Exploring the Work of Nurses who Administer Chemotherapy

86 Pages·2006·0.75 MB·English

by  Catherine Forward

Exploring the Work of
Nurses who Administer
Chemotherapy:
A Multi-Method Study
December 2005

D

Dr Theresa Wiseman
Ms Rebecca Verity
Dr Emma Ream
Miss Emma Alderman

Professor Alison Richardson
This study was supported by a European Oncology Nursing Society (EONS/Roche) grant
(research award) and funding from King’s College London.

This report should be referenced as: Wiseman T, Verity R, Ream E, Alderman E,
Richardson A. (2005) “Exploring the work of nurses who administer chemotherapy: A
multi-method study”. London: King’s College London

December 2005 © King’s College London
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Acknowledgements

We would like to express our gratitude to all the nurses & patients who participated in this
study, without their enthusiasm and honesty this study would not have been possible.
Particular thanks go to the lead nurses for their help in the recruitment process.

We are grateful for the grant from EONS/Roche. The money that came with this grant
provided the foundation with which to undertake this work and was augmented with
resources from the Florence Nightingale School of Nursing and Midwifery, King’s College
London.

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Contents

Section Page

1 Introduction and Aims..............................................................................................................1
Introduction.................................................................................................................................1
Purpose of the study...................................................................................................................2
2 Literature Review....................................................................................................................3
Introduction.................................................................................................................................3
The Literature Search.................................................................................................................3
The Chemotherapy Process........................................................................................................3
The Role and Responsibilities of the Nurse.................................................................................4
Chemotherapy Treatment Environment.......................................................................................5
Patient Satisfaction, Education and Communication...................................................................6
Communication and Patient Psychological Support....................................................................6
Nurses’ Attitudes towards Chemotherapy and Cancer................................................................7
Nurses’ Concerns and Feelings..................................................................................................8
Occupational Risks of Exposure..................................................................................................9
Attitudes towards Occupational Risks of Exposure....................................................................10
Chemotherapy Administration Errors........................................................................................10
Preparation and Support for the Role........................................................................................11
Conclusion................................................................................................................................12
3 Method..................................................................................................................................14
Introduction...............................................................................................................................14
Component One - Survey..........................................................................................................14
Survey aims..........................................................................................................................14
Rationale for Survey Methodology.........................................................................................14
Survey Instrument and Design..............................................................................................14
Questionnaire Development..................................................................................................15
Revisions Made To Original Questionnaire...........................................................................16
Population and Sample.........................................................................................................16
Study Sites and Setting.........................................................................................................16
Sample Size..........................................................................................................................17
Ascertaining and Accessing Sample.....................................................................................17
Procedures for Survey Administration...................................................................................18
Reliability and Validity...........................................................................................................19
Pre-test.................................................................................................................................20
Data Preparation...................................................................................................................20
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Ethical and Research Governance Approval.........................................................................21
Component two – ethnography.................................................................................................22
Aims of the ethnography.......................................................................................................22
Rationale for ethnographic method...........................................................................................22
The settings..............................................................................................................................22
Participants...........................................................................................................................23
Data Collection..........................................................................................................................23
Analysis....................................................................................................................................24
Issues of Rigour....................................................................................................................24
Ethical considerations and approvals........................................................................................24
Time Frame for Both Elements.................................................................................................25
Study Activities..........................................................................................................................25
4 Results from component 1.....................................................................................................26
Introduction...............................................................................................................................26
Response rate...........................................................................................................................26
Sample demographics..............................................................................................................26
Respondents Educational Preparation......................................................................................29
Pre-registration......................................................................................................................29
Post-registration....................................................................................................................29
Formal Chemotherapy Education..........................................................................................31
Feelings towards chemotherapy administration.........................................................................33
Issues of Practice......................................................................................................................34
Support for Nurses................................................................................................................35
Worries about administering Chemotherapy..............................................................................36
Cross tabulations..................................................................................................................37
Non-Parametric tests – Mann Whitney..................................................................................39
Attitudes towards Chemotherapy administration.......................................................................39
Cross tabulations – Somer’s d...............................................................................................41
Non-Parametric tests determining difference in attitudes.......................................................42
Ordinal Regression...................................................................................................................43
5 Results from Component two – ethnography.........................................................................47
Introduction...............................................................................................................................47
Chemotherapy Day Unit 1 (CDU 1)...........................................................................................47
Factors which facilitate nurses’ work.....................................................................................47
Factors which impinge on the work of chemotherapy nurses - CDU 1......................................52
Chemotherapy Day Unit 2 (CDU 2)...........................................................................................53
Factors which facilitate nurses’ work.........................................................................................53
Factors which impinge on nurses’ work (CDU 2)......................................................................54
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Conclusion................................................................................................................................58
5 Discussion.............................................................................................................................58
Introduction...............................................................................................................................59
Summary of Findings................................................................................................................59
Feelings, Attitudes and Beliefs..............................................................................................59
The nature and extent of educational preparation.................................................................60
The challenges of chemotherapy administration.......................................................................61
Limitations of the study.............................................................................................................62
Component One....................................................................................................................62
Component Two....................................................................................................................63
Implications for Practice and Recommendations.......................................................................63
Conclusion................................................................................................................................64
6 References............................................................................................................................65
7 Appendices...........................................................................................................................71

Appendix 1: Questionnaire................................................................................................I
Appendix 2: Revisions to Questions.................................................................................II
Appendix 3: Questions Added.........................................................................................III
Appendix 4: Information for Lead Cancer Nurses ..........................................................IV
Appendix 5: Cover letter to participants...........................................................................V
Appendix 6: Nurse Information Sheet.............................................................................VI

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Figures

Figure 4.1 Frequency of Chemotherapy Administration..........................................................27
Figure 4.2 Chemotherapy Teaching Format..............................................................................30
Figure 4.3 Formats for Further Education.................................................................................32
Figure 4.4 Support of nurses with regards to their queries and concerns about
chemotherapy administration............................................................................................35
Figure 4.5 Nursing support for decisions not to give chemotherapy......................................36
Figure 4.7 Nurses’ Response to Attitude Statements..............................................................41

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TABLES

Table 3.1: Example questions and response formats..............................................................15
Table 3.2: Number of hospital sites and nurses who administer chemotherapy within each
London Cancer Network.............................................................................................................18
Table 3.3: Time Frame for Both Elements.................................................................................25
Table 4.1 Response rate across Cancer Networks...................................................................26
Table 4.2 Response rate across hospital sites.........................................................................26
Table 4.3 Sample Characteristics..............................................................................................27
Table 4.4 Distribution of clinical areas within the sample........................................................28
Table 4.5 Nursing grade.............................................................................................................28
Table 4.6 Professional qualifications obtained or currently being undertaken......................28
Table 4.7 Amount of chemotherapy education of those in receipt of some pre-registration
training........................................................................................................................................29
Table 4.8 Adequacy of the amount of chemotherapy teaching pre-registration....................29
Table 4.9 Amount of chemotherapy education of those in receipt of some post-registration
training........................................................................................................................................30
Table 4.10 Adequacy of the amount of chemotherapy teaching post-registration................30
Table 4.11 Formal chemotherapy education received and further education required.........31
Table 4.12 Most important issues of chemotherapy education as rated sample...................33
Table 4.13 Feelings about Administering Chemotherapy........................................................33
Table 4.14 Reasons given as to when it is not safe to administer chemotherapy.................34
Table 4.15: Frequency of those who felt supported in decision to not give chemotherapy..35
Table 4.16 Associations between nursing grade and worries.................................................38
Table 4.17 Cross tabulations between nursing grade and not worrying about chemotherapy
administration.............................................................................................................................38
Table 4.18 Associations between clinical area and worries....................................................38
Table 4.19 Cross tabulations between clinical area and worries.............................................39
Table 4.20 Attitudes towards chemotherapy administration...................................................40
Table 4.21 Significant associations between attitude and nursing grade..............................42
Table 4.22 Significant associations between attitudes and place of work.............................42
Table 4.23 Mann Whitney results- Attitude by chemotherapy experience..............................43
Table 4. 24 Ordinal regression model for worries about chemotherapy role.........................44
Table 4.26a Ordinal regression model for attitudes towards chemotherapy (Site and Educational
level)................................................................................................................................................................45
Table 4.26b Ordinal regression model for attitudes towards chemotherapy (Nursing grade and
Experience)....................................................................................................................................................46
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1 Introduction and Aims

Introduction
Chemotherapy is presently the main systemic treatment available to treat cancer. Of the
one in three people diagnosed with cancer (Department of Health, 2002) approximately
60% will receive chemotherapy as part of their treatment (Bremnes, 1999). It is, however,
a treatment that can potentially cause much harm, both to those receiving it and those
administering it. Over the last two decades chemotherapy administration has increasingly
become the role of the nurse. Nurses have four main roles in the chemotherapy
administration process: educating patients and their families about this form of therapy,
administering the chemotherapy agents safely and managing any side effects patients
may have (Tanghe et al., 1994). In addition, nurses need to support patients emotionally
through the process (Dennison, 1995; Richardson, 1996; Wilkinson, 1991)

A number of studies have indicated that patients are often unsatisfied with aspects of the
chemotherapy administration process including communication and psychological support;
waiting times; assessment and management of side effects; and information giving (see
for example (Mun et al., 2001; Sitza & Wood, 1998a). Although nurses are competent in
providing information, they rarely make any assessment of patients’ feelings about their
treatment (Dennison, 1995). In addition, poor management of chemotherapy induced side
effects, such as nausea and vomiting has been shown to adversely affect patients’ quality
of life (Brown et al., 2001; Richardson, Marks, & Levine, 1998) and levels of anxiety about
treatment (Mun et al., 2001). However, when patients are assessed, given information and
their side effects managed effectively, their anxieties decrease and their compliance with
treatment improves (Sitza & Wood, 1998a). One area patients are rarely dissatisfied with
is the nursing skills involved in the technical aspects of chemotherapy administration (Mun
et al., 2001). When trying to explain their findings researchers have identified a need to
explore the chemotherapy process in more depth.

While there is research investigating patient satisfaction with chemotherapy nursing care
there is currently a dearth of research from nurses’ perspectives. It is argued that to give
quality emotional and physical support to the individual with cancer and their families, the
nurse’s perception and experience of work in this field of care needs to be explored in
some depth (McCray, 1997). Recent national clinical guidelines for the administration of
cytotoxic chemotherapy recommended that more research is urgently required to
understand factors which may influence effective practice. Two areas particularly
highlighted were:
• Nature of staff and others’ beliefs and knowledge deficits
• Impact on practice of beliefs, knowledge and knowledge deficits
(Goodman, 1998a)

Some of these issues were explored using an investigator designed, self-completion,
questionnaire sent to 260 nurses working within a specialist cancer hospital (Verity, 2002).
Results showed that factors influencing patient care included; staff education and
experience, pressures of time and workload, nurses receiving regular knowledge updates;
and working with more experienced and knowledgeable nurses. The findings also
suggested that nurses who were educationally prepared and underwent practice
supervision had a positive attitude towards their role in chemotherapy. There also
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appeared to be wide variation in educational preparation for the role, a cause for concern,
given the implications of chemotherapy administration. Although this study was useful in
terms of its findings, it was a small, local, study so the results cannot be generalized.

Care that was once delivered in hospital is now being delivered in busy outpatient settings
due to reduced resources, increasing monetary constraints, increased workload and
increased demand for treatment (Fitzsimmons et al., 2002). Administration of
chemotherapy is one such area where restructuring of services has led to the majority of
patients now receiving chemotherapy in outpatient departments. As chemotherapy
regimes have developed and become more amenable to delivery in an out patient setting,
it is important that current chemotherapy practice be examined to understand factors
which may impinge or enhance care received by patients. Evaluation of the role of nurses
is imperative because it can inform decision-making, influence educational programme
development and ultimately impact on nursing practice (Kearney, 2000).

Purpose of the study
This overall purpose of this study was to explore the process and context of nurses
administering cytotoxic chemotherapy.

The study sought to:
• Observe and describe nurses’ practice of chemotherapy administration.
• Explore attitudes, feelings and beliefs of nurses’ administering chemotherapy.
• Highlight any discrepancies between attitudes and behaviours.
• Understand the factors that contribute to these discrepancies.

In order to fulfil these aims methodological and investigator triangulation was considered
necessary; this research therefore, consisted of two elements. Element one involved
undertaking a questionnaire survey to investigate nurses’ perspectives of administering
chemotherapy. Element two was an ethnographic study exploring the work of nurses in
two chemotherapy outpatient settings. This allowed for collection of both quantitative and
qualitative data which, it was believed, would lead to a more comprehensive
understanding of chemotherapy administration from a nurse’s perspective. In addition, the
use of more than one research strategy would enable more robust testing of the validity
and reliability of research findings (Aldridge & Levine, 2001)

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