most cancer education programmes focus on one or more of the following:
- Prevention and detection/diagnosis
- Symptoms and management
- Treatments; psychological aspects; death and dying and the organisation of care.
Yet even though most nurses had had some form of cancer education, and had claimed it was an important foundation to underpin practice, it was not applied in written care plans.
Areas which required improvement were knowledge of pain and pain assessment and management of symptoms or side-effects of treatments and medication. Although discharge was reasonably planned, with multidisciplinary involvement, preparing the patient for death and dying was noticeably avoided, with a lack of assessment and documentation.
People with cancer can and do cross many sub-specialities, where cancer is only a part of the clinical care. Consequently staff caring for these patients may face a multitude of unrealistic training needs.
While sub-specialisation has benefits for patients and professionals, the compartmentalisation of practice, priorities and agendas can exclude other clinical specialties and a wider agenda.
These issues, along with competing and conflicting national policies, perpetuate confusion, duplication, competition and often waste. These structures are forcing nurses down a route that is not necessarily helping to make a difference in practice.
Nurses care for patients with cancer at varying stages from diagnosis to death. Although the type of cancer is important because different cancers behave in different ways, many aspects of care remain the same.
This study suggests that even after ensuring nurses specialising in oncology have received some form of cancer education, many remain unprepared, leaving them feeling uncomfortable and inadequate when dealing with dying people and their families.
Nurses give the best care possible to each individual patient, whether they have cancer or not. Education develops the skills of critical analysis, problem-solving, critical and creative thinking, the ability to question, review and evaluate literature as well as encouraging personal growth and development. All have the potential to make a real difference in practice.
The study did not intend to generalise its findings to other units, but to produce local recommendations. These include to:
- Establish effective systems, including data collection, to support, monitor, implement and evaluate the learning of students into practice
- Explore and implement more creative methods of learning in practice
- Use opportunities to promote the uniqueness of cancer nursing.
In today’s changing and demanding environment, education and training are essential. Practical skills and knowledge are relevant, but so, too, is the whole package, including documentation and planning how these skills are to be used.
While we have not shown that cancer education has influenced the planning of care for a group of patients, the researchers still consider cancer education has a positive influence on practice.
The feedback from the focus groups suggests that the nurses, whether experienced or not, apply the skills acquired from education alongside their experience. We need to ensure that this is not only shown in the care delivered but the way that this care is planned and documented.
Burnet, K., Robinson, L. (2000) Psychological impact of recurrent cancer. European Journal of Oncology Nursing 4: 1, 29-38.
Calman, K., Hine, D. (1995)A Policy Framework for Commissioning Cancer Services: A report by the expert advisory group on cancer to the chief medical officers of England and Wales. London: Department of Health.
Corner, J. (1996)Review: Cancer nursing services in Scotland: are we ready to meet the challenge? Nursing Times Research 1: 5, 381.
Corner, J., Wilson-Barnett, J. (1992)The newly registered nurse and the cancer patient: an educational evaluation. International Journal of Nursing Studies 29: 2, 177-190.
Department of Health. (1996)Burdens of Disease: A discussion paper. London: NHS Executive, DoH.
Dickerson, D.C. (1990)Education for staff who care for cancer patients in the critical care unit. Journal of Nursing Development 6: 4, 202-203.
Kooker, B.M., Shoultz, J., Sloat, A.R., Trotter, C.M.F. (1998)Focus groups: a unique approach to curriculum development. Nursing and Health Care Perspectives 19: 6, 283-286.
Kremar, C. (2000)Cancer nursing as a speciality. In: Kearney, N., Richardson, A.D., Guilio, P. (eds). Cancer Nursing Practice. A textbook for the specialist nurse. Edinburgh: Churchill Livingstone.
Langton, H., Blunden, G., Hek, G. (1999)ENB Cancer Nurse Education Final Project Report: Literature review and documentary analysis. Bristol: Bristol University of West England.
Morgan, D.L. (1997)Focus Groups as Qualitative Research. Thousand Oaks, Ca: Sage Publications.
Royal College of Nursing. (1996)A Structure for Cancer Nursing Services. London: RCN.
Singer, B.A. (1994)The psychological impact of cancer on the patient and family. Journal of Medical Society of New Jersey 81: 5, 383-385.
Twycross, R. (1997)Symptom Management in Advanced Cancer (2nd edn). Oxford: Radcliffe Medical Press.
Twycross, R., Harcourt, J., Bergl, S. (1996)A survey of pain in patients with advanced cancer. Journal of Pain and Symptom Management 12: 273-282.
Yasko, J.M. (1991)Role implementation in cancer nursing. In: Baird, S.B., McCorkle, R., Grant, M., Frank-Stromborg,M. (eds). Cancer Nursing: A comprehensive textbook. Philadelphia, Pa: W.B. Saunders.