1 Queensland Cancer Fund
2 School of Nursing, Griffith University
3 School of Nursing, Queensland University of Technology
4 Wesley Medical Centre
Purpose: To evaluate nurses’ perceptions of an intensive mode post-graduate cancer nursing education program targeting regional and rural registered and enrolled nurses. Design: Cross-sectional Setting: Urban non-government cancer control agency. Sample: 147 nurses, of who 95% were female, with a mean age of 45 years and a mean of 13 years experience in oncology nursing, 40% of nurses worked in highly accessible areas, and 57% in accessible to very remote areas. Method: Nurses were surveyed using self-report measures assessing recalled impact of the education program on nursing practice, effectiveness in meeting nurses educational needs and perceived need for further training in cancer care. Findings: Participants rated the cancer-nursing program as highly effective in improving their knowledge about cancer, professional networking, information about support/referral sources and knowledge of other health facilities. Other benefits described included increased confidence in cancer nursing skills and improved community referral skills. Barriers to implementing new skills were lack of interest, motivation or cooperation from work colleagues, organisational structure or procedural policies and financial or time constraints. Respondents requested further training in pain and symptom management, palliative care, psychosocial aspects of cancer, and communication skills with Brisbane-based Queensland Cancer Fund courses and seminars in their local area as a preferred delivery method. Conclusions: Results suggest that intensive mode cancer nursing education programs are a preferred and effective learning mode for regional and rural nurses.
The role of the cancer nurse is evolving. For example, the emerging requirement for cancer care to include psychosocial care has led to an expansion in the role of the cancer nurse1,2. Similarly, the shift to outpatient or home-based care in Australia has added complexity, particularly evident in the case of chemotherapy administration3-5. To assist nurses, continuing nursing education programs that are delivered in a variety of modes including distance education, online learning, university based courses, joint university-health agency programs and vocational programs have emerged. However, there are barriers preventing or deterring nurses in the cancer workforce undertaking ongoing education. These barriers include a lack of awareness of continuing education opportunities, accessibility and the clinical relevance of educational courses6.
Rural and remote nurses have specific needs that relate to a broad nursing role encompassing knowledge and skills in a range of medical contexts, including cancer and palliative care7. Due to the scarcity of health resources in remote areas, these nurses often provide health services that in larger centres are undertaken by medical or allied health professionals8,9. Geographical isolation limits opportunities for regional and rural nurses to extend their knowledge and interact with their peers10. Specific barriers to ongoing education reported by Queensland regional and rural nurses include family constraints, physical distance from nursing programs, lack of access to resource personnel for education on site, lack of resources for external consultants, and inadequate funding to support travel to education programs and to replace staff absent for educational support11,6. Regional and rural nurses are a priority group for ongoing education programs sensitive to the context in which they work.
Accordingly, the Queensland Cancer Fund cancer nursing education scholarship program was developed to specifically target rural and remote nurses, a group that accounts for 27% of the Australian nursing workforce12. Scholarships address issues of access by providing participants from all areas of Queensland with travel, accommodation, course registration and materials. Intensive mode course time-tabling, delivered over a five-day period, assists with time constraints. Finally, locating the program in a major centre facilitates professional networking. In terms of uptake by nurses in Queensland, these programs have been particularly successful. For example, since 1997, 305 nurses have attended fully-funded residential nursing education programs offered by the Queensland Cancer Fund. Of this group, 81% were from regional and rural Queensland.
The present study investigated participants’ recalled impact of attending the cancer nursing education program between 1997 and 2001. This included impact on nursing practice, effectiveness in meeting nurses educational needs, perceived need for further training in cancer care, and barriers to the implementation of new skills and learning.
Participants and procedure
One hundred and forty-seven participants who had attended a Queensland Cancer Fund Cancer nursing education program between 1997 and 2001 inclusive (55% response rate) were surveyed by mail. The programs attended by respondents were Cancer Nursing for Enrolled Nurses (25%), followed by Palliative Care for Registered Nurses (23%), Introduction to Cancer Nursing for Registered Nurses (21%), Breast Cancer Nursing for Registered Nurses (16%), and Chemotherapy Awareness for Registered Nurses (14%) programs. In all, 91% of participants resided outside of the Brisbane metropolitan area, with 22% residing in south-west Queensland, 25% from the Gold and Sunshine Coasts, 15% from central Queensland and 29% from north and far-north Queensland.
Demographic data was provided by 144 respondents, with a mean age of 45 years (SD=8.66, range of 23 to 69 years). Most participants were female (95%) and had been working as registered or enrolled nurses for an average of 19 years (range = 1 to 41 years). The mean duration of time for participants providing nursing care to people with cancer was 13 years (range = 1 to 34). With respect to nursing qualifications, 81% of respondents reported that they had obtained a hospital certificate, 27% had been awarded bachelor degrees, 23% had completed post-registration certificates, and 11% held either post-graduate qualifications or TAFE diplomas or certificates. A further 9% of participants reported that they had obtained other forms of nursing qualifications, 6% held post-graduate degrees specifically in the area of oncology and 4% had been awarded undergraduate diplomas. Finally, 88 participants (61%) reported that they were members of the Oncology Nurses Group of the Queensland Cancer Fund. The demographic of the participants was consistent with the demographic of other studies investigating rural and remote area nurses8.
A questionnaire was developed to assess study aims. Seven items assessed the impact of the program on cancer nursing knowledge, knowledge about community cancer care services, professional networks, confidence and skills in providing care for cancer patients, overall program benefit and fit with learning needs. For each item participants were asked to indicate how helpful/effective the program was on a scale of one, not at all helpful/effective, to five, very helpful/effective. The second section of the questionnaire asked about the nurses’ use of community cancer support services. The third section of the questionnaire assessed participants’ preferences for further ongoing education in cancer care.
The program consists of five-day residential courses for nurses working with people with cancer on four topic areas: palliative care, breast cancer, chemotherapy awareness and introduction to cancer nursing. By providing specific cancer-related training and information to nurses currently working in health care settings, the program aims to improve the supportive care of people with cancer across the state of Queensland. Participants are selected on the basis of written application with two participants selected from seven geographical regions across the state. Selection criteria include demonstrated involvement in the care of people with cancer, professional development activities and leadership qualities. Clinical experts deliver course content using didactic instruction, clinical visits, small group work and interactive workshops. Course materials include journal articles and an oncology text with participants mailed course ‘pre-readings’ two weeks prior to the course. On completion participants are required to submit an assignment and achieve a passing grade to fulfil assessment requirements. Assessment aims to reflect integration of theoretical knowledge into clinical practice.
Geographic location and work history
The ARIA coding system was used to ascertain respondents’ geographic accessibility/remoteness. Forty percent of nurses were employed in highly accessible regions, with excellent access to goods and services and opportunities for social interaction. An additional 48% reported that their workplace was in an accessible or moderately accessible location (27% and 21% respectively), with only 13 participants working in remote (6%) or very remote (4%) regions. Six nurses (4%) reported that they were not working at the time of the study.
In all, 87% of nurses were providing nursing care to people with cancer at the time of the study. Of these, 27% were employed in combined clinical settings that included a specialist oncology or palliative care component. A further 15% of nurses were caring for people with cancer through domiciliary nursing services or in other clinical settings (15%) and oncology/haematology units (9%). The remainder (34%) were employed in varied clinical settings (for example, medical units, surgical units, palliative care units, and nursing homes). In all, 35% of nurses reported that between 50% and 100% of their work each month was in cancer nursing, with the remainder reporting that caring for cancer patients comprised less than 50% of their work.
Nurses indicated their perceptions of course effectiveness across seven domains relating to improvements in their knowledge and skills, and how well the program met their learning needs. Scores for assessment of the effectiveness of the course were uniformly high indicating high levels of satisfaction with these aspects of the program (see table one). Nurses were also given the opportunity to comment on:
1. strengths and weaknesses of the program;
2. suggested changes in order to improve learning outcomes; and
3. aspects of their work that changed as a result of their participation in a bursary program.
The most commonly reported benefits from attending the program were: gaining knowledge about cancer, diagnosis and treatment; professional networking; obtaining information about support/referral sources; and site visits to observe other health facilities. Most nurses (75%) felt that there were no unhelpful aspects of the program, while 20% described theoretical components as unhelpful. Three nurses felt more practical exercises would have been helpful and other aspects described as unhelpful indicated by two or less individuals included items such as having to travel for the course. The most common suggestion for improving the program was to include more practical exercises, indicated by 19% of respondents.
The most common changes nurses reported making in their nursing practice as a result of attending the program were providing staff or patient education, increased confidence in their cancer nursing skills, and knowing how to refer patients to support services in the community. Twenty-two percent of nurses reported that they experienced barriers at work that affected their ability to implement the skills that they had acquired as a result of participating in the program. Of these, just over half maintained that a lack of interest, motivation or cooperation from work colleagues was the primary barrier. However, other responses included organisational structure or procedural policies and financial or time constraints.
Need for further education
In relation to further education, 93% of nurses reported that they would like further training or education in cancer care. The most preferred topics were: pain and symptom management; palliative care; psychosocial aspects of cancer; and communication skills (see table two). The methods most preferred by nurses for the delivery of future educational programs were Brisbane-based Queensland Cancer Fund courses and seminars in their local area (see table three). The majority of nurses (65%) indicated that the Queensland Cancer Fund was the preferred provider for education programs, followed by universities (11%) and health care employers (10%). Most nurses reported that it was not important that education programs provide credit toward university study, with only 20% indicating that this was an important issue. Only 3% of nurses reported that they had used the Queensland Cancer Fund nursing program as credit for a university-based course.
Referral to Queensland Cancer Fund cancer support services
Of all participants who were currently working in cancer nursing, 94% reported that they referred cancer patients and their families to Queensland Cancer Fund cancer support services, with 79% of these nurses referring patients to the Cancer Helpline. Other services referred to by more than half of nurses were volunteer peer support programs and accommodation facilities for country patients travelling for cancer treatment. Finally, 43% of nurses referred patients to the Living with Cancer Program and Wig Service. With regard to nurses who did not make referrals to cancer support services were: other professionals arranging referrals (63%); and patients already being aware of Queensland Cancer Fund services (37%). Finally, 94% of nurses reported that they provided Queensland Cancer Fund patient education material to their patients. Those that did not provide this information, reported that the information was provided to the patient by someone else.
The delivery of appropriately targeted and accessible educational programs for nurses working in cancer care is a priority both nationally, and in terms of regional, rural and remote health service delivery6,14. Given that the demographic profile and identified needs of this cohort is consistent with the profile of regional, rural and remote nurses interstate, and the similar national trend towards referral of chemotherapy to these areas, it is reasonable to generalise these Queensland results to nurses working in other rural and remote areas of Australia6,8,14.
The current study suggests that for regional, rural and remote area nurses, the Queensland Cancer Fund cancer nursing education programs were effective in meeting these nurses’ educational needs and were a preferred mode of education. It is important to note that the nurses who accessed this program were, for the most part, already experienced in cancer nursing and working in cancer nursing in the field. Thus, this model may have broader potential in terms of its contribution to cancer care services given that nursing education has been identified as an important strategy for increasing the retention of experienced nurses in the cancer workforce13.
Nurses expressed a strong interest in further nursing education, with supportive care topics most preferred. As outlined earlier, recent documents regarding cancer care have emphasised the role of the nurse in psychosocial care1,13. Accessible nursing education programs addressing these areas, in particular communication skills and psychosocial aspects of cancer care, will be needed if such proposals are to operationalised.
The impetus for this program has largely been to positively influence cancer care by educating and supporting cancer nurses, in line with the overall mission of the Queensland Cancer Fund. In this regard, it is pleasing to note the high level of referral by nurses who attended these programs to community-based cancer support services, and in particular the Cancer Helpline. Cancer Councils generally utilise a number of strategies to inform patients and their families of the support services they provide, often relying on professional networking. The present study suggests that close interaction with nurses through the provision of nursing education programs is an effective way to promote referral and use of Cancer Council services and patient education materials.
A limitation of this study is the cross-sectional design and reliance on retrospective recall. As a consequence, a further study utilising a prospective design has been undertaken. However, the consistency of nurses’ responses supports the positive nature of the results. It is also important to acknowledge that these nurses were a specific subgroup, in so far as they resided regionally. Nurses from major metropolitan centres who have easier access to nursing education programs may have different preferences. This may also explain in part the low preference for tertiary-based education programs that may be less accessible for geographically isolated nurses. Future research should address this question by assessing the needs and preferences of nurses from a broader more representative sample, and including nurses from tertiary treatment centres.
In conclusion, we believe that the key aspects of this program that differentiate it from other educational initiatives and suggest it may have a wider application outside of Queensland, are the intensive mode time-tabling, emphasis on building professional networks, use of small-group learning in a face-to-face setting, the focus on current nursing practice and targeting of nurse participants within the current cancer care workforce. Both nurses and ultimately patients benefit from this approach, and in the face of current concerns nationally about nursing workforce shortages this model may be of interest to others.
13. Clinical Oncological Society of Australia, The Cancer Council Australia and the National Cancer Control Initiative. Optimising Cancer Care in Australia, National Cancer Control Initiative, Melbourne, 2003.
14. A McCarthy, TR Broadribb, L Brown, P Gilbar, D Hegney, L Raith, J Swales. The Chemotherapy Education Needs of Nurses Working in Rural and Remote Areas of Queensland. Centre for Rural and Remote Area Health, University of Southern Queensland, Queensland, 2002.