Expanding the role of the oncology nurse
University of Pittsburgh Cancer Centers, Radiation
Oncology, Pittsburgh, Pennsylvania, United States
Oncology nursing continues to evolve in response to
advances in cancer treatment, information and biotechnology. As new scientific
and technological discoveries are integrated into cancer care, oncology nurses
need to play a key role in the management of this patient population. The role
of the oncology nurse has expanded significantly and can differ greatly across
cultures. Sophisticated treatments and the growth of targeted therapies will
create the challenge of ensuring that all nurses working in this arena are
well-educated, independent thinkers. Thus the future success of oncology nurses
will focus on enhancement of nursing practice through advanced education. The
increased globalisation of healthcare offers exciting opportunities to accomplish
this goal by allowing for collaborative relationships among oncology nurses
across the globe. � 2008 Biomedical Imaging and Intervention Journal. All
Keywords: Nursing; cancer; oncology
The role of oncology nurses
Historically, nurses have played a special role in the
care of patients with cancer, a role that was especially significant in those
few institutions devoted exclusively to cancer care before the United States of
America National Cancer Act of 1971. However, the recognition of cancer as a
major American health problem and the subsequent expanded research and
treatment program against cancer, which has occurred during the past
quarter-century, has been a catalyst for the development of oncology nursing as
a separate specialty. At first many oncology nurses worked as nurses and data
managers for cancer research studies, but as the treatments in oncology became
increasingly complex so did the need for a collaborative relationship between
the nurse and physician in order to provide unique comprehensive patient care.
Today oncology nurses in the United States practise in a
variety of settings, including acute-care hospitals, outpatient clinics,
private oncologists� offices, radiation therapy facilities, home healthcare
agencies and community agencies. They may practise in surgical oncology,
gynaecologic oncology, bone-marrow transplantation, radiation oncology,
paediatric oncology or medical oncology. The majority are involved in direct
patient care, with 35 percent working in a hospital/multi-hospital system, 40
percent in the outpatient/ambulatory care setting, 20 percent in radiation
oncology, and 5 percent in hospice or home care . The roles of the oncology
nurse vary from the intensive care focus of bone marrow transplantation to the
community focus of cancer screening, detection and prevention. Oncology nurses
in the U.S. also tend to specialise in certain cancer types, working in areas
such as breast cancer centers or lung cancer clinics.
�Nurses working in cancer care focus on patient
assessment, education, symptom management, and supportive care. In medical
oncology they play an integral role in the administration of antineoplastic
agents and are responsible for safe drug handling; evaluation of laboratory
data; calculation of drug dosages on the basis of body surface area; insertion
of intravenous lines or accessing central venous devices; continuous and time
intensive monitoring to address potential adverse reactions or drug
interactions; and screening patients for inclusion in available research trials
or protocols . In the radiation oncology arena the nurses need to
have an understanding of radiobiology and radiation physics. They are also
responsible for extensive symptom management, patient education and the submission
process for clinical trials or research protocols.
As more complex treatment protocols are implemented,
nurses working in oncology will need to expand their knowledge base on new
drugs, new technologies, and biologic therapies. For example, The National
Cancer Institute (NCI) announced in January 2006 that intraperitoneal (IP)
combined with IV chemotherapy postoperatively was the preferred treatment
method for advanced ovarian cancer. IP administration allows a high
concentration of chemotherapy to come into direct contact with tumours and
surrounding tissues and organs. The announcement stimulated the need for oncology
nurses to become familiar with IP chemotherapy administration and patient
management guidelines. These patients require constant monitoring of renal and
cardiac function through laboratory values as well as intake and output to
prevent fluid overload and electrolyte imbalances. The patients also need
advanced nursing assessment to prevent any complications from the infusion.
Advances in molecular science have led to new biologic
therapies for patients with cancer. These biological agents have created a
challenge and require nurses to have a thorough understanding of their
mechanism of actions and side effect profile. Patients may continue on these
medications at home thus requiring the nurse to do a complete assessment of the
knowledge level of the patient and/or caregivers regarding the preparation and
administration of the medication at home, as well as management of possible
side effects in the home setting.
In Asian countries the role of the oncology nurse
continues to expand as cancer becomes a leading health concern. However, across
Asia there is growing acknowledgement of the need to clarify the role of
nurses in order to maximise their contribution to cancer care. Asia has many faces and is extraordinary in its diversity of cultures, habits, and
healthcare systems. Oncology nurses in Asia function mainly in a caregiver role
focusing on treatment delivery, education and symptom management. Specialisation
is rarely seen. A study in 2005 by Gopal et al looked at information needs of
women with newly-diagnosed breast cancer in Malaysia and the United Kingdom. Malaysian women in this study emphasised the importance of medical
information on prognosis and spread of disease and the need for more education.
Although nurses specialising in breast cancer are not features of the Malaysian
healthcare system, the findings from this study support the view that
specialised nurses may have a vital role to play .
Standards of practice and competencies for oncology nurses
appear to be similar across continents . Oncology nurses in an outpatient
medical oncology clinic in Thailand, just as in the U.S., are responsible for
starting their own intravenous lines, triaging patient phone calls, calculating
absolute neutrophil counts, administering chemotherapy and reporting all
relevant laboratory, pathology and imaging studies. In Thailand chemotherapy is generally mixed by the pharmacy except in smaller hospitals where
the nurses are required to mix their own. Unlike the U.S., double-checking the
dose of chemotherapy by calculating the body surface area (BSA) is the
responsibility of the pharmacist. In radiation oncology the nurses once again
have similar competencies to those nurses in the U.S. with a focus on symptom
management and patient education.
Universally the oncology nurse has tremendous
responsibility in educating the patient about his or her cancer treatment and
often has better opportunities than any other member of the healthcare team to
review the treatment plan. However, for some Asian countries the challenges of
education extend well beyond diagnosis and treatment. In certain areas a
diagnosis of cancer is taboo and rarely discussed within the family and never
with outsiders. For example, breast cancer literature in Malay languages, even
in the official Bahasa Melayu language, did not exist largely because of
cultural mores regarding privacy about women's bodies, lack of education about the
disease and the lack of public hospitals to prescreen women and provide early
diagnosis as well as treatment options.
The use of alternative medicines is also a common practice
in Asian countries and oncology nurses in these areas need to be familiar with
the role such medicines play in cancer treatment. According to the World Health
Organization (WHO), up to 80 percent of developing countries' populations use
traditional medicines as their primary source of health care . Those
diagnosed with cancer in Southeast Asia will routinely find the local doctor's
choice of treatments something many medical insurers consider unusual. Outside
major cities in places like China, for instance, herbal treatments are used
regularly . Although alternative therapies are becoming more common in the US, the oncology nurses in Asia must routinely educate patients regarding the use of such
alternative treatments within the context of different cultural values. Furthermore,
it is not unusual for a patient to be offered treatment with standard
Western-style protocols with the addition of alternative therapy.
In 2000, the number of new cancer cases in Asia almost
exceeded the combined incidence of new cancer cases in North America, Europe
and Australia combined, and is predicted to increase further . WHO has
projected that new cancer cases in Southeast Asia will rise from 1.3 million to
2.1 million between 2002 and 2020 - a dramatic 60 percent jump . With the
rising incidence and prevalence of cancer, the need for adequate nursing staff
is becoming urgent.
One theme that rings true globally is the lack of nursing
personnel (Table 1). A nursing shortage is an organisational challenge and has
a major negative impact on healthcare. The failure to provide adequate levels
of nursing staff has led to the undesirable trend of poor nursing services, as
2005 International Council of Nursing (ICN) makes clear. The average ratio in
Europe is 10 times that in South East Asia, where the latter region also
suffers from a poor distribution of nurses, with few nurses available in rural
and remote areas . The demand for nurses in many countries in Asia is so staggering that it has led to many nurses migrating due to better financial
rewards in highly developed areas . In the highest paid areas of
the United States � for example, California � an average starting salary for a
nurse ranges from $36,000- $45,000 a year, compared to nurses in Malaysia who have an average starting salary of $4,000 a year. The maximum salary in the U.S. for a nurse with more than 10 years of experience is around $58,000 while in Malaysia advanced practice nurses typically make around $10,000 a year. In China nurses in the smaller cities make as little as $200 a month. In the larger cities the
nurses can make $1,000 a month, but these jobs are very limited.
According to the 2005 ICN Asia Workforce there is little
difference in wages, benefits and working conditions between nurses in the
private hospitals and those in the public hospitals. However, Malaysian nurses
in private hospitals are paid more than nurses in public hospitals. This
contrasts with Taiwan where the starting salary for nurses in public hospitals
is higher than that offered by private hospitals. In Singapore, the basic pay
in both sectors is similar .
Educational preparation also varies depending on the
country. Thailand�s entry level into practice is at the baccalaureate level,
but in other countries one can practise after completing a two-year diploma
program. Most of the Asian countries require nurses to sit for licensing
examinations in their national language, although this is a fairly new
practice. In Thailand, the first national examination for nursing graduates was
administered by the Nursing Council in 1998. Prior to this, graduation from an
approved school of nursing or university was all that was required for
licensing. The license is renewed every five years. In Taiwan approximately 25 percent of nurses have a baccalaureate degree . In contrast, in
1905, the state of North Carolina required nurses who had successfully
completed formal education programs to pass a licensing exam. According to the
most recent survey from the Oncology Nursing Society approximately 48 percent
of nurses in the U.S. hold a bachelor�s degree .
Advanced nursing education varies tremendously between the
U.S. and Asian countries. In the U.S. the development of the advanced
practice role began over 35 years ago in response to a shortage of primary care
providers in rural areas. In 1989, nurse practitioner programs were required to
be master�s granting programs or post-master�s degree programs. In contrast, in
Asia the role regarding advanced practice nursing first emerged in Taiwan in 1994. Before that nurses in Taiwan were reluctant to work in an advanced practice
capacity as it was considered illegal. Today advanced nursing practice in this
country is booming but the standards of education have not been well-developed.
The majority of the advanced practice nurses are either junior college
graduates with four years of clinical experience or bachelor degree nurses with
two years of clinical experience . Short-term hospital-based continuing
education courses are the only way of preparing advanced practice nurses in Taiwan.
Future of oncology nursing
It has been estimated that there will be another 20
million new cancer patients worldwide in 2020 . In the developing countries
of Asia this poses a huge burden on an already taxed healthcare system. When
the rise in cancer rates is coupled with concurrent therapies, targeted
therapies and advanced treatment technology, the need for advanced practice
nurses becomes extremely important. Enhancing the oncology nurse�s education is
the main goal of the future and will allow nurses to have a greater
contribution to cancer care in developing countries.
As stated previously, throughout Asia there is great
diversity of educational preparation. Nurses are, at best, given a broad
overview of cancer care in their basic educational programs, yet to practise in
oncology, nurses must quickly learn the language of this discipline. Each type
of cancer has a different etiology, pathophysiology, natural history and course
of treatment. The number of chemotherapeutic agents and drug combinations, as
well as targeted agents being added to treatment regimes is staggering. In
radiation oncology, advances in technology have led to more defined treatment
and a greater need for patient education.
A decade ago, an oncology nurse could become an expert in
one treatment modality such as surgical, medical or radiation oncology. Now
patients frequently receive concomitant and sequential therapies that require
assessment and management skills for all three modalities. Nurses now have
subspecialties such as breast care nurses, palliative care nurses, stem-cell
transplant nurses and so on. In the larger cities of Asia, nurses may be
familiar with newer technology, but more education is needed for nurses working
in remote, less-developed areas of the country. As relevant healthcare systems
are put in place to manage the rapidly increasing numbers of cancer diagnosed
in this part of the world, there will be a greater need for education of
oncology nurses who have never been exposed to managing skin rashes from
targeted therapies or radiation therapy equipment. For instance, the WHO
estimates that the Asia-Pacific region needs 4,000 radiotherapy machines to
treat its patients, but has only 1,200 . If an increase in radiotherapy
centres is the future of cancer care in this area, then many more nurses will
need to become experts in radiation oncology.
Although some countries require their nurses to have
continuing education credits, this is not the standard for all countries.
Programs focusing specifically on oncology are rare for nurses practising
outside a major city. This leaves a lack of further education on newer
Oncology nurses in Asia will also need to take an active
role in developing prevention programs for cancer. The rapid rate of economic
development in some Asian countries, along with the accompanying
industrialisation and urbanisation, are contributing to an ever-increasing risk
of common cancers. In Thailand 57 percent of boys begin smoking between the
ages of 15 and 20, and unfortunately most countries in Asia have weak policies
and programs for tobacco control .
Abundant evidence in the U.S. has demonstrated the
benefits of the advanced nursing practice [16-18]. In the developing countries
of Asia, advanced oncology nurses can also be instrumental in creating cancer
prevention programs. For example, cervical cancer is the most common
carcinomatous lesion in women in Thailand, accounting for 18.1 percent of all
cancers found in Thai women . In 2002, the Alliance for Cervical Cancer Prevention
and the Thai Ministry of Public Health (MOPH) examined an innovative approach
to cervical cancer prevention in Thailand . Twelve nurses with advanced
training used visual examination of the cervix with acetic acid (VIA) and
cryotherapy to provide testing and treatment to women in a rural area of the
country. Over 7 months, 5,999 women were tested for cervical cancer or
pre-cancer with VIA. If they tested positive, they were given counseling and
offered cryotherapy and further counseling regarding its benefits. The results
of the project indicated the VIA and cryotherapy performed by advanced practice
nurses was safe and feasible. Moreover it provided a cost-effective approach to
providing cancer screening and treatment to women in the rural areas of Thailand where a more traditional approach to cancer prevention is low .
For the oncology nurse, the learning curve is steep. The
integration of targeted therapies into practice, advances in combined modality
therapy and an increase in treatment delivery technology means that the
oncology nurse must be well-educated to care for this population of patients. Oncology
nurses must be able to think critically, analyse, reflect, problem-solve, and
apply high-level knowledge that is evidence- and research-based to clinical
interactions with patients who need their care. For some Asian countries,
advanced practice nurses do not exist or they exist with a lack of role-clarity
and educational preparation.
With cancer rates in Asia on the rise and an increase in
complex treatments, there is a greater need for the advanced practice nurse. Advances
in information technology can allow us to bring educational opportunities to
nurses across the globe and establish a uniform process of educating and credentialing
advanced practice nurses. The oncology nurse of the future will need to become
comfortable and flexible with technology. Creating a global advanced oncology
nursing curriculum can help to bridge the gap between oncology nurses across
continents and enhance education of nurses working in the cancer setting in Asia.
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|Received 1 July 2008; accepted 2 July 2008
Correspondence: Program Manager, Radiation Oncology, University of Pittsburgh, Hillman Cancer Center, 5230 Centre Ave, Pittsburgh, PA 15232, United States. Tel.: +412-623-2061; E-mail: firstname.lastname@example.org (Annette Quinn).
Please cite as: Quinn A,
Expanding the role of the oncology nurse, Biomed Imaging Interv J 2008; 4(3):e34