314 Volume 28, Issue 4, Fall 2018 • CanadIan onCology nursIng Journal reVue CanadIenne de soIns InFIrmIers en onCologIe
FEA TURES /Ch R o niq UES PleNArY PreseNtAtiON
Editor note: This manuscript was based on a plenary presentation provided at the Annual Canadian Association of Nurses in Oncology Conference 2017 held in Gatineau, Quebec.
The evolution of oncology nursing:
Leading the path to change
by Greta G. Cummings, Sarah D. Lee, and Kaitlyn C. Tate
ABstrAct
The roles and responsibilities of oncology nurses have rapidly transformed over the past century from general nurses providing bedside comfort care with few technologi- cal advances to advanced practice oncology nurses responsible for everything from per- forming invasive procedures to diagnostic interpretation and screening for cancer pre- vention. As cancer care continues to evolve, nurses will play a key role in the field of oncology, whether as specialized oncology nurses providing clinical care or as nurse researchers spearheading groundbreaking oncology research.
O
ncology nursing has evolved sig- nificantly over the last century, as cancer becomes one of the leading causes of death globally. Current statis- tics show that almost 45% of Canadian women and 49% of men will develop cancer during their lifetime, and one out of every four Canadians will die from cancer (Canadian Cancer Society, 2018). This increase in cancer bur- den has left many oncology nurses stressed and burned out, as nursing resources are spread too thin to meet the care needs of cancer patients (Ko& Kiser-Larson, 2016). Bakker et al.
(2006) found that Canadian nurses felt their workload had increased by as much as 30–50% through increased
patient numbers. The situation is not unique to Canada; the role of oncology nurses is expanding and adapting to care needs and scarce resources inter- nationally (So et al., 2016). Supporting oncology nurses is vital to ensure peo- ple with cancer are appropriately cared for and guided through their individ- ual journeys in a time of utmost need and vulnerability (Komatsu & Yagasaki, 2014). As cancer rates continue to rise, we explore the role and responsibilities of the oncology nurse in cancer care by reflecting on where it all started, exam- ining our current practices and think- ing forward to the future and how to best practise nursing within oncology.
As cancer remains prevalent, the role of oncology nurses at the forefront of can- cer care is more involved and compli- cated than its humble beginnings.
HistOrY OF ONcOlOGY NursiNG
Over the last hundred years, cancer care has come a long way from general nurses caring for patients with cancer, using primarily bedside and comfort measures, to the development of oncol- ogy nursing as a specialty (Haylock, 2008) with a defined knowledge base, supported by research and expert prac- tice. Without specialized education or training in oncology, early cancer nurses were often forced to be creative in caring for patients with various com- plications of cancer treatment, such as radiation burns and pain (Ferris, 1930).
In the early 20th century cancer nurs- ing was perceived as arduous, depress- ing and even dangerous work, as the prospects of cancer patients surviv- ing were slim and nurses were often exposed to harmful chemicals (Barckley, 1985). Radiation was accepted as the therapeutic option for many forms of
cancer by the 1920s. However, the way in which radiation was administered often left nurses in contact with dan- gerous substances, such as radium and radon (Haylock, 2008). Some nurses refused to take care of cancer patients, as they believed doing so posed a signif- icant risk to their own health and ideas that cancer was contagious were well entrenched until the 1930s (Haylock, 2008). Another factor influencing the role of oncology nurses was the broader context of the shifting roles of women during World War I. As many men went off to war, nurses began to take on roles originally reserved for physicians, such as venipuncture (Haylock, 2011).
Oncology nursing has developed and changed over recent decades. In the 1940s, nursing of people with cancer began to change with the introduction
ABOut tHe AutHOrs
Greta G. Cummings, RN, PhD, FAAN, FCAHS
Sarah D. Lee, MSc
Kaitlyn C. Tate, RN, BN, doctoral student
Figure 1: A physician is changing the dressing on a patient’s neck, while a nurse holds the patient’s head.
(Unknown, 1950)
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of oncology nursing as a specialty in the United States and the creation of specialized education and training for oncology nurses (Lusk, 2005). In 1947, the first university course in can- cer nursing was offered at Columbia University and represented the begin- ning of a shift in oncology nursing edu- cation (Yarbro, 1996). By the 1950s, the full impact of cancer was starting to be realized, which led to the recognition that nurses required additional prepa- ration to provide comprehensive care to those who had cancer (Peterson, 1954).
Cancer care continued to change rapidly over the next few decades. According to Lynaugh (2008) “the period between 1950 and 1980 was a time of erratic, but fundamental change in every arena of nursing” (Lynaugh, 2008, p. 13). The 1960s saw an increase in the number of clinical trials in oncology and with this came the desire of care continuity from trial participants (Haylock, 2011).
During this time of rapid change, the role of the oncology nurses evolved from a primarily task-oriented care role to integral member of the cancer care team, often serving as liaison between clinical investigators and other disci- plines that were becoming common to cancer care teams (Haylock, 2011).
During this time of change, nursing leaders in oncology saw the need and an opportunity to found societies and
associations of cancer nurses across var- ious countries to support nurses and share oncology nursing knowledge.
The International Society of Nurses in Cancer Care (ISNCC) was founded in 1984 (International Society of Nurses in Cancer Care [ISNCC], 2018) and in con- junction, the first cancer nursing jour- nal, Cancer Nursing: An International Journal for Cancer Care was established in 1978 (Cancer Nursing, 2018). Shortly after ISNCC, the Canadian Association of Nurses in Oncology (CANO/ACIO) was founded in 1985, by a unanimous vote of more than 300 Canadian oncol- ogy nurses, with the goal to create a professional body to support other Canadian nurses working with cancer patients and advocate for appropriate care for patients and roles for oncology nurses (CANO/ACIO, 2018).
suPPOrtiNG tHe PrOFessiONAl DeVelOPMeNt OF ONcOlOGY NursiNG
The role of CANO/ACIO has evolved since its inception along with the chang- ing field of oncology nursing, most nota- bly with the development of the CANO/
ACIO Standards of Care for oncology nursing in the early 2000s (CANO/ACIO, 2017). These nine standards of care were intended to reflect the core compo- nents of oncology nursing and include:
individualized/holistic care, family-cen- tred care, self-determination, navigat- ing the system, coordinated continuous care, supportive therapeutic relation- ship, evidence-based care, professional care, and leadership (CANO/ACIO, 2017). Standards were developed to guide oncology nurses in their work, but the mechanisms by which these apply to the day-to-day practice of oncology nursing in Canada are less understood.
One study found a lack of awareness of CANO standards of care among oncol- ogy nurses, as well as a disconnect between predefined roles and enactment of these roles (Lemonde & Payman, 2015). Oncology nurses were most chal- lenged in taking on leadership roles and engaging in professional development, warranting the further development of leaders in the field of oncology nursing (Lemonde & Payman, 2015).
While many studies have shown that relational nursing leadership is signifi- cantly related to improved outcomes for the nursing workforce, the work environment (Cummings et al., 2018) and for patients (Wong, Cummings, &
Ducharme, 2013), it is helpful to under- stand what leadership is and how it applies to the role of the oncology nurse.
Leadership is being able to see the pres- ent for what it really is, seeing the future for what it could be, and then taking action to close the gap between today’s reality and the preferred future of tomor- row (Cummings, 2012). For the nursing leaders in the early 1980s who envisioned that oncology nursing societies were needed to support nurses in their roles to provide the best care, education and sup- port for those living with cancer and their families, seeing what this future looked like and then moving on to actually build and sustain that future is an awesome feat. Likewise, we have many immediate opportunities to envision and act to build a preferred future with our patients every shift, every day, every year. In many dif- ferent ways, all oncology nurses can be leaders, as they envision, advocate and innovate ways that caring with and for their patients can be improved, expecta- tions can be discussed and outcomes can be changed. It may mean that there is something you will do differently tomor- row that will lead to different outcomes Figure 2: Patient receiving Cobalt 60 cancer therapy. (Unknown, 1951)
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for your patients. You will listen differ- ently, advocate more clearly, prepare your care with new knowledge, take on a new perspective, and see the work and its problems differently. Nursing lead- ership is characterized by critical think- ing, action and advocacy across all roles, practice settings and domains of nursing practice (Truant & Chan, 2017).
lOOKiNG tO tHe Future
While it is important to examine the history of oncology nursing, we must also consider where the future of oncology nursing is headed. One way in which oncology nursing is changing is in the increased specialization and advancement of nurse training, includ- ing an increase of specialized oncol- ogy nurses and Professional Cancer Navigators. Professional Navigators are nurses who provide continuity for patients and their families through- out the entire cancer treatment process by helping them navigate the system and liaising with other healthcare pro- fessionals and community agencies on their behalf (Cook et al., 2013). The future is pointing towards an increase in advanced practice nurses (APNs), as they function to meet both the medical and nursing needs of patients through a model of collaboration, shared respon- sibility, and accountability (Rieger
& Yarbro, 2003). Most provinces in Canada now have APNs in oncology that provide advanced nursing care to patients and families.
The role of oncology nurses will con- tinue to evolve, as research expands and cancer treatment options change. One such emerging health sciences research model is Precision Health, which uses very large datasets (“Big” data), an indi- vidual’s genetic makeup, environmen- tal exposures and lifestyle to create and apply a program of illness prevention, detection and intervention that is tai- lored to that individual (Nevidjon, 2018).
The origins of Precision Health began as personalized medicine built on early genome research to identify what kinds of treatments would be more or less effective in certain populations, groups and individuals. Precision Health is now an interdisciplinary research approach to refining our knowledge about effectiveness of treatment, and risk per patient. Nurse researchers play a key role in exploring the possibili- ties for Precision Health to improve treatment for oncology patients and reduce the harmful side effects experi- enced from traditional chemotherapy.
One such nursing oncology researcher from the University of Alberta, Dr.
Edith Pituskin, is leading Cardiotoxicity Prevention Research Initiative (CAPRI), the development of a database that aims to identify risk of cardiotoxicity in indi- viduals receiving chemotherapy for breast cancer. Her work aims to develop a biomarker that identifies this risk and then to eventually give the health team a decision-making tool that supports personalized, safer chemotherapy treat- ment. “CAPRI will lead to a system that
enables the treatment team to identify, based on a simple blood test, who is at risk of major complications from che- motherapy and possibly alter the ther- apy or start another intervention early”
(Young, 2017). As treatment for cancer evolves, oncology nurses will require continued education to understand how Precision Health can inform prevention and treatment options for individual patients. It will allow oncology nurses to provide more individualized care, and will also come with increased responsi- bility to provide education and support for patient decision-making related to their diagnosis and treatment options.
Understanding the social, ethical and legal frameworks around Precision Health and its implications for patients will become increasingly important for the oncology nurse in the future.
The roles and responsibilities of oncology nurses have rapidly trans- formed over the past century from gen- eral nurses providing bedside comfort care with few technological advances to advanced practice oncology nurses responsible for everything from per- forming invasive procedures such as bone marrow aspiration, and biopsies, to diagnostic interpretation and screen- ing for cancer prevention (Bishop, 2009). As cancer care continues to evolve, nurses will play a key role in the field of oncology, whether as specialized oncology nurses providing clinical care, or as nurse researchers spearheading groundbreaking oncology research. The future of oncology nursing is bright.
reFereNces
Bakker, D., Fitch, M.I., Green, E., Butler, L.,
& Olson, K. (2006). Oncology nursing:
Finding the balance in a changing health care system. Canadian oncology nursing journal / Revue canadienne de nursing oncologique, 16(2), 79–98.
Barckley, V. (1985). The best of times and the worst of times: Historical reflections from an American Cancer Society National Nursing Consultant. Oncology Nursing Forum, 12(1 Suppl), 16–18.
Bishop, C.S. (2009). The critical role of oncology nurse practitioners in cancer care: Future implications. Oncology Nursing Forum, 36(3), 267–269.
doi:10.1188/09.ONF.267-269
Canadian Cancer Society. (2018). Cancer statistics at a glance. Retrieved from http://www.
cancer.ca/en/cancer-information/cancer-101/
cancer-statistics-at-a-glance/?region=on Cancer Nursing. (2018). Cancer Nursing: An
International Journal for Cancer Care.
Retrieved from http://www.ovid.com/
site/catalog/journals/374.jsp
CANO/ACIO. (2017). Standards of care.
Retrieved from https://www.cano-acio.ca/
page/standards_of_care
CANO/ACIO. (2018). History. Retrieved from https://www.cano-acio.ca/page/history Cook, S., Fillion, L.F., Fitch, M., Veillette,
A.-M., Matheson, T., Aubin, M., … Rainville, F. (2013). Core areas of
practice and associated competencies for nurses working as professional cancer navigators. Canadian Oncology Nursing Journal, 23(1), 44–52.
doi:10.5737/1181912x2314452
Cummings, G.G. (2012). Editorial: Your leadership style - how are you working to achieve a preferred future? Journal of Clinical Nursing, 21(23–24), 3325–3327.
Cummings, G.G., Tate, K., Lee, S.D., Wong, C.A., Paananen, T., Micaroni, S.P.M., &
Chatterjee, G.E. (2018). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 85.
317
Canadian OnCOlOgy nursing JOurnal • VOlume 28, issue 4, Fall 2018 reVue Canadienne de sOins inFirmiers en OnCOlOgie
FEA TURES /Ch R o niq UES
Ferris, A.A. (1930). The nursing care of cancer patients: Some recent developments. The American Journal of Nursing, 30(7), 814. doi:10.2307/3410484 Haylock, P.J. (2008). Cancer nursing: Past,
present, and future. Nursing Clinics of North America, 43, 179–203. doi:10.1016/j.
cnur.2008.02.003
Haylock, P.J. (2011). Cancer nursing: The modern era. Oncology Nursing Forum, 38, E7–E14.
International Society of Nurses in Cancer Care (ISNCC). (2018). About ISNCC.
Retrieved from https://www.isncc.org/
page/About_ISNCC
Ko, W., & Kiser-Larson, N. (2016). Stress levels of nurses in oncology outpatient units. Clinical Journal of Oncology Nursing, 20(2), 158–164. doi:10.1188/16.
CJON.158-164
Komatsu, H., & Yagasaki, K. (2014). The power of nursing: Guiding patients through a journey of uncertainty.
European Journal of Oncology Nursing, 18, 419–424. doi:10.1016/j.ejon.2014.03.006 Lemonde, M., & Payman, N. (2015).
Perceived roles of oncology nursing.
Canadian Oncology Nursing Journal, 25(4), 422–431. doi:10.5737/23688076254422431
Lusk, B. (2005). Prelude to specialization: US cancer nursing, 1920-50. Nursing Inquiry, 12(4), 269–277.
Lynaugh, J.E. (2008). Nursing the Great Society: The impact of the nurse training Act of 1964. Nursing History Review, 16, 13–28. doi:10.1891/1062-8061.16.13 Nevidjon, B.M. (2018). Oncology nurses:
Innovating precision care in a changing treatment environment. Asia-Pacific Journal of Oncology Nursing, 5(2), 131–133.
doi:10.4103/apjon.apjon_1_18
Peterson, R.I. (1954). Knowledge of cancer:
Equipment for nursing. The American Journal of Nursing, 54(4), 463–466.
doi:10.2307/3460957
Rieger, P.T., & Yarbro, C.H. (2003). Advanced practice in oncology nursing. In P.R.
Kufe DW, Weichselbaum RR, et al. (Ed.), Holland-Frei Cancer Medicine (6th ed.).
Hamilton (ON): BC Decker.
So, W.K.W., Chan, R.J., Truant, T., Trevatt, P., Bialous, S.A., & Barton-Burke, M.
(2016). Global perspectives on cancer health disparities: Impact, utility, and implications for cancer nursing. Asia- Pacific Journal of Oncology Nursing, 3(4), 316–323. doi:10.4103/2347-5625.195885
Truant, T., & Chan, R.J. (2017). Future ready: Strengthening oncology nursing leadership in the context of professional oncology nursing organizations.
Canadian Oncology Nursing Journal, 27(1), 2–8.
Unknown. (1950). Doctor changing dressing 1950. In National Cancer Institute Visuals Online: National Cancer Institute.
Unknown. (1951). Cobalt 60 cancer therapy 1951. In National Cancer Institute Visuals Online: National Cancer Institute.
Wong, C.A., Cummings, G.G., & Ducharme, L. (2013). The relationship between nursing leadership and patient outcomes:
A systematic review update. Journal of Nursing Management, 21(5), 709–724.
doi:https://dx.doi.org/10.1111/jonm.12116 Yarbro, C. (1996). The history of cancer
nursing. In M.R. Baird SB, Grant M (Eds.), Cancer nursing : A comprehensive textbook (2nd ed.). Philadelphia W.B.
Saunders.
Young, L. (2017, May 29). Database aims to personalize chemotherapy and reduce long-term heart risks. Folio. Retrieved from https://www.folio.ca/database- aims-to-personalize-chemotherapy-and- reduce-long-term-heart-risks
