Position Statement

Role of the Professional Nurse in Caring for Individuals Receiving Cancer Therapies and Effects on Long-Term Survivorship

The intent of this position statement is to reaffirm the role of Registered Professional Nurses (RNs) in the evolving care of the individuals, families, and groups at risk for, or with, a diagnosis of cancer, and addressing the effects of the treatment sequelae on long-term survivorship.

Definitions

Chemotherapy/hormonal therapies are systemic therapies…used as single drugs, or in combination with other drugs…limited by their toxic effects on normal tissues. (Chemotherapy and Biotherapy Guidelines, 2005, p.2)
Biotherapy/targeted agents are systemic treatments [that] may modify the patients own immune system;may be so specific as to target a single receptor on the surface of tumor cells; may promote tumor regression; [and] may stimulate hematopoiesis.
Immunotherapy is defined by the National Cancer Institute (NCI) (2006) as a “treatment to stimulate or restore the ability of the immune system to fight cancer, infections, and other diseases. Also used to lessen certain side effects that may be caused by cancer treatment. Also called biological therapy, biotherapy, biological response modifier therapy and BRM therapy” (www.cancer.org)
Radiation Therapy according to NCI is “The use of high-energy radiation from x-rays, gamma rays, neutrons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy, implant radiation, or brachytherapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that circulates throughout the body” (www.cancer.org)

Position

It is the position of the New York State Nurses Association that:

Patients/family and significant others are entitled to safe, quality health care at all times while receiving chemotherapy, immunotherapy, biotherapy agents and radiation therapy.
Patients/family members and significant others are entitled to education and counseling that will facilitate optimum physical and mental functioning throughout the continuum of care.
Registered Professional Nurses (RNs) are responsible for researching, acquiring and demonstrating the knowledge and skills that display competence in the care of individuals receiving cancer therapies.
RNs have an obligation to provide safe, competent, and ethical care to patients in all practice settings.
RNs are responsible for creating a plan of care, that is focused on mutually established goals, culturally relevant, evidence-based, practical, and flexible, to ensure conclusion of the regimen with a positive outcome.
RNs are responsible for multidisciplinary collaboration to ensure development, review and adherence to policies related to safe preparation, storage, labeling, administration, documentation and disposal of chemotherapeutic agents.
RNs are responsible for standards and evidence-based practice in areas of treatment and long-term sequelae.
RNs are responsible for advocating for their patients/families and significant others in facilitating adequate education and promoting the maximum level of independence desired by the patient.
RNs are responsible for providing the leadership in assuring and advancing competent and comprehensive care for the millions of cancer patients, which includes addressing long-term sequelae and the needs of families and significant others.

Background

The transformation from intravenous administration of chemotherapeutics to nurses caring for a multifaceted population has expanded into the unique and evolving specialty area of oncology nursing. “Cancer is the second leading cause of death in the US, exceeded only by heart disease…[and] the 5-year relative survival rate for all cancers diagnosed between 1995 and 2000 is 64%” (Cancer facts & figures, 2005, p. 2) The impact of the extent of cancer and its sequelae, has penetrated multiple levels of nursing throughout the healthcare spectrum. Nurses are experiencing an increase in the number of individuals, admitted with multiple co-morbidities and often with a past or present diagnosis of cancer or treatment related issues... Nurses who assist these multidimensional populations encounter evolving challenges in the delivery of safe, quality care. An additional area for nurses to consider and continue to evaluate is that of quality of life for those individuals, their families facing cancer and the possible effects of long-term sequelae. “Quality of life (QOL) for individuals with cancer should be a concern for all nurses, whether caring for patients in the hospital, clinic, private office, homecare, or a hospice setting…. QOL is an essential aspect of nursing care” (King, 2006, p. 5)

Nursing continues to expand towards a more comprehensive role in areas of patient care, research and education. Opportunities exist for all nurses including those who specialize in oncology, to impact advances in technology, therapies, and quality of life and survivorship Long-term survival is now a reality and it is now evident that the direct care provided to these individuals becomes evidence-based and comprehensive.

“Competent and comprehensive care for survivors requires that all nurses understand and assess for the broad range of long-term sequelae whenever they evaluate at-risk patients, whether in primary care, home care, the emergency room, medical-surgical unit, occupational health, or other health care setting” (Curtiss & Haylock, 2006, p. 5).

Nursing continues to evolve in response to ongoing changes in treatment options, care delivery settings, and diverse patient populations. The expertise required to deliver safe, efficient, patient-centered cancer care continues to evolve as these challenges blend with the dynamic healthcare environment of today and the unforeseen events of the future.

Ethical and legal issues, such as an increase in the availability of unproven treatments and the number of under and uninsured patients, complicate the professional indices of nursing. Nurses are obligated to interact with advances in medicine and technology, which have the ability to sustain life and potential belated long-term sequelae of these therapies. Nurses must challenge the evolving healthcare environment regarding these and other issues to remain advocates for the population.

To advance and preserve the progression of oncology nursing, national initiatives and professional, consumer and advocacy organizations have supported the adherence to standards of care, which protect the patient/families and significant others. The Oncology Nursing Society (ONS) has provided updated statements on the Scope and Standards of Oncology Nursing practice to ensure the documentation and preservation of its history and evolution. ONS exemplifies how oncology nurses have contributed to the increase of cancer survival rates in the past century; especially in the areas of prevention and early detection. ONS cites the Institute of Medicine (IOM) challenge to healthcare professionals to ensure the American Nurses Association’s (ANA) Standards of Care and Standards of Professional Performance by promoting, advocating and delivering care that is “safe, effective, patient-centered, timely, efficient and equitable” (ONS, 2003, p. 3) care. The standards offered by the ONS, published in collaboration with the ANA in 1987 and revised in 1996, provide the benchmark from which the healthcare community can move forward in designing and supporting care to meet this challenge.

ONS also highlights the ongoing need for generalist and advanced practice oncology nurses reinforce proper training to fulfill the safe, quality care patients have come to expect. The challenge of an evolving healthcare environment, ethical and legal complications, and the increasing incidence of long-term survival sequelae, has demonstrated a priority for oncology nursing to provide the leadership in caring for and in advancing the evidence-based guidelines for the changing needs of cancer patients.

Recommendations

In order to facilitate safe, quality patient care by RNs caring for individuals receiving chemotherapy, immunotherapy, biotherapy agents and radiation therapies, and to ensure that the rights of RNs are upheld within their legal scope of practice, the New York State Nurses Association recommends that:

RNs who provide cancer therapies should have specialized preparation and ongoing opportunities to develop and demonstrate competency.
RNs caring for patients with a diagnosis of cancer in all areas of the healthcare system should assess their level of personal competency and skill levels, and seek additional evidenced based practice as indicated.

The RN has the responsibility to:

Advocate for all patients through a systematic, careful review of all medications and treatments ordered which have potentially harmful effects or side-effects.
Refuse and be supported in the refusal to perform any care or medication administration that is outside their personal scope of practice.
Inform the supervisor if given an assignment which involves knowledge or skills beyond his/her competency.
Explore alternatives, within reason, to gain the necessary information to perform required tasks (e.g., review unit specific policies and procedures, access other available references, confer with an experienced co-worker); and
Document the problem using the appropriate forms with objective facts about the situation, including the date, time, place, practice setting, and people present, and retain a copy.
Collaborate with other healthcare providers in coordinating, reviewing, advocating, and guiding patient care.
Actively participate in professional role development initiatives, quality improvement, research, and education aimed at improving the evidence-based standards in the areas of care and treatment, including long-term sequelae.
Assess the cancer patients’ evolving needs and address in various ways, such as

Through the use of the holistic nature of nursing,
Advocating for adequate education of colleagues toward these needs,
and through ensuring that resources for support and coping are made available for each individual.

The facility should be responsible for:

Establishing, as a priority, the availability of adequate educational opportunities for all nurses in order to provide patients/family members and others close to the patient with safe, quality care.
Establishing resources that are readily available twenty-four hours a day for all nursing staff such as websites, reference books, and when possible personal specifically trained in oncology.
Providing adequate access to information, adaptable to the individual patient’s developmental and educational level, which includes treatment modalities, ethical issues, medication side effects, and clinical trial information, for patients/family members and significant others.
Ensuring that resources for support systems are available to the patient/family and others close to the patients, which are reflective of economic, developmental, emotional and educational levels.
Supporting interdisciplinary collaboration for providing the best available options, for the patient receiving the chemotherapy, immunotherapy and biotherapy agents.
Supporting and participating in ongoing research opportunities which focus on the reality of long-term survivorship and the advancement of evidence-based guidelines to support cancer patients and those who care for them.

Note: The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.

Approved by the Board of Directors on 6/07. This position statement was developed under the direction of NYSNA's Council on Nursing Practice.

References

American Cancer Society (2006) Cancer Facts & Figures 2005. Atlanta: Amercian Cancer Society.

Boyle, D. A., Bruce, S. D., Iwamoto, R. R., & Summers, B. L. (2004). Statement on the scope and standards of oncology nursing practice. Pittsburgh, PA: Oncology Nursing Society.

Curtis, C. P., & Haylock, P. J. (2006). State of the science. Editorial: Survivor-centered care. American Journal of Nursing, 106(3S), 4-11.

Ferrell, B. R., Virani, R., Smith, S., & Juarez, G. (2003). The role of oncology nursing to ensure quality care for cancer survisors: A report commissioned by the National Cancer Policy Board and Institute of Medicine. Oncology Nursing Forum, 30(1), E1-E11.

King, C. R. (2006) Advances in how clinical nurses can evaluate and improve quality of life for individuals with cancer. Oncology Nursing Forum 33 (S1), 1-12

National Cancer Institute (2006). Retrieved on January 26, 2007 from www.cancer.org

Polovich, M., White, J.M., & Kelleher, L.O. (2005). Chemotherapy and biotherapy guidelines and recommendations for practice, 2nd ed. Pittsburgh, PA: Oncology Nursing Society.

For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.