Nursing, as an integral part of the health care system, encompasses the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages, in all health care and other community settings. Within this broad spectrum of health care, the phenomena of particular concern to nurses are individual, family, and group responses to actual or potential health problems. These human responses range broadly from health restoring reactions to an episode of illness to the development of policy in promoting the long-term health of a population (International Council of Nurses, 1999, p. i).
Nursing knowledge is derived from biological, social, behavioral and physical sciences. Knowledge is advanced through research findings and the integration of theoretical models applied to nursing practice. Research and utilization of the nursing process support clinical decision-making. Nursing interventions and interactions are directed at influencing a change in health status and quality of life. Nurses develop the ability to deliver therapeutic nursing interventions through formalized education combined with guided clinical experience (Buchanan, 1994).
Nurses are prepared at a variety of educational levels:
· masters, and
· doctoral degrees.
However, it is essential to understand that preparation at the diploma and baccalaureate degree level is basic and general, and does not make nurses expert in cancer care. Additional educational preparation must be provided to support nurses to gain enhanced knowledge and clinical expertise to provide the specialized care required by people with cancer and their families (Given, 1980). Students in their basic education program have limited exposure to the cancer field, and the quality and amount of oncology content is dependent on whether there are faculty with background and interest in cancer care (Mooney, 2000).
Oncology nursing education has focused on the knowledge and practice of providing care to cancer patients. In-service education or certificate courses at a community college level over and above that acquired in basic nursing education may deliver the knowledge. Cancer organizations have focused attention on developing nurses to administer chemotherapy, work in clinical trials, deliver care to patients receiving radiation treatment, and acquire specialized skills (e.g. central line management). Some organizations have developed formal educational processes to support nurses in working with cancer patients within major tertiary centers and in communities. Analysis of the current situation reveals the role that continuing education has played in supporting oncology practice, but there are significant limitations in the breadth of role preparation and programs in oncology nursing.
One university has undertaken to design a curriculum of courses for nurses in Pediatric Oncology and Adult Oncology. This program consists of 6 courses, earning students 21 credits towards the baccalaureate degree at McMaster or other universities. The courses incorporate the CANO/ACIO Standards of Practice (CANO/ACIO, 1995a), the continuum of cancer care, development of psychosocial and supportive care skills and the application of research and educational principles to practice. This type of program is consistent with the direction that other countries have taken to support specialty education in oncology.
Oncology nursing is specialty practice. Additional knowledge and cognitive and clinical skills must support this practice. Certification (CNA) confirms the acquisition of knowledge applied to clinical practice. The designation of CON(C) is one aspect of the Specialized Oncology Nurse. Continuing education and development in the clinical areas is needed for oncology nurses to grow and enhance their knowledge and practice base. Life-long learning is an element that supports excellence in practice.
The evolving health care system and new technologies require new approaches to oncology nursing education. On-going advances in cancer and nursing research and treatment and care require continual revision of specialty content. There needs to be greater focus on the impact of cancer genetics, risk analysis and prevention, palliative care, long-term survivorship, cancer in the aged, psychosocial counselling and interventions and pediatric oncology nursing. Key to the educational preparation of oncology nurses is the skill in understanding, use and application of an evolving knowledge base. In addition to knowledge application skills, oncology nurses need increasing knowledge and competence in influencing the direction of care.
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Delineating Roles in Oncology Nursing
In 1987, Robert Tiffany published a paper in the International Nursing Review, “The Development of Cancer Nursing as a Specialty”. Tiffany proposed three categories of cancer nurses:
· The Generalist Nurse, who may care for cancer patients within an assigned caseload and is prepared at the basic educational level.
· The Oncology Nurse, who cares for patients in specialist centers or works with cancer patients as a specialized population in hospitals or communities. The Oncology Nurse has undertaken a formal training program and may hold a nationally recognized qualification.
· The Specialist Oncology Nurse, is an expert in one aspect of oncology nursing and is supported by advanced preparation (Tiffany, 1987).
Specialization in nursing is supported in the literature (Cotton, 1997; Melchior-MacDougall, 1992; Dunn et al., 2000). The British Royal College of Nursing (RCN) Cancer Nursing Society (1996) developed a structure for cancer nursing services. The RCN outlined that less than 1% of registered nurses have specialist cancer training and that there is a need for adequately trained nurses not only to provide care, but to lead services in the future (Royal College of Nursing, 1995). It was proposed that specialist nurses successfully complete higher and advanced educational level programs in order to possess in-depth and specific knowledge and skills.
The literature outlined above speaks primarily to care of the adult population. Within the specialty of pediatric oncology, there is support of advanced practice in pediatric oncology settings (Fergusson & Diserens, 1996; Christensen & Akcasu, 1999).
The Oncology Nursing Society (ONS) created a certification process for registered nurses in the U.S. to confirm their knowledge in oncology. By meeting the criteria and successfully completing an examination, nurses can become an Oncology Certified Nurse (OCN). ONS recommends that nurses working with cancer patients achieve this certification, and many employers recognize this certification.
The Oncology Nursing Society furthered their perspective on levels of oncology nursing by publishing the Statement on the Scope and Standards of Advanced Practice in Oncology Nursing (Oncology Nursing Society, 1997a). ONS took the approach of delineating Advanced Practice in Oncology. Several authors have outlined the characteristics, competencies and utilization of advanced practice roles in the U.S. (Lin, 2001) and Canada (Davies & Hughes, 1995; Patterson & Haddad, 1992; Dunn & Nicklin, 1995). The Canadian Nurses Association (CNA) has proposed a framework for advanced nursing practice (Canadian Nurses Association, 1999a).
The CANO/ACIO worked in concert with the Canadian Nurses Association (CNA) to develop oncology as a specialty practice within nursing. CANO/ACIO nurses developed competencies that created the blueprint for the certification examination. In the late 1990's, nurses across Canada began to seek certification by meeting criteria to apply to write a national examination. Nurses who are successful in this process hold the designation of CON(C), Certified in Oncology Nursing (Canada).
Based on existing models from other countries and the supporting literature from within and external to Canada, CANO/ACIO believes that there are three nursing roles to support people living with cancer and their families. The role statements that follow are intended to delineate the levels in which nurses practice in cancer care environments. The three roles generalist, specialized oncology and advanced oncology nurse are integral in the cancer system. These statements do not infer a title or job description. Nor are these statements prescriptive in delineating the number of patients or the number of clinical resources required to fulfill a particular role.
Employers, nurses and cancer patients can use these statements to decide on:
· the levels appropriate to the care environment;
· hiring practices; and
· models of care delivery.
As a national professional organization, CANO/ACIO is responsible for delineating the role statements and supporting these with competencies that meet the Standards of Care. The roles are:
1) Generalist Nurse;
2) Specialized Oncology Nurse; and
3) Advanced Oncology Nurse.
The Generalist Nurse is one who has graduated from a diploma or baccalaureate level program. There is strong nursing professional and educational support for entry to practice at the nursing baccalaureate level, and several provinces have amended their entry to practice criteria to require the B.Sc.N./B.N. level. The nursing curriculum prepares the new graduate as a Generalist Nurse, prepared to work in a variety of health care settings, such as acute or chronic care, community or primary health, or long-term care. The nurse brings to the care setting the knowledge, skills and problem-solving ability to manage care for individuals appropriately.
The Generalist Nurse may work in settings where people with cancer receive care along with other patient populations, such as an Emergency unit, surgical unit or community. Nurses working in hospital settings are encouraged to be medical-surgical generalists, providing care to a variety of patients. The Generalist Nurse may also be one who is new to the knowledge and skills in cancer care working, in a setting where individuals with cancer and their families are the prime focus of care. When the nurse is in the setting she/he must spend time to learn the breadth of knowledge and additional skills and critical thinking that are required in cancer care. Thus, even though she/he may have experience in another practice area, when first entering into a setting where the primary focus is cancer care, the nurse is designated as a Generalist Nurse. Once the nurse has acquired additional knowledge, through in-service, continuing education, skill development and practice, and has gained clinical experience in a setting where individuals with cancer and their families are the prime focus of care, she/he may move onto the next level.
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The Specialized Oncology Nurse is one who has a combination of expanded education focused on cancer care and experience, such as two years in a setting where the primary focus is cancer care delivery. The Specialized Oncology Nurse might acquire specialty education through a variety of ways; for example, enrolment in an undergraduate nursing program, completion of an Oncology Certificate Program, distance specialty education (such as offered in Adult and Pediatric Oncology Nursing); or registration in and completion of the certification exam offered by the Canadian Nurses Association and attainment of the distinction CON(C).
The Specialized Oncology Nurse is one who works in a specialized inpatient setting, such as an oncology unit, or bone marrow transplant unit, or in an ambulatory setting where focused on the delivery of cancer care, or in a screening program, or in a supportive care setting, or community setting offering palliative care. There are many environments where the enhanced specialty knowledge and skill can be utilized to manage symptoms and side-effects of treatment, counsel patients in coping strategies, teach self-care behaviours, and monitor the responses to treatment and nursing interventions.
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The Advanced Oncology Nurse is prepared at the Master’s level (M.Sc.N. or equivalent). Ideally, the graduate program would be focused in oncology nursing, likely with a particular emphasis on a sub-population or area within cancer control, such as prevention, screening, and counseling or a theme within cancer care such as coping, psychosocial care and counseling. Theoretical knowledge in nursing and other sciences grounds the nurse in the advanced provision of care to individuals, their families and the communities within which cancer care is given. Additional certification as an Acute Care Nurse Practitioner, or other levels, may be acquired either within the Graduate Program or as a post-graduate course and certification. The domains of the Advanced Oncology Nurse include the following:
· advanced clinical practice;
· scholarly/professional leadership; and
· organizational leadership.
All nurses move along a trajectory from novice to expert, as described by Benner (1984). It is recognized, that, irrespective of whether a Generalist, Specialized Oncology or Advanced Oncology Nurse, each individual nurse will experience this trajectory from novice to expert. The degree of expertise will be influenced by the nurse’s ongoing learning and day-to-day practice experiences.
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