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RATIONALE FOR STANDARDS OF CARE
CANO/ACIO recognizes and respects the knowledge, skill and professional judgement of all health professionals involved in the care of people with cancer and their families. The Standards of Care described in this document presuppose that nurses work within interdisciplinary teams, whose focus is on the immediate and long-term needs and goals of the individual and family.
In determining the practice domains and responsibilities of health professionals and stakeholders interacting with a specialized group of clients/patients, it is important that Standards of Care be stated relevant to the population. Several standard statements are supported by key literature references that validate the content, thinking, and where applicable, evidence for the statement.
Standards of Practice are within the domain of professional regulatory bodies. These regulatory groups define the scope of practice and process and structure within which the discipline can apply knowledge and skill to designated populations of clients.
Stating the Standards of Care relevant to the individual with cancer in Canada encourages professionals to determine their roles relevant to those Standards and subsequently, the competencies required both in providing that care and evaluating its outcome.
Standard 1: Individualized and Holistic Care Individuals with cancer and their family are entitled to care that is individualized, holistic, and responsive to and respectful of individual differences, such as but not limited to, developmental, physical, cultural, spiritual, social, economic, philosophical, political, or gender.
Nurses must assess and collaborate with patients in developing a plan that fits the individual's preferences, beliefs and needs. A major challenge to nurses across the cancer continuum is to provide comprehensive psychological and physiologic assessment of the individual’s response from the point of diagnosis through to treatment and beyond, and to provide effective and holistic intervention when necessary. No two patients deal with the experience of cancer in the same manner. A diagnosis of cancer affects the physical, psychological, social, spiritual, and economic aspects of the person's life. Patients are seeking to be treated as whole persons rather than as a physical illness. People are complex entities and nurses providing care must take into consideration the multiple aspects of each individual, and their personal circumstances. It is this philosophy of care that offers people who are diagnosed with cancer a means to adapt successfully to the psychological and physiological stresses associated with cancer (Dean, 1999; McMullin, 1992).
Standard 2: Family Centered Care Individuals with cancer and their family are entitled to care that is family centered, incorporates growth and the developmental needs of each member, and is respectful of the family’s resources and coping style.
The experience of cancer causes stress and anxiety in both the individual and the family. The expansion of care from the hospital to the community has resulted in increasing complexity of cancer care at home. The goal of care is to initiate, manage, and evaluate the resources necessary to promote the individual’s optimal level of wellness. The family as the unit of care is essential in achieving this goal. Family refers to those closest to the patient in knowledge, care and affection. This includes:
- the biological family;
- the family of acquisition (related by marriage/contract); and
- the family of choice (not related biologically or by marriage/contract) (Canadian Palliative Care Association, 1995).
The acuity level and complex needs of people with cancer require nurses to have a broad knowledge base. Competency in family assessment, teaching, counseling, supervising and coordinating community and family resources is essential to provide effective care. Nurses must be ready to assess, intervene, and monitor the ongoing progress of both patient and family (McEnroe, 1996).
Standard 3: Self-Determination and Decision-Making Individuals with cancer and their family have the right to self-determination*, the right to access information, the right to make decisions about their health-care, and the right to have an advocate, if they are unable or choose not to participate in decision-making.
The experience of cancer puts individuals and families in a position where they have to make important decisions about their health, including decisions about treatment options, type of caregivers who will provide their care, options related to supportive care and advance directives. It is essential that appropriate and accurate information that allows and supports informed decisions is provided. In cases where individuals are unable or choose not to make their own decisions, their chosen or legal advocate should be involved. Individuals with cancer and their families deserve to be cared for by nurses who will advocate on their behalf, supporting their beliefs and opinions and their decisions about their health, illness, and treatment.
Standard 4: Navigating the System Individuals with cancer and their family are entitled to care that is respectful of and responsive to their community of living. A community of living includes home, work, school, circle of friends and family and community in which the individual lives. The individual with cancer and family are entitled to assistance in navigating through cancer and health care systems. Navigation begins when the person first enters the cancer care system, receives treatment and care, and returns to their own community, and re-enters the system at any point along the continuum of care.
The current health care system that provides care to individuals with cancer is complex. Patients and families often report difficulty in obtaining integrated care and community-based services that consider the domains that make up an individual's life:
- religious and social institutions.
Coordinating efforts to provide home care, psychosocial and educational supports, and information to help those who are experiencing the disease can ultimately help them develop effective coping strategies to maximize their healthy functioning. Effective care planning needs to incorporate patient care needs and a focus on the patient's successful reentry into the community (Athlin, Furaker, Jansson, & Norberg, 1993; Chielens & Herrick, 1990; Shegda & McCorkle, 1990; Conkling, 1989).
People with cancer and their families have become the primary providers of ongoing care to themselves, increasing their need for knowledge and skill in self-care. As a result more people are involved in their health care, seeking information on the Internet, participating in support groups, and exploring more options such as nontraditional complementary therapies (Mooney, 2000).
Standard 5: Coordinated, Continuous Care Individuals with cancer and their family are entitled to care that is coordinated among providers and across the continuum of cancer control (prevention, screening, early detection, pre-diagnosis, diagnosis, treatment, survivorship and palliation).
Health care is changing rapidly. There are more options for screening programs, not only in breast screening, and cervical screening, but early detection of prostate cancer, and colorectal cancers. Research continues in early detection and screening for lung cancer. Thus, there are more options for people to know about, to access and to utilize for screening and early detection. Nonetheless, participation in population screening programs is low amongst certain cultural groups (Bottorff, et al. 1999), exacerbating the need for better coordination and public awareness of option.
Patients now spend less time in acute care settings and more time receiving care in an ambulatory care environment. Early discharge from the clinic, hospital or home health agency necessitates effective continuity of care planning in order to assure that patients and families will have their health care needs met after discontinuance of tertiary health care services. Simultaneously, the instability of the disease and responses to specific treatments can mean rapid changes in patient status. Patients and families value the phenomena of:
- proximity and availability;
- 24 hour a day individualized care that meets physical, psychological, social, and spiritual needs;
- care that extends beyond the individual to encompass family (Athlin et al., 1993; Chielens & Herrick, 1990; Shegda & McCorkle, 1990; Conkling, 1989).
Standard 6: Supportive, Therapeutic Relationship Individuals with cancer and their family are entitled to a supportive, knowledgeable, caring and therapeutic relationship with care providers throughout their cancer experience.
Individuals with cancer and their families are entitled to receive care from nurses who are the best at what they do. The exemplary nurse is professional, committed and caring; delivers excellent nursing care in all practice domains; is knowledgeable; has advanced communication skills, and establishes strong therapeutic relationships with clients and peers. Nurses need to maintain the values of health care as characterized by:
- acting on patients' behalf,
- intervening appropriately, and
- providing safe, competent care.
Nurses participate in patients' experiences which have been characterized as, "being there" for patients; and “being with” patients through their illness experience (Perry, 1998; Kendall, 1999; Steeves, Cohen, & Wise, 1994).
Standard 7: Evidence-based Care Individuals with cancer and their families are entitled to care that is based on theory, science (physiologic and psychosocial sciences), and incorporates principles of evidence-based practice, best practice or available evidence.
The experience of cancer is complex, and affects all aspects of individual and family life. The knowledge about cancer, cancer treatments and how individuals and families cope with cancer is expanding rapidly. Patients and families deserve to be cared for by professionals who possess the most up to date knowledge about cancer control and the experience of being treated for cancer. The utilization of evidence-based decision-making is an important element of quality nursing practice (Canadian Nurses Association, 1998). By definition, evidence-based practice requires the synthesis of knowledge from research, retrospective or concurrent reviews of records, quality improvement and risk data, standards of care, cost-effectiveness analysis, benchmarking data, patient preferences and clinical expertise (Goode & Piedalue, 1999).
Nursing exists in a world in which an evidence base for professional practice is required (Donaldson, 1999). Nurses need to apply a broad range of theoretical and empirical knowledge to care for patients and families. Nurses need to use the best available evidence with the intent of making practice better for the patient or client (Estabrooks, 1998). Nurses contribute to evidence-based practice through the generation and dissemination of knowledge. Nurses think critically, identify and solve problems, manage complexity, uncertainty and ambiguity on a daily basis. Critical thinking skills and evidence-based methods for making clinical decisions are essential for maximizing the quality and cost-effectiveness of care (Kessenich, Guyatt, & DiCenso, 1997).
Standard 8: Professional Care Individuals with cancer and their family are entitled to care that is professional and incorporates ethical principles and legislative requirements.
Values guide behaviour and attitude. Nurses’ awareness of their own values and how these values influence behaviour is an essential component of humanistic care (Elfrink & Lutz, 1991). Values are a basic aspect of nursing and are integral to professional socialization, nursing care, and decisions that affect practice. Nurses make practice decisions that have the potential for creating values conflict, and may result in ethical dilemma.
The experience of cancer may involve situations where ethical principles are challenged, such as, in connection with telling the truth, in providing information, in the treatment of pain, and in decision-making concerning treatment. It is imperative that nurses understand the relationship among style of moral reasoning, coping style, and ethics in order to provide moral and ethical care to patients and families (Raines, 2000; Kuuppelomaki & Lauri, 1998).
Standard 9: Leadership Individuals with cancer and their family are entitled to care within a system that has patient-focused, professional leadership.
Health care environments and organizations are becoming increasingly complex. Patients and families may be affected by a complex and possibly impersonal health care environment. The care depends on the resources allocated to health care, including financial and human resources. Patients and families deserve to be cared for in environments that have leaders who will advocate on their behalf.
Strong and effective nurse leaders help to ensure that patients receive care from appropriately educated and trained caregivers, and that resources are allocated in a way that will support and protect their quality of life. Leaders work towards change at the organizational level and at the level of policy-making, in order to facilitate improvement in the system as a whole, and ultimately, improve care at the clinical level.
Visionary leaders set the direction; they guide, facilitate and enable others to meet and exceed their potential and they create an environment that supports professional autonomy within clinical practice, interdisciplinary collaboration and decision-making (Scott, Sochalski, & Aiken, 1999). Leaders must have courage:
- to make tough decisions; and
- to the tackle challenges and turn them into opportunities for success.
Leadership is not about power over, but power with; it is the notion of coaching others to be accountable and responsible for actions in keeping with core values. Nursing leadership at the corporate level drives the vision for patient care; leadership at all levels is essential to implement the vision. Leadership is not inherent in a job title or position; it is within the character of individuals who choose to lead (Green, 1999).
Last Reviewed: Jan 12, 2017