When the NHS first evolved, the prognosis for patients with Cancer was appalling, but over the last 30 years, the revolution in drug therapies has transformed nursing practice. Advancing technology over the last decade in particular, has resulted in major changes in the specialist field of oncology, where medical innovations have had an enormous impact on the role of the nurse working in cancer care. Cancer nurses are now performing tasks that nobody would ever have thought possible, and their contribution to patient care is now being increasingly recognised.
The past few years have seen remarkable advances against cancer, which have led to dramatic improvements in longer-term survival and cure. One prime example, is in the area of childhood cancers, where by the year 2000, it is estimated that 1 in 1000 of our young adult population between the ages of 20-29yrs, will be survivors of childhood cancer (Meadows et al, 1986). Although innovations have resulted in a current 65% overall cure rate in childhood cancer, the associated effects carry the potential of multi-organ system morbidity. As a result, cured and grown survivors have the potential to develop significant problems, which may last a lifetime. In this respect childhood cancers are qualitatively and quantitatively unique. A 5 year old cured of cancer has over 70 years of life expectancy left, thus allowing the emergence of long term effects in the future, which wouldn’t have the same effect in a 70 year old cured of cancer with around 5 years of life expectancy left. This has an enormous impact on the nurse working with children and young people with cancer.
Medical innovations, which have led to increased survival in many types of cancer, in both adults and children, have not been without consequence. For some it has meant the development of intensive treatment protocols, with devastating widespread side effects, which have created a higher dependency of patient, who require intensive nursing care and support. For Example: –
- the development of biological therapies, such as
i) Monoclonal antibodies, which can target specific tumours; i.e. Mibg therapy.
ii) Colony stimulating factors, such as GCSF, that help the patient’s immune system recover more quickly from the effects of cancer drugs, enabling more high dose intensive treatments to be given.
- Peripheral stem cell harvests and transplantation, to support high dose therapies.
For other patients, innovations have improved the quality of life, decreased hospitalisation and facilitated for many, ambulatory care. For example : –
- less radical surgery for breast, and prostate cancers
- limb sparing surgery for many sarcoma patients
- more accurate, less invasive procedures for detection, using fibre-optic technology
- increased precision in treatments such as Radiotherapy, decreasing normal tissue toxicity
- increased ability to individualise treatments because of improved diagnostic tools
- the development of drugs, which have facilitated better control of pain, nausea and vomiting.
The impact, however, is just as great on the patient, but poses different challenges to the nurse. They require as much support as patients receiving intensive in-patient treatments, their diseases and treatments being as much a source of anxiety and stress. In relation to Radiotherapy treatment in particular, the vast majority attend daily, and the location of the treatment centre and frequency of treatments can cause additional significant disruption (Hinds and Moyer, 1997).
The role of the nurse in out-patient care is rapidly changing, and nurses need to be empowered to assume new roles, which can be achieved through the development of nurse-led clinics. This is vital, as the whole thrust of modern care is towards treating as an outpatient whenever possible. The number of outpatient attenders is therefore rising, and the need to rationalise how care is delivered is becoming imperative.
Professional nursing bodies, have, in response to changing needs, encouraged nursing to open the door to further expansion and development, through their work on the Code of Professional Conduct, and the Scope of Professional Practice, both, 1992. These frameworks have assisted nurses in the move further along the road towards professional accountability and autonomy in practice. The Scope of Professional Practice, 1992, in particular, has helped pave the way for nurses to extend their role in the provision of care, in a way which has increased the status and value of nursing, instead of allowing ourselves to remain handmaidens to the medical profession. Nurses now have the opportunity to extend their roles appropriately, absorbing activities into the holistic nature of nursing, informed by nursing values (Denner, 1995).
Medical innovations have therefore, had a major impact on the role of the nurse working in cancer care, presenting a myriad of challenges. The nurses’ role has expanded to incorporate co-ordinator, facilitator, educator , researcher, communicator, innovator and advocate, to name but a few of the competencies required. To meet these goals, the nurse must have the authority and autonomy to manage and control nurses’ practice (Bowman, 1995).
Nursing care of the patient today makes great demands on nurses’ knowledge and skills, especially if the care given is to be competent, efficient and effective. It also raises many ethical issues and dilemmas, and it is imperative that nurses’ familiarise themselves with basic ethical principles. Ethical dilemmas remain an uncomfortable issue for many nurses, who are increasingly faced with decisions that have no clear “right” answers. The role of the nurse in this capacity, is to work in collaboration with other healthcare professionals, to make the best possible decisions that support the underlying ethical principles of highest value (Vestal, 1995).
The possibilities for progressive and innovative practitioners are wide-ranging, but to be effective, must have the support of managers and the organisation as a whole.
Educationally, oncology nurses need to develop a wide knowledge base, in order keep up to date with current practices, and the continually changing wealth of oncology literature. It is imperative for each individual nurse to be familiar with the potential effects on the patients they care for, regarding problems which may arise relating to treatments, and unique aspects of definitive management of those problems. Nurses therefore need to ensure they keep up to date with personal and professional development, and are supported throughout professional life. Indeed, there is
no end point in the need to maintain and develop standards of practice, (UKCC, 1993), particularly in a rapidly changing environment such as oncology nursing.
There are an ever increasing variety of roles for the cancer nurse. Much of the progress made, over the years, has resulted from clinical trials and research. Nurses are currently developing their roles alongside of this, in particular, through specific disease orientated groups, thereby creating specialist roles within a speciality. Nurses are also working more in the promotion of health, in an attempt to utilise prevention strategies.
For patients on intensive treatments, reliable intravascular access for administration of chemotherapy agents, fluids, blood products, antibiotics and nutritional support, has become an essential feature of medical care (Maki, 1991). The increasing use of central venous access devices has greatly facilitated safe and effective administration for patients on intensive protocols, with minimal discomfort. However, there are potentially very dangerous consequences, and they require effective management. Nursing staff, must undertake specific training in order to develop a knowledge, expertise and competence if they wish to care for them, an extended role undertaken by many nurses’ in an attempt to provide holistic and efficient care for the patient. Indeed the creation of specialist nursing roles, are facilitating insertion of the central lines by appropriately trained nurses, with extremely effective outcomes.
In relation to technology, the nurse has to contend with the increasing sophistication of information, and the growth of telecommunications, which continue to speed up the exchange of information, knowledge and ideas. Our specialised body of knowledge is now being challenged. Both the medical and nursing professions no longer have a monopoly over their knowledge bases. Access to information from the media and the Internet, and the increasing emphasis placed on health promotion has resulted in the wider public becoming far more aware of medical innovations taking place all over the world. Families bring this information into our clinical areas when discussing treatment options. In addition, there have been the ever-increasing demands of informed patients on matters relating to their health, care and progress, with rights enshrined in the Patient’s Charter. (DOH, 1991).
It is now, therefore, even more crucial that nursing keep abreast of developments in cancer care. Alongside of this, it has become increasingly important that nurses recognise their own limitations in practice, referring clients to the appropriate personnel as required. In an era of increasing litigation and accountability, the nurse working in cancer care needs to develop a solid understanding of legal issues. With advances in practice through medical innovations, nurses are increasingly confronted with many varied and complex practice situations. It is therefore imperative to produce legible, accurate, effective, contemporaneous nursing records which co-ordinates and communicates patient care activities.
The role of the nurse not only involves planning, implementing and evaluating hospital care effectively, but planning for discharge, must be commenced right from admission, so that effective care can be maintained following discharge of care into the community. This is an essential aspect of the nursing role, as, regardless of whether the patient is being treated with curative or palliative intent, it is important that their individual needs continue to be met by the appropriate personnel at all stages in their illness.
Medical innovations have resulted in the rapid and continuing expansion of specialisation and complexity in the delivery of healthcare. This has led to the development of an array of levels of nursing practice and a multitude of titles, competencies and training programmes (Furlong and Glover, 1998).
The creation of enhanced nursing roles, with titles being inconsistently applied, such as clinical nurse specialist, specialist practitioner, advanced nurse practitioner, nurse specialists and nurse practitioner, suggests that the scope and content of roles vary widely, but even where roles share a common title, there is evidence to suggest that they operate in different ways (Furlong and Glover, 1998). Fellow healthcare professionals, both nursing and medical, and, more importantly, patient’s themselves, are finding it difficult to keep up with the changes, often not clearly understanding an individual’s nursing role. We have been used to sharp boundaries between services, and clearly defined roles for professionals in the past, but these are slowly being eroded by medical innovations with shifting demands, and resulting ethical challenges, which have blurred professional boundaries (DOH, 1994). Therefore, alongside of developing roles, we need to establish a recognised framework that encompasses ethical, educational and legal accountability issues, and clarifies for the post- holder, fellow healthcare professionals and patients, the scope and remit of their role.
Educationally, staff must receive appropriate training and development in order to carry out their roles effectively. Lack of clarity and definition of certain roles has hampered this to some extent, but nurses need to, and must learn to take responsibility for their own personal and professional development, and plan how these needs are going to be met. The opportunities for staff development in cancer care are numerous. There is a multitude of support available, from teaching sessions and relevant study days, through to specialist courses, leading to recognised specialist qualifications. These are, in the main, easily accessible and well supported by management. The Calman-Hine Report re-iterates that if the treatment and care of patients with cancer is to be maintained at a uniformly high standard, the health care professionals involved must receive special training in oncology (DOH, 1995). This has become even more vital, as technology affects where a service is offered and by whom. It has in the past promoted centralisation of services, but now its effect is to facilitate movement the other way (DOH, 1994). Indeed, it is the objective of the Calman-Hine recommendations that commoner cancers are treated in cancer units, with specialist centres caring for the more complex and unusual tumours.
Nurses’ working in cancer care, must therefore seize the initiative, and take responsibility for their own learning needs, if they are to increase their expertise in line with the complexity of modern medicine.
While many innovations have been made, cancer mortality rates remain high in a number of areas, and more work still needs to be done. We do, however, now know much more about the limits, as well as the triumphs, of medical science. As our understanding of what constitutes health care shifts, and we continue to develop partnerships with the patient, patients may not welcome increased medical intervention at the expense of quality of life. This is all about informed choice, and an important aspect of care. One thing for certain, is that the skills involved in caring and communicating with the cancer patient, the traditional domain of the nurse, will continue to become increasingly important to all cancer nurses. (Hancock, 1998). As Christine Hancock recently said, “Perhaps for the patient’s of the next century, the key question will not be: Can you cure me doctor? but: What are my options, nurse?” (Hancock, 1998).
Denner S, 1995. “Extending Professional Practice : Benefits and Pitfalls”. Nursing Times, Vol 91, no 14, pp27-29, 1995.
Department of Health, 1991 “The Patients Charter”. HMSO. London.
Department of Health, 1994. “The challenges for nursing and midwifery in the 21st century.” HMSO. London.
Department of Health, 1995. “A Policy framework for commissioning cancer services : a report by the expert advisory group on cancer to the chief medical officers of England and Wales”. HMSO. London.
Furlong S and Glover D, 1998. “Confusion surrounds piecemeal changes in nurses’ roles”. Nursing Times; Sept 16, Vol 94, no 37, pp54-55, 1998.
Hancock C, 1998. “Wide awake and stretching”. Nursing Times, July 1, Vol 94, no 26, p32, 1998.
Hinds C and Moyer A, 1997 : “Support as experienced by patients with cancer during radiotherapy treatments.” Journal of Advanced Nursing, 1997, 26, pp371-379.
Maki D.G., 1991 : “Improving catheter site care”. International congress and symposium series. Royal Society of Medicine services Ltd, 1991. Series no. 179.
Meadows A.T. and Hobbie W.L., 1986. “The medical consequences of cure”. Cancer. 58. pp524-528.
UKCC, 1992. “Code of Professional Conduct for the Nurse, Midwife and Health Visitor”. UKCC. London.
UKCC, 1992. “The Scope of Professional Practice”. UKCC. London.
Vestal K.W, 1995. “Nursing Management : concepts and issues.” pp 297-318. J.B. Lippincott. Philadelphia.
Hunt G and Wainwright P, 1995. “Expanding role of the nurse”. Blackwell science. Oxford.
Robinson J, Gray A and ElkanR, 1993. “Policy issues in nursing.” Open university press. Milton Keynes. Philadelphia.