Chapter 70Principles of Oncology Nursing

Johnson M, Yarbro CH.

Any text on cancer medicine would be incomplete without a discussion of oncology nursing. Cancer management is a multi-disciplinary endeavor, and understanding the principles of oncology nursing is fundamental to the effective practice of all other oncologic subspecialties.

Oncology nurses are engaged in a collaborative practice with all members of the care team to provide optimal management of patients with cancer. Their professional practice requires detailed knowledge of the biologic and psychosocial dimensions of the cancer problem. They have key roles not only as caregivers but in patient and family education and clinical cancer research. Cancer nurses also are continuously involved in the enhancement of nursing practice through research, continuing education, and advanced education.

Oncology Nursing as a Specialty

Historically, nurses have had 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 National Cancer Act of 1971. However, the expanded research and treatment program against cancer that has occurred during the past quarter century has been a catalyst for the development of oncology nursing as a separate specialty.1–4 The recognition of cancer as a major national health problem was key to formally establishing the specialty of oncology nursing. This increased attention to cancer coincided with and complemented a major new emphasis in the nursing profession toward expanded roles in comprehensive patient care. Many oncology nurses first worked both as nurses and data managers for cancer research studies. As oncology called for increasingly more complex therapy, the collaborative relationship between nurse and physician became the best way to provide uniquely comprehensive patient care.5–7

The Oncology Nursing Society (ONS) was established by a small group of nurses working primarily in research settings with medical oncologists involved in clinical research.4,8 Their initial goals were to provide a forum for discussing practice issues in cancer nursing and to develop mechanisms for nurses to contribute to this new and evolving specialty area. There was a need to promote the advanced practice of oncology nurses in different care settings and develop national as well as local networking and continuing education programs. Research in cancer nursing subsequently became a high priority of the ONS. The success of this national organization has contributed to the recognition of oncology nursing as a valued specialty.

Today, the ONS has a membership of over 28,000 and 209 chapters across the United States. The majority of members (68%) provide direct patient care.9 Educational conferences, publications, legislative activities, and research initiatives are just a few of the concentrated areas of effort. The ONS Foundation, which was established in 1981, awarded almost a million dollars in research grants, scholarships, and awards in 1998 alone.

The ONS and the American Nurses’ Association have developed Professional Practice Standards (Table 70.1),10–12 and the ONS has developed Advanced Practice Standards (Table 70.2).13 These standards serve as a definition of the highest quality of oncology nursing practice.

Table 70.1. Professional Standards of Oncology Nursing Practice.

Table 70.1

Professional Standards of Oncology Nursing Practice.

Table 70.2. Professional Advanced Practice Standards.

Table 70.2

Professional Advanced Practice Standards.

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.

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 texts16–23 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.

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

Role of the Oncology Nurse

Oncology nurses practice in a variety of settings including acute-care hospitals, ambulatory-care clinics, private oncologists’ offices, radiation therapy facilities, home health-care agencies, and community agencies. They practice in association with a number of oncologic disciplines: surgical oncology, radiation oncology, gynecologic oncology, pediatric oncology, and medical oncology. The majority of ONS members are involved in direct patient care, with 44% working in a hospital/multi-hospital system, 21% in the outpatient/ambulatory-care setting, 9% in physician offices, and 5% in hospice or home care.9 Positions in the outpatient and home care setting have increased as more patients are being treated out of the hospital setting.21,28 The roles of the oncology nurses vary from the intensive care focus of bone marrow transplantation to the community focus of cancer screening, detection, and prevention. The advanced practice of oncology nursing includes participation as principal investigators in nursing research studies, serving as patient-care consultants, designing educational curricula, and performing executive functions. In all these roles, there is emphasis on providing nursing care to patients and families by efficient use of the nursing process, including assessment and data collection, nursing diagnosis, planning, intervention, and evaluation. This process permits an organized and systematic approach to nursing care.

The following discussion on the role of the oncology nurse focuses on patient assessment, patient education, and coordination of care. This is followed by a specific discussion on nursing care related to surgery, radiation therapy, chemotherapy, biotherapy, and supportive care.

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.

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.

Nursing Care Related to Specific Cancer Therapies

Nursing care of patients receiving surgery, radiotherapy, chemotherapy, or biologic therapy, alone and in combination, begins with physical and psychological preparation. The oncology nurse reviews the treatment plan with the oncologist, is aware of expected outcomes and possible complications, and independently assesses the patient’s general physical and emotional status.

Assessment of the patient’s understanding of the disease and proposed treatment is fundamental in allaying anxiety and formulating a care plan. Obtaining this information will help avoid misunderstanding and confused expectations. Possible side effects of treatment as well as recommendations to prevent or minimize these effects should be explained. Thorough patient preparation improves compliance with treatment programs and may impact treatment outcomes as well.

A nursing care plan is developed in response to the particular needs identified from the assessment.38 At a minimum, this plan will promote (1) the patient’s understanding of therapy goals, treatment schedules, and possible side effects of therapy; (2) physical and psychological preparation for therapy; (3) physical and psychological comfort; and (4) compliance. Patient and family education starts before therapy and continues during and after therapy. Reinforcement helps ensure success. Appropriate written and visual teaching aids may be utilized as well as referrals to other professionals or community programs, such as cancer support groups.

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.

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.

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.

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.

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.

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.

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

Supportive Care

Oncology nurses are closely involved with numerous supportive care issues encountered by cancer patients and their family. This chapter does not allow a detailed discussion of the numerous areas of supportive and palliative care, but two areas deserve special mention, that is, the involvement of nurses in pain management and in survivorship.

Because nurses spend more time with a patient who is experiencing pain than do any other health professional, it is of utmost importance that the nurse be knowledgeable about pain assessment and both pharmacologic and nonpharmacologic management of pain, in order to provide good pain control as well as patient and family education.75,76 However, barriers to providing effective pain control have not eluded the nursing profession. The major problems are misconceptions and fears about addiction, drug tolerance, sedation, and respiratory depression; lack of knowledge about pain assessment and analgesics; and undertreatment with analgesics.77 This is understandable when one considers the minimal time that is devoted to pain control in traditional undergraduate nursing curricula. Fortunately, these problems are now being addressed, and the education programs and resources available have improved considerably. State cancer pain initiatives, guidelines, and organizational position statements have been excellent efforts toward improving pain management. The ONS developed a position paper on cancer pain that delineated the scope of practice for nurses with different levels of expertise.78 Even the Joint Commission for Accreditation for Healthcare Organizations has recognized the problem of inadequate pain management and changed their standards of care to emphasize appropriate management.79

Nursing care should be planned to promote patient comfort, provide patients and their families with information related to pain control, provide information about and assistance with behavioral and physical interventions, prevent and alleviate side effects of pharmacologic therapies, and promote patient compliance with therapy and required follow-up. The nurse should explain the rationale of interventions and provide time for patient and family questions. Patient education should include the names of the pharmacologic agents, dosage schedules, side effects, interventions to alleviate nausea and vomiting, such as antiemetics, and interventions to alleviate constipation. The nurse should monitor the effectiveness and side effects of pharmacologic interventions, respiratory status, bowel functioning, as well as mental and cognitive functioning. The patient and family must know how to contact medical personnel in case of an emergency and should feel free to do so.

Survivorship

Over 50% of individuals who are diagnosed with invasive cancer will live beyond 5 years, and most will be considered cured. Thus, issues of survivorship and living with the effects of cancer and its treatment are a significant concern. This is evidenced by the emphasis on rehabilitation. The ONS was the first professional group to provide a practical definition of cancer rehabilitation as a “process by which individuals within their environments are assisted to achieve optimal functioning within the limits imposed by cancer.”80

The National Coalition of Cancer Survivors and the American Cancer Society have brought survivorship issues to the public and are promoting rehabilitation as the first phase in preparing cancer survivors to lead fulfilling lives.81 Bushkin,82 a cancer nurse who died of cancer in 1993, said “surviving a chronic illness is a hard fight.” She also provided insight and understanding into the process of being a cancer survivor through her teaching, caring, and conceptualization of the process of survival, best expressed in her lecture entitled “Signposts of Survivorship.”82 She provided, by word and example, a mechanism to combine the challenges of life into a cohesive plan for living.

Summary

The progress of professional oncology nursing parallels the progress made in the surgical, radiologic, and medical approaches to the treatment of cancer. The oncology nurse has become an integral component of the cancer-care team. Oncology nurses have earned the respect of physicians, other health-care professionals, and, most importantly, of patients and their families. Oncology nursing will continue to develop as a dynamic element within the health-care delivery process as the number of these nurses increases and their levels of knowledge, experience, and expertise advance.

References

1.
Henke C. Emerging roles of the nurse in oncology. Semin Oncol. 1980;7:4–8. [PubMed: 7367896]
2.
Hilkemeyer R. A historical perspective in cancer nursing. Oncol Nurs Forum. 1985;12(1 Suppl):6–15. [PubMed: 3844257]
3.
Hubbard S M, Donehower M G. The nurse in a cancer research setting. Semin Oncol. 1980;7:9–17. [PubMed: 7367902]
4.
Yarbro CH. The history of cancer nursing. In: Cancer nursing, 2nd ed. McCorkle R, Grant M, Frank-Stromborg M, Baird SB, editors. Philadelphia, PA: WB Saunders; 1996. p. 12–24.
5.
Baird S B. Nursing roles in continuing care: home care and hospice. Semin Oncol. 1980;7:28–38. [PubMed: 7367894]
6.
Hilderley L J. The role of the nurse in radiation oncology. Semin Oncol. 1980;7:39–47. [PubMed: 7367895]
7.
Thaney K M. The nurse in a community hospital setting. Semin Oncol. 1980;7:18–27. [PubMed: 7367893]
8.
Yarbro C H. ONS the early days: four smiles and a post office box. Oncol Nurs Forum. 1984;11:79–85. [PubMed: 6558687]
9.
Oncology Nursing Society. Demographics report, as of July 1, 1999. Pittsburgh, PA: Oncology Nursing Society; 1999.
10.
American Nurses Association and the Oncology Nursing Society. Standards of Oncology Nursing Practice. Washington, DC: American Nurses Association; 1987.
11.
Oncology Nursing Society and American Nurses Association Division of Medical Surgical Nursing Practice. Outcome Standards for Cancer Nursing Practice. Kansas City, MO: American Nurses Association; 1989.
12.
American Nurses Association and the Oncology Nursing. Statement on the Scope and Standards of Oncology Nursing Practice. Washington DC: American Nurses Publishing; 1996 .
13.
Oncology Nursing Society. Standards of Advanced Practice in Oncology Nursing. Pittsburgh, PA: Oncology Nursing Press; 1990.
14.
McMillan S C, Heusinkveld K B, Spray J A, Murphy C M. Revising the blueprint for the AOCN examination using a role delineation study for advanced practice oncology nursing. Oncol Nurs Forum. 1999;26:529–537. [PubMed: 10214595]
15.
Oncology Nursing Certification Corporation. 2000 certification bulletin. Pittsburgh, PA: ONCC; 1999.
16.
Itano JK, Taoka K, editors. Core curriculum for oncology nursing, 3rd ed. Philadelphia: WB Saunders; 1998.
17.
Yarbro CH, Frogge MH, Goodman M, editors. Cancer nursing: principles and practice, 5th ed. Boston, MA: Jones and Bartlett; 2000.
18.
Yarbro CH, Frogge MH, Goodman M, editors. Cancer symptom management, 2nd ed. Boston, MA: Jones and Bartlett; 1999.
19.
Gross J, Johnson BL, editors. Handbook of oncology nursing, 2nd ed. Boston, MA: Jones and Bartlett; 1994.
20.
Dow KH, Hilderley LJ, editors. Nursing care in radiation oncology. Philadelphia, PA: WB Saunders; 1992.
21.
Buchsel PC, Yarbro CH, editors. Oncology nursing in the ambulatory setting. Boston, MA: Jones and Bartlett; 1993.
22.
McCorkle R, Grant M, Frank-Stromborg M, Baird SB, editors. Cancer nursing, 2nd ed. Philadelphia, PA: WB Saunders; 1996,
23.
McNally JC, Somerville ET, Miaskowski C, Rostad M, editors. Guidelines for oncology nursing practice, 2nd ed. Philadelphia, PA: WB Saunders; 1991.
24.
McGuire D B, Ropka M E. Research and oncology nursing practice. Semin Oncol Nurs. 2000;16:35–46. [PubMed: 10701239]
25.
Stetz K M, Haberman M R, Holcombe J, Jones L S. 1994 Oncology Nursing Society Research Priorities Survey. Oncol Nurs Forum. 1995;22:785–789. [PubMed: 7675685]
26.
Haberman M. The measurement of symptom distress. In: Cancer symptom management, 2nd ed. Yarbro CH, Frogge MH, Goodman M, editors. Boston, MA: Jones and Bartlett; 1999. p. 10–19.
27.
Haberman M. Advancing cancer nursing through nursing research. In: Cancer nursing: principles and practice, 5th ed. Yarbro CH, Frogge MH, Goodman M, editors. Boston MA: Jones and Bartlett; 2000. p. 1728–1740.
28.
Linn E M, Martin V R. Ambulatory cancer care. Semin Oncol Nurs. 1994;10:227–305.
29.
Johnson J L, Blumberg B D. A commentary on cancer patient education. Health Educ Q. 1984;10(Suppl):7–18. [PubMed: 6706618]
30.
Padberg RM, Padberg LF. Patient education and support. In: Cancer nursing: principles and practice, 5th ed. Yarbro CH, Frogge MH, Goodman M, editors. Boston, MA: Jones and Bartlett; 2000. p. 1609–1631.
31.
Oncology Nursing Society. Standards on oncology education: patient/family and public. Pittsburgh, PA: Oncology Nursing Press; 1989.
32.
Dodd MJ. Managing the side effects of chemotherapy and radiation therapy: a guide for patients and nurses, 3rd ed. San Francisco, CA: UCSF Press; 1996.
33.
National Cancer Institute. Chemotherapy and you: a guide to self help during treatment. NIH Publication A92–1136. Bethesda, MD: U.S. Department of Health and Human Services; 1991.
34.
Stevenson E, Crosson K. Patient education: history, development, and current directions of the American Cancer Society and National Cancer Institute. Semin Oncol Nurs. 1991;7:135–142. [PubMed: 1882152]
35.
Public Health Service, National Institutes of Health. Eating hints, recipes and tips for better nutrition during cancer treatment. NIH Publication No. 92-2079. Bethesda, MD: U.S. Department of Health and Human Services; 1992.
36.
Public Health Service, National Institutes of Health. Radiation therapy and you: a guide to self-help during treatment. NIH Publication No. 92-2227. Bethesda, MD: U.S. Department of Health and Human Services; 1992.
37.
Camp-Sorrell D. Chemotherapy: toxicity management. In: Cancer nursing: principles and practice, 5th ed. Yarbro CH, Frogge MH, Goodman M, editors. Boston, MA: Jones and Bartlett; 2000. p. 444–486.
38.
Bushkin E. Principles of oncology nursing. In Cancer medicine, 3rd ed. Holland JF, Frei E, Bast RC, et al., editors. 1993. p. 1034–1053.
39.
Ewer M, Ale M K. Surgical treatment of the cancer patient: preoperative assessment and perioperative medical management. J Surg Oncol. 1990;44:185–190. [PubMed: 2196400]
40.
Sladek M L, Swenson K K, Ritz L J, Schroeder L M. A critical pathway for patients undergoing one-day breast cancer surgery. Clin J Oncol Nurs. 1999;3:99–106. [PubMed: 10690040]
41.
Weiland D E. Why use clinical pathways rather than practice guidelines? Am J Surg. 1997;174:592–595. [PubMed: 9409579]
42.
Spencer C M, Goa K L. Amifostine: a review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential as radioprotector and cytotoxic chemoprotector. Drugs. 1995;50:1001–1031. [PubMed: 8612469]
43.
Tannehill S P, Mehta M P, Larson M. et al. Effect of amifostine on toxicities associated with sequential chemotherapy and radiation therapy for unresectable non-small cell lung cancer: results of a phase II trial. J Clin Oncol. 1997;15:2850–2857. [PubMed: 9256128]
44.
Shepard N, Kelvin J F. The nursing role in radiation oncology. Semin Oncol Nurs. 1999;15:237–249. [PubMed: 10588028]
45.
Bruner DW, Iwamoto R. Altered sexual health. In: Cancer symptom management, 2nd ed. Yarbro CH, Frogge MH, Goodman M, editors. Boston, MA: Jones and Bartlett; 1999. p. 523–551.
46.
Kelvin JF. Gastrointestinal cancers. In: nursing care in radiation oncology, 2nd ed. Dow KH, Bucholtz JD, Iwamoto R, et al., editors. Philadelphia, PA: Saunders; 1997. p. 152–183.
47.
Oncology Nursing Society. Manual for radiation oncology nursing practice and education. Pittsburgh, PA: Oncology Nursing Press; 1998.
48.
Stewart-Amedei C. Delayed effects of therapeutic brain irradiation. Crit Nurs Clin North Am. 1995;7:124–133. [PubMed: 7766366]
49.
Kelly L D. Nursing assessment and patient management. Semin Oncol Nurs. 1999;15:282–291. [PubMed: 10588032]
50.
Sitton E. Early and late radiation-induced skin alterations. Part II: Nursing care of irradiated skin. Oncol Nurs Forum. 1992;19:907–912. [PubMed: 1635872]
51.
Piper,B. Measuring fatigue. Instruments for clinical health-care research. Frank-Stromberg M, Olsen S, editors. Boston, MA: Jones and Bartlett; 1997. p. 482–496.
52.
Winningham M L, Nail L M, Burke M B. et al. Fatigue and the cancer experience: the state of the knowledge. Oncol Nurs Forum. 1994;21:23–36. [PubMed: 8139999]
53.
Rea E, Richardson A. From theory to practice: designing interventions to reduce fatigue in patients with cancer. Oncol Nurs Forum. 1999;26:1295–1303. [PubMed: 10497769]
54.
Griffin A, Butow P, Coates A. et al. On the receiving end. Part V: Patient perceptions of the side effects of chemotherapy. Ann Oncol. 1996;7:189–195. [PubMed: 8777177]
55.
Tennebaum L, editor. Cancer Chemotherapy and Biotherapy, 2nd ed. Philadelphia, PA: WB Saunders; 1994.
56.
Yarbro CH. Nursing implications in the administration of cancer chemotherapy. In: The chemotherapy source book. Perry MC, editor. Baltimore, MD: Williams and Wilkins; 1991. p. 873–883.
57.
Oncology Nursing Society. Cancer chemotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Press; 1999.
58.
Schulmeister L. Chemotherapy medication errors: descriptions, severity, and contributing factors. Oncol Nurs Forum. 1999;26:1033–1042. [PubMed: 10420421]
59.
Cohen M R, Anderson R W, Attilio R M. et al. Preventing medication errors in cancer chemotherapy. Am J Health Syst Pharm. 1996;53:737–746. [PubMed: 8697025]
60.
Olsen M. Order sheets help prevent chemotherapy administration errors. Oncol Nurs Forum. 1997;24:802–803. [PubMed: 9244865]
61.
Rogers B B. Preventing and detecting cancer chemotherapy drug errors. Oncol Nurs Updates. 1999;6:1–12.
62.
Engelking C. Cancer treatment-related diarrhea: challenges and barriers to clinical practice. Oncol Nurs Updates. 1998;5:1–16.
63.
Curtiss CP. Constipation. In: Cancer symptom management, 2nd ed. Yarbro CH, Frogge MH, Goodman M, editors. Boston MA: Jones and Bartlett; 1999. p. 508–522.
64.
Wujcik D. Infection. In: Cancer symptom management, 2nd ed. Yarbro CH, Frogge MH, Goodman M, editors. Boston, MA: Jones and Bartlett; 1999. p. 307–327.
65.
Wilkes J D. Prevention and treatment of oral mucositis following chemotherapy. Semin Oncol. 1998;25:538–551. [PubMed: 9783593]
66.
Perry MC, Yarbro JW. Complications of chemotherapy: an overview. In: Toxicity of chemotherapy. Perry MC, Yarbro JW, editors. Orlando, FL: Grune & Stratton; 1984. 1–19.
67.
Cotanch P. Relaxation training for control of nausea and vomiting in patients receiving chemotherapy. Cancer Nurs. 1983;6:277–283. [PubMed: 6349791]
68.
Lindley C, Hirsch J, Oneill C. et al. Quality of life consequences of chemotherapy-induced emesis. Qual Life Res. 1992;1:331–340. [PubMed: 1299465]
69.
Rhodes V A, McDaniel R W. The index of nausea, vomiting, and retching: a new format of the index of nausea and vomiting. Oncol Nurs Forum. 1999;26:889–894. [PubMed: 10382187]
70.
Nolte M J, Berkery R, Pizzo B. et al. Assuring the optimal use of serotonin antagonist antiemetics: the process for development and implementation of institutional antiemetic guidelines at Memorial Sloan-Kettering Cancer Center. J Clin Oncol. 1998;16:771–778. [PubMed: 9469369]
71.
Oncology Nursing Society. Biological response modifier guidelines. Pittsburgh, PA: Oncology Nursing Press; 1989.
72.
Reiger PT. Biotherapy: a comprehensive overview. Boston, MA: Jones and Bartlett; 1995.
73.
Reiger PT. Clinical handbook for biotherapy. Boston, MA: Jones and Bartlett; 1999.
74.
Shelton BK, Turnbough L. Flu-like syndrome. In: Cancer symptom management, 2nd ed. Yarbro CH, Frogge MH, Goodman M, editors. Boston, MA: Jones and Bartlett; 1999. p. 77–94.
75.
Coyle N, Cherny N, Portenoy RK. Pharmacologic management of cancer pain. In: Cancer pain management, 2nd ed. McGuire DB, Yarbro CH, Ferrell BR, editors. Boston, MA: Jones and Bartlett; 1995. p. 89–130.
76.
Spross JA, Burke MW. Nonpharmacological management of cancer pain. In: Cancer pain management, 2nd ed. McGuire DB, Yarbro CH, Ferrell BR, editors. Boston, MA: Jones and Bartlett; 1995. p. 159–206.
77.
Yeager, K, McGuire DB, Sheidler VR. Assessment of cancer pain. In: Cancer nursing: principles and practice, 5th ed. Yarbro CH, Frogge MH, Goodman M, editors. Boston, MA: Jones and Bartlett; 2000. p. 633–656.
78.
Spross J, McGuire DB, Schmitt R. Oncology Nursing Society: position paper on cancer pain. Pittsburgh, PA: Oncology Nursing Press; 1991.
79.
Joint Commission on Accreditation of Healthcare Organizations. Accreditation manual for hospitals. Oak Brook Terrace, IL: JCAHO; 1993.
80.
Mayer D, O’Connor L. Rehabilitation of persons with cancer: an ONS position statement. Oncol Nurs Forum. 1989;16:433. [PubMed: 2734228]
81.
Watson P G. Cancer rehabilitation: an overview. Semin Oncol Nurs. 1992;8:167–173. [PubMed: 1523364]
82.
Bushkin E. Signposts for survivorship: a universal travel guide. Oncol Nurs Forum. 1993;20:869–875. [PubMed: 7690128]