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Oncology Professional Performance:
Scope, Standards, and Related Care
Standards of Professional
Performance
OCN Review Course
March, 2018
Juanita L. Madison, RN, MN, AOCNS, BMTCN
Oncology Clinical Nurse Specialist
Objective
• Discuss current issues in care that impact
professional performance of the oncology nurse.
2
2018 OCN Test Content OutlineContent Area Percentage of
2018 Exam
# of Scored Test
Questions*
Care Continuum 19% 28
Oncology Nursing Practice 17% 25
Treatment Modalities 19% 28
Symptom Management &
Palliative Care
23% 33
Oncologic Emergencies 12% 17
Psychosocial Dimensions of Care 10% 15
*To determine the number of scored items from each subject area, multiple the percentage by 145.
2018 Oncology Nursing Certification Test Candidate Handbook (2018). Oncology Nursing Certification
Corporation, page 8, https://www.oncc.org/files/2018TestCandidateHandbook.pdf, accessed February 7, 2018.
Oncology Nursing Practice – 17% (25 Questions)
A. Scientific basis
1. Carcinogenesis
2. Immunology
3. Clinical trials (e.g. research
protocols)
C. Scope, standards, and related issues
1. Standards of care (nursing process)
2. Legal (including documentation)
3. Accreditation (e.g. The Joint
Commission)
4. Self-care (e.g. managing compassion
fatigue)
B. Site-specific cancer
considerations
1. Pathophysiology
2. Common metastatic
locations
3. Diagnostic measures
4. Prognosis
5. Classification
6. Staging
7. Histological grading
D. Standards of professional performance
1. Ethics (e.g. patient advocacy)
2. Education
3. Evidence-based practice (e.g. Putting
Evidence Into Practice (PEP)
guidelines) and research
4. Quality of practice
5. Communication
6. Leadership
7. Collaboration
8. Professional practice evaluation
9. Resource utilization
10. Environmental health (e.g. Safety,
personal protective equipment, safe
handling)
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Oncology Nursing Practice – 17% (25 Questions)
A. Scientific basis
1. Carcinogenesis
2. Immunology
3. Clinical trials (e.g. research
protocols)
C. Scope, standards, and related issues
1. Standards of care (nursing process)
2. Legal (including documentation)
3. Accreditation (e.g. The Joint
Commission)
4. Self-care (e.g. managing compassion
fatigue)
B. Site-specific cancer
considerations
1. Pathophysiology
2. Common metastatic
locations
3. Diagnostic measures
4. Prognosis
5. Classification
6. Staging
7. Histological grading
D. Standards of professional performance
1. Ethics (e.g. patient advocacy)
2. Education
3. Evidence-based practice (e.g. Putting
Evidence Into Practice (PEP)
guidelines) and research
4. Quality of practice
5. Communication
6. Leadership
7. Collaboration
8. Professional practice evaluation
9. Resource utilization
10. Environmental health (e.g. Safety,
personal protective equipment, safe
handling)
Professional Performance Study Resources
• Itano, et al (2016). Core Curriculum for Oncology Nursing, 5th Edition, Part 9:
Professional Practice
– Chapter 44: Evidence-Based Practice and Standards of Oncology Nursing
– Chapter 45: Education Process
– Chapter 46: Legal Issues
– Chapter 47: Ethical Issues
– Chapter 48: Professional Issues
• Eggert, J. (2017). Cancer Basics, 2nd Ed, Pittsburgh, PA: Oncology Nursing
Society, Chapter 31: Ethical Issues (pp. 649-672).
• Yarbro, C.H., Wujcik, D., & Holmes Gobel, B. (2018). Cancer Nursing:
Principles and Practice, 8th Edition. Chapter 76: Legal Issues.
6
Professional Practice – Oncology RN
On Demand ONS Online Module
• $85 for ONS Members, 6.03 CE Credits
• It is also part of the “OCN Certification Review Bundle” ONS
Online Module ($234 for ONS Members, 40.87 CE Credits)
• Topics Covered:– Professional Performance Overview
– Scope and Standards of Oncology Nurse Practice
– Evidence-Based Practice
– Patient Advocacy
– Navigation Throughout the Cancer Continuum
– Quality and Performance Improvement
– Professional Development and Interprofessional Collaboration
– Accreditation and Certification Standards
– Education: Teaching and Learning Principles
– Ethical Issues
– Legal and Risk Management Issues
7
https://www.ons.org/education/certification , accessed March 8, 2017.
ONS Online Resources:
Standards & Professional Practice
https://www.ons.org/practice-resources, accessed March 8, 2018.
From ONS
Homepage
(www.ons.org),
click on “Practice
Resource” Link
3/9/2018
3
ONS Online Resources:
Standards & Professional Practice
https://www.ons.org/practice-resources, accessed March 8, 2018.
Links to Evidence-
Based Practice
Resources, Quality,
& Standards
Resources
Standards
• Definition: Authoritative statements that delineate
duties that all registered nurses are expected to
perform competently
• Standards of Practice
– Outline nationally determined practice
expectations for individuals or organizations
– Provide guidance to nurses, employers, and
educators
– Often used in legal situations to determine
whether an individual or organization met what is
regarded as the standard of care
10Wickham, R. (2016). Evidence-based practice and standards of oncology nursing. In Itano, J.K. (Ed),
Core Curriculum for Oncology Nursing, 5th Edition. Elsevier, St. Louis, MO, pages 531 – 540.
Standards of Practice
• Nursing professional practice standards
– Nursing: Scope and Standards of Practice, American Nurses
Association (ANA), 2015.
• 17 national standards of practice and performance that define
the who, what, where, why, and how of nursing practice
– Code of Ethics for Nurses with Interpretative Statements,
American Nurses Association (ANA), 2015.
• Framework for ethical analysis and decision-making for RNs
across all practice levels, roles and settings.
• Oncology nursing standards of practice or position statements
– ONS Statement on the Scope and Practice of Oncology Nursing
– Oncology Nursing Society (ONS) Position Statements
– American Society of Clinical Oncology (ASCO)/Oncology Nursing
Society (ONS) Chemotherapy Administration Safety Standards,
Including Standards for Pediatric Oncology
11http://nursingworld.org/, accessed March 9, 2018; http://www.ons.org/, accessed March 9, 2018.
Statement on the Scope and Standards
of Oncology Nursing Practice
• Developed in conjunction with the
American Nurses Association
• Describes the role of the
professional oncology nurse
• Available to order online from ONS
(www.ons.org)
12Brandt, J.M, & Wickham, R.S (eds), 2013. Statement on the scope and standards of oncology
nursing practice, Generalist and advance practice, Oncology Nursing Society, Pittsburgh, PA.
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Statement on the Scope and Standards
of Oncology Nursing Practice
• Defines scope of nursing practice in measurable terms
• Provide guide for evaluating healthcare services provided
– Quality
– Effectiveness
– Appropriateness
• Assist profession in meeting requirements created by regulation
13Brandt, J.M, & Wickham, R.S (eds), 2013. Statement on the scope and standards of oncology
nursing practice, Generalist and advance practice, Oncology Nursing Society, Pittsburgh, PA.
• Describes
– Responsibilities for which oncology nurses are accountable
– Competent level of professional performance & professional nursing practice
• Standards of practice: two key sections
– Standards of Care
– Standards of Professional Practice
14
Statement on the Scope and Standards
of Oncology Nursing Practice
Brandt, J.M, & Wickham, R.S (eds), 2013. Statement on the scope and standards of oncology
nursing practice, Generalist and advance practice, Oncology Nursing Society, Pittsburgh, PA.
ONS Standards of Care
Standard Nursing
Process
Definition
I Assessment The oncology nurse systematically and continually collects data
regarding the health status of the patient
II Diagnosis The oncology nurse analyzes assessment data to determine
nursing diagnosis
III Outcome
Identification
The oncology nurse identifies expected outcomes
individualized to the patient
IV Planning The oncology nurse develops an individualized and holistic plan
of care that prescribes interventions to attain expected
outcomes
V Implementation The oncology nurse implements the plan of care to achieve the
identified expected outcomes for the patient
15Brandt, J.M, & Wickham, R.S (eds), 2013. Statement on the scope and standards of oncology
nursing practice, Generalist and advance practice, Oncology Nursing Society, Pittsburgh, PA.
Pertains to professional nursing activities demonstrated
through nursing process
Standards of Care:Address 14 High-Incidence Problem Areas
Areas common to patients cared for by oncology nurses:
1. Health Promotion 8. Mobility
2. Patient & family education 9. Gastrointestinal (GI) and
urinary function
3. Coping 10. Sexuality
4. Comfort 11. Cardiopulmonary function
5. Nutrition 12. Oncologic emergencies
6. Complementary and
alternative medicine
13. Palliative and end-of-life care
7. Protective Mechanisms 14. Survivorship
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ONS Standards of
Professional Performance
• Describe competent, professional nursing behaviors
• Includes activities related to:
– Ethics
– Education
– Evidence-based practice & research
– Quality of practice
– Communication
– Leadership
– Collaboration
– Professional Practice Evaluation
– Resource Utilization
– Environmental health 17
ONS Position Statements
https://www.ons.org/advocacy-policy, accessed March 8, 2018.
From ONS
Homepage
(www.ons.org),
click on
“Advocacy and
Policy” tab
E p
https://www.ons.org/advocacy-policy, accessed March 8, 2018.
Links to ONS
Position
Statements,
Health Policy
Resources,
etc.
It
20
ONS
Position
Statements
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ONS/ASCO Chemotherapy
Administration Safety Standards
• Collaborative project between the
American Society of Clinical Oncology
(ASCO) and the Oncology Nursing Society
(ONS)
• Standards addressing the safety of all
routes of chemotherapy administration in
the outpatient and inpatient settings.
• Intended to reduce the risk of error and to
provide a framework for best practices in
cancer care.
• Institutions can use them to inform
practice policies and procedures, and
quality assessment.
21Meuss, M.N., et al (2017). 2016 Updated American Society of Clinical Oncology/Oncology Nursing
Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology.
Oncology Nursing Forum, 44 (1): 31 - 43 -
Regulation of Nursing Practice
• Licensure
– A license granted by a governmental agency
confirms that the person has met minimum
requirements to practice
– RNs are licensed through state boards of
nursing
• Accreditation
– Evaluation of compliance with standards
22Thoele, K. (2016). Professional Practice. In Faimen, B. (ed.). BMTCN Certification Review Manual,
ONS: Pittsburgh, PA, page 267.
Accreditation
• Evaluation of compliance with standards
• This process recognizes that an institution maintains
standards set by accrediting agencies
• Accreditation involves continuous improvement and
monitoring of outcomes within an organization
• Healthcare accreditation agencies
– The Joint Commisson (TJC) www.jointcommission.org
• National Patient Safety Goals (NPSG) www.jointcommission.org
– American College of Surgeons Commission on Cancer (COC)
www.facs.org/cancer/
– Foundation for Accreditation of Cellular Therapies (FACT)
www.factwebsite.org
23Ponto, J. (2016). Legal Issues. In Itano, J.K. (ed). Core Curriculum in Oncology Nursing, 5th Ed.
ONS, Pittsburgh, PA, page 548.; Thoele, K. (2016). Professional Practice. In Faimen, B. (ed.).
BMTCN Certification Review Manual, ONS: Pittsburgh, PA, page 264.
The Joint Commission (TJC)
www.jointcommission.org
• Develops standards to
improve safety,
efficiency, quality, and
value of health care
• Evaluates
organizations based
on compliance with
measurable standards
24
• Ambulatory Care
• Behavioral health care
• Home health
• Hospitals
• Nursing care centers
• Laboratories
• Office-based surgery
centers
Ponto, J. (2016). Legal Issues. In Itano, J.K. (ed). Core Curriculum in Oncology Nursing, 5th Ed. ONS,
Pittsburgh, PA, page 548.; Thoele, K. (2016). Professional Practice. In Faimen, B. (ed.). BMTCN
Certification Review Manual, ONS: Pittsburgh, PA, page 264.
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The Joint Commission (TJC)
www.jointcommission.org
Categories of Standards for Hospital Accreditation
Accreditation
participation
requirements
Leadership Provision of care,
treatment, & services
Environment of care Life safety Performance
improvement
Emergency
management
Medication
management
Record of care,
treatment, & services
Human resources Medical staff Rights, responsibilities
of individuals
Infection prevention &
control
National Patient Safety
Goals
Transplant safety
Information
management
Nursing Waived testing
25Ponto, J. (2016). Legal Issues. In Itano, J.K. (ed). Core Curriculum in Oncology Nursing, 5th Ed. ONS,
Pittsburgh, PA, page 548.; Thoele, K. (2016). Professional Practice. In Faimen, B. (ed.). BMTCN
Certification Review Manual, ONS: Pittsburgh, PA, page 264.
Legal Liability Terms and Definitions
• Malpractice: When a person deviates from a normal
standard of care or acts in a way that differs from how a
reasonably prudent provider would act in a similar
circumstance
– Malpractice can be through omission (failure to act) or
commission (inappropriate action)
– Negligence is malpractice (failure to act)
– Required elements of malpractice:
• Duty (care relationship between patient and provider)
• Breach of duty (failure to meet an acceptable
standard of care; failure to perform one’s agreement)
• Injury
• Causation
26Ponto, J. (2016). Legal Issues. In Itano, J.K. (ed). Core Curriculum in Oncology Nursing, 5th Ed.
ONS, Pittsburgh, PA, page 549.; Thoele, K. (2016). Professional Practice. In Faimen, B. (ed.).
BMTCN Certification Review Manual, ONS: Pittsburgh, PA, page 270.
Documentation
• Purposes of documentation
– Communication tool
– Evidence of work done by a nurse
• Role of documentation in reducing legal risks
– Can be used in legal disputes to determine whether a standard of
care was met
• Seven essentials of quality nursing documentation
– Patient centered
– Contained actual work of nurses including education and
psychosocial support
– Written to reflect objective clinical judgment of nurse
– Presented in logical and sequential manner
– Written as events occur
– Reflected variances in patient’s condition (e.g. changes in patient
response or nursing interventions)
– Fulfilled legal requirements 27
Ponto, J. (2016). Legal Issues. In Itano, J.K. (ed). Core Curriculum in Oncology Nursing, 5th Ed. ONS, Pittsburgh, PA, page 550.
Compassion Fatigue
• The physical and mental exhaustion and emotional
withdrawal experienced by those who care for sick
or traumatized people over an extended period of
time (Merriam-Webster Dictionary)
• Unlike burnout, which is caused by everyday work
stresses (dealing with insurance companies, making
treatment choices, short staffing), compassion
fatigue results from taking on the emotional burden
of a patient’s agony (Tim Jarvis)
28https://www.merriam-webster.com/dictionary/compassion%20fatigue,
accessed March 9, 2018.
3/9/2018
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Compassion Fatigue
• Compromised of two parts:
– Burnout
• Characterized as “exhaustive frustration,
anger, and depression” (Stamm, 2010, p. 12)
– Secondary traumatic stress
• Described as the negative consequences
secondary to fear and work-related trauma
• Compassion fatigue is not a character flaw
• It is a defined syndrome individuals may develop
when they internalize pain or anguish related to
other people in their work environment (Todaro-
Franceschi, 2013)29
Burnout versus Compassion FatigueBurnout Compassion Fatigue
Anyonor paine who works in a difficult work
environment is at risk
Health care professionals who regularly
observe or listen to experiences of fear and
pain and suffering are at risk
Adapt to exhaustion by becoming less
empathetic and more withdrawn
Reduced personal achievement Continue to give but cannot maintain a
healthy balance between empathy and
objectivity
Response to work situation Response to people.
Personally identify with patient and
personally absorb patient’s trauma or pain.
Results from being busy Results from giving high levels of energy
and compassion over a prolonged period of
time.
Evolves gradually when differences between
the expectations of the individual and the
organization are in conflict.
30Lavier, J. & Brunt, B (2018). Running on Empty: Compassion Fatigue in Nurses and Non-Professional
Caregivers. The Bulletin (Ohio Nurses Association), November, December 2017, January 2018.
pages 10-14
Compassion Fatigue InterventionsPersonal Self-Care Strategies Organizational/Work-Place Strategies
Recognized feelings of grief and loss, allowing
time to grieve
Allow time and opportunities for grieving –
mediation areas, memory boards or books,
remembrance ceremonies
Identify ways to renew personal strength and
well being (e.g. spirituality, music, yoga,
relaxation)
Ensure outlets for sharing emotional
expressions, such as closure conferences,
debriefings, retreats, professional counseling,
and pastoral care
Maintain physical health Offer education on grief theories, compassion
fatigue, end-of-life care, and communication
Develop an appropriate work-life balance
Build positive relationships in personal and
professional lives
Seek professional help when needed
Recognize the positive impact nurses have on
patients and families
31Houck, D. (2014). Helping nurses cope with grief and compassion fatigue: An educational intervention. Clinical
Journal of Oncology Nursing, 18 (4): 454-458.
Self Care:
Compassion Fatigue Resources
• Zajec, L.M., Moran, K.J. & Groh, C.J. (2017). Confronting
Compassion Fatigue: Assessment and Intervention in Inpatient
Oncology. Clinical Journal of Oncology Nursing, 21 (4): 446-
453.
– Offers 0.5 CE credits
• Finley, B.A. & Sheppard, K.G. (2017). Compassion Fatigue:
Exploring Early Career Oncology Nurses’ Experiences. Clinical
Journal of Oncology Nursing, 21 (3): E61 – E-66.
– Offers 0.5 CE credits
• Houck, D. (2014). Helping nurses cope with grief and
compassion fatigue: An educational intervention. Clinical
Journal of Oncology Nursing, 18 (4): 454 – 458.
• Compassion Fatigue Awareness Project– www.compassionfatigue.org
32
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Sample Question
A nurse plans to take the oncology certified nurse
examination in the next year. This action demonstrates
which of the following Oncology Nursing Society
Standards of Practice:
A. Professional development
B. Performance appraisal
C. Quality of care
D. Education
33
Sample Questions
Quality of patient care on an oncology unit can best be
evaluated by referring to which of the following?
a. American Cancer Society Cancer Sourcebook for Nurses
b. Oncology Nursing Society Statement on the Scope and Standards of Oncology Nursing Practice
c. ONS Chemotherapy & Biotherapy Guidelines & Recommendations for Practice
d. Cancer Nursing Principles and Practice
34
Sample Question
The 14 high-incidence problem areas in oncology
nursing, cited in the Statement on the Scope and
Standards of Oncology Nursing Practice, are:
a. Key areas in which oncology nurses assess, plan,
and intervene
b. The problems with the highest incidence rates in
cancer care
c. Problems that most often affect the client in the
acute care setting
d. Clinical indicators that are measurable dimension of
the quality of cancer care
35
Sample Question
A nurse fails to implement interventions in a timely
manner according to the established plan of care. The
nurse’s action is an example of:
A. Fraud
B. Judgment
C. Slander
D. Negligence
36
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10
Sample Question
A nurse assigned to care for a group of five patients
provides assessment and documentation on only four of
the patients. The nurse misread the assignment. The
nurse’s action is an example of:
A. Nonmaleficence
B. Malpractice
C. Breach of duty
D. Absent documentation
37
Sample Question
A nurse manager is reviewing the policy and procedure for
the staff nurse responsible for chemotherapy
administration. In what way can the ASCO/ONS
chemotherapy administration safety standards assist in this
process?
A. It outlines the professional responsibilities of oncology
nurses in the administration of chemotherapy.
B. It provides data collection tools for the purpose of
quality improvement.
C. It gives an example of oncology nurse job descriptions.
D. It lists the education classes that are required for
oncology nurses.38
Sample Question
A patient with bone metastasis is experiencing
uncontrolled pain. The nurse reviews the plan of care
with the patient and the palliative care nurse practitioner.
This is an example of:
A. Mentoring
B. Professional Development
C. Collaboration
D. Peer review
39
Oncology Nursing Practice – 17% (25 Questions)
A. Scientific basis
1. Carcinogenesis
2. Immunology
3. Clinical trials (e.g. research
protocols)
C. Scope, standards, and related issues
1. Standards of care (nursing process)
2. Legal (including documentation)
3. Accreditation (e.g. The Joint
Commission)
4. Self-care (e.g. managing compassion
fatigue)
B. Site-specific cancer
considerations
1. Pathophysiology
2. Common metastatic
locations
3. Diagnostic measures
4. Prognosis
5. Classification
6. Staging
7. Histological grading
D. Standards of professional performance
1. Ethics (e.g. patient advocacy)
2. Education
3. Evidence-based practice (e.g. Putting
Evidence Into Practice (PEP)
guidelines) and research
4. Quality of practice
5. Communication
6. Leadership
7. Collaboration
8. Professional practice evaluation
9. Resource utilization
10. Environmental health (e.g. Safety,
personal protective equipment, safe
handling)
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11
https://www.ons.org/advocacy-policy, accessed March 8, 2018.
Click on
“Advocacy &
Policy” link
from ONS
homepage
Evidence Based Practice (EBP)
• Definition: The process of finding and applying the best
available evidence to clinical practice (Gobel & Tipton, 2009)
• Goal: To provide and guide nursing interventions to
enhance the quality and continuous improvement of cancer
care that impacts the clinical, psychosocial, financial, and
educational outcomes of that care
42
Using Evidence In Practice (Multistep Process)
Step Description
Problem Identification Asking clinical question in a PICOT format:
P: Patient or Population of interest
I : Intervention, Issue, or area of Interest
C: Comparison intervention or group
O: Outcome
T: Time
43
PICOT Format:
Example of a Clinical Question
44
In adult HSCT recipients, does chlorhexidine bathing
decrease central line infections during hospitalization?
Population to be studied Adult HSCT recipients
Issue or intervention Chlorhexidine bathing
Comparison group Bathing without
chlorhexidine
Outcome Central line infections
Time frame During hospitalization
The clinical question helps effectively guide the search for evidence.
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12
Using Evidence In Practice (Multistep Process)
Step Description
Problem Identification Asking clinical question in a PICOT format:
P: Patient or Population of interest
I : Intervention or area of interest
C: Comparison intervention or group
O: Outcome
T: Time
Search the Evidence Finding the best evidence with which to answer
the question
Critique of Research Critically appraise the evidence to determine
which are most reliable, valid, relevant, applicable
to question
Integration Integrating the evidence with clinical expertise,
patient preferences & values
Evaluation Evaluating outcomes of practice change
Disseminating Sharing information from change
Data sources for EBP• Several different levels of evidence can be used to support a
research question and inform practice improvement and/or
decision making.
• Include, but not limited to:
– Research-based evidence:
• Meta-analyses
• Systematic reviews
• Randomized clinical trials
• Nonrandomized studies
– Non-Research evidence:
• Case reports/clinical experience
• Clinical guidelines
• Expert opinion
• Quality improvement data, risk data, cost-effectiveness analysis
• Benchmarking studies
46Wickham, R. (2016). Evidence-based practice and standards of oncology nursing. In Itano, K. Core
curriculum for Oncology Nursing, 5th ed. ONS: Pittsburgh, PA, pp 531-540.
Levels of Evidence
Level Description Strength
I A systematic review or meta-analysis of all relevant randomized controlled trials (RCT’s), or evidence-based clinical practice guidelines based on systematic reviews of RCTs
Strongest
II At least one well-designed RCT
III Well-designed controlled trials without randomization
IV Well-designed case-control and cohort studies
V Systematic reviews of descriptive and qualitative studies
VI Single descriptive or qualitative study
VII Opinion of authorities and/or reports of expert committees Weakest
47
Melnyk & Fineout-Overhold, 2005
Resources for EBP
• Cochrane Collaboration (www.cochrane.org)
• Agency for Healthcare Research and Quality
(AHRQ) www.ahcpr.gov
• National Guidelines Clearing House
(www.guideline.gov)
• ONS Putting Evidence Into Practice (PEP)
– Symptom management resources designed to offer
evidence-based interventions for patient care,
teaching and staff development
– https://www.ons.org/practice-resources/pep
• National Comprehensive Cancer Network (NCCN)
Clinical Practice Guidelines (www.nccn.org)
48
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Evidence-Based Practice: Putting
Evidence Into Practice (PEP) Resources
From ONS
Homepage
(www.ons.org),
click on “Practice
Resources”
Evidence-Based Practice: Putting
Evidence Into Practice (PEP) Resources
Click on “Putting
Evidence Into Practice
(PEP)
PEP Topics
• Anorexia
• Anxiety
• Caregiver Strain & Burden
• Chemotherapy-Induced Nausea &
Vomiting
– Adult
– Pediatrics
• Cognitive Impairment
• Constipation
• Depression
• Diarrhea
– Chemotherapy-Induced
– Immunotherapy-Induced
– Radiation Therapy-Induced
• Dyspnea
• Fatigue
• Hot Flashes
• Lymphedema
• Mucositis
• Pain
– Acute Pain
– Chronic Pain
– Breakthrough Pain
– Refractory/Intractable Pain
• Peripheral Neuropathy
• Prevention of Bleeding
• Prevention of Infection
– Prevention of Infection: General
– Prevention of Infection: Transplant
• Radiodermatitis
• Skin reactions
• Sleep Wake Disturbances
51
https://www.ons.org/practice-resources/pep, accessed March 8, 2018.
Putting Evidence Into Practice
(PEP) Resources• Green = GO!
– Recommended for Practice
– Likely to Be Effective
– Evidence supports the consideration of these interventions in practice
• Yellow = CAUTION!
– Benefits Balanced with Harm
– Effectiveness Not Established
– Not sufficient evidence to say whether these interventions are effective or not
• Red = STOP!
– Effectiveness Unlikely
– Not Recommended for Practice
– Evidence indicates these interventions are ineffective or harmful
52
https://www.ons.org/practice-resources/pep, accessed March 8, 2018.
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14
National Comprehensive Cancer
Network (NCCN) Guidelines
• NCCN Clinical Practice Guidelines in Oncology are free
at www.nccn.org
– Must register for a free account
• NCCN Guidelines for Treatment of Cancer by Site
• NCCN Guidelines for Detection, Prevention, & Risk
Reduction
• NCCN Guidelines for Supportive Care
• NCCN Guidelines for Specific Populations
• NCCN Guidelines for Patients
53https://www.nccn.org/professionals/physician_gls/default.aspx , accessed March 9, 2018
NCCN Guidelines for Supportive Care
• Adult Cancer Pain
• Antiemesis
• Cancer- and
Chemotherapy-Induced
Anemia
• Cancer-Associated Venous
Thromboembolic Disease
• Cancer-Related Fatigue
• Distress Management
• Management of
Immunotherapy-Related
Toxicities
• Myeloid Growth Factors
• Palliative Care
• Prevention and Treatment
of Cancer-Related
Infections
• Smoking Cessation
• Survivorship
54https://www.nccn.org/professionals/physician_gls/default.aspx#supportive , accessed March 9, 2018
Clinical Trials: Drug Approval Process
• Research protocols designed:
– Within an academic environment
– Through the National Cancer Institute (NCI)
– By pharmaceutical companies
– By cooperative research groups
• Funding may originate from private or public sources
• If trial involves a new agent, U.S. Food and Drug
Administration (FDA) reviews and approves the agent as
an Investigation New Drug (IND)
• Phase I – III clinical trials conducted
• FDA approves new drug for commercial use when
studies have documented efficacy & safety
55Polovich, M., Olsen, M. & LeFebvre, K (Eds). (2014). Chemotherapy and biotherapy guidelines and
recommendations for practice (4th ed.). Pittsburgh, PA: Oncology Nursing Society, page 19.
Phases of Clinical Trials
Phase Description
I • Evaluate safety and toxicities
• Determine maximally tolerated dose (MTD) of new
compound
• Evaluate pharmacokinetics and pharmacodynamics
II • Evaluate response
• Continue to evaluate safety, toxicities, pharmacokinetics,
and pharmcodynamics
III • Randomization
• Compare efficacy & toxicity of new drug to standard of
care or placebo (if no standard of care)
IV • Post FDA approval (after drug is available commercially)
• Collect additional data related to greater number of
patients
• Evaluate new indications56
Polovich, M., Olsen, M. & LeFebvre, K (Eds). (2014). Chemotherapy and biotherapy guidelines and
recommendations for practice (4th ed.). Pittsburgh, PA: Oncology Nursing Society, page 19.
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Clinical Trials
• U.S. Food and Drug Administration (FDA) regulates clinical
trials that involve the licensing of a drug or product
regardless of the source of research funding
• Institutional Review Boards (IRBs) are institutionally based
and assess clinical trials for risks, benefits, and ethical
status
– Monitor overall conduct of the clinical trial
• A data monitoring committee is required for all Phase III
trials
– Independent group of experts
– Purpose: protect the safety of trial participants,
credibility of study, and validity of study results
– May recommend termination of a study if appropriate
57Polovich, M., Olsen, M. & LeFebvre, K (Eds). (2014). Chemotherapy and biotherapy guidelines
and recommendations for practice (4th ed.). Pittsburgh, PA: Oncology Nursing Society, page 19
Role of RN in
Evidence-Based Practice
• Identify practice problems.
• Participate in evaluation of existing evidence
• Collaborate with other health care providers/nurse
researchers
– Identify and implement potential solutions to
specific-clinical problems
• Participate in research activities that may lead to
practice change and add to EBP
• Participate in clinical trials
58Wickham, R. (2016). Evidence-based practice and standards of oncology nursing. In Itano,
K. Core curriculum for Oncology Nursing, 5th ed. ONS: Pittsburgh, PA, pp 531-540.
Education Process
(Teaching & Learning Principles)
Adult Learning Theory
• Describes an adult learner as someone who is self-
directed, independent, and problem centered
• Principles of adult learning
– Adults should understand why they must learn
something
– Adults should be self-directed
– Teaching plan should take prior learning &
experience into account
– Educators should create a learning environment
& culture59
Client/Staff Teaching
• Needs assessment
– What does the patient know?
– What does the patient want to know?
– Cultural or religious practices that impact teaching?
– Physical impairments that may impede learning?
– Preferred language?
– Education background?
• Goals and Objectives
• Teaching Plan
• Evaluation
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Goals & Objectives
Also Called “Outcome Criteria”
• Goals
– Provide a global view of intended outcome (e.g.
“patient will be able to care for self at home)
– Example: Ability for self-care after discharge
– SMART:
• Specific
• Measurable
• Attainable
• Realistic
• Timely61
Objectives
• State “who” will do “what” by “when”
• Effective objectives follow ABCD
– A – Audience (who is the learner)
– B - Behavior (what is the learner to do)
– C – Condition (under what circumstances)
– D – Degree (how much; to what extent is the
learner to perform)
• Provide specific assessment criteria
• Example:
– Client will be able to state 4 foods high in iron
content after reading information regarding foods
with high iron content62
Sample Questions
In developing a staff education program in the ambulatory setting, the nurse educator would do which of the following first?
A. Determine a meeting time and place.
B. Perform a needs assessment to identify the staff’s educational needs.
C. Comply with the JCAHO standard requiring that ambulatory care meet the same quality standards as inpatient care.
D. Certify chemotherapy competency as needed.
63
Sample Question
A data monitoring committee is required for which phase
of a clinical trial?
A. I
B. II
C. III
D. IV
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Sample Question
An oncology nurse is the chairperson of a hospital
committee that is to develop guidelines for fatigue
management. The standard used to guide this effort
would be based on which of the following?
A. American Cancer Society position statement
B. National Institute of Health guidelines
C. National Comprehensive Cancer Network
D. American Nurses Association Nurse Practice Act
65
Sample Question
A patient newly diagnosed with cancer is considering
entering a clinical trial that compares the current
standard treatment with an investigational
chemotherapeutic agent. This is an example of which
phase of a clinical trial?
A. I
B. II
C. III
D. IV
66
Sample Questions
Evidence-based practice (EBP) can best be explained as practice that:
a. Incorporates both research-based and non-research-based evidence
b. Is based solely on findings from multiple, randomized, controlled clinical trials
c. Takes the outcomes of a single research study and uses it in practice with a specific client
d. Uses previous clinical experiences and client outcomes to inform current practice
67
Oncology Nursing Practice – 17% (25 Questions)
A. Scientific basis
1. Carcinogenesis
2. Immunology
3. Clinical trials (e.g. research
protocols)
C. Scope, standards, and related issues
1. Standards of care (nursing process)
2. Legal (including documentation)
3. Accreditation (e.g. The Joint
Commission)
4. Self-care (e.g. managing compassion
fatigue)
B. Site-specific cancer
considerations
1. Pathophysiology
2. Common metastatic
locations
3. Diagnostic measures
4. Prognosis
5. Classification
6. Staging
7. Histological grading
D. Standards of professional performance
1. Ethics (e.g. patient advocacy)
2. Education
3. Evidence-based practice (e.g. Putting
Evidence Into Practice (PEP)
guidelines) and research
4. Quality of practice
5. Communication
6. Leadership
7. Collaboration
8. Professional practice evaluation
9. Resource utilization
10. Environmental health (e.g. Safety,
personal protective equipment, safe
handling)
