Certification

In 1985, the ONS established the Oncology Nursing Certification Corporation (ONCC) to provide an examination for the formal certification of oncology nurses. Certification in oncology nursing promotes continuing education and communicates to the public and other professionals that an oncology nurse has specialized knowledge and expertise. Nurses who pass the generalist certification examination may use the OCN (Oncology Certified Nurse) credential with their signature. Recertification is required every 4 years by examination or by the Oncology Nursing Certification Points Renewal option (ONC-PRO). The ONC-PRO program allows the renewal candidate to accrue points through continuing education, academic education, publications, and presentations or participation in test item writing for the certification examination. Renewal by retesting is required at least every 8 years. As of 1999, there are over 18,000 oncology nurses who have been certified. In the fall of 1999, the ONCC began to offer pediatric oncology nursing certification and the CPON (Certified Pediatric Oncology Nurse) credential.

The ONS is the first nursing specialty organization to provide certification for advanced practice nurses. In 1998, the ONCC conducted a role delineation study to distinguish advanced practice nursing from basic nursing practice in oncology and to describe the professional roles and practice behaviors of advanced oncology nurses.¹⁴ The AOCN (Advanced Oncology Certified Nurse) test is based on the results of this study. Unique to the advanced examination is the requirement that an oncology nurse must have at least a master’s degree. Nurses who pass the advanced examination may use the AOCN credential with their signature. As of 1999, there are over 1,000 AOCNs. Table 70.3 describes the eligibility criteria for oncology nursing certification at both the generalist and advanced levels.¹⁵

Table 70.3

Eligibility Criteria for Oncology Nursing Certification.

Oncology Nursing Education

Educational curricula have been developed and implemented to provide oncology nurses with an appropriate understanding of cancer biology, epidemiology, prevention, treatment, nursing practice issues, and trends in cancer care. Several cancer nursing texts^16–23 and journals, such as the Oncology Nursing Forum, Cancer Nursing, and Seminars in Oncology Nursing, deal with these topics in appropriate formats. Cancer nursing is part of the general undergraduate and graduate nursing educational curricula. In addition, doctoral programs and oncology nursing professorships have been established.

The usual educational level of the oncology nurse at the time of entry into practice is a bachelor’s degree in nursing. Figure 70.1, which is based on the membership demographics of the ONS, shows the highest nursing degrees of ONS members. Membership in the ONS offers opportunities for the study and education necessary to qualify for the OCN and AOCN credentials by passing the certification examinations. Increasingly, master’s level preparation is specified in many oncology job descriptions. For example, a master’s degree is required for oncology clinical nurse specialists and nurse practitioners. Currently, 26% of the ONS members are pursuing graduate education, and 10% are doctoral students.⁹

Figure 70.1

Highest educational degrees in nursing of Oncology Nursing Society members. Source: Oncology Nursing Society.

Oncology Nursing Research

The development of oncology nursing research to guide oncology nursing practice has been extraordinary over the past 25 years. From a modest beginning in the 1970s, nursing research evolved in the 1980s to the identification of research priorities, companion studies in cooperative group clinical trials, as well as initial programs of research and funding. In the 1990s, continued advances have included mature programs of research, multi-site studies, increased funding sources, research utilization through state-of-the-knowledge conferences, and major areas of studies (e.g., fatigue, quality of life, pain) that are having a major impact on cancer care.²⁴ The ONS has conducted five research priority surveys since 1981. The top 10 research priorities from the most recent survey included pain, prevention, quality of life, risk reduction/screening, ethical issues, neutropenia/immunosuppression, patient education, stress, coping and adaptation, detection, and cost containment.²⁵ As a result of today’s health-care environment, nurses are being challenged by insurers, health policy makers, and managed-care organizations to demonstrate the effectiveness of their care through research that examines the link between specific nursing interventions and patient outcomes.^26,27

Patient Assessment

Nurses are expected to be expert in assessing patients’ physical and emotional status, past health history, health practices, and both patients’ and families’ knowledge of the disease and its treatment. It is essential that a detailed nursing history and physical examination be completed. An oncology nurse is expected to be aware of the results and general implications of all relevant laboratory, pathology, and imaging studies.

Patient Education

The nurse often has a better opportunity than any other member of the health-care team to spend the necessary time with patients and their families to develop the required rapport for effective educational efforts. Such education includes structured and unstructured experiences to assist patients cope with their diagnosis, long-term adjustments, and symptoms; to gain information about prevention, diagnosis and care; and to develop skills, knowledge, and attitudes to maintain or regain health status.²⁹ This planned education uses a combination of methods to best meet the needs, capabilities, and learning style of the nurse scholar.³⁰ The ONS has enhanced this definition by recommending the following patient education outcome criteria:³¹ the patient and/or family should be able to (1) describe the state of the disease and therapy at a level consistent with his or her educational and emotional status; (2) participate in the decision-making process pertaining to the plan of care and life activities; (3) identify appropriate community resources that provide information and services; (4) describe appropriate actions for highly predictable problems, oncologic emergencies, and major side effects of the disease and/or therapy; and (5) describe the schedule when ongoing therapy is predicted.

There are a variety of teaching tools and methods available, the choice of which is based on individual patient needs and abilities. Printed, visual, and audiovisual educational materials are used in conjunction with discussion and continued reinforcement. Numerous patient educational materials also are available that relate to cancer, cancer therapy, and the management of side effects.^18,32–36 With the increased development of the Internet, more and more cancer patients and family members are accessing the World Wide Web (www) to gain information about cancer. Chat groups are serving as a source of information as well as support. This method of communication will continue to be an increasing source of knowledge for consumers.

Patients should be encouraged to keep personal, written, daily diaries that record treatment dates, symptoms, test dates, and questions. A personal diary provides additional written documentation of the onset of specific phenomena and accurate dates of therapy, in case the patient’s medical record is not available.

Coordination of Care

The oncology nurse plays a vital role in coordinating the multiple and complex technologies now commonly employed in cancer diagnosis and treatment. This coordination encompasses direct patient care, documentation in the medical record, participation in therapy, symptom management, both patient and family education, as well as counseling throughout diagnosis, therapy, and follow-up. The nurse should serve as the patient’s first line of communication. Ideally, the patient and family should feel free to contact the oncology nurse by phone during the entire treatment program. Many patients travel long distances, so the importance of communication by telephone must be emphasized. It allows continuous patient communication, early recognition of emergencies, and regular emotional support.

Camp-Sorrell³⁷ noted that most patient problems can be managed without the patient being seen in the office or emergency room. However, it is important for the nurse to gather sufficient information to determine patient management. A telephone triage flow sheet was developed (Figure 70.2) that provides the basic steps which are helpful in identifying patient problems over the phone before consulting with the physician and relaying specific instructions for follow-up care. This format can be used with complex problem areas, and several specific examples are included below in the discussion on chemotherapy.

Figure 70.2

Telephone triage flow sheet of the basic steps to identify patient problems. Source: Camp-Sorrell.

Modern cancer care is performed at multiple sites by a variety of personnel at a pace that is accelerated by a cost-conscious staff. Communication between personnel at different facilities may be suboptimal, and the communication and coordination that the oncology nurse can provide represents an invaluable service to patients who may be confused and frightened.

Surgery

Surgery is the most frequently used treatment for cancer. A definitive diagnosis of cancer requires tissue confirmation and most patients undergo some type of surgical procedure early in the course of their treatment. Beyond diagnosis, surgery is the definitive means of cure for most solid tumors and has many other applications in cancer management. Surgical procedures are performed for cancer prevention, primary tumor removal, disease staging, tumor debulking, hormonal ablations, disease palliation, reconstruction, and placement of vascular devices.

The patient and family may experience a wide range of emotions and reactions to the diagnosis of cancer and the need for surgery. The diagnosis often has been made only a few days before a major procedure is scheduled. The nurse has a key role in assessing the patient’s understanding of possible surgical outcomes, such as change or loss of body function, limitations of mobility, and change in physical appearance. Careful preoperative assessment may identify significant factors that could increase surgical morbidity and mortality.³⁹ Nursing care of the patient undergoing surgery for cancer includes fostering the patient’s understanding of the specific procedure and expected outcome, preparing the patient physically and psychologically for the surgery, reducing anxiety, supporting the patient’s postoperative physiologic stability, relieving pain, preventing complications, and promoting compliance with postoperative instructions.

The trend to shift surgical procedures from inpatient to outpatient facilities continues. Nurses are challenged to ensure quality patient outcomes, while controlling costs. Clinical pathways have been developed to standardize approaches to care. They provide patients with a treatment course that results in the best possible outcome, while using fewer resources and less time.^40,41 An example of a clinical path used for breast cancer surgery is provided in Figure 70.3.

Figure 70.3

In addition to the shift of inpatient procedures to the outpatient setting, hospital stays for patients undergoing cancer surgery have decreased significantly. Patients and families are faced with assuming responsibility for their postoperative care. Nurses have a responsibility to coordinate early discharge planning and home care, as indicated. Referrals must be sent to appropriate professionals and community support services.

Radiation Therapy

Radiation therapy may be used to cure, control, or palliate cancer. It may be the primary treatment for cancers such as Hodgkin’s disease or seminoma. It may be effective in achieving control from months to years for recurrent breast cancer or lung cancer. Radiation therapy can be very effective in palliating symptoms such as pain or obstruction. It may be combined with chemotherapy, surgery, or immunotherapy. Examples include preoperative combination radiotherapy plus chemotherapy for rectal cancer or radiation following breast surgery for early breast cancer or for locally advanced breast cancer.

Understanding the fundamental principles of radiation therapy, including the principles of radiobiology and radiation physics, enables nurses to provide support and care for patients receiving radiation therapy. The most common method of delivering radiation therapy is external beam or teletherapy. Brachytherapy is the temporary or permanent placement of a radioactive source either in or on a tumor. Specialized radiotherapy delivery techniques include stereotactic radiosurgery, stereotactic radiotherapy, and stereotactic brachytherapy.

Cytoprotective agents have been found to shield normal cells from the toxic effects of cancer therapy.⁴² Amifostine protects a wide range of normal tissues from the toxicities of radiation, while preserving the antitumor effect of the therapy.⁴³ Coordinating the daily administration of amifostine before radiation therapy and monitoring for additional possible side effects present another challenge for nurses.

Nursing care of the patient receiving radiation therapy focuses on preparing the patient physically and psychologically for therapy.⁴⁴ Pretreatment assessment includes knowledge of the treatment plan and goal of therapy, physical assessment with particular attention to areas that may be affected by radiation, nutritional assessment, the patient’s and family’s understanding of the disease process and proposed treatment plan, the patient’s knowledge of possible side effects, and practical problems, such as patient’s transportation to the treatment center.

After completing an initial assessment, an individual care plan is formulated. Assessment of a patient’s needs, patient education, and implementation of interventions during the course of treatment are dynamic. As treatment progresses, the potential for side effects increases. Expected side effects usually occur approximately 14 days after treatment has commenced, depending on the site, dose, and volume. Side effects occur as a result of cell damage due to alteration of mitotic activity and may be acute or delayed occur late, (e.g., after 6 months). If acute effects are not reversed or controlled, late and possibly permanent changes occur. Common potential side effects include skin reactions and fatigue. Side effects vary, depending on the site of treatment; Table 70.4 contains a list of side effects the nurse should be prepared to discuss with the patient.^45–50

Table 70.4

Early and Late Side Effects of Radiation Therapy.

Fatigue may be multi-factorial and may already be a problem for the patient before therapy begins. It is the most common side effect of radiation therapy. Oncology nurses have been instrumental in the recognition, measurement, and treatment of this distressing side effect.^51–53 Most patients consider it to be the side effect that interferes most with quality of life.⁵⁴ There are several tools available to assist in identifying and measuring fatigue.

Preparing patients for the possibility that they may experience some degree of fatigue is recommended. This may allay anxiety and provide patients with needed information to plan their daily activities and set priorities for energy expenditure. Strategies to reduce fatigue include reducing nonessential activities, maintaining normal night-time sleep habits, increasing physical or social activity, distraction, maintaining good nutrition, and allowing family and friends to help.⁵³

The effects of radiation on the skin are categorized as early and late. The time of onset, duration, and intensity of effects are affected by patient-related factors as well as treatment-related factors. Patient-related factors include nutritional status, age, compliance with recommended care, individual differences, skin folds, and tangential radiation fields. Treatment-related factors include radiation type and energy, volume of skin radiated, site of radiation field, fractionation, and possible concurrent therapy, such as chemotherapy. Early skin side effects include erythema, tanning, dry desquamation, moist desquamation, and loss of hair in the radiation field. Late effects include changes such as atrophy, thinning, telangiectasia, altered pigmentation, fibrosis, ulcerations, necrosis, and carcinogenesis.⁵⁰ Most treatment centers have recommendations for skin care during therapy, and an example is given in Table 70.5. It is the responsibility of the nurse to be certain that patients understand guidelines such as these.

Table 70.5

Radiation Oncology Department Skin Care Guide.

Chemotherapy

Providing nursing care to patients receiving chemotherapy presents many challenges. The majority of patients receiving chemotherapy are treated in ambulatory-care settings, and some patients may even receive treatments in their homes. Oncology nurses are faced with increased responsibility for coordinating quality care with fewer resources.

The delivery of chemotherapy is primarily the responsibility of oncology nurses.^55,56 The nurse must have knowledge of the pharmacology of antineoplastic agents, proper techniques of drug preparation and administration, drug interactions, and possible adverse effects of individual agents. The nurse must be skilled in the technique of venipuncture and the management of various types of venous access devices and drug administration systems. In addition, nurses prepare patients and families to manage anticipated side effects of chemotherapy and to report symptoms of potentially serious side effects early to avoid serious consequences. The ONS recognizes that chemotherapy administration is complex and requires training and clinical preparation beyond the basic nursing education. Nursing practice varies from state to state, but the ONS recommends that only registered nurses who have received this additional education and training administer chemotherapy.⁵⁷ National certification for chemotherapy currently does not exist. Each institution should have written policies for chemotherapy certification, administration of antineoplastic drugs (all routes), safe drug handling and disposal, management of untoward reactions, such as allergic reactions, and methods for documentation.

An important responsibility of nurses involved in the delivery of chemotherapy is to ensure that the correct dose of the correct drug is administered by the correct route to the right patient. Complex regimens of potentially lethal drugs are being employed in a variety of settings. Individual institutional guidelines should be developed to minimize the risk of chemotherapy errors. These guidelines should include a reporting system for errors and a systematic way to review current practice to provide changes to prevent repetition of errors. Recommendations for preventing errors are listed in Table 70.6.^58–61

Table 70.6

Guidelines to Prevent Chemotherapy Administration Errors.

Chemotherapy may be used to cure, control, or palliate cancer. It may be used in a neoadjuvant or adjuvant setting. Patients receiving chemotherapy in conjunction with other cancer therapies are at increased risk for experiencing side effects. The goal of nursing interventions is to prevent or minimize side effects caused by cancer treatments. Detailed information regarding the prevention and management of cancer-related symptoms and side effects from chemotherapy can be found elsewhere in the cancer literature.^{17,18,37,62–65} It is imperative to assess accurately the patient’s physical and emotional status before therapy is initiated. This information assists the members of the health-care team to identify risk factors that could contribute to the occurrence or severity of side effects. Other factors that may affect the patient’s response to therapy are age, performance status, coexisting illnesses, and nutritional status.

The change to outpatient administration of chemotherapy has increased the necessity for accurate and thorough patient and family education. This requires nurses to understand the possible side effects of each antineoplastic agent and the self-care activities for reducing their severity. Describing the side effects or problems that patients might experience from the regimen as a whole is more effective than focusing on each separate drug. Patients are more concerned about the occurrence and management of side effects than the actions of particular agents. Reiteration of important points will assist in achieving the desired outcome. Identifying a time sequence in which side effects generally occur may allay patient anxiety and will assist nurses in selecting the appropriate interventions. This may help to distinguish side effects of chemotherapy from other possible causes of similar symptoms. Patient education is facilitated when side effects are classified as immediate, early, delayed, and late.⁶⁶ Immediate side effects, such as hypersensitivity reactions, occur within the first 24 hours. Diarrhea and alopecia have an onset of days to weeks and are considered early side effects. Delayed effects, such as anemia or pulmonary fibrosis, occur within weeks to months, and late effects, such as second malignancies, may not appear for months or years (Table 70.7).

Table 70.7

A Classification of Chemotherapy Side Effects Designed to Facilitate Patient Education.

Nurses frequently triage patient problems and assist in the evaluation of symptoms and initiation of interventions. Subjective and objective data, including information about the last chemotherapy treatment and knowledge of the patient’s history, guide the nurse in determining the patient’s disposition and treatment. Many institutions have developed guidelines for triaging phone calls and problems. See Table 70.8 provides a triage guideline for cancer-related diarrhea.

Table 70.8

Example of a Triage Guideline for Nursing Management of Cancer-Related Diarrhea.

Much progress has been made in managing the side effects of chemotherapy, and nurses have contributed significantly to this success. For example, nausea and vomiting are two of the most common symptoms associated with chemotherapy. Control of these symptoms has been a nursing research priority. Multiple studies have helped to define nausea and vomiting and to develop tools to measure occurrence, distress, and individual experiences associated with these symptoms.^67–69 This information assists in the treatment of nausea and vomiting and evaluation of the effectiveness of prescribed treatments.

Increases in health-care costs and decreases in financial resources have challenged professionals involved in the administration of chemotherapy to evaluate the cost-effectiveness of medical and nursing treatments. Oncology nurses have assisted in the development of guidelines for the use of antiemetics particularly the 5-hydroxytryptamine receptor antagonists.⁷⁰ These guidelines outline the optimal use and safe delivery of antiemetic drugs and have proved to be an effective means of cost containment.

Biotherapy

Biotherapy is often considered the fourth modality of cancer therapy. Biologic therapy may alter host immune response to the tumor or be primarily aimed at reconstituting normal host functions, such as granulocyte repopulation. On occasion, the precise function of a noncytotoxic pharmacologic agent may be unknown, as in the case of levamisole. Biologic agents include the interferons, interleukins, vaccines, colony-stimulating factors, and monoclonal antibodies. These often are used in conjunction with other cancer therapies, such as chemotherapy, radiation therapy, or surgery.

The two most common side effects associated with biotherapy are a flu-like syndrome and fatigue. Intradermal, subcutaneous, and intralesional vaccines can cause localized skin inflammation and systemic side effects, such as fever, chills, diaphoresis, and fatigue. High-dose cytokines can results in toxicities affecting nearly all organ systems. The hematopoietic growth factors are generally well tolerated aside from bone pain. Since many of these agents are administerd subcutaneously, oncology nurses must teach patients or family members how to prepare and inject the drugs as well as to manage possible side effects.^71–74