RESEARCH REPORT ONCOLOGY NURSING CARE STANDARDS

Astrid M de Kleijn and Marie E Muller

introduction medical diagnoses convey so dramatically and unambiguously the spectre of death as does Oncology is the study of malignant neoplastic Abstract cancer. From the moment of detection and diseases generally referred to as cancer Oncology nursing as a specialised diagnosis, the certainty of mortality influences (Baldonado & Stahl, 1982: 1). Oncology nursing discipline has no published the behaviour of both the patient and the medical nursing is the nursing of patients suffering from nursing care standards for South Africa. care team. Consequently it is important that some form of neoplastic pathology. As a The purpose o f this study was to formulate those involved in patient treatment and support disease, cancer has been known thoughout oncology nursing standards for a examine their own attitudes toward cancer and re^rded history. Hippocrates himself particular research hospital A specific death before attempting to care for others d^^ibed many types of neoplasm and he approach was used and the oncology (Portlock & Goffinet, 1986: 295). Oncology probably coined the term carcinoma (Kahn, nursing experts in the research hospital nursing care therefore requires special nurses. Love, Shermand & Chakravorty, 1983: 3). Until compiled and formulated the standards. the late 1950’s, because of the apparently Group discussions and critical debating The professional responsibilities of a registered incurable nature of the disease, a diagnosis of of the standards followed. The standards nurse are embodied in the South African cancer was viewed by both the patient and were ratified by means of verbal Nursing Council (1984) regulation relating to health care provider, as a death sentence. consensus between the experts and the scope of practice of persons who are However, advances in surgical techniques, professional nurses in the oncology unit. registered or enrolled under the Nursing Act radiation therapy, chemotherapy and These standards could serve as a guide to (RSA, 1978). immunotherapy have greatly altered prognoses ensure quality oncology nursing care. The registered nurse is responsible for for the better. Today it is estimated that 40% of National validation of the standards is scientifically based physical, chemical, diagnosed neoplasms are curable and 15% of the recommended remaining have a life expectancy greater than 15 psychological, social, educational and years (Dietz, 1981: 3). Uittreksel technological nursing care. This therefore requires specialised knowledge on the part of Therapy, however, may cause primary and/or Onkologiese verpleging, as 'n the nursing staff in an oncology nursing unit and secondary disabilities and the patient is exposed gespesialiseerde verpleegdissipline, het meeting the basic health needs of the oncology to many difficulties. Not only is his future geen formeel-gepubliseerde patient becomes a specialised area of nursing. unpredictable but the methods of treatment used verpleegstandaarde in Suid-Afrika nie. The professional responsibilities also include to alleviate his condition are often very toxicand Die doel van hierdie studie was om mav induce a variety of unpleasant side effects onkologiese verpleegstandaarde vir 'n preventive, promotive, curative and rehabilitative aspects of nursing care and the a^P^oblems. Most patients receive a course of spesifieke navorsingshospitaal te recognition of the patient as part of a family and chemotherapeutic drugs and/or radiation formuleer. ‘n Spesifieke benadering ten a community. The acts and interventions the therapy as part of their treatment regimen. opsigte van standaardformulering is nurse is expected to perform ensure that the Successful therapy depends upon meeting the gevolg. Kundiges in die hospitaal het patient is nursed in totality with his physical, individual needs and carrying out evaluation of standaarde saamgestel en geformuleer. the quality of care on an ongoing basis. This Groepbesprekings en kritiese social and psychological needs being met. The professional nurse is responsible too for the Valuation of the quality should take into debatvoering het gevolg. Die standaarde specific nursing care of patients at high risk, in consideration the potential course and outcome is by wyse van verbale i’consensus deur die this case the patient suffering from cancer. The of the disease (Dietz, 1981: 172-173). kundiges en professionele verpleegkundiges in die onkologie objective of the health team is the rehabilitation The oncology nurse plays an important role in verpleegeenheid bekragtig. Hierdie of the patient, back into family and community the multiprofessional treatment regimen and is standaarde behoort as riglyn te dien vir life. In order to maintain control of their lives, accountable for rendering quality nursing care. gehalteverpleging in hierdie verband. many cancer patients need to change their Nurses are, however, unable to objectively and Nasionale validering van die standaarde habits, modify their normative prescribed social formally evaluate the quality of oncology word aanbeveel. roles, redefine and reinterpret basic concepts nursing care due to a lack of standards and such as health and illness. Thus the nurse’s evaluation instruments in this regard. Standards objectives are to assist the patient to adjust to guide the nursing practice and will help to different ways of meeting his daily monitor the quality of nursing care rendered in LITERATURE REVIEW requirements, establishing new techniques of the oncological nursing unit. Oncology nursing care is a multifaceted self care, modifying self-image, revising his routine of daily living, and developing a new The purpose of this study is to formulate speciality which deals with patients who may be life-style compatible with the effects of any oncology nursing care standards for a particular at any point on the health-illness continuum disabilities (Dietz, 1981: 170). hospital. ranging from the high risk patient needing information about prevention to the patient On respecting the right of the patient to needing comfort and support duri ng dy i ng. Few self-determination, his involvement in the

Curationis, Vol. 14, No. 2, August 1991 23 planning and implementation of a nursing care anxious to begin treatment, he will also be appropriately (Portlock & Goffinet, 1986: programme is of paramount importance. The reluctant to suffer its side effects. 254-263). patient has the right to give informed consent Communication, accessibility, and consistent Oncology nursing care is a specialised regarding all medical and nursing interactions support assist in lessening this ambivalence. discipline requiring very special nurses. (Given & Given, 1984: 146). For those patients who are cured, stress and Oncology patients receive quality nursing care anxiety do not end with the completion of In assessing the patient’s health needs and when the nurse rendering that care adheres to treatment but may be present continuously for problems, the nurse should take into the scientific principles of diagnosing the many years to come. For those whose disease consideration his lifestyle, history, cultural patients’ health needs and problems, recurs or who cannot be cured, there is a background and self-care performance. The formulating and implementing an appropriate persistent confrontation with mortality. patient’s abilities and disabilities which will nursing care plan and evaluating the Care-givers should bear in mind such determine the extent of his engagement in effectiveness of her nursing interactions. The fundamental features of human worth as respect self-care activities should also be assessed patient’s response to the treatment modality is for the individual, inclusion in a community, (Given & Given, 1984: 140). Problems most dependent upon such variables as the cancer concern for the physical body, and personal commonly experienced by the oncology patient diagnosis, the stage of the disease, health meaning beyond the self (Portlock & Goffmet, are nutritional, psychological and comfort history, socio-economic status and motivation. 1986: 295). (pain) status, potential for infection and injury, Malignant diseases prevail in all organs and knowledge of the disease process and the Main physical problems to be considered are systems of the body and therefore the oncology i mpl ications of the treatment modalities, as wel 1 pain, nutritional status, haemoptysis, pleural nurse needs to be a specialist in all the different as the ability to carry out activities necessary for effusion, pericardial effusion, hepatic types of cancer. daily living (Cox & Wark, 1980: 109-132). metastases, bowel obstruction, renal failure, bone metastases, and viral/fungal infections. DEFINITION OF TERMINOLOGY The progressive anorexia-cachexia Pain in a patient with cancer may be due to accompanying advanced malignancy may be a Oncology nursing care benign, unrelated causes, may be referred, and major source of morbidity. Cachectic patients may be very difficult to control. The patient also Oncology nursing care is the nursing of patients are often unable to tolerate the complications of needs to cope with fear, anxiety and depression suffering from cancer and may be curative, cancer therapy and are more susceptible to of chronic pain (Portlock & Goffinet, 1986:297; restorative, palliative or supportive, depending infections (Pruitt, 1983: 370; Smith, 1975: 53). Cox & Wark, 1980: 109-132; Hauck, 1986: upon the medical diagnosis of the patient. Fever as a manifestation of malignant disease 67). may present a difficult diagnostic problem. Standard While at least two-thirds of all cancer patients Effusions may affect pulmonary and/or cardiac A standard is a descriptive statement of the will have fever at some time during their iilness, function which require many local, systemic or expected level of performance againstwhich the in most instances this symptom is attributable to surgical therapeutic interventions. Metastases quality of oncology nursing care can be infection (Portlock & Goffinett, 1986: 37). It is can result in severe pain and other complications evaluated. therefore important to undertake a increasing the mortality rate. Bowel obstruction comprehensive patient history and physical is one of the most common gastrointestinal examination regarding the patient’s physical, problems resulting in abdominal pain, emesis, RESEARCH METHODOLOGY social and psychological status. and abdominal distention. Infection is a A descriptive approach was followed whereby common complication. As one of the side the domain variables related to oncology Nursing a patient in totality implies that the effects, chemotherapy causes a decrease in the nursing care were explored, described and psychological needs of the patient are being met. leucocyte count. This increases the potential for validated. A literature review was undertaken The importance of this aspect is highlighted in infection. Another cause of leucopenia is to ensure theoretical and content validity of the the SANC (1984) regulati on:" moni tori ng of the metastatic involvement of the bone marrow standards. American and British literature was patient’s reaction to disease conditions, trauma, (P o rtlo c k & Goffinet, 1986: 295-321; utilised to identify the prerequisites of quatffc stress, anxiety, medication and treatment." and Speechley, 1985: 21-22). There is also a oncology nursing care. A specific approach™ the patient may experience certain emotional potential for injury. Thrombocytopenia is standard formulation was utilised, focusing on stages such as denial, anger, bargaining, usually chemotherapy induced or as the result the needs of a particular health institution. depression and acceptance. Besides the fear of of bone marrow metastasis and will cause dying, patients fear pain and body The research hospital utilised in this study is the haemorrhage. The nurse’s role is confined disfigurement. The patient’s psychological referral hospital for the Southern Transvaal for mainly to early detection, by daily physical response to body disfigurement depends upon black patients requiringspecialist oncology care examination of the patient as well as testing his self-concept and body image, which are and is also a training hospital for the post-basic faeces and urine for occult blood (Pruitt 1983: uniquely personal, social, emotional and course in oncology nursing science. 374). psychological (Baldonado & Stahl, 1982: In this contextual study the target population for 134-147). There are many specific problems related to the formulation of oncology nursing care specific cancer diagnoses. Specific signs and In assessing psychological status, the oncology standards were oncology nursing care symptoms need to be detected by the nurse, for nurse therefore needs to identify the patient’s specialists working in the research hospital. example excessive bleeding, offensive and family’s coping mechanisms and meeting Clinical nurse specialists were selected discharges, etc. The side effects of these needs requires a multi-professional team purposefully according to their professional chemotherapy and radiation should be approach (Maguire, 1978: 33). qualification in Oncology Nursing Science, as monitored and appropriately addressed. well as their experience in oncology nursing The relationship between patient and care-giver Surgical interventions may lead to ostomies care. These clinical specialists served on a should be open, honest, and based on trust. which also require special nursing care. committee to formulate and validate the Goals of treatment should be realistic, Radiation therapy may cause acute skin standards. All committee members were nurses recognising that both quality and quantity of reactions, cardiopulmonary complications, employed at the research hospital and consisted survival are important. Whatever therapy is gastrointestinal problems, and specific organ of the following members: chosen, the patient must be informed not only complications. Chemotherapy causes acute and of its potential benefits but of its potential chronic toxicides of which nausea and vomiting * a clinical nurse educator for the post basic hazards as well. Although the patient may be are most common and must be addressed course of Oncology Nursing Science; * two chief professional nurses in charge of * basic health needs/activities of daily * malaise living oncology wards in the hospital; * haematological dysfunction * food and fluid preferences * two senior professional nurses who had at * psychological status * appetite changes/weight changes least two years experience in specialised 2.4.2 Side effects of chemotherapy: oncology nursing care; 1.2 Psychological assessment regarding: * gastrointestinal dysfunction * two professional nurses who had at least two * emotional status * extravasation years experience in specialised oncology * concerns during hospitalisation nursing care. * inflamation of mucosa 1.3 Physical assessment regarding: * haematological dysfunction All the committee members held the post-basic registration of the South African Nursing * physical status 2.4.3 Side effects of radiation therapy: Council in Oncology Nursing Science. * nutritional status * skin reactions * personal hygiene and grooming The committee members were requested to * alopecia formulate standards and criteria for oncology * organ/systemic dysfunction * gastrointestinal dysfunction nursing care. They held weekly discussions for 1.4 Assessment regarding personal perception three months. Through group discussions and * haematological dysfunction of illness by reaching verbal consensus, standard care 2.4.4 Specific problems: plans were drawn up for the common treatment * type of illness modalities and medical diagnoses of patients * breast carcinoma: dyspnoea head and * severity and prognosis neck tumours: mucal reaction; nursed in the oncology wards. The formulated standard care plans were d rculated among other 1.5 The data for the comprehensive patients * glossitis; throat infection; dental carries. ^B tered nurses in oncology wards for their history is obtained from all available sources: * cervical carcinoma: offensive consideration and input and ratification and discharge; vaginal bleeding; dysuria; validation of standards was done verbally by incontinence of urine and faeces; * patient and/or family these nurses. condyloma ta. * health care providers * other cancer problems From these standard care plans the committee * medical practitioner(s) reports members identified the patient problems that 2.5 The patient/family agree with the nurse as * laboratory reports required the same nursing interventions. These to what the desired outcomes should be. problems were grouped together and formulated 1.6 The data are collected using a scientific 2.6 The formulated desired outcomes are according to the scientific method of nursing methodology: congruent with the patient’s problems and care, namely assessment, nursing diagnosis, * interview the established objectives which are to planning, implementation and evaluation. The restore the patient’s optimal functioning terminology appearing on the standardised * observation and inspection capabilities and/or to ensure a peaceful provincial nursing records was incorporated in * examination: palpation/auscultation death, and therefore focus on: the wording of the standards and criteria so as * reports and records to prevent confusion. 1.7 The data gathered are organised * enabling the patient to function comfortably within the limitations due No standard of nursi ng care was accepted by the systematically: to cancer; committee unless full verbal consensus was * controlling the symptoms; reached among members and unless it was * provincial records utilised * improving the nutritional status of the accepted by the registered nurses in the * details completed fully patient; logy wards. Standards and criteria were 1.8 The patient’s history and physical * enabling the patient to cope with the idered and debated according to their examination is done within 48 hours of illness; appropriateness/applicability, completeness admission. * enabling the patient to understand the and clarity, as well as their realistic usefulness nature of the disease, the chosen in the unit. 2. Nursing diagnosis is made and recorded treatment plan and care; and accompanied by an appropriate * ensuring the the patient experiences The final standards and criteria therefore had minimal discomfort or complications nursing care plan: content validity based upon the literature and from the chosen treatment; ratified by domain specialists/experts. 2.1 The present and potential problems are * ensuring that the patient is identified and recorded. knowledgeable about self care and resources for continuity of care. RESULTS 2.2 The extent and intensity of the problem(s) 2.7 The desired outcomes are consistent with experienced, as well as the exact location, The following standards and criteria were other health provider’s expectations. character and duration are described. formulated; Cognisance is therefore taken of the I A comprehensive patient history and 2.3 The underlying causes are identified and patient’s medical prognosis. the data base recorded. physical examination is done for every 2.8 The desired outcomes are measurable patient The assessment includes: 2.4 The most common problems experienced within a certain time frame and specifically are assessed and appropriately addressed. stated. I I A patient interview regarding: 2.4.1 General care regarding: 3. The nursing care plan is implemented * chief complaint effectively including the following: * history of present illness * pain * allergies * weight loss * the patient and family are actively involved; * medications * presence of infection: local or systemic * the actions are consistent with the * past medical history * palpable mass or lymph mass nursing prescriptions; * cultural environmental and socio­ * limited mobility * the actions are flexible and economic conditions individualised for each patient;

Curationis, Vol. 14, No. 2, August 1991 25 * the actions include principles of safety 3.2.3.2 Systemic infection: * take any precautionary measures to and infection control; prevent potential complications, eg * monitor any signs and symptoms of when using a Hickman line. 3.1 The prescribed nursing actions: systemic infection; 3.2.7 Psychological effects: * are specific to the identified patient * utilise the most appropriate techniques problems and desired outcomes; of lowering body temperatures; * assess whether the patient and /or family are in a grieving phase; * are based on current scientific * initiate isolation procedures/nursing knowledge; when appropriate; * accept the patient’s response and emphathise appropriately; * incorporate principles of patient * obtain blood, sputum, urine and other teaching; samples for culture when appropriate; * establish a trust relationship; * incorporate principles of psychological * administration of prescribed antibiotics * identify resource persons; interactions; and monitoring of possible side effect; * allow family and patient as much time * incorporate environmental factors * educate patient regarding personal together as desirea; influencing the patient’s health; hygiene. * assist patient to cope with body image * include human, material and 3.2.4 Palpable lymph nodes or mass: changes; community resources; * encourage participation in self care; * include keeping patient knowledgeable * re-inforce medical petitioner's of health status and total health care explanation of illness and treatment; * facilitate interaction with other patients undergoing similar therapy, if plan. * explain/answer questions regarding appropriate; 3.2 The prescribed actions focus on specific diagnostic procedures; * assure continued support regardless of cancer related problems: * explain/answer questions regarding the patient’s decision about therapy; outcome of diagnostic studies done to * give positive reinforcement and 3.2.1 Pain: determine basenne data and metastatic disease, as well as the frequency and realistic hope about progress; purpose of repeating procedures/ * teaching patient how to use the pain studies; 3.2.8 Chemotherapy: ® chart to inform nurses of site and * explai n the course of treatments); intensity of pain, as well as the * reinforce physician’s explanation of effectiveness of prescribed analgesics; * assess level of understanding; disease, treatment and prognosis; * together with the patient decide on the * if a limb is affected institute the * clarify with patient/family the aims of best combination of analgesics and appropriate nursing regi men to alleviate chemotherapy; sedatives for pain relief; pain, swelling, pressure and complications. * explain types of drugs administered, * listening to patient and allowing to frequency and possible side effects; express Tears; 3.2.5 General malaise: * explain all procedures and special care * utilising diversional pain therapy; required; * collaborating with medical * determine the patient’s current capabilities; * collaborate with physician and practitioners and other health appropriate resource people to manage professionals to revise pain treatment; * establish a rest/activity programme in treatment and its effects at home; * monitoring vital signs that will indicate accordance with the patient’s needs, * provide and teach measures to prevent pain or complications of pain treatment. limitations and tolerance level; or control side effects: nausea and vomiting; loss of appetite; stomatitis; 3.2.2 Weight loss: * provide assistance and supervision as necessary to achieve the appropriate weakness and fatigue; chills and fever; Promote optimum food and fluid level of functioning; alopecia; gastrointestinal ulceration intake by: and/or bleeding; diarrhoea and * encourage family participation in the constipation; skin changes; programme; myelosuppression; infection; * assisting patient to eat well balanced extravasanon; meals witnin diet, considering patient’s * provide an environment and measures condition and preferences; conducive to rest and relaxation; * take measures to preserve the veins on patients who require frequent invastf * provide for flexibility of menus and 3.2.6 Haematological dysfunction: procedures; ^ timing of meals; * plan discharge with patient and family; * reduce nausea- stimulating factors; * determine the exact aetiology; * extravasation: monitor blood flow; * with patient/family identify * obtain blood laboratory results; signs and symptoms of infiltration; nausea-therapy methods; * a bed rest nursing regimen is instruct patient to report buming/pain at * refer a dietician to teach/inform implemented; site; patient/family regarding diets; * assist patient in maintaining personal 3.2.9 Radiation therapy: * support patient by answering questions; hygiene; * weigh patient according to needs; * assist patient in activitiesof daily living; * explain/answer questions and listen to concerns about pre-therapy * participate in plan for special feeding * assess and monitor any signs and preparation; regimens; symptoms of intratissual bleeding; * reinforce patients’ and family’s * examine urine, faeces, vomitus and understanding of aims of therapy; 3.2.3 Infection: sputum for any visible blood; * provide general measures for patient 3.2.3.1 Wound infection: * explain/answer questions pertaining to undergoing radiation therapy; disease process; * discuss/explain possible side effects; * dress wound(s) as fequently as * assess the patient’s level of required; understanding; * discuss and explain the patient’s responsibilities; * teach patient or relatives the necessary * institute a patient/family teaching wound care techniques; programme to prevent/minimise * stress importance of preventive trauma; measures at beginning, during and after * support patient by giving relevant course of therapy; information; * prevent possible systemic infection by a reverse barrier nursing regimen; * initiate measures to control nausea and * assess wound healing or non-healing; vomiting; * administer prescribed antibiotics and * take part in deciding upon alternative monitor for possible complications or * promote optimum food and fluid intake; wound care regimens; side effects; * institute measures to maintain skin * monitor temperature according to integrity; individual needs. * assist patient who has alopecia;

1 L Cnrationis. Vnl 14 Nn 7 . August 1991 * intervention in the critical areas of REFERENCES SMITH EA 1975: A comprehensive approach patient care related to specific treatment to rehabilitation of the cancer patient. New sites. BALDONADO AA & STAHL AD 1982: York: McGraw Hill. The nursing care regimen is continually Cancer nursing-, 2nd ed. New York: Medical evaluated and revised according to the examination. SPEECHLEY V 1985: The chemotherapy challenge. Nurse’s role in the intravenous changes in the patient’s health status. COX S & WARK E 1980: The delivery of administration of cytotoxic drugs. Nursing 4.1 The data are collected to assess whether nursing care: oncology for nurses and health Mirror, 161(4), July 24, 1985: 21-22. specific desired outcomes have been care professionals. London: G Allen & achieved. Unwin. SOUTH AFRICAN NURSING COUNCIL 1984: R2598, as amended. Regulations 4.2 The collected data are compared with the DIETZ JH 1981: Rehabilitation oncology. relating to the scope of practice of persons stated desired outcomes. New York: J Wiley & Sons. who are registered or enrolled under the *•3 The patient/family and nurse(s) evaluate GIVEN BA & GIVEN CW 1984: Creating a Nursing Act, No 50 of 1978. Pretoria: the achievement of stated desired climate for compliance. Cancer Nursing, Government printing office. outcomes. 7(2), April, 1984: 139-147. ♦■4 All data concerning the patient’s progress REPUBLIC OF SOUTH AFRICA 1978: and nursing interventions are recorded. HAUCK SL 1986: Pain: problem for the Nursing Act, No 50 of 1978. Pretoria: person with cancer. Cancer Nursing, Government printing office. *■5 The nursing care regimen is reviewed and 9(2),April, 1986:66-76. modified according to the patient’s needs. Acknowledgments *■6 The patient profile is updated as new KAHN SB .LOVE RR SHERMAND C & The authors acknowledge the contribution of CHAKRAVORTY R 1983: Concepts in information is received. the oncology registered nurses of the Hillbrow cancer medicine. New York: Grune & hospital. The researcher wishes to thank the Stratton. Oc c l u s i o n a n d Rand Afrikaans University for a bursary which recommendations MAGUIRE P 1978: The psychological effects made this study possible. Local oncology nursing care standards were of cancer and their treatment: oncology for This article is based upon research conducted formulated and validated by oncology clinical nurses and health care professionals. for the degree M.CUR. (Nursing management) ^are experts employed by the research hospital. London: G Allen & Unwin. at the Rand Afrikaans University. These standards can serve as a guide to improve PORTLOCK CS & GOFFINET DR 1986: the quality of oncology nursing care in this Manual of clinical problems in oncology; A strid M de Kleijn hospital and can be used for the development of 2nded. Boston: Little Brown. M.CUR. (RAU) an evaluation instrument in this regard. Hillbrow Hospital PRUITT BT 1983: Supportive care: concepts National validation of the standards is Senior Nursing Service Manager in cancer medicine. New York: Grune & recommended to prove statistically the validity Stratton. Marie E Muller of the standards. D.CUR. (RAU) RandAfrikaans University Associate Professor

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