Prepared By: 

Under The Supervision Of :

Professor / Abdullah Hujaily Dr / Muhammed OsmanDr / Nayef Altarawneh

Acknowledgment

To the light, our Professor, who guided us through the way. To Professor / Abdullah

Hujaily, Dr / Muhammed Osman, and Dr / Nayef Altarawneh, for their great efforts of

supervising and leading us, to accomplish this fine work. To my friends and families, they

were a great source of support and encouragement, we thank them all and wish them all the

best in their lives. To m mother and father, for their warm, kind encourage, and love. To

every person gave me something to light our pathway, we thank them for believing in us .

Thank you all…..

II

Table of Contents

Contents Page

Acknowledgement II

Table of Contents III

Abstract IV

The First Chapter: Background and Significance

1.1. Introduction 6

1.2. Research problem 7

1.3. The research questions 9

1.4. The role of oncology nurses 11

The Second Chapter: Literature review

2.1. literature review 18

2.2. Design and method 19

2.3. Discussion 22

2.4. Implications 25

The Third Chapter: The Methodology

3.1. Communication in cancer nursing 33

3.2. Knowledge informing cancer care 36

3.3. The emotional nature of cancer nursing 39

3.4. Discussion 42

3.5. Conclusion 46

References 49

III

Abstract

As cancer is the leading cause of death worldwide, every nurse will be required to

care for patients with the condition at some point in his/her career. However, non-specialized

oncology nurses are often ill-prepared to nurse patients suffering from cancer. This literature

review aims to provide an overview of current trends and developments in cancer care

nursing in an attempt to identify the range of previous research pertaining to caring for

patients with cancer on non-specialist wards. The review finds that non-specialized cancer

nurses report a lack of education and training with regard to cancer care and cancer

treatments, which acts as a barrier to providing quality nursing care. Emotional and

communication issues with patients and their families can also cause non-specialist nurses

significant distress. International research has shown that specialist oncology nurses make a

considerable difference to physical and psychosocial patient care. It is therefore paramount

that non-speciality nurses’ educational needs are met to develop clinical competence and to

provide supportive holistic care for both patients and their families.

Oncology nursing continues to evolve in response to advances in cancer treatment,

information and biotechnology. As new scientific and technological discoveries are

integrated into cancer care, oncology nurses need to play a key role in the management of this

patient population. The role of the oncology nurse has expanded significantly and can differ

greatly across cultures. Sophisticated treatments and the growth of targeted therapies will

create the challenge of ensuring that all nurses working in this arena are well-educated,

IV

independent thinkers. Thus the future success of oncology nurses will focus on enhancement

of nursing practice through advanced education. The increased globalization of healthcare

offers exciting opportunities to accomplish this goal by allowing for collaborative

relationships among oncology nurses across the globe.

V

The First Chapter:

Background and Significance

1.1. Introduction

According to Arnold & Boggs (1995) and Balzer-Riley (1996), communication is a

reciprocal process of sending and receiving messages using a mixture of verbal and

nonverbal communication skills. However, Sheppard (1993) suggests that, in the nurse–

patient relationship, communication involves more than the transmission of information; it

also involves transmitting feelings, recognizing these feelings and letting the patient know

that their feelings have been recognized. Peplau (1988), Severston (1990), Fosbinder (1994),

Wilkinson (1999), Attree (2001) and Thorsteinsson (2002) support this view and indicate that

communication is a fundamental part of nursing and that the development of a positive

nurse–patient relationship is essential for the delivery of quality nursing care. However,

Crotty (1985), Reid (1985) and Hodges et al. (1986) also highlight that nurses do not

communicate well with patients and approach patients only to deal with administrative or

functional activities. Morse (1991), Bergen (1992), Haggman- Laitila & Astedt-Kurki (1994),

Jarman (1995), Hostutler et al. (1999) and Jarrett & Payne (2000) suggest that this is because

nurses are not aware of the meaning and significance of the nurse–patient relationship for

patients. This lack of awareness by nurses results in them making assumptions about what

nursing care a patient needs or wants because they do not ask patients (Bergen, 1992; Booth

et al., 1996). This type of communication is not patient-centered and can adversely affect the

development of a positive nurse–patient relationship that is essential for the provision of

quality patient care. Patient-centred communication is defined by Langewitz et al. (1998, p.

230) as ‘communication that invites and encourages the patient to participate and negotiate in

decision-making regarding their own care’.

7

1.2. Research Problem

This paper is about to depict the factors that have influences on nurses while communicating

with cancer- patients, and the factors that manage this relation and communication process.

cancer is a significant cause of morbidity and mortality worldwide (World Health

Organization (WHO), 2009), and every nurse will, at some stage of their career, care for a

patient diagnosed with cancer (Kendall, 2007). Nurses are challenged with meeting the needs

of patients and their families through all stages of the cancer trajectory; from diagnosis,

through treatment, potential recurrence, survivorship or possible death (Wilkinson, 1999).

The nursing care of patients with cancer has been described as stressful, challenging and

emotionally demanding (Corner, 2002), requiring advanced communication skills,

counselling skills and specialist theoretical and practical knowledge. Oncology patients and

their families’ physical and psychosocial needs are generally not being met in non-specialist

clinical settings.The scope of professional nursing practice has evolved over the years with a

shift towards increased specialization. Furthermore, the development of nurses’ scope of

practice has been described by Castledine (1992) in the context of general and specialist

practice. General practice has been described as general experience across traditional

specialist domains of nursing, while specialist practice includes specific expertise in

particular fields of nursing (Castledine, 1992) .

Oncology nursing is one area that has developed as a specialist domain. The role of the

clinical nurse specialist and advanced nurse specialist in cancer care has long been

established in the UK and more recently in Ireland, particularly in breast cancer, palliative

care, and chemotherapy administration. One rationale for the development of the role was to

curtail healthcare costs and meet the complex physical and psychosocial needs of patients

with cancer and their families (Willard and Luker, 2007). The nurse specialist role is

fundamental to patient-centred care, and cancer specialist nurses make a significant

8

contribution to the physical, psychological and social care of patients with cancer both in the

hospital and in the community (Skilbeck and Payne, 2003). The core competencies for the

nurse specialist, according to the National Council for the Professional Development of

Nursing and Midwifery (2008), include :

Having a clinical focus

Acting as patient advocate

Undertaking research and audit

Teaching and educating colleagues and patients

Acting as a consultant for the specialty .

Furthermore, the cancer nurse specialist is also expected to fulfill a further range of activities

such as information giving, symptom control, psychological care and social support, and to

be a patient advocate and expert in the provision of palliative care (Willard and Luker, 2007).

In essence, the nurse specialist in cancer care enhances patient care in a holistic manner .

The acknowledgement of the complexity of the needs of individuals diagnosed with cancer

and their families has led to an increased awareness of the need for specially trained and

educated nurses (Henke-Yarbro, 1996). Nevertheless, many patients with cancer are cared for

by non-specialist nurses both in hospital and in the community (Wood and Ward, 2000). The

aim of this literature review is to provide an overview of current trends and developments in

cancer care nursing in an attempt to identify the range of previous research and available

knowledge pertaining to caring for patients with cancer on non-specialist wards.

9

1.3. Research Questions

This paper attempts to answer a few questions:

2. What is the current need for Clinical Nurse Specialists in cancer care?

3. Why are Clinical Nurse Specialists required by people living with cancer?

4. Why are there inconsistencies in access to Clinical Nurse Specialists?

5. What impact do Clinical Nurse Specialists have in cancer care?

6. What is the importance of Communication in cancer nursing?

7. What are the fields or kinds of communication given to cancer-patients?

10

1.4. The role of oncology nurses

Historically, nurses have played 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 United States of America National Cancer Act of 1971. However, the

recognition of cancer as a major American health problem and the subsequent expanded

research and treatment program against cancer, which has occurred during the past quarter-

century, has been a catalyst for the development of oncology nursing as a separate specialty.

At first many oncology nurses worked as nurses and data managers for cancer research

studies, but as the treatments in oncology became increasingly complex so did the need for a

collaborative relationship between the nurse and physician in order to provide unique

comprehensive patient care.

Today oncology nurses in the United States practice in a variety of settings, including

acute-care hospitals, outpatient clinics, private oncologists’ offices, radiation therapy

facilities, home healthcare agencies and community agencies. They may practice in surgical

oncology, gynecologic oncology, bone-marrow transplantation, radiation oncology, pediatric

oncology or medical oncology. The majority are involved in direct patient care, with 35

percent working in a hospital/multihospital system, 40 percent in the outpatient/ambulatory

care setting, 20 percent in radiation oncology, and 5 percent in hospice or home care]. The

roles of the oncology nurse vary from the intensive care focus of bone marrow transplantation

to the community focus of cancer screening, detection and prevention. Oncology nurses in

the U.S. also tend to specialize in certain cancer lung cancer clinics.

Nurses working in cancer care focus on patient assessment, education, symptom

management, and supportive care. In medical oncology they play an integral role in the

administration of antineoplastic agents and are responsible for safe drug handling; evaluation

of laboratory data; calculation of drug dosages on the basis of body surface area; insertion of

11

intravenous lines or accessing central venous devices; continuous and time intensive

monitoring to address potential adverse reactions or drug interactions; and screening patients

for inclusion in available research trials or protocols. In the radiation oncology arena the

nurses need to have an understanding of radiobiology and radiation physics. They are also

responsible for extensive symptom management, patient education and the submission

process for clinical trials or research protocols.

As more complex treatment protocols are implemented, nurses working in oncology

will need to expand their knowledge base on new drugs, new technologies, and biologic

therapies. For example, The National Cancer Institute (NCI) announced in January 2006 that

intraperitoneal (IP) combined with IV chemotherapy postoperatively was the preferred

treatment method for advanced ovarian cancer. IP administration allows a high concentration

of chemotherapy to come into direct contact with tumors and surrounding tissues and organs.

The announcement stimulated the need for oncology nurses to become familiar with IP

chemotherapy administration and patient management guidelines. These patients require

constant monitoring of renal and cardiac function through laboratory values as well as intake

and output to prevent fluid overload and electrolyte imbalances. The patients also need

advanced nursing assessment to prevent any complications from the infusion.

Advances in molecular science have led to new biologic therapies for patients with

cancer. These biological agents have created a challenge and require nurses to have a

thorough understanding of their mechanism of actions and side effect profile. Patients may

continue on these medications at home thus requiring the nurse to do a complete assessment

of the knowledge level of the patient and/or caregivers regarding the preparation and

administration of the medication at home, as well as management of possible side effects in

the home setting.

12

In Asian countries the role of the oncology nurse continues to expand as cancer

becomes a leading health concern. However, across Asia there is growing acknowledgement

of the need to clarify the role of nurses in order to maximize their contribution to cancer care.

Asia has many faces and is extraordinary in its diversity of cultures, habits, and healthcare

systems. Oncology nurses in Asia function mainly in a caregiver role focusing on treatment

delivery, education and symptom management. Specialization is rarely seen. A study in 2005

by Gopal et al looked at information needs of women with newly-diagnosed breast cancer in

Malaysia and the United Kingdom. Malaysian women in this study emphasized the

importance of medical information on prognosis and spread of disease and the need for more

education. Although nurses specializing in breast cancer are not features of the Malaysian

healthcare system, the findings from this study support the view that specialized nurses may

have a vital role to play .

Standards of practice and competencies for oncology nurses appear to be similar across

continents . Oncology nurses in an outpatient medical oncology clinic in Thailand, just as in

the U.S., are responsible for starting their own intravenous lines, triaging patient phone calls,

calculating absolute neutrophil counts, administering chemotherapy and reporting all relevant

laboratory, pathology and imaging studies. In Thailand chemotherapy is generally mixed by

the pharmacy except in smaller hospitals where the nurses are required to mix their own.

Unlike the U.S., double-checking the dose of chemotherapy by calculating the body surface

area (BSA) is the responsibility of the pharmacist. In radiation oncology the nurses once

again have similar competencies to those nurses in the U.S. with a focus on symptom

management and patient education.

Universally the oncology nurse has tremendous responsibility in educating the patient about

his or her cancer treatment and often has better opportunities than any other member of the

healthcare team to review the treatment plan. However, for some Asian countries the

13

challenges of education extend well beyond diagnosis and treatment. In certain areas a

diagnosis of cancer is taboo and rarely discussed within the family and never with outsiders.

For example, breast cancer literature in Malay languages, even in the official Bahasa Melayu

language, did not exist largely because of cultural mores regarding privacy about women's

bodies, lack of education about the disease and the lack of public hospitals to prescreen

women and provide early diagnosis as well as treatment options.

The use of alternative medicines is also a common practice in Asian countries and

oncology nurses in these areas need to be familiar with the role such medicines play in cancer

treatment. According to the World Health Organization (WHO), up to 80 percent of

developing countries' populations use traditional medicines as their primary source of health

care . Those diagnosed with cancer in Southeast Asia will routinely find the local doctor's

choice of treatments something many medical insurers consider unusual. Outside major cities

in places like China, for instance, herbal treatments are used regularly . Although alternative

therapies are becoming more common in the US, the oncology nurses in Asia must routinely

educate patients regarding the use of such alternative treatments within the context of

different cultural values. Furthermore, it is not unusual for a patient to be offered treatment

with standard Westernstyle protocols with the addition of alternative therapy.

FUTURE OF ONCOLOGY NURSING

It has been estimated that there will be another 20 million new cancer patients

worldwide in 2020 . In the developing countries of Asia this poses a huge burden on an

already taxed healthcare system. When the rise in cancer rates is coupled with concurrent

therapies, targeted therapies and advanced treatment technology, the need for advanced

practice nurses becomes extremely important. Enhancing the oncology nurse’s education is

14

the main goal of the future and will allow nurses to have a greater contribution to cancer care

in developing countries.

As stated previously, throughout Asia there is great diversity of educational

preparation. Nurses are, at best, given a broad overview of cancer care in their basic

educational programs, yet to practise in oncology, nurses must quickly learn the language of

this discipline. Each type of cancer has a different etiology, pathophysiology, natural history

and course of treatment. The number of chemotherapeutic agents and drug combinations, as

well as targeted agents being added to treatment regimes is staggering. In radiation oncology,

advances in technology have led to more defined treatment and a greater need for patient

education.

A decade ago, an oncology nurse could become an expert in one treatment modality

such as surgical, medical or radiation oncology. Now patients frequently receive concomitant

and sequential therapies that require assessment and management skills for all three

modalities. Nurses now have subspecialties such as breast care nurses, palliative care nurses,

stem-cell transplant nurses and so on. In the larger cities of Asia, nurses may be familiar with

newer technology, but more education is needed for nurses working in remote, lessdeveloped

areas of the country. As relevant healthcare systems are put in place to manage the rapidly

increasing numbers of cancer diagnosed in this part of the world, there will be a greater need

for education of oncology nurses who have never been exposed to managing skin rashes from

targeted therapies or radiation therapy equipment. For instance, the WHO estimates that the

Asia-Pacific region needs 4,000 radiotherapy machines to treat its patients, but has only 1,200

. If an increase in radiotherapy centres is the future of cancer care in this area, then many

more nurses will need to become experts in radiation oncology.

Although some countries require their nurses to have continuing education credits,

this is not the standard for all countries. Programs focusing specifically on oncology are rare

15

for nurses practising outside a major city. This leaves a lack of further education on newer

treatment modalities.

Oncology nurses in Asia will also need to take an active role in developing prevention

programs for cancer. The rapid rate of economic development in some Asian countries, along

with the accompanying industrialization and urbanisation, are contributing to an ever-

increasing risk of common cancers. In Thailand 57 percent of boys begin smoking between

the ages of 15 and 20, and unfortunately most countries in Asia have weak policies and

programs for tobacco control .

Abundant evidence in the U.S. has demonstrated the benefits of the advanced nursing

practice . In the developing countries of Asia, advanced oncology nurses can also be

instrumental in creating cancer prevention programs. For example, cervical cancer is the most

common carcinomatous lesion in women in Thailand, accounting for 18.1 percent of all

cancers found in Thai women . In 2002, the Alliance for Cervical Cancer

Prevention and the Thai Ministry of Public Health (MOPH) examined an innovative approach

to cervical cancer prevention in Thailand . Twelve nurses with advanced training used visual

examination of the cervix with acetic acid (VIA) and cryotherapy to provide testing and

treatment to women in a rural area of the country. Over 7 months, 5,999 women were tested

for cervical cancer or pre-cancer with VIA. If they tested positive, they were given

counseling and offered cryotherapy and further counseling regarding its benefits. The results

of the project indicated the VIA and cryotherapy performed by advanced practice nurses was

safe and feasible. Moreover it provided a cost-effective approach to providing cancer

screening and treatment to women in the rural areas of Thailand where a more traditional

approach to cancer prevention is low .

16

The Second Chapter:

Literature review

17

2.1. Literature Review

In order to investigate trained nurses’ self-perception of their communication skills, Burnard

& Morrison (1988, 1989, 1991) conducted studies using Heron’s six-category intervention

analysis. The findings of these studies were consistent, in that the participants generally

perceived themselves to be more skilful in the authoritative than facilitative categories. The

authoritative interventions attempt to direct or control patient behaviour while the facilitative

interventions attempt to empower the patient. Burnard & Morrison (1988, 1989, 1991)

propose that the findings of their studies be used as a basis for planning and developing

education programmes for training and research into nurses’ interpersonal communication

skills. However, the findings of these studies are limited by the use of Heron’s framework

because it does not take account of how contextual differences influence which intervention

is used by nurses and it is impossible to know to what degree nurses focused on their

intentions or actual behavior in nurse–patient interactions. Therefore, the relevance of the

findings for changing or developing nurses’ interpersonal communication skills can only be

viewed tentatively. Ashmore & Banks (1997) concur with this view and recommend that

further exploration of patients’ perceptions of nurses’ communication skills be conducted. If,

as Briggs (1982), Macleod Clark (1985), Severston (1990), Fosbinder (1994) and Oermann et

al. (2000) suggest, good communication is essential for quality nursing care, then it is

imperative that nursing research elicits patients experiences of nurse–patient communication

and identifies what they value most in their interactions with nurses (Haggman- Laitila &

Astedt-Kurki, 1994). Such information can inform nursing theory and education and,

therefore, allow nurses to develop patient-centred communication skills that are fundamental

to the delivery of quality nursing care.

Another view presented by Menzies (1960, 1970), Burton (1985), McMahon (1990), Telford

(1992) and Chant et al. (2002) suggests that nurses do not communicate well because of the

18

organizational culture. Traditionally nurses were not encouraged or supported by ward or

hospital management to establish therapeutic relationships with patients. According to

Menzies (1960, 1970) the reason for this is to protect nurses from difficult emotional

situations, thereby preventing stress. Studies by Wilkinson (1991) and McColl et al. (1996)

conducted 25 years later concur with this. They found that nurses have the necessary skills to

communicate well with patients but choose not to because of the lack of organizational

support and encouragement. It appears that, over the last 40 years, this organizational strategy

to prevent stress has resulted in a socialization process that has perpetuated the notion in

nursing that patient-centred communication should be discouraged and is unsupported by

management (Wilkinson, 1991; Graham, 1994; Cody, 1998; Williams, 1998). Bowles et al.

(2001) supports this view and adds that criticism of nurses’ communication may be

unrealistic as no benchmark for effective nurse–patient communication currently exists.

However, in order to establish a benchmark for effective nurse–patient communication it is

essential to discover patients experiences and views.

2.2. Design and methods

The purpose of this study was to explore and produce factors relating influencing nurses

relation with cancer patients and how nurses communicate with them. A qualitative

perspective using a Heideggarian/Gadamarian hermeneutic phenomenological approach was

chosen for this study because it is concerned with reaching a new understanding of the

meaning of the phenomenon (nurse–patient communication) being studied as experienced by

the participants (LoBiondo-Wood & Haber, 1998). The site chosen for this study was a

general hospital in the Republic of Ireland and ethical approval was granted by the Hospital’s

ethics committee.

19

Sampling

Using purposeful sampling, eight patients agreed to participate in the study. Purposeful

sampling is where the participants are selected prior to the study on the basis that they have

experience of the phenomenon being studied and can articulate this experience (Holloway &

Wheeler, 1996; Mays & Pope, 1996). Each participant provided written consent and chose a

pseudonym that was the only identification used on any documentation related to the study,

thus ensuring their anonymity. The participants included three males and five females whose

ages ranged from the mid-20’s to early 70’s and who had been inpatients for a minimum of 4

days. This meant that each participant would have communicated regularly with nurses

during their stay.

Data collection

Data were collected using unstructured interviews that were tape recorded and lasted 30

minutes on average. Each interview began with me asking the participant to tell me about

his/her experiences of how nurses communicated with her/him during their time as an

inpatient. The participants were asked to clarify and elaborate on certain issues as this helped

the researcher to understand the meaning of the experience of how nurses communicated for

individual patients. At some stage during most of the interviews the participants talked about

issues unrelated to nurse–patient communication. Holloway & Wheeler (1996) refer to this as

‘dross’ and say that unstructured interviews will always contain a certain amount of irrelevant

material. In order to re-focus the participants during interviews I asked the same question ‘If

you had to describe the qualities required to be a good communicator, what would you say

they were’? This was sufficient to re-focus the direction of the interview.

20

Data analysis

The aim of data analysis in phenomenological research is to reveal the meaning of the lived

experience of the phenomenon being studied for the participants. According to Bergum

(1991) and Ray (1994) data analysis in hermeneutic phenomenological research is a reflective

process. Data analysis in this study was a reflective process using the metaphor of the

‘hermeneutic circle’ to explain the dynamic nature of gaining an understanding of a

phenomenon (Annells, 1996) and reference to Gadamer’s ‘fusion of horizons’ to explain how

the researcher came to a new understanding of the meaning for patients of nurse–patient

communication. This is presented through the description and interpretation of themes and

sub-themes. In order to demonstrate trustworthiness in this study Sandelowski’s (1986)

framework was used. This framework comprises four factors that are essential for

demonstrating trustworthiness. These factors are: credibility, fittingness, auditability and

confirmability. The credibility of this study was achieved by including an interview transcript

and a thick description of one of the themes in the final report. As no personal information

was recorded during the interviews, all audiotapes used to record the interviews have been

retained by the researcher as a record of data authenticity. Fittingness occurs when the

findings of a study ‘fit’ into similar contexts outside the study. The literature used to discuss

the findings demonstrates its fittingness. Auditability of this study was achieved by recording

details explaining and justifying any decisions made regarding the study in a reflective

journal and incorporating this information into the final report as a ‘decision trail’. The

confirmability of this study arises from its credibility, fittingness and auditability

(Sandelowski, 1986).

21

2.3. Discussion

‘Lack of communication’ was the theme referred to most frequently by the

participants in this study. They commented on how nurses were more concerned with

completing their ‘tasks’ than talking to them. Some of the participants were frustrated by this

and felt that the nurses did not care about them as individuals. Other participants

acknowledged that nurses were more concerned with their work and accepted this as being

normal, although they did indicate that they would have liked to be treated as an individual.

However, regardless of how the participants felt about how nurses communicated, they did

not blame them. They all attributed the nurses’ poor communication skills to them being ‘too

busy’. Pontin & Webb (1995) and Attree (2001) suggest that patients are reluctant openly to

criticize nurses because of a fear of retribution or the passive nature of the patient role or

acceptance of the national health care delivery. They propose that instead patients ‘wrap up’

their criticisms in socially acceptable responses (Pontin & Webb, 1995). This type of

communication is particularly evident in the responses from the participants in this study.

However, it remains very clear from the participants’ responses that nurses do not always

communicate in a patient-centred way. According to Sines (1995) patients become

empowered by a patient-centred approach to communication. It allows them to be a partner in

making decisions about their own needs rather than the nurses making assumptions about

what their needs are (Sines, 1995). Patient-centred communication does not take up more of

the nurses’ time or require extra resources (Astedt-Kurki & Haggman-Laitila, 1992;

Williams, 1998), it is initiated by nurses in the words and body language that they choose to

use when approaching patients.

A possible reason why nurses do not always communicate in a patient-centred way is

that although they have the necessary communication skills, they choose to use taskcentred

22

communication as a protection mechanism against emotional or advocacy aspects of their

work (Sines, 1995; Kruijver et al., 2001). This could be because they feel unsupported or

even discouraged from communicating in a patient-centred way by management (McMahon,

1990; Wilkinson, 1991; Telford, 1992).

The second theme that emerged from the data was ‘attending’. When the participants

experienced some or all of these behaviours they felt reassured, safe and cared for as an

individual. Attending behaviours as experienced or valued by the participants in this study do

not require extra time or resources. Knowing that they can trust the nurses to be open/ honest,

understanding and be available if they needed them was the level of commitment required by

the participants. However, the effective use of attending behaviours by nurses requires that

they value patient-centred communication

(Arnold & Boggs, 1995) and have a strong sense of selfawareness (Burnard, 1990).

The third theme that emerged from the data is ‘empathy’. Empathy is defined by

Reynolds & Scott (2000), p. 226) as:

the ability to perceive and reason as well as the ability to

communicate understanding of the other person’s feelings and their attached meanings…

Reynolds & Scott (2000) describe empathy as an essential prerequisite for good nursing

practice. If nurses fail to empathize with their patients, then they cannot help them to

understand or cope effectively as individuals with their illness

(Morse et al., 1992; Peplau, 1997; Reynolds & Scott, 2000). Most of the participants had

positive experiences of empathetic communication by nurses. However, one participant also

23

experienced non-empathetic communication. This made her feel unhappy, uncomfortable and

uncared for. Although the issues that she refers to are physical needs, it is important to note

that, by not meeting the participants’ physical needs, the nurses were failing to communicate

to her that they understood her predicament or needs. This supports the view that empathetic

communication is an essential prerequisite for the delivery of quality nursing care. Because of

the positive influence that empathetic communication and the negative influence non-

empathetic communication has on patients, it is essential that nurses are aware of the impact

of the way they choose to communicate has on their patients. The implications are that nurses

who chose to use nonempathetic communication favour task-centred rather than patient-

centred communication. According to Gould (1990) the professional socialization of nurses

encourages them to lose their individuality and lose the natural ability to empathize. This

concurs with the literature (Menzies, 1960, 1970; Burton, 1985; McMahon, 1990; Telford,

1992; Graham, 1994; McColl et al., 1996) which suggests that the professional socialization

of nurses results in task-centred communication rather than patient-centred communication.

The fourth theme that emerged from the data referred to ‘friendly nurses’. All of the

participants in the study praised the nurses for being friendly, chatty and humorous. This

fulfilled an important social function by relaxing the participants, passing the time and

helping them to forget their troubles. A possible reason why all the nurses used humour and

were friendly and chatty was that they perceived it as a superficial level of communication

that creates an atmosphere that although relaxed and sociable, is unsuitable for dealing with

emotional or difficult issues. The nurses, therefore, felt relatively safe communicating this

way with all the participants.In contrast, although they can be superficial, social interactions

give patients the opportunity to step out of their sick role and according to Sumners (1990)

and Astedt-Kurki(2001) humour in the nurse–patient relationship helps to establish rapport

24

and trust, relieves anxiety and tension and conveys unspoken emotional messages. This is

evident from the findings of this study. The participants appeared to value highly the informal

humorous exchanges with the nurses. This type of communication can help to pass the time

and deflect from mundane, routine hospital life and patients are frequently instrumental in

creating such interactions (Holloway et al., 1998; Jarrett & Payne, 2000).

2.4. Implications

The participants in this study indicate that nurses do not always communicate in a

patient-centred way even when they have the ability to do so and that nurse–patient

interaction is heavily influenced by the work and culture of the organization (Jarrett & Payne,

2000). However, the literature (Peplau, 1988; Severston, 1990; Fosbinder, 1994; Redfern &

Norman, 1999; Thorsteinsson, 2002) suggests that a positive nurse– patient relationship is

essential for quality nursing care and that this can only be achieved through patient-centred

communication. The implications of this are that, if health care management want to ensure

that patients receive quality nursing care, they will need to consider positive nurse–patient

communication as essential and not an optional extra (Attree, 2001; Chant et al., 2002).

Spending long periods of time with patients does not always result in a positive nurse–patient

relationship. Astedt-Kurki & Haggman-Laitila (1992) suggest that patient-centred

communication does not require additional resources. This implies that staff shortages or

being ‘too busy’ cannot be used as an excuse for poor nurse– patient communication. It is the

quality of the interaction that determines whether the relationship is a positive one or not and

it is the nurse who has the greatest influence on whether this happens (Milne & McWilliam,

1996). Commitment to providing patient-centred care and a change in individual,

professional and organizational values is sufficient (Attree, 2001) in order to result in the

delivery of high quality nursing care.

25

At an undergraduate and postgraduate level, education relating to patient-centred

communication should focus on illustrating that this type of communication does not require

a great deal of time. Role-play and the use of critical incidences is an ideal way of helping

students and staff nurses to critically reflect on how they communicate with patients (Quinn,

1995). This would also help to develop their sense of self-awareness and subsequently

increase their ability to communicate using attending and empathetic communication

behaviours. The consequence of this in conjunction with other organizational factors is the

delivery of high quality nursing care. This type of teaching strategy would require small

group teaching and this has implications for how large undergraduate groups of students are

organized for the effective use of such strategies. The findings of this study and similar

patient-focused studies could, however, be used to inform even large groups of nursing

students about what patients value about nurse–patient communication.

There is a need to conduct further research that explores patients’ experiences of how

nurses communicate rather than conducting studies that examine nurses’ views of what they

perceive good nurse–patient communication to be. Patient focused studies may identify

specific nursing behaviours that patients value highly in terms of patient-centred

communication. This kind of information would allow nurses to demonstrate and develop

specific interpersonal skills that are patient-centred. A possible limitation to this study is that

the small number of participants means that the findings cannot be generalize to a wider

context or population, however, the findings are useful in that they can be used to inform

undergraduate and postgraduate nursing students about the possible impact of their

communication behaviour on the delivery of quality nursing care.

26

Dealing with the research questions

1- Each year just under 270,000 people are diagnosed with cancer in England. There are

currently two million people living with cancer and it is estimated that this will double

to four million people by 2030 as incidence increases due to an ageing and growing

population and treatments improve. Research shows that current models of care are

not identifying or meeting the needs of all patients living with cancer and the current

cancer workforce needs to adapt to improve care and support for cancer patients. The

role of the key worker needs to become embedded in practice and the current and

future workforce need to be developed with specific skills and specialist knowledge in

cancer, for example understanding and supporting the management of consequences

of cancer treatment. The cancer journey is complex and disjointed and involves the

care interventions from various multisite professionals such as oncologists, surgeons

and counselors. The CNS role provides and reinforces relevant information and

appropriate liaison with other professionals and agencies to improve the cancer care

process for patients.

The main functions of the specialist nurse role can be described as technical, information

provision, emotional support and coordination.

‘Emotional support should be accessible to all patients, as psychological wellbeing is

important when so much has to be faced. Often the psychological aspect of breast cancer is

not considered a high priority by health professionals. Although this is understandable when

their focus is on clinical issues, it should be an integral part of the overall care. The role of

CNSs is crucial in this respect"

The supportive care and information elements of the cancer CNS role include.:

providing support at initial diagnosis

providing individualised information

27

providing support with treatment decision making

providing advice on management of symptoms and side effects

providing support and assistance with practical issues such as finance

providing emotional and basic psychological support

signposting to specialised support services

being a named and readily available contact for the patient

running diagnostic or follow-up care clinics.

Despite this, only half of respondents of a 2006 survey reported that a nurse was involved in

the management of their condition7. In addition, 75% of cancer survivors in 2009 did not

know who to contact for advice outside of office hours and 43% would have liked more

information and advice.

2- A 2008 Royal College of Nursing (RCN) survey revealed the scale of the potential loss of

CNS expertise. More than a third of CNSs said their organisations had a vacancy freeze in

place, almost half reporting being at risk of being downgraded and 68 per cent had to see

more patients. The survey also revealed that 1 in 4 specialist nurses were at risk from

redundancy and 45% were asked to work outside their specialty to cover staff shortages.

Access to cancer CNSs varies both geographically and by tumour site, leading to inequalities

in patient experience. On average, there is only one lung cancer nurse in England for every

161 people diagnosed with lung cancer, compared to 117 people per breast cancer nurse.

Although there has been a small increase in CNS posts since 2007 in brain/central nervous

system, lung, upper gastrointestinal and haematological cancers, the increase is insufficient to

keep pace with the current growth in cancer prevalence.

A 2007 survey of breast care nurses found that almost 50% of nurses felt unable to provide

the quality of care to all breast cancer patients that they would like to. This was due to a

28

variety of reasons including increased workload because of new, additional duties, staff

shortages, and redeployment to other areas, e.g. general wards. There is inconsistency in job-

titles of roles that can be categorised as a CNS. Recent research found that almost 50

different job titles are in use for nurse specialists working in the field of urological cancers.

Inconsistency in job titles has also been related to ambiguity in terms of the requirements and

duties of the CNS role. In addition the specific services offered by CNSs may vary across the

cancer care pathway as there is no minimum standard for the skills and knowledge required

to function in a nurse specialist role.

3- Improving quality and experience of care

The English government’s cancer reform strategy (CRS) highlights that patients regularly

emphasise the role of the CNS in improving their cancer experience The results of the

2011/12 National Cancer Patient Experience Survey support this. 87% of patients reported

that they had been given the name of a CNS. Of these over 91% reported that the CNS had

listened carefully and that they got understandable answers from the CNS all or most of the

time. Patients with a CNS responded far more positively than those without on a range of

items related to information, choice and care. Recent research into complex treatment

decisions for patients with advanced lung cancer showed that CNSs play a valuable role in

supporting decision making and are seen as trusted sources of information.

The National Lung Cancer Audit 2010 shows that in 2009 64.8% of patients seen by a lung

CNS received cancer treatment compared to 30.4% of those who did not see a lung CNS, The

audit collected data on more than 37,000 patients in the UK and Northern Ireland,

representing approximately 95% of the expected number of new lung cancer cases. A UK

survey of the experiences of men with prostate cancer found that specialist nurses were

29

ranked the highest by men, in terms of healthcare professionals and help-lines, for the

provision of emotional support around the time of diagnosis and treatment decision-making.

Research has shown that significantly more patients who received nurse led follow up from

lung cancer CNSs died at home rather than in a hospital or hospice: 40% compared to 23%

receiving conventional medical follow up. Additionally, in 2009 65% of people with lung

cancer seen by a lung CNS received cancer treatment compared to 30% of those who did not

see a lung CNS. A 2009 study of rheumatology clinical nurse specialists showed that almost a

quarter of physical clinical interventions involved enhancing self-management principles and

managing unresolved symptoms using specialist knowledge and assessment.

CNSs help improve patients experience and safety28 because they have in depth knowledge

of the physical, psychological and social effects of a specific condition and play a key role in

the management of patient care. They have considerable experience, are highly qualified and

carry out a range of functions that make them a key member of a multi disciplinary team

(MDT). Patient safety and level of inadequate staffing are often interlinked. Between April

2008 and March 2009 more than 33,000 patient safety incidents were recorded as relating to

the lack of suitably trained or skilled staff. Cancer Clinical Nurse Specialists coordinate ward

admissions for patients who are unwell, expedite outpatient clinic appointments, reorganise

reviews to minimise cancelled procedures or operations and give advice on managing

medication throughout the cancer journey. This enables patients to move through the system

as smoothly as possible and diverts pressure away from other professionals such as doctors

and the ward nursing team. A study in 2009 to monitor the complex workload of CNSs in

rheumatology care revealed the importance of CNSs in providing safe advice on medication,

showing that more than a quarter of physical clinical interventions involved management of

medication including dealing with toxicity and rescue work associated with the unexpected

adverse effects of treatments.

30

A 2010 Department of Health report illustrates the ability for CNS roles to influence, lead

and advance practice and demonstrates the extent to which advanced nursing practice can

support positive patient outcomes. Specialist nurses have a much greater role in the delivery

of healthcare than they had five years ago. Between 2005 and 2010 the number of referrals to

a specialist nurse clinic rose from 115,000 to 650,000a; an average increase of approximately

107,000 a year. It is therefore evident that GPs and consultants are a more likely now than

ever to refer patients to specialist nurses. Cancer CNSs have clearly demonstrated their

commitment to work collaboratively with their colleagues to ensure that patients have access

to best practice, equity of care and continuity of care throughout the cancer journey. CNSs

provide support to their colleagues and can be seen as experts by other members of the MDT,

providing specialist advice and guidance to colleagues on a range of issues including

symptom control and patient communication. CNS expertise is essential to the functioning of

MDTs and they are often nominated as the ‘key worker’ within the team.

31

The Third Chapter:Nursing & Cancer

32

3.1. Communication in cancer nursing

Good communication is acknowledged as the cornerstone of nursing and is essential to the

delivery of effective patient care (Thorne, 1999; Leydon et al, 2000). However, many of the

studies reviewed identified communication with patients with cancer as a significant source

of concern and anxiety for both patients and nurses (Dunniece and Slevin, 2000; McCaughan

and Parahoo, 2000a; Wood and Ward, 2000; Wilkinson et al, 2002; Davis et al, 2003; Mohan

et al, 2005; Botti et al, 2006; Cunningham et al, 2006; Kendall, 2006). Patients with cancer

often face uncertainty, isolation and vulnerability (Halldorsdottir and Hamrin, 1996).

Furthermore, patients often experience psychological distress and have many questions with

regard to their disease and the treatment options available. According to Kruijver et al (2000),

the communicative behaviours of nurses can help patients who experience considerable

distress after diagnosis to integrate the disease into their lives. Unfortunately, non-specialized

nurses are not always prepared to manage distressed patients with cancer owing to their lack

of experience and specialized knowledge.

In a triangulated research study on the experiences and perceptions of 134 pre-registration

first-year student nurses, Cunningham et al (2006) found that students expressed concerns,

fears and inadequacies when communicating with patients with cancer. However, it is

important to realize that only half of the sample had any experience of caring for patients

with cancer, and only nine students attended the one-to-one interviews. Furthermore, first-

year student nurses may have very little experience of communicating and caring for patients

with cancer in comparison to final-year nursing students. Therefore, the sample chosen for

inclusion is a significant limitation of this research study. Sampling final year nursing

students may have resulted in more in-depth findings, considering only nine first-year

33

students participated in the interviews and the questionnaire only took 15 minutes to

complete.

Wood and Ward (2000) used a multidisciplinary sample of specialized and non-specialized

staff and patients to explore the educational needs of non-specialized staff when caring for

patients with cancer. The researchers used focus groups, and individual and paired interviews

to gather information. Wood and Ward (2000) claimed that non-specialized staff experienced

difficulties with communication and often felt daunted and unsure of how to deal with

difficult questions from patients or relatives concerning diagnosis, treatment and prognosis.

The patients also echoed these findings, stating that non-specialized staff were fearful of the

disease and were unable to communicate with them, displaying a general lack of confidence

overall. Dunniece and Slevin (2000) agree, and further identified nurses’ feelings of

inadequacy and fear of ‘saying the wrong thing’ when dealing with newly diagnosed patients

with cancer. In essence, feelings of fear and inadequacy relating to communicating with

patients with cancer emerged throughout many of the studies reviewed, and related in part to

a lack of knowledge regarding cancer as a disease and cancer treatments (Dunniece and

Slevin, 2000; Wood and Ward, 2000; Botti et al, 2006; Cunningham et al, 2006). Other issues

that impacted on nurse–patient communication in cancer care included a lack of time to

provide individualized care (Dunniece and Slevin, 2000; Botti et al, 2006) and a lack of

training in communication skills (McCaughan and Parahoo, 2000a; Wood and Ward, 2000).

One of the main coping strategies used by non-specialist nurses with regard to perceived

inadequacies in communication skills was the use of blocking techniques. Blocking

behaviours were described by Kruijver et al (2000) as the use of avoidance techniques or

distancing tactics in situations nurses perceived as stressful. Wilkinson (1991) identified

factors influencing how nurses communicate with patients with cancer and found that in more

than 50% of cases nurses used blocking behaviours. This finding was supported by Mohan et

34

al (2005) and Cunningham et al (2006), who identified that nurses who felt unable to answer

patients’ questions developed strategies for avoiding ‘difficult moments’ by appearing too

busy to talk, or by simply avoiding these patients altogether. Many health professionals fear

that by asking patients ‘how they are’, uncontrollable emotions such as anger or despair will

be unleashed, and it is often the case that non-specialist nurses are unprepared to deal with

any consequential emotional outbursts (Maguire and Pitceathly, 2003). Furthermore, Parle et

al (1997) identified that without the appropriate assessment skills, health professionals may

find it easier to avoid discussing cancer patients’ concerns altogether and inadvertently

maintain a personal distance. However, the use of avoidance behaviours by nursing staff can

have a negative effect on patients. For example, in a phenomenological study on the caring

encounters of nine patients with cancer (Halldorsdottir and Hamrin, 1996), the patients

identified that a lack of willingness to communicate and connect with them could be

perceived as rejection. Rejection was also reiterated by patients in Wood and Ward’s (2000)

study. Additionally, the maintenance of personal distance was identified by Botti et al (2006)

as a strategy used by specialist cancer nurses to avoid being drawn into the patient’s

emotional world, thereby protecting nurses from becoming too involved with patients and

becoming emotionally burnt-out and drained as a consequences of caring.

From the patient perspective, communication can be the most important aspect of treatment

(Thorne, 1988; Wood and Ward, 2000). Halldorsdottir and Hamrin (1997) identified open

communication as paramount to the concept of professional caring in cancer nursing.

However, communication with cancer patients requires complex and advanced skills,

including the ability to cope with stress and tension. This follows as communication with

individuals living with life-threatening illnesses is multifaceted and emotionally demanding

(Field and Copp, 1999). However, ineffective communication has been linked to adverse

effects on patient compliance with treatment plans and furthermore, can lead to patients

35

feeling anxious, uncertain and dissatisfied with their care (Audit Commission, 1993). Many

of the studies that focused on non-specialist nurses’ experiences of caring for patients with

cancer identified communication as an area that caused stress for inexperienced nurses,

leading to avoidance behaviours and increased stress for patients with cancer and their

families. This perceived stress is due, in part, to a lack of education, but is also the result of a

lack of theoretical and practical knowledge with regard to cancer and cancer treatments.

3.2. Knowledge informing cancer care

According to Frost et al (1997), a significant challenge for all nurses is meeting the social,

cultural, spiritual and developmental needs arising from the patient’s response to their cancer

diagnosis, the complexities of treatment, and the impact of cancer on the patient’s family. In

order to face these challenges, nurses should be appropriately equipped with the knowledge

and skills required to manage and care for patients requiring treatment and management of

cancer (McCaughan and Parahoo, 2000a).

In Wood and Ward’s (2000) qualitative study, one of the overarching themes identified was

the need for a better understanding of cancer and how cancer affects the patient. Many staff

reported instances when they felt they lacked the knowledge and skills required to provide the

optimal care. This feeling was also reiterated by patients in the study, who stressed the

importance of being cared for by staff who were well informed. A Northern Irish study was

carried out by McCaughan and Parahoo (2000a) using a quantitative survey design to assess

the self-reported level of competence and educational needs of 73 medical and surgical

nurses employed in a district hospital, when caring for patients with cancer. The study took

place in a district hospital with 57.5% of the sample employed in medical wards and 41.1%

employed in surgical wards; one respondent did not supply this information. Two thirds of

the sample had over ten years’ nursing experience. The researchers reported an identified lack

36

of knowledge and skills regarding cancer care and treatment and in particular, pain

management was identified as a source of concern for many of the nurses. Ethical dilemmas

such as withholding information and inadequate psychological care also emerged. However,

the percentage of requests for additional knowledge in cancer care ranged from 13.9–70.8%,

with psychosocial knowledge being the most requested educational concern. As a

consequence of the study being based on nurses’ self-assessment of competence, the

reliability of the findings are questionable. In a second publication (McCaughan and Parahoo,

2000b) using the same sample, the nursing attitudes to caring for cancer patients were

favourable. The researchers suggest that the study should be repeated using a triangulation of

data collection methods to obtain a more detailed picture of non-specialist nurses’ needs,

attitudes and experiences when caring for patients with cancer in Northern Ireland.

Further studies, including Mohan et al (2005) and Cunningham et al (2006) identified

concerns about nurses’ knowledge of cancer and cancer treatments. Cunningham et al (2006),

found that many student nurses held preconceptions about cancer as a disease, such as the

uncertainty of whether cancer is curable or not, and the need to speak in hushed tones when

mentioning the word ‘cancer’. Misconceptions about cancer and negative attitudes towards

the disease can have a detrimental effect on the patient, who is no doubt struggling to come to

terms with his/her diagnosis, treatment or recurrence. Likewise, specialist oncology staff in

Wood and Ward’s (2000) study highlighted that a lack of understanding about some basic

issues in cancer only led to feelings of pessimism about the disease and at the very least, was

not beneficial to patients.

Liu et al (2006) carried out a qualitative descriptive study using semi-structured interviews to

explain the meaning of ‘caring’ from the perspectives of 20 patients with cancer. The

researchers’ analysis identified that patients perceived ‘caring’ as nurses having qualified

professional knowledge, empathetic attitudes and skills in cancer care in order to provide

37

information and education, and building and maintaining a trusting nurse–patient

relationship. In addition, Coffey (2006) undertook a detailed concept analysis to gain an

understanding of the nurse–patient relationship in cancer care. Data was collected from 167

articles and from two other sources; 12 nurses participated in two focus group interviews, and

eight patients with an experience of cancer participated in a semi-structured interview. From

an analysis of the data the attributes of the nurse–patient relationship in cancer care included

‘enduring relationship’, ‘caring benevolence’, and ‘contextually negotiated reciprocity’. As

with any concept analysis, the findings cannot be generalized, as concepts are influenced by

significance, use, culture, personal experiences and context, and therefore change and alter

their meanings over time (McEvoy and Duffy, 2008).

Throughout the nursing literature, non-specialist nurses identified a need for greater

understanding with regard to cancer as a disease, and knowledge relating to treatment.

Misconceptions about cancer were also identified, particularly in relation to the prognosis,

and were highlighted as having a potentially detrimental effect on the patient. The need for

education regarding the assessment and management of cancer pain was also identified in

many studies (McCaughan and Parahoo, 2000a; Wood and Ward, 2000; Mohan et al, 2005)

with non-specialist staff reporting difficulties in dealing with patients requiring palliative care

and caring for the patients’ families. In essence, non-specialized nurses felt they needed a

better understanding of the role of the palliative care team, other support mechanisms

available, and knowledge with regard to the appropriate time to seek support if required

(Wood and Ward, 2000; Mohan et al, 2005).

Evidently, the care of patients with cancer is complex and encompasses a wide range of

skills. Nurses caring for patients with cancer are challenged to provide holistic care

encompassing physical, social, spiritual and psychological care, not only for the patient, but

also for his/her family. Patients who are newly diagnosed, patients with disease recurrence,

38

patients receiving treatment, and patients in the final stages of illness all need the greatest

help and support that nurses can possibly provide (Rustoen et al, 2003). The provision of safe

care is paramount and therefore having the ability to recognize the treatment side-effects,

symptoms or changes in a patient’s overall health status is vital for all nurses caring for

patients with cancer (Wood and Ward, 2000). It would seem essential, therefore, that in order

to provide comprehensive holistic care that meets the needs of patients with cancer, nurses

require both practical and theoretical knowledge regarding the treatment and management of

cancer from a holistic perspective.

3.3. The emotional nature of cancer nursing

A diagnosis of cancer is a significant life event that causes disruption to the lives of patients

and their families (Kendall, 2007). Meeting the emotional and psychosocial needs of patients

with cancer presents a compelling challenge to health professionals and particularly to those

who are not specialists in oncology care (McCaughan and Parahoo, 2000a). Many of the

studies undertaken to explore the experiences and educational needs of non-specialist nursing

staff identified issues with regard to dealing with the psychological needs of patients, the

emotional nature of caring, and dealing with death and dying as difficult to manage

(Dunniece and Slevin, 2000; McCaughan and Parahoo, 2000a; Wood and Ward, 2000;

Mohan et al, 2005). A dominant feature in much of the research was the emotionally

demanding nature of caring, with descriptions of cancer care as emotionally draining,

challenging, sad and distressing (Mohan et al, 2005).

Dunniece and Slevin (2000) undertook a descriptive phenomenological study to describe the

experiences of nurses who were present with a patient receiving a diagnosis of cancer. Six

qualified nurses with over 18 months’ experience of caring for patients with cancer

participated in the study. The participants had all completed post-registration study days and

39

three of the six nurses had a degree qualification. Data was collected using one-to-one semi-

structured interviews and analysed using Colaizzi’s (1978) data analysis framework. The

participants identified a range of emotions, including inadequacy, fear, distress and anger.

These feelings related to being unable to help the patient, in part owing to a lack of

knowledge and difficulties with communication. All participants identified and empathized

with patients their own age, and two participants described how they placed themselves in the

patient’s position when bad news was being delivered. Furthermore, all participants in the

study felt that ‘being there’ was a central role of the oncology nurse, and that this included

providing information, answering questions, listening and being silently present. The more

experience nurses have in cancer care, the more comfortable they are with not having all the

answers (Quinn, 2003), and the more comfortable nurses are with just ‘being there’.

Dunniece and Slevin (2000) also found that being present with younger patients heightened

nurses’ awareness of their mortality and made the experience more difficult to deal with.

Kendell (2007) claimed that when nurses were faced with caring for a youthful patient they

experienced considerable emotional distress. Additionally, nurses in a study by Botti et al

(2006) recognized the need to distance themselves emotionally from patients with

haematological malignancies. Interestingly, the findings of Botti et al’s (2006) qualitative

exploratory study identified that non-specialized and inexperienced nurses were the most

vulnerable and most likely to become emotionally involved and drawn into the lives of

oncology patients.

The care of dying patients was a further emotional issue, raising many concerns for non-

specialist cancer nurses. Caring for dying patients in an acute hospital setting may be

particularly stressful and challenging for nursing staff, owing to the blend of care required in

an acute ward (Davis et al, 2003), staffing and resource pressures, lack of time, and lack of

skills and the palliative care knowledge required to provide satisfactory nursing care. Browne

40

et al (2005) agree, and found that staff reported regular stress when dealing with death and

dying. Some of this stress was thought to occur because nursing staff often come to the job

with little or no experience in dealing with difficult dying situations. The management of pain

and communication with dying patients and their families has also been identified as a

significant stressor when caring for dying patients (McCaughan and Parahoo, 2000a; Mohan

et al, 2005). Dealing with patients’ families was highlighted in a number of studies as being

particularly emotionally demanding for non-specialist nurses (McCaughan and Parahoo,

2000a; Wood and Ward, 2000; Davis et al, 2003; Mohan et al, 2005).

Mohan et al (2005) undertook a qualitative descriptive study in Australia and found that

dealing with and supporting family members, explaining issues such as end-of-life care and

bereavement, and withholding information were difficult issues for non-specialist cancer

nurses to manage. Only 50 packets consisting of seven open-ended survey questions,

participant information leaflets and return address envelopes were distributed to four wards in

two hospitals (420 beds and 32 beds). Twenty-five surveys were returned and five nurses

agreed to be interviewed in one-to-one interviews. It is not clear why the researchers

distributed only 50 questionnaires, which interviewed only five nurses. The use of a larger

sample would have increased the rigour of the study. Also, the use of the questionnaires,

albeit open-ended, leads to methodological confusion. Questionnaires are not generally used

in qualitative research, but the use of the open-ended questionnaire could provide rich data in

terms of participant narratives. Nevertheless, the researchers did not provide a justification

for their use of questionnaires in this particular study, and could potentially cause confusion

for novice researchers when attempting to interpret the findings. Fundamentally, Mohan et al

(2005) concluded that non-specialized nurses require education in cancer care, the

development of time management skills, counselling skills, and family-centred care in order

to provide effective holistic nursing care to patients with cancer.

41

Embedded in the emotional nature of caring for patients with cancer is the notion of time.

Many studies acknowledged the importance of time when providing psychosocial care for

patients and families (Dunniece and Slevin, 2000; McCaughan and Parahoo, 2000a; Mohan et

al, 2005). However, the nature of acute hospital care is such that high workloads and a lack of

time are typical. Nurses emphasized that the environment of a busy ward is not conducive to

adequate patient care, and some nurses further believed that patients would feel better cared

for if they could share their experiences with others in similar situations (Mohan et al, 2005).

3.4. Discussion

There have been many issues raised in the nursing literature by non-specialist staff caring for

patients with cancer. Issues relating to communicating with patients and families were

identified in all studies, and staff reported feeling ill-equipped to deal with the information

needs of patients with cancer throughout all stages of the cancer trajectory. Furthermore, non-

specialized nursing staff reported a lack of education and training with regard to cancer and

cancer treatments as a significant obstacle in the provision of comprehensive holistic care to

patients with cancer and their families. The management of symptoms was also reported as a

source of anxiety and stress for non-specialist nurses (McCaughan and Parahoo, 2000a;

Wood and Ward, 2000; Mohan et al, 2005). The emotional nature of care and care of dying

patients, the perceived lack of knowledge regarding symptom management and

communication, the environment of care and a lack of time due to the inherent busyness of

acute medical and surgical wards, were also acknowledged as problematic for non-specialist

nurses. Many nurses held the view that patients with cancer would feel better cared for in a

specialist area, and while this is ideal, the current state of healthcare environments and the

42

projected increase in the numbers of patients with cancer suggests that this solution is a long

way from being realized.

As a result of the increasing demand on the health service and the expanding need for

specialist cancer nurses, there must be a commitment to advancing education in cancer care.

Oncology nurse education begins with student nurses in the classroom, and particularly in the

clinical practice area. However, student nurses are rarely prepared to care for patients with

cancer (Ferguson, 1994), and Closs et al (1996) highlight that very few qualified nurses

pursue post-registration education in cancer care. The DH (2000b) recommends that pre-

registration programmes should ‘accommodate the initial and ongoing care for people

affected by cancers’. Furthermore, The Royal College of Nursing (2003) published a

Framework for Adult Cancer Nursing identifying that nurses are key in the delivery of expert

effective care to people with cancer:

‘...it is essential that the structure, training and education of the nursing workforce provides

nurses with a sound knowledge and understanding of the care needs of cancer patients, their

families, significant others and friends.’

Clinical and theoretical education should therefore focus on topics related to understanding

the nature of cancer, prevention, diagnosis, treatment, interpersonal communication,

psychosocial support, death and dying, and the organization and management of cancer care

(Cunningham et al, 2006). In addition, expert oncology nurses could deliver in-house

education to all hospital nurses and provide advice to non-specialist nurses in times of need.

Clinical nurses should be encouraged to develop both practical and theoretical knowledge in

cancer care, because all nurses at some stage in their career will care for patients with cancer,

and therefore need to develop an understanding of the physical, psychological and social

dimensions of this aspect of nursing.

43

3.5. Nursing In Saudi Arabia

In accordance with the Saudi constitution, the government provides all citizens and

expatriates working within the public sector with full and free access to all public health care

services. Government expenditure on the MOH increased from 2.8% in 1970 to 6% in 2005

and 6.2% in 2009 (figure, Table 1) . According to WHO the total expenditure on public

health during 2009 was 5% of gross domestic product . The MOH is responsible for

managing, planning and formulating health policies and supervising health programmes, as

well as monitoring health services in the private sector . It is also responsible for advising

other government agencies and the private sector on ways to achieve the government’s health

objectives .

The MOH supervises 20 regional directorates-general of health affairs in various parts of the

country . Each regional health directorate has a number of hospitals and health sectors and

every health sector supervises a number of PHC centres. The role of these 20 directorates

includes implementing the policies, plans and programmes of the MOH; managing and

supporting MOH health services; supervising and organizing private sector services;

coordinating with other government agencies; and coordinating with other relevant bodies .

Figure 2 illustrates the organizational structure and the relationship of departments within the

Saudi health care system from the community to MOH level. “Health friends” is a selective

committee consisting of useful and influential community members, including representatives

from PHC centres, who are knowledgeable about common social norms and the potential of

the community. The essential role of this committee is to liaise between PHC centres and the

communities they serve . In recent years, the MOH has continued to develop the number of

PHC centres (Figure 2) and has initiated further projects aimed at developing health care in

general and PHCs in particular. For example, the project of the Custodian of the Two Holy

44

Mosques aims to establish 2000 advanced PHC centres, and to develop the existing ones in

terms of buildings, workforce and services.

Figure:1

Figure: 2

45

3.5. Conclusion

The paper summarized the current nursing literature with regard to caring for patients

with cancer on non-specialist wards. Throughout the analysis it became evident that nursing

patients with cancer and their families was an area that non-speciality nurses working on

general medical and surgical wards found particularly difficult. Dealing with the emotional

responses of patients, patient’s families and at times, the nurses’ own emotional responses to

caring for patients with cancer, were identified as being stressful, upsetting and frustrating.

These difficulties were further compounded by time constraints, lack of experience, problems

relating to communication, and the provision of psychosocial care .

While it is preferable that patients with cancer are cared for on specialist wards, the

dedicated cancer ward may be unable to cope with the volume of admissions, and therefore

patients will continue to be nursed on general medical and surgical wards. As a result, there is

an overwhelming need for stakeholders to embrace the needs of patients and nurses in the

organization of cancer care nursing. These developments are not only unique to European

countries, but in keeping with international trends, and advances in cancer care are required

worldwide. Research, although somewhat dated, has shown that educated oncology nurses

make a significant difference to the patient’s physical, psychological and social wellbeing

(McCaughan and Parahoo, 2000a; Mohan et al, 2005). Consequently it is paramount that the

educational needs of non-speciality nurses are met, so that all nurses are equipped with the

competence and confidence to provide care for patients with cancer.

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