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
ii
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.
iii
Contents
Section
1
Page
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
iv
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
v
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
vi
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
vii
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
viii
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
1
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)
2
2 Literature Review
Introduction
Cytotoxic chemotherapy is the main systemic treatment currently used to treat cancer. It is
a treatment, which can without exception, cause extreme harm to patients, staff and the
environment if the drugs are not prescribed, handled and administered safely and
correctly. It continues to be a rapidly expanding treatment modality for many malignant and
some non-malignant diseases. Treatment regimes are also becoming increasingly
complex. Nurses are undertaking this role not only in specialist cancer centres but also in
general hospital settings and the community. Furthermore, chemotherapy is now more
likely to be administered on an outpatient basis; this trend will continue to rise over the
coming years due to the significant increasing numbers of patients receiving
chemotherapy and financial constraints (Taylor & Birch, 2004)
While oncology nurses have appeared to embrace this extended role there has been little
work exploring nurses’ experiences, attitudes and feelings in relation to the chemotherapy
administration process. Little is also known nationally in the UK about the educational
standards, needs and competence of practitioners in this area, due to a dearth of research
and audit findings. To clarify the purpose and rationale for this study this next section will
critically examine the available past and current literature within the area of the nurses’
role in chemotherapy administration.
The Literature Search
Extensive searches were undertaken through the following databases:
•
•
The Cumulative Index to Nursing and Allied Health Literature (CINAHL) 1982August 2005
Medline 1975-August 2005
Key words used included: cytotoxic, chemotherapy, antineoplastic agents/adverse effects,
neoplasm’s/drug therapy, education, stress, burnout, communication, oncology
nurses/nursing, cancer nursing/nurses; drug administration; occupational risk/exposure,
quality assurance, patient satisfaction, outpatients, nurse-led clinics.
The Chemotherapy Process
Administering cytotoxic drugs should be viewed more as process rather than the isolated
act of just giving these drugs to patients (Goodman, 1998b; Grundy, 1999)The findings of
a quality assurance case study undertaken by (Tanghe et al., 1996) identified that
chemotherapy administration is a four-stage process incorporating the prescribing of the
drug, preparation, administration and post-chemotherapy assessment. The Royal College
of Nursing (RCN) guidelines for the administration of chemotherapy state that this process
incorporates three components, that of the drug, patient and staff pathways, which
converge at the point of administration (Goodman, 1998b). While Tanghe et al (1996)
contend that nurses are involved in this process from the point of preparation of the drug; it
is argued that nurses are involved in the prescription phase of these drugs, for example
3
ensuring informed consent, assessing patient fitness for treatment and checking that the
prescription is correct.
It should also be recognised that nurses are not the only health-care professionals
involved within this process. Goodman (1998b) suggests that it is a collaborative activity
involving a multi-disciplinary approach and should always involve the patient.
The Role and Responsibilities of the Nurse
Where once chemotherapy administration was the domain of doctors it has been the nurse
in the last two decades who is responsible for ensuring that patients receive their
treatments safely. During this time there have been significant changes in the number of
patients undergoing chemotherapy treatments and the way it is administered.
Tanghe et al (1994) suggest that the nurse has three main roles in the chemotherapy
administration process (to educate patients, administer and manage side effects). It is also
identified that nurses must provide emotional support to patients and their relatives
(Dennison, 1995; Wilkinson, 1991) and act as a facilitator of learning and a role model to
less experienced staff (Verity & Bloomfield, 2005). Other nursing responsibilities include
taking all necessary actions to ensure that the environment and the nurse themselves are
safe, e.g. disposing of waste safely and wearing protective clothing. Nurses therefore have
a legal and professional responsibility to feel competent in this role and follow all of the
procedures laid down by the organisation within which they work, to ensure the safe
handling, delivery and disposal of cytotoxic drugs (Allwood, Stanley, & Wright, 2002)
Developments in chemotherapy practice and increasing numbers of patients receiving
chemotherapy in the UK will mean that many more nurses are needed in various clinical
settings to undertake this role. Worryingly it has been reported that there is a national
shortage of qualified nurses working in this area (Taylor & Birch, 2004). What is apparent
is that oncology nurses are playing a pivotal role in the rapid developments occurring in
chemotherapy practice and as such the role is continually evolving. Hence we are also
now seeing an increasing number of nurse-led chemotherapy clinics (Fitzsimmons et al.,
2005; Harrold, 2002; Munro, 2005) and chemotherapy triage telephone services (Groves,
2005).
Future developments for the nurses’ role have also emerged in the literature. Taylor and
Birch (2004) describe the implementation of a new pilot role that of chemotherapy support
worker (CSW), this initiative involved extending the role of the health care assistant (HCA).
The HCA was provided with knowledge and skills to then support the nursing team but not
actually administer chemotherapy in the chemotherapy setting. The educational support
received appears comprehensive and was delivered over a four-day HCA ‘training in
cancer care course’ and then a further ten specific study days to meet identified learning
needs. Clinical skills, such as cannulation, flushing lines and disconnecting treatment,
were taught in the clinical area and supported by an experienced practitioner acting as an
enthusiastic mentor. Overall, this initiative was positively evaluated and the CSW was
viewed as a valuable addition to the team, so much so that Taylor and Birch (2004)
contend that this role in the future could be expanded to include administrating
chemotherapy. With the advent NHS Knowledge and Skills Framework (Skills for Health,
2005), this is plausible. The role of the nurse in the chemotherapy process should be
explored to ensure future developments, such as the CSW, role are properly developed
and supported in other clinical settings.
4
Chemotherapy Treatment Environment
Chemotherapy is administered to patients in both inpatient and outpatient settings.
However, over the last two decades the rising trend has been to administer chemotherapy
in out-patient and day care settings, in the community, and in patients’ own homes. While
this is because of the increasing numbers of patients receiving chemotherapy and the
subsequent financial implications (Wood, Hyde, & Salter, 2005), it is mainly feasible due to
more sophisticated delivery methods, new oral preparations of these drugs and improved
management of side-effects enabling patients to tolerate their treatments without the need
for being hospitalised. Very few chemotherapy treatments now actually need to be
administered in an inpatient setting (Allwood et al., 2002). These changes in
chemotherapy delivery settings however, have significant implications for the management
of these patients and for the nurses caring for them.
Patients who are receiving their treatments as an outpatient and in their homes are likely
to face problems alone with limited opportunities to receive support from specialists who
work with chemotherapy. They will therefore require from health professionals detailed
information and education on how to manage side effects and how to recognise when
medical intervention is required. However, Dennison & Shute (2000) found that the nurse’s
role in the general oncology outpatient setting tends to focus on non-nursing duties,
including administration, chaperoning and organising notes rather than supporting and
educating patients.
Blay, Cairns, Chisholm, & O'Baugh's (2002) study, undertaken in Australia, investigated
the workload and roles of oncology nurses within an outpatient setting where treatment
was also given. They found that over 60% of the nurses’ time was spent on indirect
nursing activities, as also observed in Dennison and Shute’s (2000) study. McCaughan &
Thompson (2000) argue that the challenge for nurses in the chemotherapy outpatient
setting is finding ways to organise the service so that patients are given the appropriate
information and guidance to ensure promotion of self-care whilst having treatments that
can cause life-threatening and/or debilitating side effects.
Interestingly, little consideration has actually been given to the physical environment where
chemotherapy is administered. Allwood et al (2002) contend that it is often frequently
inadequate. Unless the chemotherapy outpatient setting has been specifically designed
with the administration of chemotherapy in mind (which few have been), chemotherapy is
often administered in areas too small to cope with the increasing numbers of patients and
with little consideration to the safety aspects of administering these drugs (Allwood et al.,
2002).
Many inpatient settings are also inappropriate and patients can receive their treatments on
general wards (unless in specialist centres) where there are competing patient care
priorities for the nurses, such as caring for a dying patient whilst trying to ensure the
chemotherapy is administered on time (Allwood et al., 2002). Mohan et al (2005) found
that nurses caring for patients with cancer in non-specialist wards had concerns related to
their lack of knowledge about treatments and hence felt that they were not able to support
patients and relatives appropriately. These nurses also believed that patients would feel
better cared for in an environment where they could share their experiences with others in
similar situations (Mohan, Wilkes, & Walker, 2005).
Patient satisfaction with treatment can also be adversely affected by factors in the physical
environment. Sitza & Wood (1998a) suggest that those factors involved include
accessibility to treatment, such as transport, car-parking issues and waiting times.
5
Expressed concerns of nurses working in an Australian haematology/oncology day unit
were the impetus for an action research project undertaken by Wallis & Tyson (2003) to
improve the nursing management of patients. These nursing concerns related to increased
numbers of patients, with subsequent increased patient waiting times and this led to more
patient complaints. Nurses also worried that there was an increased risk of chemotherapy
administration errors and patients were not receiving the appropriate support from both the
nurses and others in the multi-disciplinary team. Changes were made to both the
appointment booking system and nursing workload resulting in an improved service.
Problems such as those described above have been found to have a direct link to
increased levels of patient anxiety (Sitza & Wood, 1998a). The impact of these factors on
the work of the nurse in chemotherapy environment has not been explored in-depth in the
UK but there is anecdotal evidence from nurses to suggest that these factors do impinge
on the care that they give.
Patient Satisfaction, Education and Communication
The literature suggests patients’ satisfaction and acceptance of this therapy also relies
upon the provision of information, advice and explanation; and the need to discuss the
emotional consequences caused by the treatment (Davidson, 2005; Sitza & Wood, 1998a;
Soothill, Morris, & Thomas, 2003). Patients have been found however, to be often
dissatisfied with aspects of the administration process including, communication and
psychological support; waiting times; assessment and management of side effects; and
information giving (Mun et al., 2001; Sitza & Wood, 1998b)
Dennison (1995) found that although nurses were competent in providing information, they
rarely made any assessment of patients’ feelings about their treatment. In addition,
research has shown that poor management of chemotherapy-induced side effects, such,
as nausea and vomiting can adversely affect quality of life (Brown et al., 2001; Richardson
et al., 1998) and their level of anxiety about treatment (Mun et al., 2001). Assessing and
managing these side effects effectively, and also providing necessary information, can
increase patients’ satisfaction and also, decrease anxiety and significantly increase patient
compliance (Sitza & Wood, 1998a). Yet, (Holmes & Eburn, 1989) suggest that nurses do
not accurately perceive the extent of chemotherapy-induced problems, particularly the less
visible ones such as nausea. Interestingly, one area patients are rarely dissatisfied with is
nursing skills involved in the technical care of chemotherapy administration (Mun et al.,
2001; Sitza & Wood, 1998b). When trying to explore their findings researchers have
identified a need to explore the chemotherapy process in more depth so that factors
contributing to the findings may be revealed.
Communication and Patient Psychological Support
Wilkinson (1991) found that nurses who had not completed post-basic education in cancer
care were poor facilitators of communication compared to those that had, who were much
better at communicating with patients. Nurses use avoidance tactics in order not to have to
confront the emotional fallout caused by chemotherapy and its side effects (Dennison,
1995; Lanceley, 1995; Maguire, 1985). It is not made clear why nurses feel the need to
avoid this aspect of care when research has indicated that nurses are very aware that
patients need psychological support (Batchelor, 2001; Jacobsen et al., 2002).
Arantzamendi & Kearney (2004) explored the perceptions of a group of cancer nurses
regarding the psychological needs of chemotherapy patients. While the small convenient
6
sample limits generalization, findings do indicate that there are a number of factors why
nurses feel they may not be able to support patients’ psychological needs. These included
lack of private space and time. Also, while most of the nurses in this study felt they did
provide psychological care they admitted that they generally waited for patients to offer
information, which usually they didn’t; no formal tool was in place to systematically assess
psychological needs.
Interestingly, in a small study exploring the nurses’ perspectives of administering
chemotherapy undertaken by Verity (2002) using an investigator designed, selfcompletion, exploratory questionnaire, 65% (n=102) of the respondents felt that their
practice would benefit from further formal education in the psychological consequences of
treatment. Again the small, convenient sample accessed from a specialised hospital
utilised in this study makes it difficult to generalise the findings.
Wilkinson (1991) suggests that many cancer nurses do want to communicate openly with
their patients but often find it too stressful to continually expose themselves to their
patients’ emotional distress. Verity (2002) reported that 46% of the sample (n=102) found it
distressing to see patients affected by the chemotherapy they had administered.
Purandare (1997) offers a different perspective suggesting that negative attitudes held by
health care professionals and the general public towards the disease can create barriers to
effective communication with the newly diagnosed cancer patient. Negative attitudes
towards chemotherapy may create similar barriers.
Nurses’ Attitudes towards Chemotherapy and Cancer
Psychologists argue that the attitudes we hold towards something will influence our
behaviour towards it (Miller, Kearney, & Smith, 2000). There appears to be little research
undertaken to investigate nurses’ attitudes and beliefs regarding chemotherapy. There has
been some work investigating nurses’ attitudes towards cancer as an illness. Corner
(1988) critically reviewed research methods used to investigate nurses’ attitudes towards
cancer and found that
‘the research to date seems to reflect a consistent pattern of nurses’ and other health carers’ attitudes
towards cancer which is largely negative and stereotyped, with cancer being seen as more devastating than
other life threatening diseases’
From the findings of a further study undertaken by Corner & Wilson-Barnett (1992). Corner
(1993) produced the Attitudes towards Cancer model to depict those factors, which were
found to affect nurses’ attitudes, beliefs and feelings in relation to cancer. These included
professional preparation for the role, culturally held beliefs and personal and professional
experiences of cancer.
Elkind (1982) surveyed 785 nurses to investigate what type of impression nurses may give
the general public about cancer through their attitudes towards the disease, a number of
nurses were found to hold very negative views of cancer. Elkind (1982) also found that
while training and experience lead to a better understanding of the disease, the more
experienced and knowledgeable nurses were likely to have doubts about the value of
treatment for cancer. Only 21% of the nurses surveyed agreed with the statement ‘a
patient with cancer can never be really cured’, whereas, 75% of the trained nurses
surveyed agreed with the statement ‘treating cancer patients can do more harm than good’
(Elkind, 1982)
7
Slevin et al. (1990) British survey compared attitudes of medical oncologists, radiologists,
oncology nurses, general practitioners, the general public and cancer patients, regarding
the use of chemotherapy when the hypothetical probability of cure or benefit was varied. It
was found that cancer patients were more likely to opt for aggressive treatment with a high
degree of toxicity and minimal chance of benefit than any other group. At the same time,
the radiologists and nurses were the least likely of all the groups to accept treatment. A
later study undertaken in the United States by Damrosch et al. (1993) focused on
comparing nurse and physician cancer specialists’ attitudes toward aggressive cancer
treatments. They postulated that differences between nurses’ and physicians’ attitudes
towards aggressive treatment were a source of conflict between the two and an important
cause of stress for the nurse. This view was reflected in the studies findings.
The evidence from the literature, therefore, suggests nurses have a generally negative
attitude towards chemotherapy and this must be cause for concern. Nurses need to have a
positive approach to treatment regimes to help patients effectively (Wherney-Tedder,
1997). However, all these studies identified above have not primarily investigated nurses’
feelings about administrating chemotherapy in any depth and are somewhat dated.
Conversely findings from Verity’s (2002) study indicated that the participants tended to
have a positive attitude towards chemotherapy. Verity (2002) concluded that this finding
was due to the sample being a generally experienced and educated one, who could easily
access expert support and who was working within a specialist centre for cancer. Once
again it is difficult to generalise these findings.
Nurses’ Concerns and Feelings
Very few studies were identified in the literature search, which explored in-depth, nurses’
feelings towards caring for patients who experience chemotherapy-induced side effects.
Findings from Fall & Rose (1999) small qualitative study indicated that nurses felt that
helping and caring for these patients through their treatments was both a rewarding and
stressful experience. The rewarding elements included the powerful relationships made
during treatment between the nurse and the patient. As a result of this relationship nurses
felt that they were successful in helping the patient through their treatment, controlling the
adverse side effects. Others have also described the special, intimate, relationships forged
between the oncology nurse and the patient undergoing cancer treatments (Campbell,
1984; Glaus, Campbell, Kearney, & Richardson, 2000).
Guilt however, was expressed by one participant, in the Fall and Rose (1999) study, for
being part of the chemotherapy treatment process. Administering the drugs and thus,
having then to confront the patients’ suffering, caused intense stress at times for those
who participated in the study. A criticism of this study is that a purposive form of sampling
was used and the five participants were extremely experienced and thus, the impact of
caring for patients through their treatments for less experienced nurses was not explored.
Conversely, the findings suggested that the key to these nurses coping successfully with
the stress caused by watching patients suffer from treatment that they had administered,
was that subjects reported an awareness that they needed to distance themselves from
the treatment situation. These nurses were also found to have devised personal strategies
to cope with stress. It is questionable that less experienced nurses may be able to cope as
successfully or separate themselves in a way that was not detrimental for the patient.
Many authors have attributed nurses distancing themselves from patients as a symptom of
professional burnout (Glaus et al., 2000)
8
Other authors have also indicated that one of the main reasons for oncology nurses
experiencing stress and burnout is associated with administering cytotoxic drugs
(Barraclough, 1994; Delvaux, Razavi, & Farvacques, 1988). Why this should be the case
has not been clearly defined. The findings from Wilkinson (1990)study briefly suggested
that cancer nurses found factors such as chemotherapy induced side effects, the
uninformed patient and their own lack of knowledge regarding chemotherapy treatment as
potential factors. Clearly more investigation is required to determine the causes of stress
for nurses in this role.
Verity (2002) found that nurses had a number of significant concerns. These included
patients’ experiencing adverse reactions to treatment, extravasation and cytotoxic spillage.
Extensive training, which most had received on safety issues, did not seem to lessen
these anxieties. Verity (2002) argued that these concerns could be viewed as a positive
consequence of administering chemotherapy. Nurses need to be constantly vigilant to
these effects so that they can either be avoided or quickly identified and managed
effectively. The participants in Verity’s (2002) study also expressed concerns at
administering chemotherapy at night when there was little skilled support available from
colleagues, when the clinical area was busy or short-staffed.
Considering the potential ‘stressful’ factors of this role Fall and Rose (1999, p. 907)
suggest ‘the appropriate support systems at both the managerial level and the collegial
level for nurses who administer chemotherapy should be explored’. There is still however,
very little documented evidence to suggest what these systems should be.
Occupational Risks of Exposure
During the 1980’s much was written in the literature about the safety aspects of giving
chemotherapy and concerns regarding the potential occupational hazards to health care
workers who handle cytotoxic agents (Darbyshire, 1986; Goodman, 1985; Miller, 1987;
Selvey, 1985a, 1985b) There is a consensus in this literature that some cytotoxic drugs
are carcinogenic and teratogenic to humans. What is not known, however, is the risk, if
any, of long-term, continuous exposure to small amounts of cytotoxic drugs or indeed
identified safe staff exposure limits (Gregoire, Segal, & Hale, 1987; Lee, 1993; Miller,
1987).
Some studies have indicated that health-care workers are at risk from not only handling
the cytotoxic drugs, (spillages, leakage, inhalation or skin contamination) but also from
handling excreta and body fluids from patients who are receiving chemotherapy (Bingham,
1985; Nygren & Lundgren, 1997). Valanis & Browne (1985) found that for nursing staff one
of the commonest daily forms of cytotoxic exposure was excreta from patients. Sessink,
Boer, Scheefhals, Anzion, & Bos (1992) found cytotoxic drug contamination in areas
where high quantities of drugs were used, including on the floors of drug preparation
rooms and patient’s rooms; in cleaned urinals and bed pans, on the outer packing and
vials of drugs; and on gloves used for preparing and cleaning activities.
In 1988 (updated in 1996) the Control of Substances Hazardous to Health (COSHH)
regulations were introduced by the Health and Safety Executive. These regulations also
included guidelines on the safe handling of cytotoxic drugs so that individuals handling
cytotoxic drugs are protected. Employers are now obliged to identify risk, and implement
and provide safety measures and clothing to protect their staff. Most institutions should
now have policies and procedures in place concerning the safe handling of these drugs,
but as Grundy (1999) found most policies content and standards vary enormously, if
9
indeed there is one at all. Even if there is a comprehensive policy regarding this practice in
place how much nurses adhere to these policies is also debatable (Dougherty, 1999;
Goodman, 1998b). The findings from Christensen, Lemasters, & Wakeman (1990) study
did find that the existence of a formal hospital policy for handling cytotoxics had a positive
influence on the use of personal protective equipment. There is also considerable debate
on what type of clothing is considered to offer the most effective protection, although there
are minimal requirements for the design, type and protection standards in place (Allwood
et al., 2002; Sims, 2005).
Other studies have also shown that women who are pregnant (especially if exposed in the
first trimester) are at risk of spontaneous abortions and giving birth to malformed infants
(Hemminki, 1985; Kalter, 1986). Valanis, Vollmer, Labuhn, & Glass (1997) findings
suggest that there is a higher risk of infertility in those occupationally exposed to cytotoxics
(nurses and pharmacists) than those who are not. Therefore, women should be able to
decline preparing or delivering cytotoxic drugs whilst pregnant, planning a pregnancy or
breast-feeding without fear of sanctions (Holmes, 1997). Many UK Trust policies regarding
administering chemotherapy while pregnant clearly state that there is ‘no evidence’ that
chemotherapy drugs are harmful to those that are administering it if all safety procedures
are followed (Goodman, 1998b). It can be seen that controversy still surrounds this issue
of safety and nearly twenty years since some of these studies were conducted many
questions regarding the safety of handling cytotoxic drugs remain unanswered.
Attitudes towards Occupational Risks of Exposure
Historically in the UK nurses have been reluctant to use personal protective clothing for
reasons such as fear of frightening the patients, having lack of time and having an attitude
that they were personally immune to the dangers of these hazardous substances (Valanis
& Browne, 1985). Goodman’s (1985) small descriptive study found that nurses’ had few
concerns about the dangers of handling cytotoxic drugs. Nurses’ attitudes towards this
issue appear to be changing; one of the deciding factors to undertake this current research
study was that nurses within our own South East London Cancer Network had raised
concerns about the risk of occupational exposure. Verity (2002) also found that a number
of nurses had concerns about this issue, and 28 (n=102) were also concerned about
administering chemotherapy when pregnant.
Chemotherapy Administration Errors
Chemotherapy prescription, preparation and administration errors can be fatal. Recent
media coverage both in the USA and the UK has underlined this (Schlmeister, 1999).
However, the nature and outcomes of most chemotherapy errors is unknown, for two
reasons. A reluctance of staff to report errors for fear of reprisals means that the factors
contributing to these errors are not clearly known. Secondly, there is no national
mandatory system in place, for reporting, recording or publishing errors (Goodman,
1998b).
Schulmeister (1999) investigated nurses’ descriptions of the nature and severity of
chemotherapy, using an investigator developed postal survey. Even with the knowledge
that response rates can be poor for this type of research, in this study only one hundred
and two (26%) of the sample returned the questionnaire. While taking this limitation into
account however, the findings of this study do give cause for concern. Chemotherapy
administration errors were reported to have occurred in the workplace by 63% of the
respondents. These errors included under and overdosing patients, schedule and timing
mistakes, administering the wrong drugs, infusion rate errors, inadequate pre-
10
administration checks and tests, incorrect preparation of the drugs and even
chemotherapy being given to the wrong patient. Schulmeister (1999) also asked what
respondents thought these errors could be contributed too. Twenty-five percent of the
respondents reported under-staffing, 20% cited lack of experience, 16% stress and 15%
said these errors were caused by unclear orders.
O'Shea's (1999) review of the literature examining factors which contribute to nursing
medication errors (not specifically chemotherapy) found interruptions and distractions
during preparation and administration of drugs to be a contributory factor. Other factors
cited included - poor mathematical skills of nurses, lack of nursing experience, overwork,
long length of shift, badly written prescriptions and nurses’ lack of knowledge concerning
the drugs.
Goodman’s (1998b) review of the literature regarding cytotoxic errors (made mostly by
doctors) also reports a wide range of causes and contributing factors these included
prescription ambiguity, communication difficulties and insufficient staff knowledge.
Goodman (1998b) goes on to recommend that, to prevent errors in practice all junior staff
should have the appropriate supervision and support, what this is exactly, is not made
clear. It is stated however, that
‘staff need timely access to up-to-date, accurate information which they understand
and can act on re: individual cytotoxic drugs, regimens/protocols and individual
recipients’. (Goodman, 1998b, p.174)
Preparation and Support for the Role
Nurses must have confidence in their knowledge, ability and technical expertise if they are
going to provide effective, safe and beneficial patient care. Verity’s (2002) study found the
majority of the participants had not been adequately prepared for the role and did not have
confidence in their abilities, knowledge and skills when they first administered
chemotherapy. Ninety-nine nurses (n=102) described how they felt when they first started
giving chemotherapy, of these eighty-five of the respondents used words such as
‘terrified’, ‘very anxious’, ‘nervous’, ‘scared’ and ‘very unsure’ (Verity, 2002). Very few of
the participants had received education about this process prior to administering
chemotherapy.
The Joint Council for Clinical Oncology (1994) recommended that all nurses who
administer chemotherapy must attend one of the recognised courses on cancer
chemotherapy, Presently, there is no national standard of chemotherapy training in the
UK, and Trusts and employers are compelled to draw up local policies and education
packs, the standard and content of which vary widely (Goodman, 1998b)
Some courses such as the ENB 92, ENB 237 and ENB N59 did include instruction about
chemotherapy as part of the content of the course. Since the English National Board, for
Nursing Midwifery and Health Visiting (ENB) has disbanded, universities and colleges of
higher education have begun to offer cancer nursing courses, which include caring for the
chemotherapy patient. Again standards and content have been found to vary. (Kearney,
2000) suggests that it is likely that ‘variations in clinical nursing expertise and knowledge,
have a detrimental effect on patient care’
This variation in educational standards was highlighted in an audit undertaken by Grundy
(1999), which examined current chemotherapy administration practices of nurses in
Scotland. Of the sixty-two nurses who were interviewed, thirty-two were considered senior,
11
experienced nurses (F Grade or above) and thirty were less experienced, junior nurses. Of
the overall sample 39% had been prepared for this role by ‘learning on the job’ and only
18% had undertaken a recognised course. (Grundy, 1999) did not express surprise at the
senior nurse’s reports that they had ‘learnt on the job’, many had been involved in the
chemotherapy process before the hazards of cytotoxic drugs were really known and
education was offered in this area. However, she was disconcerted at the finding that more
senior nurses had undertaken a recognised course than junior nurses. Some 53% of the
junior nurses stated that, they had also only learnt about chemotherapy in clinical practice.
These findings were also reflected in Verity’s (2002) study where 33% (n= 102) of the
sample had ‘learnt on the job’, interestingly, 76% of the sample also stated that at times
they were worried about their colleagues’ knowledge and education deficits. Interestingly
many of the sample stated that their confidence increased due to working with
knowledgeable role models from whom they could gain support and advice (Verity, 2002).
While it is recognised that clinical experience is necessary to gain knowledge about caring
for cancer patients, for nurses to do so effectively it must be done in tandem with
education (Kearney, 2000). Nearly half the sample in Grundy’s (1999) audit felt that
receiving more education about anticancer agents would be a means of enhancing their
practice. The majority of the nurses in Verity’s (2002) study required ongoing professional
development and stated that they would benefit from further knowledge in the following
areas – developments in chemotherapy, psychological consequences of treatment, safety
issues and management of side effects. Preferred form and delivery of this required further
education included informal clinical teaching, study days and workshops.
Grundy (1999) and Verity (2002) both concluded that educational preparation in this area
must be improved and recommend that ongoing collaborative and co-ordinated
educational strategies (including regular updates) on a national level in the UK should be
developed if we are to ensure that we sustain and support a competent workforce.
The Nursing Contribution to Cancer Care document (DOH, 2002) recognised a need for
developing cancer nursing education and in response to this need there has been work
undertaken to develop core generic competencies for chemotherapy care (Skills for
Health, 2005). However, it is difficult to know how nursing competency in this role might be
measured without comprehensive evaluation of both the role and education in the practice
of chemotherapy administration.
Conclusion
There is a dearth of research and audit evaluating nurses’ roles and competence in the
chemotherapy process. The main reason perhaps for this lack of evaluation is that not all
cancer centres or units in the UK follow exactly the same policies with regard to
chemotherapy practice (Holmes, 1997). Although there are evidence-based,
multidisciplinary, UK clinical guidelines for the administration of cytotoxic chemotherapy
produced by The Royal College of Nursing (Goodman, 1998a/b) few organisations have
implemented them. These RCN guidelines also recommend that more research is urgently
required to understand factors, which may influence effective practice. Two areas (out of
many) that the review suggests should be covered include:
•
•
‘Nature of staff and others beliefs and knowledge deficits’
Impact upon practice of beliefs, knowledge and knowledge deficits’
(Goodman, 1998a)
12
The literature suggests that there are wide variations in educational preparation for this
role and practice, which must be cause for concern, given the implications of
chemotherapy administration. Evaluation of this role is imperative because it can inform
decision-making, influence educational programme development and ultimately impact on
nursing practice (Kearney, 2000). It is evident that there is an urgent need for research to
be undertaken to examine and observe the work of the nurses who administer
chemotherapy to understand factors, which may impinge or enhance care received by
patients.
13
3 Method
Introduction
This section describes the methodology used to undertake this mixed methods study.
Component one pursued a quantitative approach and consisted of a survey. Component
two, qualitative in nature, involved an ethnography. The methods used to undertake each
component will be described separately.
Component One - Survey
Survey aims
The aim of this component was to investigate nurses’ perspectives of administering
chemotherapy to patients with cancer.
Specifically, the survey sought to:
•
•
•
•
Determine the attitudes and beliefs of nurses who administer chemotherapy
Ascertain the nature and extent of educational preparation that nurses who
administer chemotherapy have received and whether this is perceived to be
sufficient
Determine whether experience and/or education have an impact on nurses’
attitudes or concerns
Characterise some of the challenges nurses experience during the process of
chemotherapy administration
Rationale for Survey Methodology
The survey method is considered an invaluable research approach for obtaining data to
describe, compare or explain nurses’ beliefs, knowledge, behaviour and attitudes (Fink,
2003; Mccoll et al., 2001). Surveys that utilise postal questionnaires as the method of data
collection are an extremely useful and relatively inexpensive method for gathering
accurate and consistent information that is comparable across a wide range of people
(Aldridge & Levine, 2001), and are especially suited to collecting data from a large sample.
The questionnaire used in this survey aimed to obtain valid, reliable data from a
representative sample of nurses who administer chemotherapy. A cross sectional design
was employed which aimed to provide descriptive data on nurses’ opinions at a single time
point (Fink, 2003)
Survey Instrument and Design
The survey instrument used in this study comprised the Chemotherapy: Education,
Worries and Attitudes Questionnaire – Hospital Version. It consists of a 25-item, selfcompletion postal questionnaire comprising seven sections which include: General
Information about Chemotherapy Role, Educational Preparation, Feelings, Issues of
Practice, Worries about Chemotherapy, Attitudes and Professional Details (appendix 1).
Key areas of questioning include attitudes, beliefs and concerns regarding the nurses’ role,
their support mechanisms and educational preparation. It uses various questioning
14
techniques including both closed and open questions. The open questions were included
so that richer, more diverse data could be obtained. In addition, the inclusion of open
questions can prevent respondents from feeling frustrated and constrained by the fixed
choice answers of closed questioning (Coolican, 1993).
The majority of the closed questions called for a nominal response choice. The section of
the questionnaire concerned with attitudes towards chemotherapy administration required
an ordinal response via a 4-point Likert scale. For examples of the various question types
and corresponding response formats see table one.
Table 3.1: Example questions and response formats
Example Question
Question
Type
Response format
Please state the
three most important
issues that should be
included when
educating nurses
about chemotherapy
administration?
OPEN
FREE TEXT
1. ………………………………………………………
2. ………………………………………………………
3. ………………………………………………………
In your current job do
you administer
chemotherapy to
patients?
CLOSED
When presented with
complications caused
by chemotherapy I
feel confident in my
competency.
CLOSED
NOMINAL RESPONSE CHOICE
Daily
Weekly
Several times a month
Occasionally
Never
4-POINT LIKERT SCALE
Strongly Agree
Agree
Disagree
Strongly Disagree
Questionnaire Development
The questionnaire was based on that developed by Verity (2002) as part of study that
aimed to investigate factors that influenced care of patients receiving chemotherapy. The
topic areas and specific questions for this original questionnaire were generated by a
number of methods including an extensive review of pertinent literature, informal
conversations and interviews with colleagues and experts in the field of chemotherapy
nursing and from the researcher’s own experience (Verity, 2002).
Content and face validity of the original questionnaire were established through grounding
the items in the literature and through critical review by clinical experts (Verity, 2002). It
was subjected to pre testing prior to use in the 2002 study to determine its acceptability,
utility and ease of use.
15
Revisions Made To Original Questionnaire
The original questionnaire developed by Verity (2002) was reviewed for relevance and
usability within the context of the current study. Some revisions were made including
sections being more clearly titled; two questions re-sequenced to enhance flow of
questioning; and some words changed to clarify their meaning and for easier handling
when undertaking statistical testing (revisions are shown in appendix II). A number of
questions were added, as they were considered relevant to the population under
examination. Finally, three further questions concerned with attitudes were added, as it
was apparent from experience of using the original questionnaire that this aspect could be
enhanced (additions are listed in appendix 3).
To improve appearance and readability the questionnaire was produced in a booklet
format with white pages and a lilac coloured front cover. All questions were printed in black
ink (Mccoll et al., 2001).
Population and Sample
The target population was all nurses who administered chemotherapy across the five
London Cancer Networks. This included nurses working across twenty-six NHS Trust
Hospitals where patients received chemotherapy. Although it was initially thought that
some form of probability sampling could be utilised for this study it became apparent that
due to the relatively small numbers of nurses administering chemotherapy in London that
this approach would compromise the sample size. Therefore, the total population of nurses
administering chemotherapy became the sample; accessed via a multi-stage approach.
The sample included individuals who:
•
Were Registered Nurses on Part 12 (General Nursing) of the Nursing and Midwifery
Council (NMC) Register.
•
Worked at an NHS Trust that is part of one of the 5 London cancer networks
•
Administered chemotherapy to adult patients with cancer as part of their role within
a cancer unit or cancer centre.
Nurses were excluded if they:
•
Were not currently involved in administering chemotherapy
•
Were employed by an Agency and therefore, not permanently contracted to the
Trust.
•
Worked in private hospitals
•
Administered chemotherapy to children
•
Were not registered on Part 12 of the NMC Register
Study Sites and Setting
Although there are thirty-two NHS hospitals in the five participating London Cancer
Networks, only twenty-eight of these were identified as places that administered
chemotherapy to adult cancer patients. Of these twenty-eight, a further two hospitals were
not included. One had already been involved in a previous study undertaken by Verity
(2002) utilising the questionnaire. The other was not included as this particular Trust did
16
not have a Research and Development Committee functioning at the time that approval
and access were being sought. Thus 26 hospitals were invited to take part.
Sample Size
A statistician was consulted in order to inform the required sample size. However, there is
no simple rule for sample size that can be used for surveys. Nevertheless, it should be
sufficient to make the results representative of the population although no more than
necessary to achieve this and always considering the size of the population (American
Statistical Association 2004).
It was deemed that for descriptive and comparative statistical analysis 200 completed
questionnaires would be needed for the study to achieve its aims (at the 5% level of
significance (α) with 80% power (1-β), (Cohen, 1992) this took into account that we
intended to test multiple hypotheses. With an anticipated response rate of 40%, a total
sample size of 500 was required.
Ascertaining and Accessing Sample
To access the sample it was necessary to progress through a number of stages, mainly
because of the limitations imposed by the Data Protection Act (OPSI, 1998). Initially, the
Lead Cancer Nurse (LCN) at each hospital site was identified via the relevant Network
Nurse Director. Each LCN was provided with written information (appendix 4) regarding
the study including the aims, procedure and expectations of the questionnaire survey.
Following approval from the relevant Research and Development Committees (see section
on Ethical and Research Governance Approval) LCNs were provided with letters and
asked to distribute these to all nurses who met the inclusion criteria within their Trust.
These letters asked whether the nurses would agree to have their names forwarded to the
research team. This invitation letter enabled each nurse to decline his or her name being
forwarded by returning a “tear off” slip to the LCN. Only the LCN would have the names of
those who declined.
Following receipt of these slips the LCN compiled a list of the nurses who fulfilled the
eligibility criteria and were willing to consider participation in the survey. This list of
potential participant names was then sent to the research team.
As a result 526 trained nurses who were administering chemotherapy across the five
London Cancer Networks were identified for inclusion in this survey. Participation ranged
from 2 to 112 nurses per hospital site (see table 3.2).
A total population sampling method was adopted in that every potential participant on the
list provided by each LCN was sent a questionnaire pack. The survey sample consisted
therefore of all the nurses who were sent a questionnaire pack.
17
Table 3.2: Number of hospital sites and nurses who administer chemotherapy within
each London Cancer Network
London Cancer
Networks
Number Of
Hospital
Sites
Number Of Nurses Within
Each Cancer Network Who
Administer Chemotherapy
North
North East
South East
South West
West
Total
5
5
6
4
6
26
102
111
122
53
157
545
Final Sample:
Number Of Nurses
Who Agreed To
Participate In Study
97
111
121
53
144
526
Procedures for Survey Administration
A unique study identification number was assigned to nurses who consented to their name
being forwarded to the research team. Questionnaire packs consisting of a cover letter
(appendix 5), a nurse information sheet (appendix 6) and a questionnaire (appendix 1)
were sent to each individual nurse, to their work address. A stamped addressed envelope
was sent with the questionnaire to encourage response. In order to maintain confidentiality
only the study identification number was included on the questionnaire and participants
were asked not to write their names anywhere on the questionnaire.
Following best practice in relation to survey response rates a reminder letter was sent to
non-respondents 2-3 weeks after the initial questionnaire pack had been sent out. After 46 weeks, a further reminder letter and copy of the questionnaire with a stamped addressed
envelope again was sent to those nurses who had not responded (Mccoll et al., 2001).
Figure 1 gives a summary of the process used to ascertain the sample
18
Figure 1: A Flowchart Illustrating Multi-Stage Approach Utilised for Ascertaining and Accessing
Sample
Study information provided to
the Lead Cancer Nurse (LCN)
at each site
RESEARCH
Trust R and D approval
TEAM
obtained
Nurse invitation letters
provided to each LCN
Nurse invitation letters distributed
to all nurses who administered
chemotherapy
LEAD
Tear off slips returned to LCN
CANCER
identifying those who did not
NURSE
wish to participate
Lists of all nurses who wanted to
participate and were eligible to do
so were compiled by LCN and sent
to research team
RESEARCH
Questionnaire packs sent to all
TEAM
names on the list provided by
the LCN.
Reliability and Validity
Pre-testing of the questionnaire was undertaken to build on the testing carried out during
the tools original development (see section on questionnaire development).
A common concern when using survey/questionnaire data collection tools generally is
whether the tool is a true reflection of the body of knowledge pertaining to the concept of
the study, and whether it is able to elicit information needed to meet the aims of the
research. Commonly the following aspects of validity are tested for: face, content,
construct and criterion validity (Fink, 2003). In the case of this tool content validity was
19
established through review of the literature, during its initial development and evaluation of
the questionnaire by those considered expert in the field.
Pre-test
A pre-test was undertaken to determine the acceptability, appropriateness and feasibility of
the revised questionnaire. Twenty pre-test questionnaires were distributed to nurses who
administered chemotherapy at a private London hospital. This hospital was not
participating in the main study. Eight questionnaires were completed and feedback
obtained. No changes were made to the wording of the questionnaire; however the
questionnaire appearance was altered from lilac coloured pages throughout to white pages
with a lilac front cover. This was due to the pre-test respondents reporting that the
questions on the lilac paper were hard to read. The average time taken to complete the
questionnaire was thirty minutes.
Data Preparation
Data Entry
An SPSS database was created. A codebook was devised based on the questionnaire to
aid scoring and data entry procedures. The findings from the open-ended questions were
entered verbatim in a Microsoft Excel spreadsheet.
Data Cleaning
To ensure the accuracy of the database, the data were systematically cleaned following
the guidelines of (Davidson, 1996). Initially a series of computerised descriptive analyses
were performed on all items of the questionnaire to check for any impossible (a data value
on a variable that cannot exist) or implausible values (a data value which is possible but
highly unlikely).
These data were then checked manually for any obvious typographical errors ensuring, for
example, that the total number of responses for each item did not exceed the total number
of survey respondents and the minimum and maximum values were within the variable
coding range. A visual check of the database was also carried out to identify blocks of
missing data and expected patterns in data.
Then a complete manual check was carried out on 10% of the data (25 questionnaires).
Every 10th questionnaire was manually checked in full against the database and the error
rate was calculated to be 0.2%. All errors were rectified and the correct data values
entered into the database.
Data analysis
Descriptive statistics such as frequency distributions were used to describe/summarise the
characteristics of the sample and the variation in response. Each section of the
questionnaire was analysed descriptively in turn.
Cross-tabulations utilising Somers ‘d test were undertaken to examine how the responses
on two of the variables were related. These were undertaken to explore the relationship
between nurses’ attitudes towards chemotherapy and their present grade; attitudes and
years of experience; attitudes and amount and adequacy of teaching received; and
attitudes and frequency of administration.
20
Cross- tabulations utilising Somers ‘d test were also undertaken to explore the relationship
between nurses’ worries about chemotherapy and all of the variables stated above.
Independent sample t-Tests were also undertaken to explore if there were any notable
differences between group means. The overall group size was considered sufficient for a
significant level to be set at alpha 0.05.
Nurses’ attitudes towards chemotherapy were further analysed by calculating the overall
score achieved on the attitude scale for each respondent. This would reflect whether the
nurses in this sample have a favourable or unfavourable attitude towards chemotherapy
administration.
The attitude scale included 21 items statements; as a 4-point Likert scale was used, the
highest possible score indicating a positive attitude would be 84. The attitude scale
included both positive and negative item statements. Positive attitude statements were
scored 4 =strongly agree, 3= agree, 2=disagree, 1= strongly disagree, conversely negative
attitude statements were scored 1 =strongly agree, 2= agree, 3=disagree, 4= strongly
disagree. The direction of scoring on the Likert scale was not included on the
questionnaire administered to the respondents.
An ordinal regression model was employed to determine which factors impact upon the
process of nurses administering chemotherapy, specifically, which factors influence
attitudes towards and worries about chemotherapy administration.
The qualitative results obtained from the open-ended questions were typed verbatim into
the computer. These findings were then coded into themes and categories, so that the
data could be more easily described. To ensure that the analysed data was a fair
representation of what was recorded two people participated in the analysis process of the
open-ended questions, ensuring inter-rater reliability.
Ethical and Research Governance Approval
The research proposal was submitted to, and approved by, a Multi Research Ethics
Committee [Ref no: 04/Q0603/51]. In addition, approval was obtained from each
participating Hospital Trust’s Research and Development Committee.
To comply with the Data Protection Act (1998) the information letter that was distributed to
all nurses who fulfilled the eligibility criteria, included a “tear-off” slip for nurses to indicate if
they did not wish their name forwarded to the research team. Questionnaires were only
sent to nurses who appeared on the ‘potential participants’ list prepared by the Lead
Cancer Nurse.
To maintain confidentiality, questionnaires were allocated a study ID number, thus
ensuring all responses were anonymous. The list linking the study ID numbers to the
names of the participants was kept in a separate, locked filing cabinet and password
protected on the researcher’s computer. This list was only accessed when reminders were
due.
As the sample was accessed through Lead Cancer Nurses, there were concerns that
nurses may feel pressurised or coerced into taking part in the study as their manager was
potentially approaching them. The Lead Cancer Nurses were given clear instructions
about the nature of the study and it was stressed that participation was voluntary; this was
also explicit in the invitation letter to the nurses.
21
One further ethical concern was that potential participants might misinterpret the aims of
the survey and think their level of knowledge was being assessed. It did not aim to
measure nurses’ knowledge deficits regarding chemotherapy practice. To ensure that
there were no misunderstandings the aims were clearly explained and it was highlighted
both in the information sheet and the questionnaire that it was the nurses’ perceived
knowledge deficits that were of interest.
Component two – ethnography
Aims of the ethnography
The aim of the ethnography was to develop an understanding, in context, of the work of
nurses administering chemotherapy in an outpatient clinic.
The ethnography sought to:
• Observe and describe nurses’ practice of chemotherapy administration
• To explore knowledge, feelings and beliefs of nurses administering chemotherapy
• To highlight any discrepancies between what people do and what they say they do
• To understand the factors which contribute to these discrepancies.
Rationale for ethnographic method
To fulfil the aims of components two, an ethnographic approach was considered an
invaluable source of obtaining data to understand the nurses’ perspective of chemotherapy
administration and how it translated into practice. Within this approach, participant
observation of nurses’ work and interactions with patients and other personnel allowed the
researcher to see both what people do and what they say they do. An ethnographic
approach offered a way in which the context could be included within the research
enterprise and take into account the effects the context had on the actions of the
participants (Savage, 2000). The relationships developed in ethnography offer an
opportunity for researchers to gain an insider (emic) view which allows those aspects of
nurses’ knowledge that are grounded in everyday life to be explored (Savage, 1995). The
study examined two different locations in London in different Cancer Networks. Although
the data formed separate descriptions, the findings from each location gave a wider picture
of the work. This design is acceptable practice when examining nurses’ work (Allan, 1999;
Jarret, 1996; Savage, 1995) and addressed the recommendation that research examining
nursing in cancer care should use observational methods (Kruijver, Kerkstra, Bensing, &
Van de Weil, 2000)
The settings
The setting for the ethnography consisted of two chemotherapy day units.
In setting 1, the Chemotherapy Day Unit (CDU1) is situated in the basement with easy
access for cars and transport. It is located within a larger department that houses the
Radiotherapy Unit and the Oncology Outpatient Clinics. On other floors within this block
are the pathology laboratories, cancer support services and other outpatient clinics (such
as surgery). The staff compliment is one sister and four senior staff nurses. The unit opens
at 09.00 hours on Monday to Thursday and 10.00 on Friday (for staff meeting 9-10.00).
The clinic closes at 17.00 hours or when the last patient has finished treatment. On
average 32-34 patients are seen in a day. Patients are scheduled with an appointment.
22
They come to the clinic two days previously to have bloods taken, see the doctor if
necessary and have their treatment prescribed. On the day they come to the clinic, their
results would have been put on to the computer and their chemotherapy dispensed. For
the most part, there was minimal waiting time.
Setting 2 (CDU2) is situated in the main hospital building on the second floor and
geographically is some distance away from the outpatients’ clinic. The staff compliment
included one sister, five senior staff nurses and one receptionist. The unit is open from
08.30 and closes at 16.30, or when the last patient has finished treatment. The number of
patients seen in any day varies from 15 to 32. Patients come on an ad hoc basis, have
their blood taken for assay and then see the doctor who prescribes their treatment. They
then wait for blood results and for their chemotherapy to be dispensed before treatment is
commenced. Waiting times are lengthy and range from 3-7 hours.
Participants
The primary participants of this study were nurses administering chemotherapy in the two
settings. All nurses employed by the Trusts as chemotherapy nurses working in the
relevant Chemotherapy Day Units (CDU) were invited to take part. Initially, the lead nurses
and ward managers of potential settings were approached about the project. A
presentation was made to determine possible interest in taking part. From this, two areas
were chosen in different cancer networks in order to give a wider picture of the work of
chemotherapy nurses. Presentations of the study were then made to the relevant staff on
the CDU’s, staff received invitations and information letters, and there was opportunity for
potential participants to meet individually with the researcher to discuss the research
further and ask any questions. Nurses were then given consent forms and asked to return
them to the researcher if they wished to take part. In both CDUs all nurses chose to
participate. As a consequence, the patients these nurses were caring for were invited as
secondary participants. All patients who were approached consented to take part. It was
reiterated at each observation that participants could chose to withdraw at any time or ask
the researcher to not be present for certain procedures. This opportunity was not taken up.
Data Collection
Participant Observation
As participant observation is time-consuming and labour intensive, it was decided to use
two researchers for data collection, each researcher observing one of the units. This
method of data collection is termed team ethnography and is associated with increased
rigor and reflexivity as there is a systematic sharing of observations, and ongoing
questioning of data and interpretation (Erickson & Stull, 1998). Participant observation was
carried out in the two units for a four-hour period, for a number of times a week for a period
of 16 weeks. In this study the role of the researchers was that of a novice helper, similar to
a healthcare assistant, helping the nurse with simple tasks so that the researcher could
observe practice and clarify understanding of primary data collected (Wiseman, 2002).
Observation began with a pilot period to increase validity, consistency and research rigor
(Wolcott, 1999). Observation included, for example, the process of chemotherapy
administration, nurse-patient interactions, information giving and noted what the nurse did,
verbal and non-verbal communication. During observations nurses would explain to the
researchers what they were doing and why and the researchers had the opportunity to ask
23
any questions or clarify any points they did not understand. Informal interviews were often
carried out with patients, nurses and other healthcare workers (for example the unit
receptionist). During periods of observation the researcher would take time out to record
notes as aide memoirs either in a pocket notebook or on a dictaphone. Field notes would
be recorded in more detail immediately following the period of observation.
Interviews
Interviews were semi-structured and aimed at understanding the nurses’ experience of the
chemotherapy administration process and clarifying any discrepancies in attitudes and
observation. Themes emerging from the observation and questionnaire data formed the
basis of the interview structure. Interviews were tape recorded and transcribed verbatim.
Following common practice (Allan, 1999; Heyl, 2001) the transcript of the interview was
shown to the participant for further comment and clarification.
Analysis
Preliminary data analysis began at the point of participant observation. Once data
collection was completed, data from each unit were analysed separately using a modified
thematic analysis (Wiseman, 2002). As themes emerged, data were then subject to further
questioning and analysis as is common with ethnographic research (Coffey & Atkinson,
1996). Findings from both settings were discussed separately, and then considered
together to give a wider perspective of the work of nurses administering chemotherapy in a
day care unit. This process is common in team ethnography (Erickson & Stull, 1998).
Issues of Rigour
In qualitative research rigor is associated with openness, adherence to a philosophical
perspective, thoroughness in collecting data and reflexivity (Burns & Grove, 2005).
Reflexivity is a constant examining of the part the researcher plays in the construction of
the data (Davies, 1999).Throughout any study, the researchers constantly re-examined
their approach to the work, the participants and the theoretical perspective from which they
were working (Brunt, 2001). Using an ethnographic framework enabled the researchers to
emphasise the importance of understanding the work of chemotherapy nurses from their
perspective. Participant observation allowed the researchers the opportunity to check
meanings and test assumptions with the participants (Heyl, 2001). In addition within the
present study, as team ethnography was used, the data were discussed and assumptions
questioned within regular meetings of the research team (Erickson & Stull, 1998). Findings
were discussed with the participants for verification and they will have a copy of the final
report.
Ethical considerations and approvals
The research proposal for the ethnographic element was submitted to the relevant Local
Research Ethics Committees (Ref no: 04/Q0705/28; 04/Q0603/51) and approved.
There may have been a possibility of coercion of nurses by the Lead Nurse not to opt
out and nurses may have felt obliged to take part. However, from discussions with the
potential participants away from their managers, they seemed keen to take part. In
24
addition, assurances related to non-participation, withdrawal, anonymity and
confidentiality were offered to participants. Though their consent was gained in advance,
it was reconfirmed on an ongoing basis on each occasion that data were collected
(Moore & Savage, 2002).
To maintain confidentiality consent forms and assigned pseudonyms were stored
separately in a locked cabinet at the university and password protected on the
researcher’s computer. The raw data contained no real names of the participants.
Tapes of interviews were kept in the researcher's office in a locked cupboard and were
identified by ID code only. Data were stored on the researcher's password protected
computer, anonymised from the outset, in accordance with regulations found in the Data
Protection Act (1998). In compliance with the Research Governance Framework
(Department of Health 2001), interview transcripts and field notes will be kept in a locked
cupboard for seven years following the research. Interview tapes were made blank as
soon as analysis was completed.
In addition, before the final report is released it will be given to the participants and they
will be asked if they are satisfied and comfortable with the level of anonymity.
Time Frame for Both Elements
Table 3.3 describes the time frame for both elements of the study.
Table 3.3: Time Frame for Both Elements
Study Timeframe
Element 1 (questionnaire Element 2 (ethnography)
Study Activities
survey)
Ethical Approval
process
July 2004-Sept 2004
Sept 2004-Nov 2004
Research and
Development Approval
process
Oct 2004-May 2005
Sept 2004- Dec 2004
Oct 2004
N/A
Data collection
Jan 2005- July 2005
Jan 2005-July 2005
Data analysis
Aug 2005-Nov 2005
August 2005-Nov 2005
Dec 2005
Dec 2005
Pre-test
Final report
25
4 Results from component 1
Introduction
This next section will present all the findings from the Chemotherapy: Education, Worries
and Attitudes Questionnaire – Hospital Version. Outcomes of analyses conducted to
determine factors that influenced nurses’ attitudes and concerns will also be included.
Response rate
In total, 526 questionnaires were sent out and 257 returned (response rate was 49%). Of
these 253 were valid and complete questionnaires. Response to the survey was fairly
evenly distributed across the five Cancer Networks but varied by hospital site as depicted
in tables 4.1 and 4.2.
Table 4.1 Response rate across Cancer Networks
London Cancer Network
North
South East
South West
North East
West
Response rate
49.5%
53.7%
50.9%
42.3%
48.6%
Table 4.2 Response rate across hospital sites
No of
No of
Response rate
Site
questionnaire questionnaire
%
no
s sent
s returned
1
2
3
4
5
6
7
8
9
10
11
12
13
11
52
28
3
3
11
35
34
8
9
24
18
8
9
21
14
2
2
5
20
15
5
8
12
14
5
81
40.4
50.0
66.7
66.7
45.5
57.1
44.1
62.5
88.9
50.0
77.8
62.5
No of
No of
Response rate
Site
questionnaires questionnaires
%
no
sent
returned
14
15
16
17
18
19
20
21
22
23
24
25
26
3
24
5
12
87
5
2
2
2
10
7
112
11
2
6
3
9
30
4
1
1
2
4
4
53
6
66.7
25.0
60.0
75.0
34.5
80.0
50.0
50.0
100.0
40.0
57.1
47.3
54.5
Sample demographics
The nurses within this sample had on average been qualified fro almost 13 years. Table
4.3 illustrates respondents’ range and average years of experience both working within
oncology and administering chemotherapy.
26
Table 4.3 Sample Characteristics
Range in years/months
Time as a qualified nurse
2 years – 42 years,
Mean
12 years 11 months
6 months
Time spent working within oncology
6 months – 26 years
7 years, 8 months
Time spent administering chemotherapy
3 months – 25 years,
6 years, 5 month
3 months
Figure 4.1 indicates that chemotherapy administration is frequently undertaken as part of
these nurses’ current role, with 171 respondents (67.6%) reporting that they administer
chemotherapy on a daily or weekly basis. 118 respondents (47%) reported that they work
in outpatients departments and 182 respondents (72%) work on a ward. There is some
overlap and thirty-five of these respondents (19.2 %) reported that they work both on a
ward and in an outpatients department.
Figure 4.1 Frequency of Chemotherapy Administration
60%
50%
40%
30%
% of respondents
20%
10%
0%
Daily
Several times a
month
Weekly
Occasionally
Table 4.4 illustrates the distribution of the sample across clinical areas. It can be seen that
131 of the sample (51.8%) reported that they worked in haematology inpatient or out
patient departments. Seventy-nine respondents (31.2%) worked in oncology departments.
27
Table 4.4 Distribution of clinical areas within the sample
Clinical Speciality
Haematology Outpatients
Haematology Inpatients
Oncology Outpatients
Oncology Inpatients
HIV and other
No response
Frequency
(n=253)
55
76
43
36
35
8
%
21.7
30.0
17.0
14.2
13.8
3.2
Table 4.5 shows the distribution of nursing grades within the sample. The majority of the
sample were F grades, while only six of the sample were D grade nurses and nine
participants did not report their present grade.
Table 4.5 Nursing grade
Grade
D
E
F
G
H
Frequency
(n=244)
6
69
82
56
31
%
2.5
28.3
33.6
23.0
12.7
The sample’s professional qualifications (either obtained or currently being undertaken)
are shown in Table 4.6. It can be seen that 150 nurses in the sample (59.2%) were
qualified to degree level or above. Only 43 nurses (17%) were qualified to degree level of
above in cancer nursing/palliative care.
Table 4.6 Professional qualifications obtained or currently being undertaken
Qualifications
Frequency
%
Diploma Nursing
BA or BSc Nursing
MSc/MA Nursing
Diploma Cancer Nursing
BA or BSc Cancer Nursing
MSc/MA Cancer Nursing
MSc/MA Palliative Care Nursing
ENB N59 (Chemotherapy)
ENB 237 (Oncology)
ENB 285 (Palliative Care)
ENB A27 (Haematology)
113
98
9
28
35
7
1
43
83
10
39
44.7
38.7
3.6
11.1
13.8
2.8
0.4
17
32.8
4.0
15.4
28
Respondents Educational Preparation
Pre-registration
Approximately two thirds of the respondents (65.1%) reported that they did not receive any
teaching regarding chemotherapy during their pre-registration training. Twenty-two
individuals (8%) did not respond to this question or were uncertain about whether they had
received education pre-registration. Only 67 respondents (27%) reported that they had
received teaching on chemotherapy during pre-registration training and these nurses
stated that this teaching was typically 1-5 hours in duration (see table 4.7).
Table 4.7 Amount of chemotherapy education of those in receipt of some preregistration training.
Less than one hour
1-5 hours
>5-10 hours
Over 10 hours
Uncertain
(n=68)
%
9
31
9
10
9
13.2
45.6
13.2
14.7
13.2
Respondents were also asked to rate the adequacy of chemotherapy teaching that they
had received in pre-registration training from ‘Comprehensive’ to ‘Inadequate’. Table 4.8
illustrates how adequate nurses felt their pre-registration education in chemotherapy had
been. It can be seen that 134 respondents (53%) found the amount of pre-registration
chemotherapy teaching inadequate. Only 42 respondents (16.6%) reported that the
amount of chemotherapy teaching was adequate.
Table 4.8 Adequacy of the amount of chemotherapy teaching pre-registration
Comprehensive
Adequate
Uncertain
Inadequate
No response
Total
Frequency
12
42
36
134
29
253
%
4.7
16.6
14.2
53.0
11.5
100.0
Post-registration
When asked about their post-registration training, 243 respondents (96.4%) stated that
they had received some teaching on chemotherapy since qualifying and that this typically
amounted to over 10 hours (71.1%). The amount of time given to chemotherapy teaching
since qualification can be seen in Table 4.9
29
Table 4.9 Amount of chemotherapy education of those in receipt of some postregistration training
Less than one hour
1-5 hours
>5-10 hours
Over 10 hours
Uncertain
Frequency
%
4
26
22
172
18
1.7
10.7
9.1
71.1
7.4
Again respondents were asked to rate how adequate this amount of post-registration
chemotherapy teaching had proved. Table 4.10 shows the reported adequacy of the
amount of chemotherapy teaching post-registration. It can be seen that 119 respondents
(47%) had found the amount of chemotherapy teaching received to be adequate and 20
respondents (7.9%) reported that it had been inadequate.
Table 4.10 Adequacy of the amount of chemotherapy teaching post-registration
Comprehensive
Adequate
Uncertain
Inadequate
No response
Total
Frequency
105
119
8
20
1
253
%
41.5
47.0
3.2
7.9
.4
100.0
Figure 4.2 illustrates the manner in which the post-registration chemotherapy teaching had
been provided. Respondents were asked to tick one or more of the formats illustrated in
the figure 4.2. One hundred and sixty-five respondents (67%) reported that chemotherapy
teaching was delivered by informal clinical teaching. One hundred and fifty-eight
respondents (63.7%) attended a study day and 149 respondents (60.3%) indicated that
they had had a lecture during a course.
Figure 4.2 Chemotherapy Teaching Format
70%
60%
50%
40%
% of respondents
30%
20%
10%
0%
Study Day
Lecture in course
Conference
Other
Uncertain
30
Formal Chemotherapy Education
Table 4.11 illustrates the topics that respondents had covered during formal education and
reports areas where they perceived further education would benefit their practice. It can be
seen that a large proportion of the sample (> 80%) had received education on 10 of the 12
topics incorporated in the survey questionnaire. Only the topics ‘Developments in
chemotherapy treatment’ (reportedly received by 180 respondents, 73.2%) and
‘Chemotherapy reconstitution on the ward’ (reportedly received by 57 respondents, 23.8%)
were received by less than 80% of the sample.
Equally large numbers reported that they would find more education in these
chemotherapy topics beneficial. Specifically, the sample reported that they would benefit
from more education in ‘Developments in chemotherapy treatment’ (93.9%), ‘Managing
long-term consequences of chemotherapy treatments’ (79.4%) and ‘Managing emotional/
psychological consequences of chemotherapy treatment’ (72.6%). Interestingly, although
236 respondents (94.8%) reported that they had received education in ‘Managing
chemotherapy related side effects’, 155 respondents (67.1%) perceived that more
education in this topic would be beneficial.
Table 4.11 Formal chemotherapy education received and further education required.
Topics
Safety issues concerning
chemotherapy
Managing chemotherapy related side
effects
Extravasation
Practical administration of
chemotherapy
Managing anaphylactic/allergic
reactions to chemotherapy
How to inform patients about their
chemotherapy treatment
Handling excreta from chemotherapy
patients
Long-term consequences of
chemotherapy treatments
Managing emotional/psychological
consequences of chemotherapy
treatment
Appropriate use of pumps/equipment
Developments in chemotherapy
treatment
Chemotherapy reconstitution on the
ward
Education Received
Further Education
Required Perceived as
Beneficial for Practice
n
%
142
61.2
n
235
%
94.8
236
94.8
155
67.1
229
226
92
91.1
148
109
64.3
47.6
215
87.0
161
70.6
211
84.7
137
59.6
208
84.2
113
50
206
83.1
189
79.4
203
82.2
170
72.6
201
180
80.7
73.2
114
229
50.2
93.9
57
23.8
114
50.4
Figure 4.3 represents the format that respondents stated they would like further education
to take. Respondents were asked to tick one or more of the formats illustrated in the figure
4.3. As can be seen 139 respondents (60%) stated they would prefer their future education
to be delivered during a study day. One hundred and nineteen respondents (51.5%) chose
workshops as their preferred teaching format and 93 respondents (40.3%) indicated they
would prefer informal clinical teaching.
31
Figure 4.3 Formats for Further Education
45
40
35
30
25
% of respondents
20
15
10
5
0
Informal clinical
teaching
Lecture in course
Conference
E-base learning
Distance learning
Respondents were given the opportunity to state any other areas related to chemotherapy
and its administration where additional education would benefit them. Sixty-five nurses
answered this question. Of these 65 respondents, 38 (59%) reported that they would find
regular updates beneficial. For example one respondent said,
“Regular
reviewing of chemo education would keep my knowledge fresh – enabling me to be
a safer practitioner”
Another respondent commented,
“Updating staff
with the current issues regarding chemotherapy administration, proper
protective clothing and research drugs for cancer treatments”
Sixteen respondents (24.6%) stated that they would benefit from more knowledge about
pharmacological aspects of chemotherapy. For example,
“How each drug works in killing the cancer cells”
Six respondents (9.2%) said that they would like to learn more about fertility issues and
chemotherapy. As one respondent put it,
“Fertility and chemotherapy is an issue I would like to study further as I feel it is never
addressed during courses”
Respondents were further asked to state the three most important issues that should be
included when educating nurses about chemotherapy administration. As illustrated in table
4.12 one-hundred and fifty-two respondents rated health and safety issues of highest
importance
32
Table 4.12 Most important issues of chemotherapy education as rated sample
Important issues
Number of
respondents
Health and safety – re: patients, environment and nurse
Side effects
Practical administration
Extravasation
Information and consent
How chemotherapy works
Psychological needs
Managing chemotherapy induced emergencies
Venous access and cannulation
Disposing of patient excreta
Fertility and sexuality
152
105
73
59
54
48
23
23
9
4
1
Percentage of
respondents
%
59.1
40.8
28.4
22.9
21
18.7
8.9
8.9
3.5
1.6
0.4
Feelings towards chemotherapy administration
Of the sample 247 respondents (98%) described how they felt when they first started
administering chemotherapy. Typically, respondents described negative feelings towards
chemotherapy administration such as feeling ‘nervous’, ‘anxious’, ‘scared’, ‘apprehensive’
and ‘uncertain’. Only 5% of respondents described feeling ‘comfortable, well supported or
excited’ about their new role. Examples of the typical feelings described by the
respondents can be seen in Table 4.13.
Table 4.13 Feelings about Administering Chemotherapy
Feelings described when first started to handle/administer
chemotherapy
Negative feelings (n=234)
“Very anxious and unsure I kept
watching out for any untoward events
such as extravasation as I kept
thinking that if it occurred I was not
confident I would manage”
Positive feelings (n=13)
“Having had over 3 months of
supervised practice I felt safe and
confident and quite privileged to be
able to administer chemo”
“It was quite frightening you were
“Excited at prospect of giving drugs
always worried about what could go
designed to kill tumours and about
wrong and worried whether you would patients being cured”
be able to answer all the patients’
questions”
“Quite terrified – bit like working in
Chernobyl”
However, 218 respondents (86.2%) reported that their feelings towards chemotherapy
handling/administration had changed over time. At the time data were collected, the
sample typically reported that they were feeling more confident (208 respondents, 87.3%).
Eleven of the sample (4.6%) used terms such as capable, comfortable or competent, only
8 of the sample (3.4%) still reported feeling worried or nervous.
33
Of the 218 nurses who reported that their feelings about administering chemotherapy had
changed from when they first started, 211 described the factors that contributed to this
change. Typical reasons reported were ‘experience/increased practice’ (55.5%) for
example:
“Giving lots of chemo and gaining experience”
Eighty-seven respondents gave ‘chemotherapy education/increased knowledge’ as the
catalyst:
“Knowledge is power. Chemo study day and workbook have helped me gain
theoretical knowledge, applying it in practice has made me confident and
competent”.
“Continual learning and updating my knowledge of chemotherapy”
Seven respondents cited support as their reason, as exemplified below:
“Guidance and support of superiors and specialist nurses”
Issues of Practice
Prior to administering chemotherapy 94% of respondents always or often checked with
patients the information they had received, however only 59% of the respondents always
or often discussed with the medical team information that had been given to patients.
Respondents were also asked whether they thought there were times when it was not safe
to administer/handle chemotherapy. One hundred and ninety-three respondents (76.3%)
occasionally felt that it was not safe to administer it. Reasons given for this are detailed in
Table 4.14.
Table 4.14 Reasons given as to when it is not safe to administer chemotherapy
Times when it is not safe to
administer chemotherapy
Patient status unstable
Pregnant (nurse
Inadequate staffing levels/ ward busy
Uninformed patient/no consent
Outside normal hours (not 9-5)
Poor I.V access
Blood Counts – outside normal
ranges
Not knowing drug/regime/protocol
Staff not trained
Number of
Percentage of
respondents respondents
%
88
34.3
64
24.9
40
15.6
40
15.6
40
15.6
30
11.7
29
11.3
19
17
7.4
6.6
34
Support for Nurses
Respondents were asked who they got support from when they had queries or concerns
regarding administering chemotherapy to patients. Respondents could provide one or
more replies. Figure 4.4 shows from who typically they could turn to. One hundred and
thirty respondents (53.1 %) reported that they received support from the medical team,
129 respondents (53%) from pharmacy and 87 respondents (36%) from nursing
colleagues.
Figure 4.4 Support of nurses with regards to their queries and concerns about
chemotherapy administration
60
53
53.1
% of respondents
50
40
30
36
28.2
22.4
20
10
5.4
0
Ward
manager/ sister
Colleagues
Nurse Specialist
Pharmacy
M edical Team
(consult ants, Drs)
Ot her
One hundred and eighty respondents (71.1%) reported there had been occasions when
they had not wanted to administer chemotherapy. Table 4.15 illustrates how often
respondents felt supported in their decision to not give it.
Table 4.15: Frequency of those who felt supported in decision to not give
chemotherapy
Never
Occasionally
Often
Always
No response
Frequency
14
49
37
75
78
%
5.5
19.4
14.6
29.6
30.8
Seventy-five respondents (29.6%) reported that they were always supported in their
decision to not give chemotherapy. However 49 respondents (19.4%) reported that they
were only occasionally supported their decision. Data relating to degree of support offered
were cross-tabulated with nursing grade to see whether nursing grade influenced
response to their decision not to give chemotherapy. No statistically significant relationship
was evident.
35
Respondents were also asked who supported them in decisions not to give chemotherapy.
Respondents could provide one or more response. Figure 4.5 shows that support to not
give chemotherapy was typically received from senior nurses.
Figure 4.5 Nursing support for decisions not to give chemotherapy
35
% of Respondents
30
25
20
15
10
5
0
Senior nurses Medics/Doctors
Nursing
colleagues
Pharmacists
Relatives
Patient
Occupational
Health
Worries about administering Chemotherapy
Respondents where asked how often they worried with regards to various aspects of their
chemotherapy role. Sixteen aspects of their role were presented in the questionnaire and
respondents were requested to tick whether they worried ‘Never’, ‘Occasionally’, ‘Often’ or
‘Always’ about them.
Figure 4.6 depicts how often nurses in the sample worried about administering
chemotherapy. One hundred and seventy-six respondents (71%) felt occasionally worried
about understanding chemotherapy prescriptions/protocols. Whereas 116 nurses (46.3%)
were always or often worried about the education/knowledge deficits of other nursing staff
and 109 (44.3%) were always or often worried about extravasation.
In addition, other factors that the nurses worried about also reported in the questionnaires.
For example one respondent commented that,
“Not having enough time to spend educating patients/relatives - the day unit can seem rather
like a conveyor belt at times. Also not being able to spend listening to patients/relatives on
follow-up visits re: any problems they may have”
Another respondent said,
“I worry about some attitude of nursing staff who pretend to have lots of experience in
giving chemo when in fact they just learn to give chemo recently and with no proper training
in giving/handling cytotoxic drugs”
One nurse noted that,
36
“Mistakes being made due to ever increasing daily work load and the amount of time that
each patient can have with a nurse during their treatment”
Figure 4.6 depicts the frequency of these worries reported by the sample
Figure 4.6 Frequency of Worry
80%
70%
Never
60%
Occasionally
Always/Often
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Key:
Worry Statements
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Understanding of chemotherapy prescriptions/protocols
Handling cytotoxic drugs
Reconstituting chemotherapy on the ward
The risk of exposure to self
Extravasation
Treatment side effects
Patient allergic reactions
Patient anaphylactic reactions
Accidental spillage
Disposal of cytotoxics
Giving information about treatments
Giving information about side effects of treatment
Supporting the patient emotionally
Supporting relatives emotionally
Patient distress about their treatment
Education/knowledge deficits of other nursing staff
Cross tabulations
Cross tabulations and Somer’s d tests were undertaken to depict associations between the
worry statements and the following aspects of their role: the amount and adequacy of
education both pre-registration and post-registration received; place of work and frequency
of administration and nursing grade; few statistically relationships were found. The only
statistical significant associations were between nurses grades and four of the expressed
worries (Table 4.16)
37
Table 4.16 Associations between nursing grade and worries
Worries
Understanding of chemotherapy
prescriptions/protocols
Handling cytotoxic drugs
Supporting the patient emotionally
Supporting the relatives emotionally
Somer’s d
value
-0.186
p
0.001
-0.228
-0.169
- 0.145
<0.001
0.003
0.012
Table 4.17 reports cross-tabulations between nursing grade and those reportedly ‘never’
worrying about providing chemotherapy. Typically nurses of higher grades reported
worrying less about understanding chemotherapy protocols, handling cytotoxics or
supporting patients and relatives emotionally.
.
Table 4.17 Cross tabulations between nursing grade and not worrying about
chemotherapy administration
Never worry about:
Junior (D and E)
Understanding of
chemotherapy
prescriptions/protocols
Handling cytotoxic drugs
Supporting the patient
emotionally
Supporting the relatives
emotionally
N
9
%
19.1
Higher
(F, G and H)
n
%
38
80.9
24
19
23.5
22.6
78
65
76.5
77.4
19
23.2
63
76.8
Table 4.18 depicts the statistically significant findings of the Somer’s d test for clinical area
and worries. It can be seen that there is a strong relationship between risk of exposure to
self and clinical area.
Table 4.18 Associations between clinical area and worries
Worries
The risk of exposure to self
Disposal of cytotoxics
Supporting the patient emotionally
Somer’s d
value
-0.136
-0.116
-0.110
p
0.011
0.027
0.040
Table 4.19 represents the cross-tabulation results between clinical area and nurses’
worries. Nurses that work in haematology inpatients and outpatients departments reported
worrying more about the risk of exposure, disposal of cytotoxics and giving emotional
support to patients.
38
Table 4.19 Cross tabulations between clinical area and worries
Always worry about:
The risk of exposure to self
Disposal of cytotoxics
Supporting the patient
emotionally
Haematology
(in/outpatients)
n
%
24
70.6
14
63.6
12
63.2
Oncology
(in/outpatients)
n
%
7
20.6
5
22.7
4
21.1
Other
n
3
3
3
%
8.8
13.6
15.8
Non-Parametric tests – Mann Whitney
Educational level
Non-parametric independent samples tests were carried out on each of the worry
statements to determine whether nurses’ worries were influenced by educational level.
However no statistically significant differences were found in worry statements and
educational level.
Chemotherapy administration experience
Further Mann Whitney tests were conducted to determine differences in worries according
to chemotherapy administration experience. To enable this, the sample were divided into
two groups (i.e. less experienced <5 years and more experienced >5 years).
These tests determined that more experienced nurses worried significantly less about
‘handling cytotoxic drugs’ (Z= -2.162, p=0.031) or about ‘understanding chemotherapy
prescriptions/protocols’ (Z= -2.339, p=0.019), than nurses with less than five years
experience.
Attitudes towards Chemotherapy administration
Table 4.20 indicates respondents’ attitudes to 21 different statements about their
chemotherapy practice. Two hundred and fourteen respondents (85.3%) strongly agree
that ‘patients should always be informed about their treatment’. One hundred and sixty five
respondents (65.5%) agreed that they ‘know enough about chemotherapy to answer
patients’ questions adequately’ and one hundred and thirty one respondents (52.6%)
strongly disagreed that ‘Administering/ handling chemotherapy is no different than
administering/ handling intravenous antibiotics’.
39
Table 4.20 Attitudes towards chemotherapy administration
Attitude statements
a. When presented with complications caused by
chemotherapy I feel confident in my competency. (P)
b. It causes me distress when I see patients affected by
chemotherapy I have given them (N)
c. I know enough about chemotherapy to answer
patients’ questions adequately (P)
d. When presented with emergencies caused by
chemotherapy I do NOT feel confident in my
competency(N)
e. Chemotherapy causes more harm than good. (N)
f. I handle and administer chemotherapy without
hurrying (P)
g. I handle and administer chemotherapy without
interruptions. (P)
h. Giving chemotherapy to patients makes me feel
guilty. (N)
I. I know that all precautions are taken to ensure that I
am not at risk from chemotherapy. (P)
j. Patients should always be informed about their
treatment. (N)
k. I know that when I administer chemotherapy patients
have understood as much as they wish to about their
treatment. (P)
l. I always feel that I have supported patients during
their chemotherapy treatment. (P)
m. Giving chemotherapy impedes communication with
patients. (N)
n. It is easy to inform patients about their treatment but
harder to help them emotionally. (N)
o. I focus entirely on the practical aspects of the task
when giving/handling chemotherapy (N)
p. I try to avoid patients that are experiencing bad side
effects from chemotherapy I have given them (N)
q. Administering/ handling chemotherapy is no different
than administering/ handling intravenous antibiotics (N)
r. Talking with patients about their treatments is
stressful (N)
s. Patients know more about their chemotherapy than I
do (N)
t. Administering/ handling chemotherapy is a satisfying
part of my role. (P)
u. I do not find administering/ handling chemotherapy a
challenging part of my role (P)
Number
Strongly
agree
79
(30.7%)
31
(12 %)
50
(19.5%)
2
(0.8%)
and percentage of respondents
Agree
Disagree Strongly
disagree
162
8
1
(63%)
(3.1%)
0.4%)
117
87
13
(45.5%)
(33.9%)
(5%)
165
34
3
(64.2%)
(13.2%)
(1.2%)
28
159
60
(10.9%)
(61.9%)
(23.4%)
2
(0.8%)
90
(35%)
46
(17.9%)
2
(0.8%)
56
(21.8%)
214
(83.3%)
99
(38.5%)
22
(8.6%)
122
(47.5%)
85
(33%)
12
(4.7%)
136
(52.9%)
35
(13.6%)
131
(51%)
160
(62.3%)
34
(13.2%)
103
(40.1%)
125
(48.6%)
48
(18.7%)
0
95
(37%)
6
(2.3%)
31
(12%)
19
(7.4%)
6
(2.3%)
10
(3.9%)
8
(3.1%)
3
(1.2%)
49
(19%)
10
(3.9%)
144
(56%)
17
(6.6%)
150
(58.4%)
52
(20.2%)
5
(1.9%)
8
(3.1%)
77
(30%)
23
(9%)
162
(63%)
42
(16.3%)
13
(5%)
122
(47.5%)
63
(24.5%)
143
(55.6%)
112
(43.6%)
100
(38.9%)
133
(51.8%)
164
(63.8%)
35
(13.6%)
154
(59.9%)
21
(8.2%)
62
(24.1%)
4
(1.6%)
16
(6.3%)
112
(43.6%)
9
(3.5%)
2
(0.8%)
1
(0.4%)
0
96
(37.4%)
6
(2.3%)
36
(14%)
129
(50.2%)
131
(51%)
30
(11.7%)
57
(22.2%)
4
(1.6%)
44
(17.1%)
(P) = positive statements
(N) = negative statements
In addition, scores given by respondents to the attitude items were summed to provide a
total attitude score per respondent. The attitude scale included 21 items statements; as a
4-point Likert scale was used, the highest possible score indicating a positive attitude
would be 84. The attitude scale included both positive and negative item statements.
Positive attitude statements were scored 4 =strongly agree, 3= agree, 2=disagree, 1=
strongly disagree, conversely negative attitude statements were scored 1 =strongly agree,
2= agree, 3=disagree, 4= strongly disagree. Scores reported by the sample ranged from
47-79 (mean score 63).
40
Figure 4.7 illustrates the proportion of the sample that agrees or disagrees with each
attitude statement. The majority of respondents agreed with statement a: When presented
with complications caused by chemotherapy I feel confident in my competency (96.4%)
and statement j: Patients should always be informed about their treatment (99.2%).
Conversely, most respondents disagreed with statement h: Giving chemotherapy to
patients makes me feel guilty (94.4%) and statement p: I try to avoid patients that are
experiencing bad side effects from chemotherapy I have given them (95.6%).
Figure 4.7 Nurses’ Response to Attitude Statements
120
100
%
80
Agree/Strongly Agree
60
Disagree/Strongly disagree
40
20
0
a
b
c
d
e
f
g
h
I
j
k
l
m
n
o
p
q
r
s
t
u
Attitude statements
Cross tabulations – Somer’s d
Cross tabulations were performed with the attitude statements against the variables:
nursing grade, amount of education pre- and post-registration, adequacy of education preand post-registration, place of work (i.e. unit or centre), clinical area and frequency of
administration. A Somer’s d test was also carried out to measure the association between
each of these variables and the attitude statements.
No statistically significant relationship was found between nurses’ attitudes towards
chemotherapy administration and the following variables: the amount and adequacy of
chemotherapy education pre- and post-registration, clinical area and frequency of
administration. However there was some association between nurses’ attitudes and their
nursing grade and place of work. Table 4.22 shows the cross tabulations for those with
statistically significant associations between attitudes and nursing grade.
41
Table 4.21 Significant associations between attitude and nursing grade
Disagree with:
I handle chemotherapy
without interruptions
I focus entirely on the
practical aspects of the
task when
giving/handling
chemotherapy
Higher
(F, G and
H)
n
%
78
79.5
101
Junior
(D and E)
74.3
Somer’s
d value
p
n
20
%
20.4
-0.185
<0.001
35
25.7
0.257
<0.001
It can be seen that the higher grades tend to disagree more with these attitudes
statements.
Table 4.22 shows the cross tabulations where, there were statistically significant
associations between attitudes and place of work (centre/unit).
Table 4.22 Significant associations between attitudes and place of work
Agree with:
I know enough about
chemotherapy to answer
patients’ questions
adequately
I know that all precautions
are taken to ensure that I
am not at risk from
chemotherapy
I always feel that I have
supported patients during
their chemotherapy
treatment
Centre
Unit
Somer’s d
value
p
n
%
n
%
115
69.7
50
30.3
0.147
0.026
85
62.5
51
37.5
0.152
0.022
104
72.2
40
27.8
0.229
0.001
Non-Parametric tests determining difference in attitudes
Educational Level
A non-parametric independent samples test was carried out on each of the attitude
statements to determine if there were differences in attitudes according to nurses’
educational level. The sample was divided into two groups those not educated to degree
level or above and those who were. There were statistically significant differences in
attitudes recorded on two items according to education. Those with higher qualifications
were more likely to agree with the following statements:
‘When presented with complications caused by chemotherapy I feel confident in my
competency’ (Z=-2.160, p=0.031)
42
‘I handle and administer chemotherapy without interruptions’ (Z=-2.210, p=0.027).
Chemotherapy administration experience
A non-parametric independent samples test was carried out to identify any differences
between nurses’ attitudes according to their level of chemotherapy administration
experience. Nine statements showed statistically significant associations between group
differences. (Table 4.23)
Typically those with greater experience showed a more positive attitude to chemotherapy
and exhibited statistically significant greater confidence in their competence.
Table 4.23 Mann Whitney results- Attitude by chemotherapy experience
Attitudes
When presented with complications caused by chemotherapy I
feel confident in my competency
I know enough about chemotherapy to answer patients’
questions adequately
When presented with emergencies caused by chemotherapy I
do NOT feel confident in my competency
Chemotherapy causes more harm than good
I handle and administer chemotherapy without interruptions
Giving chemotherapy to patients makes me feel guilty
I focus entirely on the practical aspects of the task when
giving/handling chemotherapy
Patients know more about their chemotherapy than I do
Mann Whitney
p
-4.183
<0.001
-3.076
0.002
-3.856
<0.001
-2.327
-2.023
-2.721
-2.777
0.020
0.043
0.007
0.005
-4.720
<0.001
Ordinal Regression
The explanatory variables: site (centre/unit), educational level, grade and experience were
entered into a regression model in an attempt to explain variability in differences regarding
worries about chemotherapy role. However, since grade appeared to be the only
significant factor, the model was re-run with grade as the only independent factor, the
outcomes of this final model are shown in Table 4.24.
43
Table 4. 24 Ordinal regression model for worries about chemotherapy role
Worries about
chemotherapy
Nursing Grade
F
D-E
a. Worries about your
understanding of
chemotherapy
b. Worries about handling
cytotoxic drugs
c. Worries about
reconstituting chemotherapy
on the ward
d. Worries about the risk of
1
exposure to yourself
e. Worries about
extravasation
f. Worries about treatment
side effects
g. Worries about allergic
reactions
h. Worries about patient
1
anaphylactic reactions
i. Worries about accidental
spillage
j. Worries about disposal of
cytotoxics
k. Worries about giving
information about treatments
l. Worries about giving
information about side effects
of treatment
m. Worries about supporting
the patient emotionally
n. Worries about supporting
relatives emotionally
o. Worries about patient
distress about their treatment
p. Worries about
education/knowledge deficits
of other nursing staff
G
β
se(β)
β
se(β)
β
se(β)
χ23df)
p
1.656
0.468
1.078
0.444
0.901
0.471
12.748
0.005
1.475
0.438
0.802
0.430
0.554
0.454
14.036
0.003
1.180
0.570
0.839
0.573
0.989
0.606
4.447
0.22
2.279
0.652
1.066
0.661
0.693
0.702
25.116
<0.001
1.372
0.427
1.083
0.420
0.703
0.442
11.636
0.009
1.266
0.417
1.018
0.408
0.278
0.431
14.197
0.003
1.040
0.431
1.051
0.425
0.493
0.449
8.467
0.037
1.249
0.513
0.991
0.509
0.666
0.539
6.912
0.075
1.106
0.427
1.136
0.422
0.734
0.444
8.487
0.037
0.914
0.429
0.419
0.427
0.432
0.451
5.624
0.13
1.172
0.422
0.455
0.413
0.197
0.440
12.128
0.007
1.092
0.421
0.409
0.413
0.135
0.440
11.173
0.011
0.781
0.405
0.028
0.398
-0.304
0.426
11.816
0.008
0.650
0.408
0.078
0.400
-0.269
0.427
8.041
0.045
0.539
0.405
-0.206
0.400
-0.399
0.425
9.404
0.024
-0.507
0.396
-0.398
0.390
-0.134
0.412
2.381
0.50
It can be seen that nursing grade had a significant impact on the worries nurses had about
their chemotherapy role as 12 of the 16 worry statements showed significant relationships
with nursing grade.
Similarly regression modelling was undertaken to determine how the variables: site
(centre/unit), educational level, grade and experience impacted on ‘attitudes towards
chemotherapy’.
Table 4.26a and 4.26b show the results of the regression with attitudes. The effect of site,
educational level, job grade and experience vary across items. Site is significantly
associated three times, educational level once, grade twice, and experience four times.
Only one item "I always feel that I have supported patients during their chemotherapy" has
two significant factors. Thus it appears that there was no one factor that explains variability
in attitudes, although aspects one would expect to be impacted by experience did appear
to be so, for example, feelings of competency.
44
Table 4.26a Ordinal regression model for attitudes towards chemotherapy (Site and Educational level)
Attitude statements
a. When presented with complications caused by chemotherapy I feel confident in my
competency.
b. It causes me distress when I see patients affected by chemotherapy I have given them
c. I know enough about chemotherapy to answer patients’ questions adequately
d. When presented with emergencies caused by chemotherapy I do NOT feel confident in my
competency
e. Chemotherapy causes more harm than good.
f. I handle and administer chemotherapy without hurrying
g. I handle and administer chemotherapy without interruptions.
h. Giving chemotherapy to patients makes me feel guilty.
I. I know that all precautions are taken to ensure that I am not at risk from chemotherapy.
j. Patients should always be informed about their treatment.
k. I know that when I administer chemotherapy patients have understood as much as they wish
to about their treatment.
l. I always feel that I have supported patients during their chemotherapy treatment.
m. Giving chemotherapy impedes communication with patients.
n. It is easy to inform patients about their treatment but harder to help them emotionally.
o. I focus entirely on the practical aspects of the task when giving/handling chemotherapy
p. I try to avoid patients that are experiencing bad side effects from chemotherapy I have given
them
q. Administering/ handling chemotherapy is no different than administering/ handling intravenous
antibiotics
r. Talking with patients about their treatments is stressful
s. Patients know more about their chemotherapy than I do
t. Administering/ handling chemotherapy is a satisfying part of my role.
u. I do not find administering/ handling chemotherapy a challenging part of my role
Site
Educational Level
Centre
HE educated
β
se(β
β)
p
β
se(β
β)
p
-0.053
0.348
-0.446
0.330
0.279
0.304
0.87
0.21
0.14
0.542
-0.692
-0.057
0.387
0.348
0.374
0.16
0.047
0.88
-0.249
-0.002
0.147
-0.026
-0.253
-0.593
-0.251
0.300
0.308
0.277
0.272
0.290
0.284
0.454
0.41
1.00
0.60
0.92
0.38
0.036
0.58
0.382
-0.580
-0.343
-0.518
-0.373
-0.367
-0.093
0.367
0.387
0.345
0.343
0.362
0.35
0.554
0.30
0.13
0.32
0.13
0.30
0.29
0.87
-0.436
-0.880
0.192
0.394
0.338
0.285
0.296
0.288
0.293
0.284
0.13
0.003
0.51
0.18
0.23
0.310
-0.171
0.183
-0.090
-0.195
0.355
0.372
0.358
0.362
0.355
0.38
0.65
0.61
0.80
0.58
0.041
0.296
0.89
0.009
0.368
0.98
-0.063
0.297
0.017
-0.670
-0.194
0.289
0.285
0.310
0.301
0.296
0.83
0.30
0.96
0.026
0.51
-0.144
-0.509
-0.312
-0.090
-0.273
0.353
0.352
0.381
0.371
0.367
0.68
0.15
0.41
0.81
0.46
45
Table 4.26b Ordinal regression model for attitudes towards chemotherapy (Nursing grade and Experience)
Nursing Grade
Attitude statements
D-E
a. When presented with complications caused by chemotherapy I feel confident
in my competency.
b. It causes me distress when I see patients affected by chemotherapy I have
given them.
c. I know enough about chemotherapy to answer patients’ questions adequately
d. When presented with emergencies caused by chemotherapy I do NOT feel
confident in my competency
e. Chemotherapy causes more harm than good.
f. I handle and administer chemotherapy without hurrying
g. I handle and administer chemotherapy without interruptions.
h. Giving chemotherapy to patients makes me feel guilty.
I. I know that all precautions are taken to ensure that I am not at risk from
chemotherapy.
j. Patients should always be informed about their treatment.
k. I know that when I administer chemotherapy patients have understood as
much as they wish to about their treatment.
l. I always feel that I have supported patients during their chemotherapy
treatment.
m. Giving chemotherapy impedes communication with patients.
n. It is easy to inform patients about their treatment but harder to help them
emotionally.
o. I focus entirely on the practical aspects of the task when giving/handling
chemotherapy
p. I try to avoid patients that are experiencing bad side effects from
chemotherapy I have given them
q. Administering/ handling chemotherapy is no different than administering/
handling intravenous antibiotics
r. Talking with patients about their treatments is stressful
s. Patients know more about their chemotherapy than I do
t. Administering/ handling chemotherapy is a satisfying part of my role.
u. I do not find administering/ handling chemotherapy a challenging part of my
role
F
Experience
G
β
se(β)
β
se(β)
β
se(β)
p
β
se(β)
p
-1.176
0.569
-0.848
0.506
-1.090
0.513
0.14
-0.693
0.335
0.038
-0.282
-1.325
0.501
0.546
-0.224
-0.810
0.458
0.492
0.358
-0.462
0.464
0.491
0.33
0.079
-0.396
-0.306
0.286
0.316
0.17
0.33
-0.444
-1.405
0.220
0.803
-0.142
0.538
0.550
0.502
0.492
0.523
-0.089
-0.894
-0.142
0.283
0.227
0.490
0.496
0.458
0.449
0.480
-0.029
-0.972
-0.692
-0.018
0.482
0.490
0.500
0.463
0.455
0.487
0.70
0.081
0.097
0.13
0.38
-0.861
-0.268
-0.019
0.165
-0.577
0.316
0.322
0.290
0.279
0.299
0.006
0.41
0.95
0.55
0.054
-0.146
-1.204
0.503
0.905
-0.364
-1.193
0.46
0.847
-0.348
-0.262
0.465
0.922
0.78
0.28
0.307
0.334
0.289
0.425
0.29
0.43
-0.604
0.514
-0.355
0.469
0.003
0.474
0.44
0.568
0.297
0.056
-0.448
-0.668
0.533
0.523
-0.637
-0.557
0.491
0.469
-0.111
-0.202
0.490
0.472
0.45
0.50
0.644
0.103
0.314
0.299
0.040
0.73
-1.189
0.532
-0.618
0.479
-0.452
0.482
0.12
0.233
0.304
0.44
-1.895
0.531
-1.453
0.484
-0.733
0.484
0.002
-0.175
0.294
0.55
-0.583
0.531
-0.008
0.483
0.356
0.492
0.13
-0.023
0.306
0.94
0.740
-1.123
-0.994
-0.231
0.519
0.523
0.554
0.537
0.702
-0.769
-0.704
-0.170
0.474
0.475
0.497
0.491
0.427
-0.619
-0.529
-0.438
0.474
0.481
0.502
0.497
0.47
0.20
0.35
0.82
-0.159
0.445
-1.058
0.413
0.298
0.294
0.337
0.311
0.60
0.13
0.002
0.18
-1.067
0.537
-0.669
0.488
0.189
0.483
0.020
-0.036
0.306
0.91
46
5
Results from Component two – ethnography
Introduction
The two units were very different in terms of their make-up, work practices and the context
in which nurses worked. Although the settings were researched independently by different
researchers, themes emerging were the same albeit from opposite ends of a continuum.
The themes centred around factors which facilitated chemotherapy nurses’ work and
factors which impinged on their work. What was interesting was that factors that facilitated
nurses’ work in one unit were the same factors that impinged on the nurses’ work in the
other. This section will begin by describing the work organisation within the different units
before continuing to discuss the themes emerging from the study.
Chemotherapy Day Unit 1 (CDU 1)
Factors which facilitate nurses’ work
Organisation of work
In CDU 1 patients were scheduled with an appointment. They came to the clinic two days
previously to have their blood taken, see the doctor and nurse if necessary, and have their
treatment prescribed. Each nurse on the unit was allocated a particular specialist clinic so
that there is continuity with the consultants, doctors, patients, and their chemotherapy
regimes. As chemotherapy regimes and treatment trials change rapidly, the nurse gets to
know the regimes/treatments very well so can pick up early if there are any anomalies in
the patient’s condition. At the end of the clinic, the nurse would get the patients results and
write them on the prescription chart before it went to pharmacy for the chemotherapy to be
dispensed. If the results were not within an acceptable range, the nurse could discuss this
with the doctor and if necessary telephone the patient. There were times when patients
needed a blood transfusion or had to wait for extended recovery time before being able to
have more chemotherapy. There were also times when regimes needed to be changed
because they were having such a debilitating effect on the patient’s condition.
When patients were referred for chemotherapy, the nurse allocated to that specialty would
telephone the patient and make an appointment for the patient to come in and have what
was referred to as a “work up”. This was an assessment interview where the nurse would
assess the patient’s physical condition, explain the process of chemotherapy, the
particular regime and possible side effects. The nurse would also talk to the patient and
assess how the chemotherapy would affect them personally and the impact it may have on
the person’s life. At this time the nurse would book subsequent appointments for the
patient depending on what time suited them and the length of the chemotherapy
administration process. The appointment book is divided into 4 columns representing 4
nurses (1 nurse is in clinic). Patients are booked onto a slot and the number of hours it will
take to treat them is blocked out.
At the beginning of the day in CDU 1, a nurse goes to pharmacy, which is a short distance
from the unit, and collects the drug charts and chemotherapy for patients expected that
day. The drugs and charts are taken to the treatment room where they remain until they
are administered. They are checked at this point so that if there are drugs missing or not
dispensed, these can be followed up early. Drugs, still packaged, are laid out with the drug
chart. The patients and drugs are checked with the appointment sheet for that day to
47
ensure all patients expected have drugs. If there are anomalies at this point they can be
followed up early. There are often drug charts missing or still in pharmacy at this point
which nurses follow up. The nurses then decide who is to take which column (of the
appointment book) and hence which patients.
When patients arrive they go to the desk at the entrance of the unit and greet Jane1, the
receptionist. Once Jane knows they have arrived the patients go and wait in the main
waiting area, which has a television and magazines etc for people as they wait. Jane goes
to the treatment room and lets the nurses know which patients have arrived. The nurse
goes to greet the patients and bring them in to the unit. The nurses do not wear uniform, at
this point the nurse is not wearing gloves or an apron. The nurse brings the patient in and
sits them down. For the most part patients are accompanied by friends or relatives. The
nurse sits down and chats with the patient, asks them how they are and how they have
been since the last treatment. Invariably, the relative or the nurse gets the patient a drink
from the kitchen space at the corner of the room. The nurse then goes to the treatment
room, puts on an apron, washes her hands and begins to prepare the aseptic tray. When
the nurse has the drugs ready, she gets a trolley that has all the equipment for cannulation
and goes back to the patient. She invariably does a set of observations and begins to
cannulate the patient to administer the chemotherapy.
The nurses like working in this planned way. Before the work was organised through the
appointment system or scheduling, the patients would turn up and have to have their
bloods taken, see the doctor or wait for him to prescribe the chemotherapy, wait for the
drugs to be dispensed and wait for a nurse to be free to administer the chemotherapy. The
nurses reported how stressful this was as can be seen by the following quote:
There were often angry patients who had been waiting too long. It was really stressful. We were helpless until
they had the results and the drugs. Often patients who were quite ill were waiting for hours which was not
good for them. Also if the patient was too unwell to have the chemo they would still be sitting here waiting for
half the day to have confirmed what you knew by looking at them. It was terrible. And the clinic was always
late. You spent all morning waiting with nothing to do and racing around having no time to talk to anyone. It
was really stressful.
Nurses spoke about how the old system made both nurses and patients more anxious.
Once people came in and the waiting started. Nurses would be anxious cos you could never know what time
you were going to start let alone finish. Patients were so anxious and they were everywhere. Every time you
went passed they were “where’s my treatment, where’s my treatment”. We used to walk passed with our heads
down trying not to give eye contact.
For the most part patients liked having their treatment scheduled especially, as they could
have their blood taken locally and phone through or have the hospital phone through the
results. However, there were one or two patients who preferred the old system.
I know it wasn’t good for everyone but it suited me. I was quite well with my treatment and didn’t want to be
up here more than I had to. Some people were very ill and you could see it took its toll…all that waiting.
The way the work was organised through scheduling facilitated the nurses administering
chemotherapy in a number of ways. It meant that the nurses could organise their work
themselves and were not waiting either for results, for doctors to see patients and write up
prescription or for drugs to be dispensed. It also meant that there was less stress within
the unit and there was a relaxed atmosphere. Nurses seemed to have more time to spend
with patients.
The nurses did not go off the ward for their tea break. Instead, whoever was making a
drink would make one for whoever wanted one. It could be patients, relatives, Jane or the
nurses. Some nurses smoked so would go for a cigarette break. However, the nurses
1
All names have been changed.
48
always went off for their lunch break. They would go in pairs so that they could go out of
the hospital, get some air and have a change of environment. Throughout the whole of
data collection there was only one time (when there were only 2 nurses on duty) the
nurses had to stay on the unit for their lunch break.
The ward team
The ward team on CDU1 was very cohesive and they worked well together. All 5 nurses
were experienced nurses with both formal education and experience in giving
chemotherapy. They helped each other with their work and discussed treatment options
and patient problems. There seemed a large degree of trust and respect among the
nurses as can be seen in this quote:
We are a good team and we work off one another. We help each other and are almost fluid in the way we work.
We can discuss things if you are not happy with something…it makes a difference to be able to discuss it with
your peers and decide what you are going to do. It wasn’t always like that. We had one nurse who used to
change the whole atmosphere if she had a row with her boyfriend…it was terrible. Luckily she left.
Each Friday an hour was put aside for a staff meeting. The unit did not open until 10.00.
The meeting was used so that Alice could feedback any information from the cancer
directorate or the Trust. It was also used for presentations from drug representatives about
new drugs; or from the research team or doctors if there was a new treatment. These
presentations were usually accompanied by breakfast so the staff looked forward to them.
Alice would also use the meeting to comment on how the week had gone and if there were
any issues. All staff also had an opportunity to put items on the agenda. An example
follows:
When everyone had gone round, Alice thanked everyone for their hard work this week. She said it had been
difficult as holiday and sickness meant they were low in numbers on most days. However, she said although we
have done really well, we haven’t done well with the follow up letters and the admin work. This is as important
as giving the chemo. “I am as much to blame but I suggest we use the rest of the hour until the patients arrive
to go through our patients’ notes and make sure they are up to date.”
Relationships with patients and relatives
All staff spoke about how their relationships with patients helped facilitate their work.
Patients coming to the CDU were very thoughtful to each other and helpful to the nurses.
They often helped each other, making drinks for each other and the nurses, or sitting down
and chatting. One woman always came early and made tea before she was due to be
seen. Sian explains
The patients are so lovely. When you think about what they are going through….they also are always buying
us treats or bring goodies for everyone to eat. Some are hard work obviously but usually they are few and far
between.
Relationships with Support staff
The unit receptionist, Jane, was seen to be a real asset by nurses, patients, doctors and
pharmacy. Jane helped to co-ordinate the work of the unit. She ensured patients were
booked in, chased up any results or notes that were missing at the beginning of the day.
She was often the first port of call when patients telephoned for advice. She knew the
patients and often spent time with them. Jane was responsible for a lot of the
administration work, recording numbers of patients treated for example.
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There were also good relationships between the portering services and the transport
services. If the nurses needed the porters to collect any samples for the laboratories or
collect some blood for blood transfusions, they seemed to be efficient and responded
quickly to the request. The transport services were especially helpful to the nurses. The
transport office was just opposite the CDU so the transport workers knew the nurses. One
particular example from field work illustrates this:
Alice is worried about an elderly who has not been collected by transport. She is due to have Cisplatin which
takes hours and Alice doe not want her going home late and missing her meals on wheels. Julie goes to see
Beth in transport. Beth says there is no record of the request. She tells Julie to get Alex to fill out another
request which Julie does. “We will try and get her as soon as possible” Beth says. “Let us know if they pick
her up before 12 that would be ok by the time she is here and settled. But if she is not picked up by 12 we will
have to leave it for tomorrow. Beth is in agreement with this and speaks to the driver by mobile. Unfortunately,
there are problems with road works and traffic. Alice and Julie are in contact with Rose on the phone. By 12
the driver calls in to say he is not going to make it. Beth books it for early the next day, Alice telephones Rose
to have the chemotherapy first thing the next day. Rather than blaming each other and wasting time on who’s
at fault, everybody just got on trying to resolve the situation.
Other healthcare professionals
For the most part, nurses had good relationships with medical staff. The nurses worked
fairly autonomously. If they were unhappy giving a patient chemotherapy, they would talk
to the patient first then inform the doctor, explaining their rationale. The doctors respected
the nurses’ decisions and would often telephone the nurses to ask their opinion of the
patient if there were any queries. It was accepted that the nurses knew the patients well
and the way in which they normally reacted to their chemotherapy regimes. There were
many examples during data collection where consultants would bring new doctors or
visiting doctors to meet the nurses in the unit as this extract from fieldnotes illustrates: .
Dr Black walked into the treatment room. Alice, Jane and myself were there. “And this is Alice and the team.
They can really help you get to grips with how things work. Alice, Jane and oh I don’t you, are you new?”
There seemed to be a great deal of respect for the nurses and their level of knowledge
and experience. There were a few exceptions, one consultant, who liked the other hospital
in the cancer unit, would not bring their patients to the CDU.
The nurses also had good relationships with the pharmacy staff. The pharmacy staff
ensured that the chemotherapy drugs were dispensed as soon as possible and if there
were anomalies would bring the chart to the nurses to discuss the prescription. This cut
down on any waiting time. Both teams worked together to ensure the chemotherapy was
administered to the patients as quickly as possible. Alice explains:
They are really good here, the pharmacy, .they work with us not against us.
The environment Managing emotions
Both nurses and patients spoke about the importance of the atmosphere in the CDU.
There is a relaxed atmosphere. There is much joking and calling over from one patient to
another. Notes from fieldwork show how patients group and joke together:
There is a group of men sitting on one side joking with each other. Alice has to move one of them because she
needs a plug for his infusion. There is much joking about her breaking them up because they are too rowdy. It
comes from them and Alice joins in. “We can’t have you in gangs”. One of the men says he will move so that
his friend can have his plug.
The importance of having fun in the unit was stressed as a way of helping people to cope
with the treatment by nurses and patients. One woman having chemotherapy for liver
cancer said:
50
I need to have a bit of a joke, it helps. I need to keep my spirits up, for the nurses to bouy me up while I am
having this. I need to keep as strong as possible. I can think about how awful it is and was later but not now. I
need to be focussed on good things.
Though there was much joking, the nurses also assessed the impact treatment was having
on the patients and their families. The importance of having fun but also being serious is
noted in the following fieldnotes.
Sian and her patient and his wife are joking with Alice and her patient. He is really laughing as he sneezes and
blows his nose. Sian says he is allergic to Alice. She waits for her patient to stop laughing, then turns more
into him and asks him how he has been. She is looking intently at his eyes and face. He says “fine”. She is then
more specific. “How many times roughly are you passing urine in a day, how much are you eating, has your
month been sore or dry, have you been itchy. The questions are concerning his physical state initially then
move into other areas. Are you sleeping, how is your mood, how are you both coping with all this. She is really
huddled over the couple.
Patients and their relatives seemed very comfortable within the CDU. They often
wandered over to other patients to see how they were, made each other (and the staff)
drinks at times. If a patient looked not very well, invariably others would come over and
see if there was anything they could do. The following notes from fieldwork are a typical
example:
As soon as Debra was feeling better, she asked for the curtains to be drawn back again. Faye, another patient,
went in to see Debra. She was wheeling her dripstand as she went. “You worried me there” she said to Debra.
“I’m sorry, I could see you worry.” “Its silly really, I know nothing can happen and the nurses always keep
everything under control but you never know…”. The patients get quite close to each other as they meet up on
the same day and often have similar diagnoses.
Knowledge and education
All participants (nurses and patients) spoke about the importance of knowledge and
education in the work of chemotherapy nurses. All nurses on CDU 1 had formal
chemotherapy education as well as a lot of experience. Patients spoke about needing to
trust that the nurse knew what they were doing. As Jake stresses:
You are putting your life literally in their hands. You can tell if they know what they are doing. They are all
very experienced here. I have been some places where the nurse is shaking as she is doing it. It doesn’t give
you confidence. You can tell when you ask a question whether they really know the answer or if they are
bluffing.
Most nurses also spoke about how their experience helped increase their knowledge and
skill as Beth’s comment shows:
I had done my N59 so I knew the theory and what I should be doing and looking for. But because I was on a
ward and we didn’t give chemotherapy that often I don’t think I was very good. There was no-one with
experience, a role model, who I could learn the idiosyncrasies.
This quote also shows the importance of role models, as Sian indicates:
I had had the theory but I was terrified of doing it. Luckily the sister on the ward was very old fashioned. She
insisted people had a mentor and observed a certain number before first trying on someone with good veins
and gradually learning techniques for people with difficult veins. It was like an apprenticeship. It made you
feel guided.
Job satisfaction
Enjoying their role and the effect they had on people was important for nurses. Most spoke
about how important they thought the role of the CDU was in people’s cancer journey.
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They also spoke about the importance of enjoying their work and the relationships they
had with people.
You know its funny when I tell people what I do, they say…oh that must be awful and sometimes I think I must
be weird because I really like it. I have my weekends off; I work with good people and we have a laugh. I like
the fact that I am good at it. I like getting to know the patients, seeing them relax and see their trust.
The telephone
The telephone was a dominant feature of fieldwork. There were three or four handsets
dotted around in various places in the CDU. It was constantly ringing with queries from
patients, relatives, doctors, district nurses, liaison workers, pharmacy, or with results.
However, the telephone was not seen as an intrusion. On the contrary, nurses regarded
the telephone as a real asset to their work. Jo explains:
You do need to have it fairly close cos its always ringing. But at least that means you can get things sorted out
before they become a problem. We tell the patients to never worry about ringing us. Often it something minor,
they just want to check something but other times…If we are worried about what they are saying ..we can call
the doctors and alert them, we can get them an ambulance and bring them in. There are also times we need to
call them. Say their results have come back low. We can ring them and say…have a rest for another couple of
days or come and have some blood etc. I remember on the ward I used to really worry about calling people, it
seemed you only did it if you had bad news…its not like that here.
Factors which impinge on the work of chemotherapy nurses
- CDU 1
The Environment
Both nurses and patients spoke about how the layout and décor of the CDU impinged on
the chemotherapy administration process. CDU 1 was in the basement so did not get any
natural sunlight. The lighting was fairly stark and the decoration was drab. There was also
a consensus of opinion that there was not enough space or facilities for the through-put of
patients. Mary indicates the effect it has in the following:
Looking at the area sometimes really gets you down. The décor is oppressive. I am sure it was bright once but
it just looks dingy. There is not enough space, we need more sockets. We never see daylight. If it dies that to
us..imagine how it must be for the patients who only have to look at the walls whilst they are having chemo.
It’s great that we are in with the clinics and radiotherapy etc but we need to have it looked at. It would be
good to get one of those programmes to design it for us!
The environment also affected the communication between the nurse and the patients.
Nurses said they would like some more space between patients so that they could talk
freely to patients. Jo reports:
It’s hard enough for people but sometimes they are almost sitting on top of each other. If we want to talk to
them about something personal, its really hard.
There was an interview room off the CDU but for the most part that was used for planned
conversations eg initial workup interview or breaking bad news. Nurses felt it drew
attention to patients and made them more anxious. Alice explains:
There are times I know we could talk to patients more, things like sexuality, how they are coping, their
relationships with their loved ones.; but to say shall we go into the other room and chat seems to single them
out more as people look at you going off. We still do it…if they seem upset or if they seem to have something
on their mind BUT it would be good to have a system where we could routinely have some private time with
them, and space to do that.
Another aspect of shortage of space was that of patient privacy. A number of patients said
they were often embarrassed by their Hickman or PICC lines if other patients were too
close.
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It’s a bit much sometimes because I have to unbutton my shirt and sometimes there’s ladies too near by. And
when you go to the toilet..everyone knows..and can hear!!!
Lack of time – increased workload
The nurses on the CDU were extremely busy. The only time they sat down was when they
were cannulating a patient or giving them their chemotherapy drugs. Nurses and patients
spoke about the increased number of patients being treated and the effect this had on the
unit. One patient, Jackie, who had had chemotherapy the previous year remarked:
I can’t believe how busy it is now. There was always a lot of people in the waiting room cos we were waiting,
but now there are so many in here having treatment. Has the number of people with cancer gone up?
There was documentary evidence of the increase in numbers according to the Directorate
figures. However, there was no corresponding increase in staff numbers. In fact even
when there was a poor staffing levels, the nurses still seemed to be left to cope on their
own. This particular incident reported in fieldnotes acts as an example:
Today there are 32 patients and only 2 nurses on the unit due to the vacancy, holiday and sickness. Alice and
Jo are really busy giving chemo. In the treatment room they are haring around but when they go outside they
move fast but not frantic as they do in the treatment room. I get sandwiches and we eat in the sister’s office.
There is no time for a break. At the end of the day they have treated all the patients …but they look exhausted.
Alice spoke about days like this in her interview:
It’s terrible. Although you do try to talk to people, all the time your mind is on the next thing you have to do.
By the end of the day you feel as if all you have been doing is shoving drugs into people. That’s important but
it’s not all that this is about…there’s so much more we need to do.
Chemotherapy Day Unit 2 (CDU 2)
The beginning of data collection was a difficult time for this unit. There were 3 staff
vacancies and one nurse was on maternity leave. They were therefore very short staffed
and had to rely on agency nurses. The modern matron was new in post and new to the
hospital and the sister’s post filled by an experienced chemotherapy nurse “acting up” until
a new appointment was made. Recruitment and retention were issues for this unit that had
an impact on the context of care. Consequently there weren’t great deal of factors
facilitating the nurses’ work.
Factors which facilitate nurses’ work
Relationships with support staff
The support staff on the unit played an important part in the running and organization of
the unit. Carol, the receptionist, seemed to help to ensure the nurses had what they
needed in terms of notes and information to “process” the patients through. These
fieldnotes indicate the role she played
Carol was very friendly and had good relationships with all the patients. They greeted her like a long lost
friend. She in turn would greet them, ask them how they were and, after sitting them down put their name on
the board. She knew all there was to know about each patient, not from their notes but what they told her.
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Relationships with patients
CDU 2 operated with a “named nurse” framework where the patients were allocated a
particular nurse at the start of their treatment. If the nurse was on duty when the patient
came in for treatment, she/he would be allocated to give the chemotherapy. Nurses and
patients liked this system as it allowed them to develop relationships and get to know each
other, as is evident on the following quote from fieldwork
We really get to know our patients. We see the same patients every week and we try to keep the same patient to
the same nurse. You can’t help but build up relationships with them.
Patients really enjoyed knowing who was going to give them their treatment:
The nurses are lovely but sometimes very busy. You get used to waiting, it is off-putting but the nurses are so
nice, you really get to know them. Sometimes you don’t see the same one…its so short staffed.
Patients showed their appreciation of the nurses by bring many gifts of chocolate, biscuits
etc. The nurses appreciated this and remarked how it made them feel cared for:
The patients are lovely. They know we don’t get proper breaks so they are always bringing us chocolate and
things to eat.
Factors which impinge on nurses’ work (CDU 2)
As stated earlier, the beginning of data collection was a difficult time for CDU 2. It did
seem that there were more factors that impinged on the work of chemotherapy nurses
than facilitated them.
Organisation of work
Patients followed a system very much like the one in place in CDU 1 before they had
scheduling. However, the clinic and labs were not in the same location. At the end of the
day, the work for the following day would be divided between the staff guided by the
outpatient’s appointment book. The patients came in early in the morning, had their blood
taken and waited for their results, which sometimes took up to 2 hours. If the bloods
showed abnormal results, the patients had to wait and see the doctor who had a
consulting room in the unit. However, it seemed most patients saw the doctor before
treatment. Once the results were seen and were satisfactory, the drugs were prescribed
and the patient waited for them to be dispensed before treatment. The unit often stayed
open late. Even though opening times were meant to be 08.30 to 16.00, there were often
people being treated at 18.00 and later.
Nurses felt very frustrated with this system but thought the waiting was inevitable. Nurses
and patients would become anxious because of the wait. The patient, wondering how long
they would be there, the nurse wondering what time she/he would get home. The following
quote is from a patient resigned to the wait:
I know when I come here I am going to be here all day. I come on my own, its too long a day for anyone to
come…its too tiring talking to someone all day …and its not natural. You just have to get on with it.
Because the nurses’ work was so busy, they did not take any breaks which had a
detrimental effect on them. Jill explains:
No-one takes lunch here so around 3 everyone started to get really ratty
At the end of data collection, it had been decided that unit would begin to be organized
through a scheduling system, similar to CDU 1. It would be interesting to see the effect this
will have on the nurses’ work.
Staffing levels
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As already stated staffing levels were very poor on the unit for most of the duration of data
collection, which had a detrimental effect on the nurses’ work and experiences. These
notes from fieldwork show the constant strain it put on nurses:
There were four nurses on duty, only one was a permanent member of staff. The other three were either bank
or from another ward. Temps are an added strain on the sister and the rest of the permanent staff as they have
to take time to show them around and check they are safe etc…its constantly looking at them.
Constantly checking people meant nurses were not able to give patients the attention they
should have, as Mike indicates here:
I feel like a factory worker, I have no time for the patients. just have to check the line is going
Another problem associated with the lack of staff were that important safety issues were
being missed as the following extract from fieldnotes shows:
Jack tells the patient that his creatinine and urea seem high. He explains that “toxicity levels are high”. The
daughter asks what that means and then shouts to her father. The patient gets agitated, “that happened last
week” Jack explains that he will need to check with the doctor. “You will have to speak up” The daughter
explains that “he has been like this for 4 days. He was a bit deaf before but now he is terrible”.
However, towards the end of the period a number of people had been recruited filling the
vacancies, which gave people hope for the future.
The nursing team
Because the staffing levels were poor and erratic, the team were not very cohesive. For
the most part, they seemed to get on with each other but because of sickness and the
tension on the unit with patients waiting, the nurses seemed to work for the most part in
isolation. They tended to concentrate on their own work and did not help each other as this
extract from fieldwork shows:
If a patient is allocated to a nurse, no other nurse goes near that patient. Even if they need their chemotherapy
etc changing. Mike says “people really do not like it if their work is interfered with”. He said it may be
something to do with lack of knowledge ….people tend to hide what they are doing when they are uncertain.
The atmosphere on the unit was very erratic depending on which staff were on duty which
made it very difficult to predict the type of day it was going to be. These quotes from
different days show how it changed at times.
Entered the unit, no-one acknowledged me. Said hello to Tracey, she grunted back. The tension today is almost
palpable, everybody has their head down, no eye contact.
Got onto the unit, Jack and Sara are laughing. They call over to me and greet me warmly. Everybody seems in
a good mood today.
Relationships with other healthcare workers and other departments
The data from CDU 1 showed how the nurses’ work was facilitated by their relationships
with other healthcare workers and other departments. Data from CDU 2 indicate that the
relationships with other departments often impinged on the nurses’ work. Two particular
examples have been chosen as they illustrate this well but within the data set there are
many examples.
It did seem that staff in other departments did not appear to consider the impact of their
actions on the work of the unit.
Rose suddenly exclaimed loudly “I swear I am going to scream! The porters picked up the bloods at 9 and they
have still not delivered them to the labs. She telephoned the porters. She was fuming when she came off the
phone. “they have just said “Well the labs usually loose them anyway.
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It may be that because the workforce was so erratic, relationships were not strong with
other departments. There was also a lack of communication from departments to the unit,
this may be because of difficulty getting through on the telephone. However this often had
major implication for the staff on the unit as this example shows:
I went and sat at the workstation. There seemed to be more people than usual. One lady was looking
perplexed and met my eye. “We have been sent back here from the phlebotomists for our bloods to be taken
here as the waiting time in the lab in 3 hours” I went to talk to the staff. The staff on the unit had not been
informed first, the patients were just sent straight up.
Stress
Without exception all nurses spoke about the amount of stress they encountered in the
work. Sources of stress included the work organization and waiting. Nurses reported that it
seemed everybody was waiting – patients, nurses, doctors. Nurses reported that the
waiting made them feel uncomfortable, as Ellen explains:
I think its because you know what they need..they need to get the chemo and get home. But there’s nothing you
can do. You know you are not giving them what they need. And all the time they are ….”is my chemo ready
yet”. You feel awful. Some patients only have an hour treatment and they are here all day.
Nurses reported that having the patient waiting resulted in them using defensive behaviour
and avoiding patients. Nurses is CDU 1 remarked on this aspect of their behaviour before
they used the scheduling system. These fieldnotes record what nurses do to cope with
waiting and patients watching.
The patients constantly watch the nurses. However, the nurses really only communicate with the patients when
they are ready to treat them. It is as if they concentrate on the task at hand and nothing else. Jill says how
difficult it feels to have everyone waiting “You feel their eyes boring into the back of you. You have to keep
your head down. There’s nothing you can do til everything is ready and you are free.
One aspect of stress from the organization of work not immediately obvious, was that
nurses felt they had no control over their work.
You never know where you are. You can never plan anything in advance like going out from work or going on
a course without worrying “will I get out in time; am I leaving everyone in the lurch. Some days there 16
patients and 7 nurses, the next there are 32 and 2, it is really stressful
In addition to the organization of work, the increase in actual workload and numbers of
patients to be treated resulted in increased stress for nurses, as Gina indicates:
I find it really hard sometimes and feel overwhelmed there is so much to do. Patients are loosing out, it makes
you feel guilty and frustrated.
Another cause of stress for nurses was the nature of cancer and the patient’s suffering.
Its very upsetting sometimes. Look at John, he is so young and such a lovely lad but he is so ill and not doing
very well. I had a patient I was thinking about the other day who was meant to come for treatment and I
wondered where she was. I looked her up on the computer. She was short of breath the last time she was here.
Well she had been admitted and died. That was supposed to be her last treatment.
Nurses also spoke in interviews about their relationships with other staff on the unit. It
seemed that one staff member in particular was having an effect on others. As this
interview with Rebecca shows:
As soon as she comes in you can feel the atmosphere change. It really stressed me out, just drained me so I
went on annual leave everytime I knew I had to be with her.
Knowledge and education
One of the greatest differences between the units apart from the organization of work, was
the education and experience level of the nurses. In CDU 1, all nurses had had formal
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education concerning chemotherapy administration, supervised practice and also had a
lot of experience. In CDU 2 most nurses did not have any formal education concerning
chemotherapy. A senior staff nurse explain her experience in her interview:
It wasn’t deemed necessary to have study days but there was a lecturer who visited 2 or 3 times and told us
what to do.
A number of people were worried about the lack of knowledge and experience of the
nurses. This remark from a senior staff nurse shows how nurses worried about each
others lack of knowledge and skill as this extract from fieldnotes shows:
Kate has very strong concerns about chemotherapy in the Trust. She feels that nurses should be educated
properly about chemotherapy and have a mentor and supervised practice before they give any chemotherapy.
Lack of knowledge, education and experience had an affect on practice in that there were
a number of safety issues. One illustration is in the example given previously of a patient
going deaf with an increased urea level (4.2.3.2). These also included the fact that nurses
did not use infusion pumps to regulate the rate of infusion and often their knowledge
deficits were revealed in the advice they gave patients:
There is a phone call from a distressed relative. He was sent home the day before with ambulatory chemo via a
portacath. The infusion was due to finish at 1300hours but has finished at 6am. The patient was feeling very
nauseous. Jill is quite abrupt and tells the woman it’s not a problem that it has run through quicker than it was
meant and have you rung the GP about his nausea?
Time
As with CDU 1 all nurses spoke about how they did not feel they had enough time to
spend with patients as patient throughput had increased.
I came into CDU because I wanted patient contact, going through their issues with them, have they got
problems I can help them solve. But now I very very rarely have the time to sit with a patient and talk to them
about their treatment and the wider issues….its like a conveyer belt just giving chemo, hello here you are
goodbye gone.
Environment
Again as with CDU 1 nurses complained about the environment. That it was not designed
for chemotherapy administration and that it was depressing to be in. These notes from
fieldwork give a first impression:
There are a few windows but they are high up, light is blocked due to surrounding buildings outside. The views
are limited to walls of other buildings. The décor is dull, walls are dirty and hardly any pictures. Lots of
treatment chairs surround the room perimeter but are all over the place with no sense of organization. The
room feels depressing.
However, during the data collection period the unit was redecorated, which occurred whilst
patients were still receiving chemotherapy.
The telephone
In CDU 1 the telephone was seen as a very positive contribution which facilitated nurses
work in the chemotherapy administration process as the nurses felt they could have an
idea of what was happening to patients in between visits and that if patients were worried
they could ring straight away without waiting for the next visit. The staff on CDU 2 saw the
telephone as one of the factors that impinged on their work as the following quote shows:
The unit, he says has constant telephones ringing, we are always on the phone and not with patients. It drives you mad.
You feel as if you can never get away from people.
57
Conclusion
This chapter has detailed the findings of the ethnographies from the two chemotherapy
day units. Though the different areas were observed, analysed and reported separately, it
can be seen that the themes that emerged are important to the participants, albeit from
different ends of a continuum. As an overview, the findings suggest that the context, work
organization, the nursing team, education and experience and staffing levels, all impact on
the nurses’ work in chemotherapy day units.
5 Discussion
58
Introduction
Having reported the findings of each component of the study separately, this next section
will discuss the findings of both components and interpret them in light of the literature.
Implications for practice and recommendations for future research will also be included.
Summary of Findings
Feelings, Attitudes and Beliefs
The findings overall suggest that the nurses in this study have a positive attitude towards
their role in the chemotherapy process, but most did not initially embrace this role nor
appear to have positive feelings towards it. Many nurses admitted to feeling nervous or
frightened when first caring for patients receiving chemotherapy. These initial fears are not
dissimilar to newly registered nurses’ reported feelings in Corner and Wilson-Barnett’s
(1992) study investigating attitudes towards cancer. In contrast to Corner’s (1993)
assertion that professional experiences then continue to have a scaring and negative
effect on nurses’ attitudes towards cancer; in this study, experience, gaining more
knowledge about chemotherapy and having support from more experienced practitioners
appear to have had a positive effect. Equally, most of the respondents in component one
disagreed with the statement; chemotherapy does more harm than good unlike those in
the study by Elkind (1982). Furthermore, nurses in practice fully appreciated the important
role chemotherapy plays within cancer and palliative care.
Unlike Fall and Rose’s (1999) qualitative study, which explored nurses’ feelings towards
chemotherapy practice, guilt about administering chemotherapy was expressed by very
few questionnaire respondents. It maybe in order to avoid feeling guilty nurses are more
proactive in preventing and managing side effects now. Though questionnaire results
showed nurses felt distressed, when they see patients affected by the chemotherapy they
had administered; this was not evident in practice. What is evident is that nurses’
experience and feelings towards chemotherapy practice are likely to be different
depending on the context in which they work. Ethnographic findings suggest that the
environment and work practices can facilitate nurses’ work in chemotherapy administration
which increase their job satisfaction and reduce perceived stress.
The findings show nurses perceive that they are comfortable with communicating with
patients about chemotherapy. They perceive they have the skills to provide emotional
support to patients and their relatives, that resonates with Aratzamendi and Kearney’s
(2004) findings where most of participants believed that they did provide psychological
care. It may be that because many of the nurses in this study have a wealth of experience
of dealing with the emotional consequences of cancer and chemotherapy, providing
psychological support does not appear to cause anxiety for these nurses. However, what
was clear was that the organisation of care and the environment often adversely effect
nurses’ ability to provide the level of psychological support that they would like. The lack of
space, time and a private place to be with the patient inhibited nurses’ work in this area.
Junior nurses do appear to worry more about the emotional aspect of their role than those
of a more senior grade. Interestingly many of this sample identified that they required more
education to help them support patients and their relatives with the
emotional/psychological consequences of chemotherapy.
Many participants reported worries related to patients having adverse reactions to
treatment, extravasation and cytotoxic spillage. Although nearly all the respondents
59
reported that they had received education in these areas, it did not seem to lessen these
concerns. Verity (2002) also found that nurses worried about these aspects of care
however, she concluded that worrying about extravasation and safety issues should be
considered a positive, inevitable consequence of administering cytotoxic drugs. Nurses
need to be constantly vigilant of these adverse effects, so that, they can either be avoided
or effectively managed. However, it is also known that policies and guidelines related to
the management of adverse effects such as extravasation are not universally agreed and
differ from hospital to hospital (Dougherty, 2005; Holmes, 1997). Confusion about the
appropriate management of such events will inevitably lead to increased anxiety for nurses
who administer chemotherapy.
A positive finding is that few nurses worry about reconstituting cytotoxic drugs, a number
of participants stated that this ‘worry’ was not applicable to them as they were not
expected to do this anymore in the ward environment. Although confusingly over 50% of
those surveyed stated that they would benefit from more education in this area.
While many respondents believe that all necessary precautions are taken to ensure that
they are not at risk from the hazards of chemotherapy, it is not clear from the findings
whether this is because of their own safe practice or from the environment in which they
work. However, a number of insightful comments suggest that nurses do have concerns
about the long-term risks of exposure to chemotherapy. A number of nurses also worry
about the effectiveness of the protective clothing used to administer chemotherapy.
The statistical analysis indicated that there are a number of factors, which influence
nurses’ worries and attitudes towards chemotherapy practice, these include nursing grade,
working in either Cancer Centres or Unit sites, educational level and experience. The
finding that factors that affect nurses’ worries are different from those that affect their
attitudes is an interesting finding. The overall factor of experience seems to influence
nurses attitudes (as depicted by the ordinal regression model) more than education. While,
education does appear to have an impact it is difficult to determine the extent from the
survey findings. However, in practice it is evident that those who had received more formal
education were more competent and confident. The ordinal regression model indicated
that worries seem to be influenced by nursing grade. For example, junior nurses worry
more about understanding prescriptions/protocols, handling cytotoxic drugs and giving
emotional support to patients and relatives. Ethnographic evidence suggests that lack of
knowledge, education and experience leads nurses to exhibit more defensive behaviour
and makes it more difficult for them to engage and communicate with patients.
The nature and extent of educational preparation
It is apparent that the participants perceive themselves to be educationally equipped to
provide information and support to patients, whilst administering chemotherapy. What is
clear is that nearly all of the nurses in the survey did not have confidence in their
knowledge and skills when they first administered chemotherapy, which is corroborated by
interview data. Consequently, they felt nervous or frightened when initially starting this
role. Only 27% of the survey sample stated that their pre-registration training had included
education about chemotherapy. This finding is consistent with the overall conclusions from
Corner and Wilson-Barnett’s (1992) study; where nurses were not adequately prepared to
care for cancer patients and as a consequence held negative views about the disease and
its treatment. Student nurses need to be made aware of the value of cancer therapy not
just in terms of survival but also in terms of the quality of survival that can be achieved.
This awareness must also come from clinical experience.
60
Though survey findings indicate that the majority of nurses have had some form of formal
education in this practice, this was not corroborated in the ethnographic evidence, which
showed that in one chemotherapy day unit none of the nursing staff had received formal
education. It is interesting to note that only 27% of the survey sample had been educated
to diploma level or above in cancer nursing care. Questions then arise about the quality
and standard of education these nurses state that they have received in chemotherapy
practice, even though 71% of the sample indicate that the amount of time spent receiving
education was over ten hours. Most of the nurses surveyed also thought that receiving
more formal education would be beneficial as a means of enhancing their practice.
While this study’s intention was not in any way to investigate nurses’ actual knowledge
deficits, the results do suggest that there are wide variations in the training and education
that this sample has undertaken. Similar to that of Grundy’s (1999) and Verity’s (2002)
findings, it appears that many nurses have gained knowledge in practice vicariously in the
absence of formal education. Given the potential harmful effects of chemotherapy drugs,
this must be cause for concern. Interestingly, 76% of the survey participants were at times
worried about colleagues' knowledge and education deficits. What is not clear is if these
nurses are worried about the knowledge deficits of staff new to the oncology arena or the
staff who have worked in this area for some time.
The findings suggest that nurses who are new to the oncology/chemotherapy arena must
be given the appropriate education and supervised practice before administering
chemotherapy. These findings therefore, are in agreement with the recommendations
made by the Joint Council for Clinical Oncology (1994) and Goodman (1998b) that all
nurses before they undertake the role of chemotherapy administration must undertake a
recognised course and be given the appropriate support.
Although the nurses in the present study perceived they were educated and experienced,
there was an underlying feeling that nurses are aware that chemotherapy practice is
constantly evolving and they need educational support to maintain their knowledge and
skills. For example developments in chemotherapy treatments was an area that 94% of
the survey sample wanted more education in. Nurses therefore, clearly require continued,
ongoing professional development to ensure their knowledge is regularly updated.
The challenges of chemotherapy administration
One of the challenges for nurses is related to time. Being busy on the ward or having staff
shortages and lack of trained staff to administer chemotherapy was cited by some, as
reasons for when it was inappropriate to handle chemotherapy or when it should not be
given at all. Nineteen of the survey respondents wrote that they were very concerned
about time pressures, lack of trained staff, patient workload increasing and the subsequent
risk of more errors occurring. This finding was substantiated by ethnographic evidence.
When considering that many patients who have a cancer diagnosis will have
chemotherapy at some stage in their disease trajectory and, given the surprisingly low
number of nurses identified in this study who administer chemotherapy in London, this
issue of increasing workload is a legitimate cause for concern. It is vital that consideration
is given to the recruitment and retention of a competent chemotherapy workforce when it
has been identified that a lack of trained staff and time pressures are major causes for
chemotherapy and medication administration errors (O’Shea, 1999; Goodman, 1998b).
Time pressures were also cited as a reason for concern in six of the sample, who due to
lack of time admitted to not being able to support and educate others as well as they would
61
like. Overall, however, the majority of nurses in this study appeared to be well supported
either by other colleagues or more senior nursing staff and it is evident that when nurses
do have concerns about treatment, they seek support and information. They also appear
to be well supported by the medical team and to lesser extent pharmacists. However, for
some of the sample administering chemotherapy did cause conflict with doctors, but only
when the nurse felt that the patient was too unwell to receive treatment or when other
ethical issues arose, such as lack of informed consent. This finding was not influenced by
grade or experience.
Forty nurses in this study stated that chemotherapy should not be administered at night
when there might be a lack of adequate staff and expert support. From both components
of the study it is evident that consideration must be given to the organisation of
chemotherapy. Ethnographic evidence suggests that organisation of work practices and
the nature of relationships, both within the nursing team and with other healthcare
professionals, may either facilitate or impinge on chemotherapy nurses work and their
ability to give optimum patient care. Though time pressures were shown to be important,
findings from the ethnographic component of the study suggested the way time was used
was equally important. Work practices that result in large amounts of time wasted in
waiting have been found to cause stress for nurses and patients and relatives. Considering
the increased workload within chemotherapy day units, it is important to adopt work
schedules which reduce waiting times. Chemotherapy scheduling which allows nurses and
patients the opportunity to organise their own time has the potential to reduce stress and
increase satisfaction with care.
The findings show that the environment severely influenced the process of care within the
Chemotherapy Day Units. Though nurses did address patients’ psychological needs to a
degree, they reported the lack of private space with patients as a barrier to more
meaningful assessment of the impact of treatment on the patient’s life. Though many were
satisfied with their level of skill in the present system, they also reported a desire for more
education and training with protected time for patients to ensure their psychological needs
were assessed and met.
Limitations of the study
Component One
A number of limitations should be considered when interpreting the findings of component
one. Due to the recruitment of participants from one geographical location in the UK the
findings of this study should not be considered as representative of the population as a
whole. A low response rate is expected when self-completion, postal questionnaires are
used for collecting data; therefore, although the response rate of 49% was a
disappointment it was not a surprise. Reasons for non-response have not been obtained
and this then means that we know nothing about those who chose not to take part. It
raises the question whether the findings are representative of all the population of nurses
who administer chemotherapy in London. Although there is a good spread of grades and
experience the low response rate does preclude the ability to make clear statistical
comparisons on subgroups of the sample, for example to compare responses of junior
staff to that of more senior nurses. However, cross-tabulations were performed on all data
to identify if there were any emergent trends between the groups (which there were).
Seeking permission from twenty-six Research and Development Committees to access
the sample was time-consuming and at times problematic. A factor that may have
influenced the initial response rate in terms of those agreeing to have a questionnaire sent
62
to them was the utilisation the Lead Cancer Nurse (LCN) as gate-keeper to access the
sample in each Trust. Many would have viewed the LCN as their manager and therefore,
may have felt obliged to agree to participate. This may also have influenced their
responses to the questions giving the expected ‘text-book’ answers rather than their actual
feelings and attitudes towards this role. Because of the somewhat low response rate
findings and possible implications of this study cannot be generalised and should be
viewed with some caution.
The tool utilised in this study has not undergone any formal assessment of its reliability
and validity and before further use should be subjected to testing. Nevertheless the
questionnaire did appear to perform well overall. There was one particular question that
yielded responses that were difficult to interpret. This was question 21 related to the
clinical area/speciality the respondent worked in. Responses were not clear and therefore,
it was difficult to make comparisons between groups. There does appear to be a
relationship between different clinical areas and worries and attitudes, for example those
that work in haematology areas do worry more about the risk of personal exposure than
those who work in general oncology areas. In any future study clinical areas where
respondents work need to be determined more clearly. It is also difficult to be certain that
the Likert scale used for measuring respondent attitudes produced reliable and valid
results. There is the possibility that respondents gave answers that portrayed ideal
practice and socially acceptable answers rather than their actual attitudes. Giving the
participant time to think about these statements can also bias the responses. Attitudes are
known to fluctuate with time, as does their expression (Corner, 1988).
Component Two
A limitation of component two is that, as with any ethnographic research, it represents a
reality that each researcher shared with the nurses and patients. The findings are an
interpretation of that reality and it is recognised that there may be other possible ways of
interpreting it (Davies 1999). Although interpretation of findings has been discussed within
the project team and with participants to increase rigor (Erickson and Stull 1998), this fact
needs to be considered when reading the report. Equally it needs to be noted that the
findings represent a particular setting, in a particular time frame and concerns particular
people (Murphy & Dingwall, 2001). It may be that if any one of these elements were
changed, it would affect the findings. The findings are, therefore, not generalisable.
Both settings involved in the ethnographic component were cancer centres as it was
thought this would give greater insight as to the experience of nurses’ work in the Cancer
Centre. However, this does mean that the work of chemotherapy nurses in the Cancer
Units have not be explored at all.
Implications for Practice and Recommendations
The most important implications from this study concern the preparation of nurses taking
on roles within the chemotherapy administration process. The findings indicate a need for
core education and skills, clear measurement and indicators of competency and an agreed
level of supervision and support. There are future developments currently underway by the
National Chemotherapy Advisory Group, as part of the portfolio of work of the Cancer
Action Team to explore issues of nursing workforce and skills. Working collaboratively with
the Knowledge Skills Framework (Skills for Health 2005) national core competencies for
63
nurses administering chemotherapy have been agreed but these have not yet been
published at the time of writing this report. Further work is needed in order to agree models
of education in order to disseminate the competencies in practice.
As chemotherapy is a dynamic area within cancer care, there needs to be debate as to
future mode of practice and direction of chemotherapy services. Once the direction has
been debated and agreed, issues such as who delivers the service, in which way, in which
location and the nature of the service may be planned together with models of support and
supervision for optimum physical and psychological care.
The ethnographic component of this study was set in cancer centres, future research,
especially observational studies, are needed to explore the process of care within cancer
units as well as the cancer centres. It is important to explore whether the delivery of care is
different in cancer units. If it is different, the impact of the difference on nurses and patients
experience and outcome needs to be identified.
Conclusion
The intention of this study was to explore the process and context of nurses’ administering
chemotherapy. Overall, nurses appear to have a positive attitude towards chemotherapy.
They realise that chemotherapy is a more involved process than just administering
intravenous drugs and have an awareness of the safety issues and consequences of
administration. It is evident that nurses must have formal education and support in clinical
practice before taking on this role. Experience in this process has positively influenced not
only nurses’ attitudes towards chemotherapy but also their interactions with patients and
colleagues. However, what both components of this study have clearly highlighted is the
impact of the context on nurses’ work. A number of factors were identified as key to
facilitating nurses’ work in chemotherapy administration. These include organisation of
work, staffing levels and skill mix, educational preparation and supervised practice,
pressures of time and workload. The challenge therefore is to provide the educational
underpinnings, positive physical environment and effective working practices nurses need
in order to achieve optimum care.
The nature of the methodology of this study has produced data from a number of different
sources. The findings offer a range of insights into nurses’ and patients’ everyday
experience of the chemotherapy administration process and contribute to our
understanding of the different factors that influence patient care. This is especially
important in the light of current policies concerning cancer treatment (DoH 2000; NICE
2004) and future planning and development of services.
64
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7 Appendices
Appendix 1
Questionnaire
Appendix 2
Revisions to Questions
Appendix 3
Questions Added
Appendix 4
Information for Lead Cancer Nurses
Appendix 5
Cover letter to participants
Appendix 6
Nurse Information Sheet
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Appendix 1: Questionnaire
To be added manually
I
Appendix 2: Revisions to Questions
Original Question
Revision
Looking back do you feel the amount of teaching
you received was adequate?
Q7. How adequate was the amount of teaching you
received on chemotherapy in pre-registration training?
Comprehensive
Adequate
Uncertain
Inadequate
Q17. Are there times when you think it is NOT safe to
administer/handle chemotherapy?
Never
Occasionally
Often
Always
Q18. Have there been times when you didn’t want to
administer chemotherapy to a patient?
Yes
No
Uncertain
Are there times when you think it is not
appropriate to handle chemotherapy?
Yes
No
Uncertain
Have there been times when you didn’t want to
administer chemotherapy to a patient?
Yes
No
Never
Occasionally
Often
Always
Do any of the following WORRY you with regards
to your chemotherapy role?
Yes
No
Sometimes
Q19. How often do you WORRY with regards to the
following aspects of your chemotherapy role?
Never
Occasionally
Often
Always
The next set of questions ask about YOUR
ATTITUDES to how YOU FEEL about your role
in administering chemotherapy
Strongly agree
Agree
Uncertain
Disagree
Strongly Disagree
Q20. The next set of questions ask about YOUR
ATTITUDES to how YOU FEEL about your role in
administering chemotherapy
Question relating to attitudes – split into two
Question 20
Administering chemotherapy is a satisfying and
challenging part of my role
Q20.t. Administering/handling chemotherapy is a
satisfying part of my role
Strongly agree
Agree
Disagree
Strongly Disagree
Q20.u. Administering/handling chemotherapy is a
challenging part of my role.
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Appendix 3: Questions Added
2. In which clinical area do you administer chemotherapy? (please tick all that apply)
Outpatients
Ward
Community
Other
Q6. Have you received formal education in any of the following?
(question l. added onto list)
Ql. – Appropriate use of pumps/equipment
Yes
No
Unsure
Q9. Would you benefit from more education/information in any of the following?
(question l. added onto list)
Ql. - Appropriate use of pumps/equipment
Yes
No
Unsure
Q20. The next set of questions ask about YOUR ATTITUDES to how you feel about
your role in administering/handling chemotherapy
(questions e, d, o, were added onto list of attitude statements)
Q20.
e Chemotherapy causes more harm than good
d. When presented with emergencies caused by chemotherapy I do NOT feel
confident in my competency
o. I focus entirely on the practical aspects of the task when giving/handling
chemotherapy
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Appendix 4: Information for Lead Cancer Nurses
Florence Nightingale
School of Nursing
and Midwifery
Professor Alison Richardson
Chair of Cancer and Palliative Nursing Care
Tel 020 7848 3503
Fax 020 7848 3506
[email protected]
Dear Colleague
Re: Exploring the work of nurses who administer chemotherapy
As you may already be aware, the Florence Nightingale School of Nursing and Midwifery at King’s College
London (in collaboration with the South East London Cancer Network Nursing Research and Development
Group) have been awarded a grant from the European Oncology Nursing Society to explore the work of
nurses who administer chemotherapy. The purpose of this project is to gain knowledge of nurses’ beliefs,
knowledge and attitudes towards chemotherapy administration, in order to enhance practice and develop
educational programmes. The study aims to include all nurses who administer chemotherapy in hospitals
throughout the London Cancer Networks.
In order to ensure that all nurses who administer chemotherapy have the opportunity to be included in this
study we need your help to compile a list of the nurses who fulfil the eligibility criteria to whom we can then
send a questionnaire. However, to fulfil the requirements of the Data Protection Act we would like you, if
possible, to give the attached letter to all nurses in permanent positions who currently administer
chemotherapy in your Trust. This letter asks them to let you know if they do not wish their name to be
forwarded to the research team. Following this exercise we ask that you compile a list of nurses’ names
along with the department where they work so we might forward them information about the study along with
a questionnaire. This study has been given ethical approval from an NHS Multi Research Ethics Committee,
Project Number 04/Q0603/51. Permission has also been sought from your Trust’s Research and
Development Committee to involve nurses in this study.
We realise this will create extra work for you but hope, like us, you can see that the information this study will
provide will help to better understand the concerns of this group of nurses and inform future education,
training and support initiatives. If you would like to discuss this study and your involvement, Rebecca Verity,
Lecturer in Nursing at King’s and a member of the research team, would be happy to meet you on an
individual basis. Rebecca may be contacted via email: [email protected] or by phone 020 7848 3671.
If you are willing to help us with this research please could you kindly email Rebecca to confirm this as soon
as possible.
Your contribution to this study will be greatly appreciated. We look forward to hearing from you.
Yours sincerely
Professor Alison Richardson
Professor of Cancer and Palliative Nursing Care
Chief Investigator
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Appendix 5: Cover letter to participants
Florence Nightingale
School of Nursing
and Midwifery
Professor Alison Richardson
Chair of Cancer and Palliative Nursing Care
Tel 020 7848 3503
Fax 020 7848 3506
[email protected]
Dear Colleague
Exploring the work of nurses who administer chemotherapy
The Florence Nightingale School of Nursing and Midwifery at King’s College London have been awarded a
grant from the European Oncology Nursing Society to explore the work of nurses who administer
chemotherapy. The purpose of this project is to gain knowledge of nurses’ beliefs, knowledge and attitudes
towards chemotherapy administration in order to enhance practice and develop educational programmes.
The study aims to include all nurses who administer chemotherapy in hospitals throughout the London
Cancer Networks.
We would like you to consider taking part in this study. It will involve you completing a questionnaire that we
will send to you via your hospital address. In order to give an opportunity to all the nurses in the London
Cancer Networks to participate, we have asked the Lead Nurses of each cancer network to forward us the
names of all nurses who administer chemotherapy in the hospitals/trusts within their particular network. If you
do not want your name forwarded to the research team so that we can send you further information and a
questionnaire, please return the “tear off” slip to your Manager/Lead Nurse.
Please be assured that the research team will not use your name for any other purpose and will not forward
you any other material other than the questionnaire.
Thank you for your time.
Yours faithfully
Professor Alison Richardson
Chief Investigator
…………………………………………………………………………………………………………………
To <<insert the name of the Lead Nurse for the Network >>
I do not wish my name to be forwarded to the Research Team at Kings College London in connection with the study
entitled “Exploring the work of nurses who administer chemotherapy”.
Please return this by: <<insert date>>
My Name:…………………………………………………………………………………………………..
My signature………………………………………………………………………………………………
V
Appendix 6: Nurse Information Sheet
NURSE INFORMATION SHEET
Study title: Exploring the work of nurses who administer chemotherapy
You are being invited to take part in a research study. Before you decide it is important for you to
understand why the research is being done and what it will involve. Please take time to read the
following information carefully and discuss it with others if you wish. Take time to decide whether
or not you wish to take part.
Thank you for reading this.
What is the purpose of the study?
The study aims to:
To determine the knowledge, attitudes and beliefs of nurses who administer chemotherapy
Explore how nurses’ view their role in the process of chemotherapy administration.
To ascertain the nature and extent of educational preparation that nurses who administer
chemotherapy have received
To determine whether nurses who administer chemotherapy think this educational preparation is
sufficient.
Why have I been chosen?
This study will include up to 450 trained nurses who are administering chemotherapy in the
hospitals/trusts within the 5 Cancer Networks in London. Lead Nurses have been requested to
provide contact details for all nurses working in their trusts. To take part individuals have to be:
Registered general nurses
Employed by the trust
Administering chemotherapy to patients in one of the London Cancer Networks
Do I have to take part?
It is up to you whether or not to take part. This information sheet tells you all about the study and
will help you decide. If you do decide to take part, please complete the enclosed questionnaire and
return it to me in the next 4 weeks. Please post the completed questionnaire in the stamped
addressed envelope enclosed. If you do decide to take part, it is important that you know you can
withdraw at any time by contacting the research team up to the point when the data are analysed.
You do not have to give a reason for this.
What will happen to me if I take part?
Around 450 nurses are being invited to take part in this study. Each person will be sent a
questionnaire. Your involvement will last the time it takes to complete the questionnaire
(approximately 30 minutes). By filling in the questionnaire, you will be confirming that you are
happy to take part in the research. However, as stated earlier you are free to withdraw at any time.
What do I have to do?
Through taking part you will be asked to fill in a questionnaire and post it back to the research team
in the envelope provided.
What is being researched?
We are exploring the knowledge, beliefs and attitudes of nurses who administer chemotherapy. The
information gained from the study will help to enhance practice and develop education
programmes.
What are the possible disadvantages of taking part?
VI
The questionnaire may take up to half an hour to complete. So there will be costs in terms of your
time. For the questionnaire you will need to think about your practice and management of patients
with cancer having chemotherapy. These questions are not intended to be upsetting, but may raise
issues for you.
What are the possible benefits of taking part?
Through taking part you will help the London Cancer Networks to find out how best to provide
education and support to nurses providing care to patients having chemotherapy. Whilst this may
not directly benefit you, the information we get from this study may help us shape future education
and support services.
What happens when the research study stops?
Your usual working life will continue both during the study and after it is completed. Once the
study is complete you will not be requested for further information.
What if something goes wrong?
The chief investigator is indemnified through the general Kings College London Liability
Insurance, with the principle of “No Fault” compensation in operation for subjects of clinical
research.
Will my taking part in this study be confidential?
All responses you give will be confidential. Any information about you, which you provide, will
have your name and work address removed so that you cannot be recognised from it. You will be
identified solely by an identification number on the questionnaire. All study information will be
stored in accordance with the Data Protection Act (1998) in a locked filing cabinet to which only
the researchers will have access.
What will happen to the results of this study?
The researchers will work with the London Cancer Networks to determine how best to disseminate
the findings from this research. Feedback will be provided to each of the Cancer Networks where
data has been collected. The researchers will also present findings at the European Oncology
Nursing Society (EONS) conference and publish findings in selected journals. Findings may also be
posted on the Kings College London website.
Who is organising and funding the research?
The research is being funded by the EONS Roche grant 2004 and conducted by researchers based at
the Florence Nightingale School of Nursing and Midwifery at King’s College London University.
The research is being monitored and overseen by a Steering Group who will advise on its conduct.
This Steering Group is made up of healthcare experts.
Who has reviewed this study?
The South East London Cancer Network Research and Development group have reviewed and
commented on the study. The study has also been reviewed by the EONS grant review group and a
Multisite Research Ethics Committee.
Contact for further information
Ms Rebecca Verity
Lecturer in Cancer and Palliative Care
James Clerk Maxwell Building
57 Waterloo Road
London SE1 8WA
Email: [email protected]
Direct telephone line: 020 7848 3671
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