Cancer remains the second leading cause of death in the United States, and as of January 2016, an estimated 15.5 million Americans with a cancer history are alive (American Cancer Society [ACS], 2016). Within a decade, this number is expected to exceed 20 million (ACS, 2016). With great strides continuing to be made in cancer detection, diagnosis, and treatment, cancer care must focus on the needs of the growing number of cancer survivors.
Cancer survivorship encompasses individuals from diagnosis throughout the remainder of their lives (ACS, 2016). In this study, the term cancer survivors is applied to individuals who have completed their initial cancer treatment, may or may not be determined to be cancer free, and receive health care services in non-oncology designated clinical settings. Survivors are at risk for long-term treatment side effects, increased incidence of secondary cancers, and chronic illness. With increasing numbers of cancer survivors, a greater number of nurses will be managing patients with cancer. The potential exists that the needs of cancer survivors may outweigh the number of oncology-prepared health care providers available to meet their needs.
Although attention has focused on the needs of cancer survivors, little or no attention has been given to the expected competencies of non-oncology nurses regarding cancer survivorship care. Nurses lacking oncology preparation and experience likely will care for survivors across all clinical settings. Preparing a workforce able to care for cancer survivors is integral for optimal outcomes. This article describes the results of a national study that identified the educational needs of non-oncology nurses who care for cancer survivors in clinical settings not dedicated to cancer care.
With the projected increase in the number of cancer survivors, nurses at some point in their careers will care for a patient with cancer. Several factors contribute to the increasing numbers of individuals newly diagnosed with cancer: the rise in obesity and lack of physically active lifestyles (Eheman et al., 2012), the growth in an aging population in the United States, and ongoing advances in cancer detection and treatment (ACS, 2016).
Additional concerns arise as an estimated 11 million cancer survivors will be older than age 65 by 2020 (Parry, Kent, Mariotto, Alfano, & Rowland, 2011), and older adults with cancer have an increased risk for additional comorbidities (Edgington & Morgan, 2011). Cancer survivors are at an increased risk for long-term and latent side effects, including chronic pain, cognitive deficits, cardiomyopathy, decreased bone density, decreased lung capacity, infertility, secondary malignancies, and various psychosocial concerns (ACS, 2016; Edgington & Morgan, 2011). Non-oncology nurses must remain cognizant that survivors often continue to focus on recurrence, neglecting potential long-term and latent treatment effects (Hewitt, Greenfield, & Stovall, 2006).
Finally, a shifting paradigm exists from an acute to a more chronic-based disease focus, resulting in increased survivorship. With increasing survivorship, a greater number of nurses will be involved in the management of patients who had been previously diagnosed with cancer and treated for the disease. These changes and shifts impact the current and future demand for oncology services.
Significant increases in the numbers of newly diagnosed patients with cancer and long-term cancer survivors reinforce the potential for survivors to enter and re-enter the health care system at multiple points along the cancer care continuum. In addition, the majority of long-term survivors most likely will transition to care provided by general practitioners and non-oncology health care workers with little experience in oncology (Edgington & Morgan, 2011; Erikson, Salsberg, Forte, Bruinooge, & Goldstein, 2007). The likelihood that cancer survivors will receive care from nurses without specialized oncology education in non-oncology clinical settings will increase significantly. However, non-oncology nurses may lack the specific knowledge and skills needed to safely care for cancer survivors.
In a previous study, Lockhart et al. (2013) assessed the depth and importance of cancer content taught in 931 prelicensure RN programs in the United States. Findings revealed that the depth of cancer content taught varied among schools; the importance of cancer content was rated consistently higher than the depth at which the content was taught. Similarly, Tam et al. (2014) surveyed Canadian educators and learners in undergraduate and postgraduate medical programs on their views of oncology education, training, and needs to care for patients with cancer. Results indicated that oncology education in both programs was considered inadequate by the majority of educators and learners.
Demands placed on nurses regarding the needs of cancer survivors with concurrent chronic illnesses supports the necessity of understanding nurses' learning needs to care for cancer survivors. Current and projected increases in newly diagnosed cancer patients, along with long-term, aging cancer survivors, supports the nation's need to prepare a nursing workforce skilled to meet the health care needs of cancer survivors. The literature lacks sufficient evidence regarding the knowledge of non-oncology nurses on the care of cancer survivors in non-oncology settings. A need exists to determine not only the educational needs of non-oncology nurses caring for survivors in these settings, but also to recommend targeted interventions.
Benner's (1984) novice to expert model provides a framework for exploring non-oncology nurses' knowledge related to cancer survivors. This model describes a process whereby nurses progress from novice to expert in their practice (Benner, 1984). Benner, Sutphen, Leonard, and Day (2010) additionally asserted that nurses need to be prepared to practice safely, accurately, and compassionately in varied settings. Nurses develop knowledge and skills related to patient care over time by engaging in targeted, evidence-based education and a multitude of experiences. Although experienced nurses may be competent in their traditional specialties, they may function at a lower level when faced with new experiences.
Identifying the learning needs of nurses related to the care of cancer survivors is an essential first step before designing targeted educational interventions to develop cancer-specific knowledge and skills that result in safe, quality patient outcomes. Therefore, this study explored the educational needs of non-oncology nurses caring for cancer survivors in clinical settings not dedicated to cancer care from the perspectives of both oncology and non-oncology nurses. Specific aims included (a) examining the depth and importance of select cancer concepts from the perspectives of both experienced oncology and non-oncology nurses, (b) comparing these responses between both groups of nurses, and (c) describing barriers to learning cancer survivor care as reported by non-oncology nurses.
Design, Sample, and Settings
A nonexperimental survey design conducted in two phases was used to address the study purpose and aims. After a pilot study was conducted to establish content validity and reliability of the survey tool for use with clinical nurses, a national pool of 302 experienced oncology RNs was surveyed in Phase 1 to gain their expert perspective on the educational needs of non-oncology nurses regarding cancer survivor care. The sample was recruited from the Oncology Nursing Society (ONS) national member database of more than 9,000 members (H. Fox, personal communication, September 25, 2012). Based on prior experience using the survey (Lockhart et al., 2013), a response rate of at least 300 participants was targeted.
Phase 2 gained similar input from non-oncology nurses about their own learning needs in cancer survivor care. Surveys were completed by a convenience sample of 313 non-oncology nurses (RNs with at least 2 years of recent staff nurse experience caring for inpatients in U.S. acute practice settings). Nurses were recruited from the national membership database of the Academy of Medical-Surgical Nurses (AMSN), an eligible pool of approximately 6,000 nurses. Nurses with at least 2 years of experience were targeted.
The Cancer Nursing Curriculum Survey (CNCS) (ONS Project Team, 2010), which was used previously to assess the depth and importance of cancer concepts in the curricula of prelicensure RN programs in the United States (Lockhart et al., 2013), served as the tool for the current study. The CNCS and its psychometrics have been reported previously (Lockhart et al., 2013). With permission, the demographic questions were revised for this study to verify participants' inclusion criteria.
A pilot study was conducted prior to Phase 1 using a convenience sample of 16 RNs recruited from two ONS chapters in the southwest and northeast to confirm content validity for the tool's use with clinical RNs, clarify language, and estimate completion time. Nurses were eligible if they had at least 6 years of recent experience caring for oncology patients in oncology-designated clinical settings (6 years of experience aligned with ONS membership database categories). Nurses were recruited with the permission and assistance of ONS chapter presidents, who sent e-mail invitations to members; permission also was given to recruit members in person at a chapter meeting. The pilot study resulted in the addition of “access devices” to the list of concepts. Cronbach's alpha was .967 for depth and .96 for importance.
The final CNCS contained 13 demographic questions tailored to each nurse group, 33 cancer concepts, and two barrier questions (AMSN RNs only). Respondents were asked to rate the depth and importance of the cancer concepts based on what non-oncology RNs (without additional preparation in oncology nursing) should know when caring for cancer survivors in non-oncology clinical settings. The Figure illustrates how each concept was rated by its depth (i.e., level of content) and its importance (i.e., priority in nursing practice) using a 5-point Likert scale with lower scores (1) representing no depth/importance and higher scores (5) representing very much depth/importance. Surveys could be completed either electronically by accessing a survey link from a computer or by using paper-and-pencil. Surveys took approximately 20 minutes to complete.
Sample questions from the Cancer Nursing Curriculum Survey. From Cancer Nursing Curriculum Survey, by ONS Project Team, 2010, Pittsburgh, PA: Oncology Nursing Society. Copyright 2010 by the Oncology Nursing Society. Reprinted with permission.
Data Collection Procedures and Analysis
Recruitment for all phases of the study began after receiving institutional review board approval from the first author's university. Potential participants were sent an e-mail explaining the purpose of the study, eligibility, and a link to access the electronic CNCS via secure software. Page one of the survey reminded nurses that their participation was voluntary, that they could withdraw from the study at any time without consequences, and that all data would be anonymous, held confidential, and reported in an aggregated form. The deadline for survey completion also was indicated. Eligible ONS members were recruited with an e-mail forwarded by ONS. Authors recruited additional participants (n = 32) in person at the ONS national congress, and AMSN members (n = 36) were recruited in a similar fashion at the AMSN national meeting.
Data were analyzed using SPSS® Version 22.0 software. Descriptive statistics were used to calculate mean scores for each cancer concept by depth and importance. Kruskal-Wallis was used to calculate differences between responses from the two nurse groups.
Demographics for both participant groups are listed in Table 1. The ONS (N = 302) and AMSN (N = 313) participants were similar demographically. The majority of participants were women (98.3% for ONS and 96.8% for AMSN), age 50 to 59 (48.8% for ONS and 35.5% for AMSN), educated at the baccalaureate level (36.1% for ONS and 46.6% for AMSN), and employed as staff nurses (52.3% for ONS and 55.6% for AMSN) in urban (48.7% for ONS and 48.6% for AMSN), nonacademic hospitals (33.4% for ONS and 53.9% for AMSN) without Magnet® designation (62.3% for ONS and 63.6% for AMSN).
Demographics of the ONS and AMSN Groups
Most nurses in both groups worked more than 10 years as RNs (87.7% for ONS and 63.9% for AMSN) in clinical settings across the United States: Northeast (21.5% for ONS and 17.2% for AMSN), Midwest (28.3% for ONS and 24.9% for AMSN), South (30% for ONS and 35.6% for AMSN), and West (20.2% for ONS and 22.3% for AMSN). Most ONS participants worked in outpatient clinic and ambulatory oncology settings (45.4%), whereas most AMSN nurses worked in inpatient surgical units (93.7%). Both nurse groups held one or more certifications in their specialties (95.4% for ONS and 76.9% for AMSN). Significant differences between the two nurse groups were noted based on age (χ2 = 39.3, p = .00) and years worked as an RN (χ2 = 71.09, p = .00), with ONS participants being slightly older and more experienced in nursing.
Oncology Content Depth and Importance
Ranges and mean (M) scores were calculated for the 33 cancer concepts based on depth and importance, and were organized by ONS and AMSN nurse groups. Depth scores for ONS nurses ranged from 2.81 to 4.43 (M = 3.19 at moderate); AMSN nurse ratings ranged from 2.83 to 4.31 (M = 3.2 at good). Importance range scores were higher than depth in both groups; ONS nurses rated importance as 3.13 to 4.47 (M = 3.42 at moderately important/important), and AMSN nurse ratings were 3.08 to 4.47 (M = 3.42 at moderately important/important).
When the 33 cancer concepts were organized by mean depth scores according to nurse group (Table 2), all but one of the top 10 concepts identified by ONS nurses (skin and musculoskeletal alterations) also were among the top 10 concepts identified by AMSN nurses. It should be noted that due to two sets of identically ranked scores on several concepts for AMSN nurses, 11 concepts were included among the AMSN rankings. Overall, AMSN nurses scored these top concepts at a higher depth than ONS nurses. Significant differences in depth ratings between both nurse groups were noted on four concepts: diagnosis of cancer (p = .036), cancer surgery (p = .00), radiation (p = .026), and oncologic emergencies (p = .011). AMSN nurses rated these concepts at a higher depth; also, oncologic emergencies was listed as the third top concept.
Top 10 Cancer Concepts Listed by Mean Depth and Importance for the ONS (N = 302) and AMSN (N = 313) Groups
Similarly, when the 33 cancer concepts were organized by their mean importance scores by nurse group (Table 2), all of the top 10 concepts rated by the ONS nurses were among those rated by AMSN nurses, with the exception of one concept (ventilation and pulmonary alterations) rated as third by AMSN nurses. It should be noted that due to three sets of identically ranked scores on several concepts for AMSN nurses, 11 concepts were included among the AMSN top 10 list. Generally, AMSN nurses scored these concepts at a higher importance level than ONS nurses.
Significant differences in importance scores between both nurse groups were noted on eight concepts: development of cancer (p = .012), cancer biology (p = .012), cancer statistics (p = .037), cancer surgery (p = .003), chemotherapy (p = .03), radiation (p = .015), major cancers (p = .024), and oncologic emergencies (p = .004). AMSN nurses rated all of these concepts at a higher importance except for two (chemotherapy and oncologic emergencies) that ONS nurses rated at a higher depth. None of these concepts were among the top 10 concepts.
Medical–Surgical Nurse Perceived Barriers
A total of 266 (80.6%) AMSN nurses responded yes to the question, “Do you think that medical–surgical nurses encounter any barriers when caring for cancer survivors admitted to non-oncology clinical settings?” The barriers cited by the nurses included a lack of time to learn about the needs of oncology survivors (72%), knowledge regarding survivor needs (72%), teaching resources (55%), access to nursing education materials (55%) or where to access such materials (49%), and access to an oncology nurse expert (50%). Some respondents thought that oncology education and resources were not a priority in the medical–surgical unit (41%) and cited costs associated with nursing continuing education (35%) and patient education resources (21%).
Study results inform the understanding of potential gaps in knowledge related to providing optimal cancer survivor care by non-oncology nurses from the perspective of nurses practicing in oncology and medical–surgical settings. Mean depth scores suggested AMSN nurses believed they should have greater depth of knowledge of cancer survivor care than ONS nurses believed the AMSN nurses needed; both nurse groups believed cancer content was moderately important in their patient care.
Interestingly, when cancer concepts were categorized by the top 10 mean depth and importance scores and compared by each nurse group, the results were similar. Most of the top 10 concepts were among the 16 “cancer symptoms and problems” category on the CNCS, except for the depth of two concepts (access devices, and prevention and detection) and importance (access devices and end of life). Significant differences were noted between nurse groups on 10 lower ranked concepts based on their depth (n = 4) and importance (n = 6).
These findings can help educators define and prioritize specific content areas in which non-oncology nurses may require further professional development to build on their prior understanding of symptom management care from an oncology clinical context. Identification of differences in rankings between the two groups pinpoints targeted areas for staff development.
Although AMSN nurses in this study were experienced RNs with an average of more than 10 years of experience, more than 70% reported lack of knowledge regarding survivor needs as a barrier to the provision of optimal cancer survivor care. The most frequently reported barriers to providing optimal care to cancer survivors in non-oncology settings noted by AMSN nurses in this study were strikingly similar to barriers reported by nurse faculty who rated the depth and importance of cancer concepts taught in prelicensure RN programs (Lockhart et al., 2013). Although educators indicated that teaching oncology-related content was important, similar barriers impacted their ability to present content in sufficient depth; these barriers included lack of time, knowledge, and access to survivor-specific resources.
Unfortunately, lack of knowledge regarding the health, medical, and other needs and issues of cancer survivors is not limited to non-oncology providers. Lack of knowledge also has been cited by clinicians many would expect to be the most knowledgeable regarding those needs—oncology nurses and oncologists (Dulko et al., 2013; Gage et al., 2011; Shayne, Culakova, Milano, Dhakal, & Constine, 2014). Other barriers to survivorship care reported in the literature include lack of standards of practice for long-time cancer survivor care, lack of payment or reimbursement for providing this type of care, and difficulty accessing survivor information from multiple providers in multiple settings in an electronic health record and protected health information environment (Buriak, Potter, & Bleckley, 2015).
Several efforts have been undertaken to provide professional development and continuing education to health care providers and administrators related to survivor issues. Grant, Economou, Ferrell, and Uman (2015) reported on the success of a National Cancer Institute project that provided multiyear, multidisciplinary courses focused on improving the quality of life of cancer survivors targeted to competitively selected teams of professionals (e.g., physician, nurse, administrator, and social worker) from cancer settings across the United States. However, this program focused exclusively on the improvement of survivor care in oncology settings.
Finally, subsequent to the release of the Lockhart et al. (2013) oncology nursing curriculum study and in an attempt to address and mitigate barriers identified by nurse educators in accessing oncology-specific experts and resources, the ONS developed and implemented the Educator Resource Center (ERC). The ERC provided access to updated, evidence-based oncology nursing-specific resources to facilitate the incorporation of oncology nursing content into prelicensure and graduate nursing education, as well as for staff development.
Study limitations include the self-report nature of the survey method, as nurses who chose not to respond may possess different opinions than respondents. AMSN nurses who worked more frequently with cancer survivors or who had a personal interest in oncology may have been more likely to respond. Most participants were experienced RNs certified in their respective specialties. Novice nurses may have rated the depth and importance of the cancer concepts differently. The CNCS did not assess the nurses' previous experience, education, or personal contact with cancer, factors which could have affected the results. Finally, for the purposes of this study, AMSN nurses were used as surrogates to represent non-oncology nurses. Therefore, generalizability of study results to other areas of nursing, such as emergency nursing where cancer patients and survivors are likely to access and receive care, are limited.
To date, no nursing organization in the United States has defined expectations, skills, and competencies for nurses caring for cancer survivors in non-oncology clinical settings, nor is there a consensus on the core knowledge required by these nurses expected to assume an increasing role in the care of cancer survivors. Also lacking are comprehensive, easily accessible resources targeted specifically to the identified knowledge gaps of non-oncology nurses developed to meet the myriad needs of the ever-growing numbers of cancer survivors. This study gained the perspectives of both oncology and medical–surgical nurses about the cancer content medical–surgical nurses should know when caring for cancer survivors. A logical next step involves collaborating with the AMSN and ONS to design continuing education and staff development activities based on this evidence. Future research is needed to identify the educational needs of other nurse groups to develop general standards of cancer care for non-oncology nurses.
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Demographics of the ONS and AMSN Groups
|Characteristic||ONS Group||AMSN Group|
|Gender (n = 299; n = 313)|
|Age, years (n = 299; n = 313)|
| 20 to 29||3||30|
| 30 to 39||35||65|
| 40 to 49||59||70|
| 50 to 59||146||111|
| 60 to 69||55||37|
|Education (n = 302; n = 309)|
| Associate degree in nursing||64||52|
| Other associate degree||1||1|
| Baccalaureate degree in nursing||109||144|
| Other baccalaureate degree||16||13|
| Master of science in nursing||67||66|
| Other master's degree||13||13|
| Doctoral degree in nursing||8||4|
| Other doctoral degree||0||2|
|Nursing experience (n = 302; n = 313)|
| 0 to 5 years||0||59|
| 6 to 10 years||37||54|
| More than 10 years||265||200|
Top 10 Cancer Concepts Listed by Mean Depth and Importance for the ONS (N = 302) and AMSN (N = 313) Groups
|Depth of Cancer Concept||Importance of Cancer Concept|
|ONS Rank (Mean)||Concept||AMSN Rank (Mean)||Difference||ONS Rank (Mean)||Concept||AMSN Rank (Mean)||Difference|
|1 (4.43)||Infection and sepsis||1 (4.55)||1 (4.31)||Infection and sepsis||1a (4.47)|
|2 (4.27)||Cancer pain||2 (4.48)||Rated 3 oncology emergencies (4.24)||2 (4.28)||Cancer pain||1a (4.47)|
|3 (4.12)||Access devices||4 (4.23)||3 (4.05)||Nutritional alterations||3 (4.05)||Rated 4.5 pulmonary alterations (4.15)|
|4 (4.06)||Circulatory alterations||7 (4.15)||4 (4.04)||Access devices||6.5 (4.15)|
|5 (4.04)||Pulmonary alterations||5 (4.21)||5 (4.01)||Circulatory alterations||5 (4.14)|
|6 (3.98)||Prevention and detection||8.5 (4.09)||Rated 8.5 psychological support (4.09)||6b (3.98)||Prevention and detection||6.5 (4.13)|
|7 (3.97)||Neurologic alterations||9.5 (4.08)||6b (3.98)||Advanced care/end of life||9.5 (4.1)|
|8 (3.96)||Nutritional alterations||6 (4.18)||6b (3.98)||Skin/musculoskeletal alterations||7c (4.12)|
|9 (3.95)||Skin/musculoskeletal alterations||Not among top 10||9 (3.96)||Neurological alterations||7 c (4.12)|
|10 (3.94)||Advanced care/end of life||9.5 (4.08)||10 (3.94)||Elimination alterations||9.5 (4.06)|