Principles of Oncology Nursing

Mary Johnson, RN, MS, CS, GNP, AOCN and Connie Henke Yarbro, RN, MS, FAAN.

Any text on cancer medicine would be incomplete without a discussion of oncology nursing.
Cancer management is a multi-disciplinary endeavor, and understanding the principles of oncology
nursing is fundamental to the effective practice of all other oncologic subspecialties.

Oncology nurses are engaged in a collaborative practice with all members of the care team to
provide optimal management of patients with cancer. Their professional practice requires detailed
knowledge of the biologic and psychosocial dimensions of the cancer problem. They have key roles
not only as caregivers but in patient and family education and clinical cancer research. Cancer
nurses also are continuously involved in the enhancement of nursing practice through research,
continuing education, and advanced education.

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Oncology Nursing as a Specialty

Historically, nurses have had a special role in the care of patients with cancer, a role that was
especially significant in those few institutions devoted exclusively to cancer care before the
National Cancer Act of 1971. However, the expanded research and treatment program against
cancer that has occurred during the past quarter century has been a catalyst for the development of
oncology nursing as a separate specialty.1–4 The recognition of cancer as a major national health
problem was key to formally establishing the specialty of oncology nursing. This increased
attention to cancer coincided with and complemented a major new emphasis in the nursing
profession toward expanded roles in comprehensive patient care. Many oncology nurses first
worked both as nurses and data managers for cancer research studies. As oncology called for
increasingly more complex therapy, the collaborative relationship between nurse and physician
became the best way to provide uniquely comprehensive patient care.5–7

The Oncology Nursing Society (ONS) was established by a small group of nurses working
primarily in research settings with medical oncologists involved in clinical research.4,8 Their initial
goals were to provide a forum for discussing practice issues in cancer nursing and to develop
mechanisms for nurses to contribute to this new and evolving specialty area. There was a need to
promote the advanced practice of oncology nurses in different care settings and develop national as
well as local networking and continuing education programs. Research in cancer nursing
subsequently became a high priority of the ONS. The success of this national organization has
contributed to the recognition of oncology nursing as a valued specialty.

Today, the ONS has a membership of over 28,000 and 209 chapters across the United States. The
majority of members (68%) provide direct patient care.9 Educational conferences, publications,
legislative activities, and research initiatives are just a few of the concentrated areas of effort. The
ONS Foundation, which was established in 1981, awarded almost a million dollars in research
grants, scholarships, and awards in 1998 alone.

The ONS and the American Nurses’ Association have developed Professional Practice Standards
(Table 70.1),10–12 and the ONS has developed Advanced Practice Standards (Table 70.2).13 These
standards serve as a definition of the highest quality of oncology nursing practice.
Table 70.1

Professional Standards of Oncology Nursing Practice.

Table 70.2

Professional Advanced Practice Standards.

Certification

In 1985, the ONS established the Oncology Nursing Certification Corporation (ONCC) to provide
an examination for the formal certification of oncology nurses. Certification in oncology nursing
promotes continuing education and communicates to the public and other professionals that an
oncology nurse has specialized knowledge and expertise. Nurses who pass the generalist
certification examination may use the OCN (Oncology Certified Nurse) credential with their
signature. Recertification is required every 4 years by examination or by the Oncology Nursing
Certification Points Renewal option (ONC-PRO). The ONC-PRO program allows the renewal
candidate to accrue points through continuing education, academic education, publications, and
presentations or participation in test item writing for the certification examination. Renewal by
retesting is required at least every 8 years. As of 1999, there are over 18,000 oncology nurses who
have been certified. In the fall of 1999, the ONCC began to offer pediatric oncology nursing
certification and the CPON (Certified Pediatric Oncology Nurse) credential.

The ONS is the first nursing specialty organization to provide certification for advanced practice
nurses. In 1998, the ONCC conducted a role delineation study to distinguish advanced practice
nursing from basic nursing practice in oncology and to describe the professional roles and practice
behaviors of advanced oncology nurses.14 The AOCN (Advanced Oncology Certified Nurse) test is
based on the results of this study. Unique to the advanced examination is the requirement that an
oncology nurse must have at least a master’s degree. Nurses who pass the advanced examination
may use the AOCN credential with their signature. As of 1999, there are over 1,000 AOCNs. Table
70.3 describes the eligibility criteria for oncology nursing certification at both the generalist and
advanced levels.15
Table 70.3

Eligibility Criteria for Oncology Nursing Certification.

Oncology Nursing Education

Educational curricula have been developed and implemented to provide oncology nurses with an
appropriate understanding of cancer biology, epidemiology, prevention, treatment, nursing practice
issues, and trends in cancer care. Several cancer nursing texts16–23 and journals, such as the
Oncology Nursing Forum, Cancer Nursing, and Seminars in Oncology Nursing, deal with these
topics in appropriate formats. Cancer nursing is part of the general undergraduate and graduate
nursing educational curricula. In addition, doctoral programs and oncology nursing professorships
have been established.

The usual educational level of the oncology nurse at the time of entry into practice is a bachelor’s
degree in nursing. Figure 70.1, which is based on the membership demographics of the ONS, shows
the highest nursing degrees of ONS members. Membership in the ONS offers opportunities for the
study and education necessary to qualify for the OCN and AOCN credentials by passing the
certification examinations. Increasingly, master’s level preparation is specified in many oncology
job descriptions. For example, a master’s degree is required for oncology clinical nurse specialists
and nurse practitioners. Currently, 26% of the ONS members are pursuing graduate education, and
10% are doctoral students.9

Figure 70.1

Highest educational degrees in nursing of Oncology Nursing Society members. Source: Oncology
Nursing Society.

Oncology Nursing Research

The development of oncology nursing research to guide oncology nursing practice has been
extraordinary over the past 25 years. From a modest beginning in the 1970s, nursing research
evolved in the 1980s to the identification of research priorities, companion studies in cooperative
group clinical trials, as well as initial programs of research and funding. In the 1990s, continued
advances have included mature programs of research, multi-site studies, increased funding sources,
research utilization through state-of-the-knowledge conferences, and major areas of studies (e.g.,
fatigue, quality of life, pain) that are having a major impact on cancer care.24 The ONS has
conducted five research priority surveys since 1981. The top 10 research priorities from the most
recent survey included pain, prevention, quality of life, risk reduction/screening, ethical issues,
neutropenia/immunosuppression, patient education, stress, coping and adaptation, detection, and
cost containment.25 As a result of today’s health-care environment, nurses are being challenged by
insurers, health policy makers, and managed-care organizations to demonstrate the effectiveness of
their care through research that examines the link between specific nursing interventions and patient
outcomes.26,27

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Role of the Oncology Nurse

Oncology nurses practice in a variety of settings including acute-care hospitals, ambulatory-care
clinics, private oncologists’ offices, radiation therapy facilities, home health-care agencies, and
community agencies. They practice in association with a number of oncologic disciplines: surgical
oncology, radiation oncology, gynecologic oncology, pediatric oncology, and medical oncology.
The majority of ONS members are involved in direct patient care, with 44% working in a
hospital/multi-hospital system, 21% in the outpatient/ambulatory-care setting, 9% in physician
offices, and 5% in hospice or home care.9 Positions in the outpatient and home care setting have
increased as more patients are being treated out of the hospital setting.21,28 The roles of the oncology
nurses vary from the intensive care focus of bone marrow transplantation to the community focus of
cancer screening, detection, and prevention. The advanced practice of oncology nursing includes
participation as principal investigators in nursing research studies, serving as patient-care
consultants, designing educational curricula, and performing executive functions. In all these roles,
there is emphasis on providing nursing care to patients and families by efficient use of the nursing
process, including assessment and data collection, nursing diagnosis, planning, intervention, and
evaluation. This process permits an organized and systematic approach to nursing care.

The following discussion on the role of the oncology nurse focuses on patient assessment, patient
education, and coordination of care. This is followed by a specific discussion on nursing care
related to surgery, radiation therapy, chemotherapy, biotherapy, and supportive care.

Patient Assessment

Nurses are expected to be expert in assessing patients’ physical and emotional status, past health
history, health practices, and both patients’ and families’ knowledge of the disease and its
treatment. It is essential that a detailed nursing history and physical examination be completed. An
oncology nurse is expected to be aware of the results and general implications of all relevant
laboratory, pathology, and imaging studies.

Patient Education

The nurse often has a better opportunity than any other member of the health-care team to spend the
necessary time with patients and their families to develop the required rapport for effective
educational efforts. Such education includes structured and unstructured experiences to assist
patients cope with their diagnosis, long-term adjustments, and symptoms; to gain information about
prevention, diagnosis and care; and to develop skills, knowledge, and attitudes to maintain or regain
health status.29 This planned education uses a combination of methods to best meet the needs,
capabilities, and learning style of the nurse scholar.30 The ONS has enhanced this definition by
recommending the following patient education outcome criteria:31 the patient and/or family should
be able to (1) describe the state of the disease and therapy at a level consistent with his or her
educational and emotional status; (2) participate in the decision-making process pertaining to the
plan of care and life activities; (3) identify appropriate community resources that provide
information and services; (4) describe appropriate actions for highly predictable problems,
oncologic emergencies, and major side effects of the disease and/or therapy; and (5) describe the
schedule when ongoing therapy is predicted.

There are a variety of teaching tools and methods available, the choice of which is based on
individual patient needs and abilities. Printed, visual, and audiovisual educational materials are used
in conjunction with discussion and continued reinforcement. Numerous patient educational
materials also are available that relate to cancer, cancer therapy, and the management of side
effects.18,32–36 With the increased development of the Internet, more and more cancer patients and
family members are accessing the World Wide Web (www) to gain information about cancer. Chat
groups are serving as a source of information as well as support. This method of communication
will continue to be an increasing source of knowledge for consumers.
Patients should be encouraged to keep personal, written, daily diaries that record treatment dates,
symptoms, test dates, and questions. A personal diary provides additional written documentation of
the onset of specific phenomena and accurate dates of therapy, in case the patient’s medical record
is not available.

Coordination of Care

The oncology nurse plays a vital role in coordinating the multiple and complex technologies now
commonly employed in cancer diagnosis and treatment. This coordination encompasses direct
patient care, documentation in the medical record, participation in therapy, symptom management,
both patient and family education, as well as counseling throughout diagnosis, therapy, and follow-
up. The nurse should serve as the patient’s first line of communication. Ideally, the patient and
family should feel free to contact the oncology nurse by phone during the entire treatment program.
Many patients travel long distances, so the importance of communication by telephone must be
emphasized. It allows continuous patient communication, early recognition of emergencies, and
regular emotional support.

Camp-Sorrell37 noted that most patient problems can be managed without the patient being seen in
the office or emergency room. However, it is important for the nurse to gather sufficient
information to determine patient management. A telephone triage flow sheet was developed (Figure
70.2) that provides the basic steps which are helpful in identifying patient problems over the phone
before consulting with the physician and relaying specific instructions for follow-up care. This
format can be used with complex problem areas, and several specific examples are included below
in the discussion on chemotherapy.

Figure 70.2

Telephone triage flow sheet of the basic steps to identify patient problems. Source: Camp-Sorrell.

Modern cancer care is performed at multiple sites by a variety of personnel at a pace that is
accelerated by a cost-conscious staff. Communication between personnel at different facilities may
be suboptimal, and the communication and coordination that the oncology nurse can provide
represents an invaluable service to patients who may be confused and frightened.

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Nursing Care Related to Specific Cancer Therapies

Nursing care of patients receiving surgery, radiotherapy, chemotherapy, or biologic therapy, alone
and in combination, begins with physical and psychological preparation. The oncology nurse
reviews the treatment plan with the oncologist, is aware of expected outcomes and possible
complications, and independently assesses the patient’s general physical and emotional status.

Assessment of the patient’s understanding of the disease and proposed treatment is fundamental in
allaying anxiety and formulating a care plan. Obtaining this information will help avoid
misunderstanding and confused expectations. Possible side effects of treatment as well as
recommendations to prevent or minimize these effects should be explained. Thorough patient
preparation improves compliance with treatment programs and may impact treatment outcomes as
well.

A nursing care plan is developed in response to the particular needs identified from the
assessment.38 At a minimum, this plan will promote (1) the patient’s understanding of therapy goals,
treatment schedules, and possible side effects of therapy; (2) physical and psychological preparation
for therapy; (3) physical and psychological comfort; and (4) compliance. Patient and family
education starts before therapy and continues during and after therapy. Reinforcement helps ensure
success. Appropriate written and visual teaching aids may be utilized as well as referrals to other
professionals or community programs, such as cancer support groups.

Surgery

Surgery is the most frequently used treatment for cancer. A definitive diagnosis of cancer requires
tissue confirmation and most patients undergo some type of surgical procedure early in the course
of their treatment. Beyond diagnosis, surgery is the definitive means of cure for most solid tumors
and has many other applications in cancer management. Surgical procedures are performed for
cancer prevention, primary tumor removal, disease staging, tumor debulking, hormonal ablations,
disease palliation, reconstruction, and placement of vascular devices.

The patient and family may experience a wide range of emotions and reactions to the diagnosis of
cancer and the need for surgery. The diagnosis often has been made only a few days before a major
procedure is scheduled. The nurse has a key role in assessing the patient’s understanding of possible
surgical outcomes, such as change or loss of body function, limitations of mobility, and change in
physical appearance. Careful preoperative assessment may identify significant factors that could
increase surgical morbidity and mortality.39 Nursing care of the patient undergoing surgery for
cancer includes fostering the patient’s understanding of the specific procedure and expected
outcome, preparing the patient physically and psychologically for the surgery, reducing anxiety,
supporting the patient’s postoperative physiologic stability, relieving pain, preventing
complications, and promoting compliance with postoperative instructions.

The trend to shift surgical procedures from inpatient to outpatient facilities continues. Nurses are
challenged to ensure quality patient outcomes, while controlling costs. Clinical pathways have been
developed to standardize approaches to care. They provide patients with a treatment course that
results in the best possible outcome, while using fewer resources and less time.40,41 An example of a
clinical path used for breast cancer surgery is provided in Figure 70.3.

Figure 70.3

In addition to the shift of inpatient procedures to the outpatient setting, hospital stays for patients
undergoing cancer surgery have decreased significantly. Patients and families are faced with
assuming responsibility for their postoperative care. Nurses have a responsibility to coordinate early
discharge planning and home care, as indicated. Referrals must be sent to appropriate professionals
and community support services.

Radiation Therapy

Radiation therapy may be used to cure, control, or palliate cancer. It may be the primary treatment
for cancers such as Hodgkin’s disease or seminoma. It may be effective in achieving control from
months to years for recurrent breast cancer or lung cancer. Radiation therapy can be very effective
in palliating symptoms such as pain or obstruction. It may be combined with chemotherapy,
surgery, or immunotherapy. Examples include preoperative combination radiotherapy plus
chemotherapy for rectal cancer or radiation following breast surgery for early breast cancer or for
locally advanced breast cancer.

Understanding the fundamental principles of radiation therapy, including the principles of

radiobiology and radiation physics, enables nurses to provide support and care for patients receiving
radiation therapy. The most common method of delivering radiation therapy is external beam or
teletherapy. Brachytherapy is the temporary or permanent placement of a radioactive source either
in or on a tumor. Specialized radiotherapy delivery techniques include stereotactic radiosurgery,
stereotactic radiotherapy, and stereotactic brachytherapy.

Cytoprotective agents have been found to shield normal cells from the toxic effects of cancer
therapy.42 Amifostine protects a wide range of normal tissues from the toxicities of radiation, while
preserving the antitumor effect of the therapy.43 Coordinating the daily administration of amifostine
before radiation therapy and monitoring for additional possible side effects present another
challenge for nurses.

Nursing care of the patient receiving radiation therapy focuses on preparing the patient physically
and psychologically for therapy.44 Pretreatment assessment includes knowledge of the treatment
plan and goal of therapy, physical assessment with particular attention to areas that may be affected
by radiation, nutritional assessment, the patient’s and family’s understanding of the disease process
and proposed treatment plan, the patient’s knowledge of possible side effects, and practical
problems, such as patient’s transportation to the treatment center.

After completing an initial assessment, an individual care plan is formulated. Assessment of a

patient’s needs, patient education, and implementation of interventions during the course of
treatment are dynamic. As treatment progresses, the potential for side effects increases. Expected
side effects usually occur approximately 14 days after treatment has commenced, depending on the
site, dose, and volume. Side effects occur as a result of cell damage due to alteration of mitotic
activity and may be acute or delayed occur late, (e.g., after 6 months). If acute effects are not
reversed or controlled, late and possibly permanent changes occur. Common potential side effects
include skin reactions and fatigue. Side effects vary, depending on the site of treatment; Table 70.4
contains a list of side effects the nurse should be prepared to discuss with the patient.45–50

Table 70.4

Early and Late Side Effects of Radiation Therapy.

Fatigue may be multi-factorial and may already be a problem for the patient before therapy begins.
It is the most common side effect of radiation therapy. Oncology nurses have been instrumental in
the recognition, measurement, and treatment of this distressing side effect.51–53 Most patients
consider it to be the side effect that interferes most with quality of life.54 There are several tools
available to assist in identifying and measuring fatigue.
Preparing patients for the possibility that they may experience some degree of fatigue is
recommended. This may allay anxiety and provide patients with needed information to plan their
daily activities and set priorities for energy expenditure. Strategies to reduce fatigue include
reducing nonessential activities, maintaining normal night-time sleep habits, increasing physical or
social activity, distraction, maintaining good nutrition, and allowing family and friends to help.53

The effects of radiation on the skin are categorized as early and late. The time of onset, duration,
and intensity of effects are affected by patient-related factors as well as treatment-related factors.
Patient-related factors include nutritional status, age, compliance with recommended care,
individual differences, skin folds, and tangential radiation fields. Treatment-related factors include
radiation type and energy, volume of skin radiated, site of radiation field, fractionation, and possible
concurrent therapy, such as chemotherapy. Early skin side effects include erythema, tanning, dry
desquamation, moist desquamation, and loss of hair in the radiation field. Late effects include
changes such as atrophy, thinning, telangiectasia, altered pigmentation, fibrosis, ulcerations,
necrosis, and carcinogenesis.50 Most treatment centers have recommendations for skin care during
therapy, and an example is given in Table 70.5. It is the responsibility of the nurse to be certain that
patients understand guidelines such as these.

Table 70.5

Radiation Oncology Department Skin Care Guide.

Chemotherapy

Providing nursing care to patients receiving chemotherapy presents many challenges. The majority
of patients receiving chemotherapy are treated in ambulatory-care settings, and some patients may
even receive treatments in their homes. Oncology nurses are faced with increased responsibility for
coordinating quality care with fewer resources.

The delivery of chemotherapy is primarily the responsibility of oncology nurses.55,56 The nurse must
have knowledge of the pharmacology of antineoplastic agents, proper techniques of drug
preparation and administration, drug interactions, and possible adverse effects of individual agents.
The nurse must be skilled in the technique of venipuncture and the management of various types of
venous access devices and drug administration systems. In addition, nurses prepare patients and
families to manage anticipated side effects of chemotherapy and to report symptoms of potentially
serious side effects early to avoid serious consequences. The ONS recognizes that chemotherapy
administration is complex and requires training and clinical preparation beyond the basic nursing
education. Nursing practice varies from state to state, but the ONS recommends that only registered
nurses who have received this additional education and training administer chemotherapy.57
National certification for chemotherapy currently does not exist. Each institution should have
written policies for chemotherapy certification, administration of antineoplastic drugs (all routes),
safe drug handling and disposal, management of untoward reactions, such as allergic reactions, and
methods for documentation.

An important responsibility of nurses involved in the delivery of chemotherapy is to ensure that the
correct dose of the correct drug is administered by the correct route to the right patient. Complex
regimens of potentially lethal drugs are being employed in a variety of settings. Individual
institutional guidelines should be developed to minimize the risk of chemotherapy errors. These
guidelines should include a reporting system for errors and a systematic way to review current
practice to provide changes to prevent repetition of errors. Recommendations for preventing errors
are listed in Table 70.6.58–61

Table 70.6

Guidelines to Prevent Chemotherapy Administration Errors.

Chemotherapy may be used to cure, control, or palliate cancer. It may be used in a neoadjuvant or
adjuvant setting. Patients receiving chemotherapy in conjunction with other cancer therapies are at
increased risk for experiencing side effects. The goal of nursing interventions is to prevent or
minimize side effects caused by cancer treatments. Detailed information regarding the prevention
and management of cancer-related symptoms and side effects from chemotherapy can be found
elsewhere in the cancer literature.17,18,37,62–65 It is imperative to assess accurately the patient’s
physical and emotional status before therapy is initiated. This information assists the members of
the health-care team to identify risk factors that could contribute to the occurrence or severity of
side effects. Other factors that may affect the patient’s response to therapy are age, performance
status, coexisting illnesses, and nutritional status.

The change to outpatient administration of chemotherapy has increased the necessity for accurate
and thorough patient and family education. This requires nurses to understand the possible side
effects of each antineoplastic agent and the self-care activities for reducing their severity.
Describing the side effects or problems that patients might experience from the regimen as a whole
is more effective than focusing on each separate drug. Patients are more concerned about the
occurrence and management of side effects than the actions of particular agents. Reiteration of
important points will assist in achieving the desired outcome. Identifying a time sequence in which
side effects generally occur may allay patient anxiety and will assist nurses in selecting the
appropriate interventions. This may help to distinguish side effects of chemotherapy from other
possible causes of similar symptoms. Patient education is facilitated when side effects are classified
as immediate, early, delayed, and late.66 Immediate side effects, such as hypersensitivity reactions,
occur within the first 24 hours. Diarrhea and alopecia have an onset of days to weeks and are
considered early side effects. Delayed effects, such as anemia or pulmonary fibrosis, occur within
weeks to months, and late effects, such as second malignancies, may not appear for months or years
(Table 70.7).
Table 70.7

A Classification of Chemotherapy Side Effects Designed to Facilitate Patient Education.

Nurses frequently triage patient problems and assist in the evaluation of symptoms and initiation of
interventions. Subjective and objective data, including information about the last chemotherapy
treatment and knowledge of the patient’s history, guide the nurse in determining the patient’s
disposition and treatment. Many institutions have developed guidelines for triaging phone calls and
problems. See Table 70.8 provides a triage guideline for cancer-related diarrhea.

Table 70.8

Example of a Triage Guideline for Nursing Management of Cancer-Related Diarrhea.

Much progress has been made in managing the side effects of chemotherapy, and nurses have
contributed significantly to this success. For example, nausea and vomiting are two of the most
common symptoms associated with chemotherapy. Control of these symptoms has been a nursing
research priority. Multiple studies have helped to define nausea and vomiting and to develop tools
to measure occurrence, distress, and individual experiences associated with these symptoms.67–69
This information assists in the treatment of nausea and vomiting and evaluation of the effectiveness
of prescribed treatments.

Increases in health-care costs and decreases in financial resources have challenged professionals
involved in the administration of chemotherapy to evaluate the cost-effectiveness of medical and
nursing treatments. Oncology nurses have assisted in the development of guidelines for the use of
antiemetics particularly the 5-hydroxytryptamine receptor antagonists.70 These guidelines outline
the optimal use and safe delivery of antiemetic drugs and have proved to be an effective means of
cost containment.

Biotherapy

Biotherapy is often considered the fourth modality of cancer therapy. Biologic therapy may alter
host immune response to the tumor or be primarily aimed at reconstituting normal host functions,
such as granulocyte repopulation. On occasion, the precise function of a noncytotoxic
pharmacologic agent may be unknown, as in the case of levamisole. Biologic agents include the
interferons, interleukins, vaccines, colony-stimulating factors, and monoclonal antibodies. These
often are used in conjunction with other cancer therapies, such as chemotherapy, radiation therapy,
or surgery.

The two most common side effects associated with biotherapy are a flu-like syndrome and fatigue.
Intradermal, subcutaneous, and intralesional vaccines can cause localized skin inflammation and
systemic side effects, such as fever, chills, diaphoresis, and fatigue. High-dose cytokines can results
in toxicities affecting nearly all organ systems. The hematopoietic growth factors are generally well
tolerated aside from bone pain. Since many of these agents are administerd subcutaneously,
oncology nurses must teach patients or family members how to prepare and inject the drugs as well
as to manage possible side effects.71–74
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Supportive Care
Oncology nurses are closely involved with numerous supportive care issues encountered by cancer
patients and their family. This chapter does not allow a detailed discussion of the numerous areas of
supportive and palliative care, but two areas deserve special mention, that is, the involvement of
nurses in pain management and in survivorship.

Because nurses spend more time with a patient who is experiencing pain than do any other health
professional, it is of utmost importance that the nurse be knowledgeable about pain assessment and
both pharmacologic and nonpharmacologic management of pain, in order to provide good pain
control as well as patient and family education.75,76 However, barriers to providing effective pain
control have not eluded the nursing profession. The major problems are misconceptions and fears
about addiction, drug tolerance, sedation, and respiratory depression; lack of knowledge about pain
assessment and analgesics; and undertreatment with analgesics.77 This is understandable when one
considers the minimal time that is devoted to pain control in traditional undergraduate nursing
curricula. Fortunately, these problems are now being addressed, and the education programs and
resources available have improved considerably. State cancer pain initiatives, guidelines, and
organizational position statements have been excellent efforts toward improving pain management.
The ONS developed a position paper on cancer pain that delineated the scope of practice for nurses
with different levels of expertise.78 Even the Joint Commission for Accreditation for Healthcare
Organizations has recognized the problem of inadequate pain management and changed their
standards of care to emphasize appropriate management.79

Nursing care should be planned to promote patient comfort, provide patients and their families with
information related to pain control, provide information about and assistance with behavioral and
physical interventions, prevent and alleviate side effects of pharmacologic therapies, and promote
patient compliance with therapy and required follow-up. The nurse should explain the rationale of
interventions and provide time for patient and family questions. Patient education should include
the names of the pharmacologic agents, dosage schedules, side effects, interventions to alleviate
nausea and vomiting, such as antiemetics, and interventions to alleviate constipation. The nurse
should monitor the effectiveness and side effects of pharmacologic interventions, respiratory status,
bowel functioning, as well as mental and cognitive functioning. The patient and family must know
how to contact medical personnel in case of an emergency and should feel free to do so.

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Survivorship
Over 50% of individuals who are diagnosed with invasive cancer will live beyond 5 years, and most
will be considered cured. Thus, issues of survivorship and living with the effects of cancer and its
treatment are a significant concern. This is evidenced by the emphasis on rehabilitation. The ONS
was the first professional group to provide a practical definition of cancer rehabilitation as a
“process by which individuals within their environments are assisted to achieve optimal functioning
within the limits imposed by cancer.”80

The National Coalition of Cancer Survivors and the American Cancer Society have brought
survivorship issues to the public and are promoting rehabilitation as the first phase in preparing
cancer survivors to lead fulfilling lives.81 Bushkin,82 a cancer nurse who died of cancer in 1993, said
“surviving a chronic illness is a hard fight.” She also provided insight and understanding into the
process of being a cancer survivor through her teaching, caring, and conceptualization of the
process of survival, best expressed in her lecture entitled “Signposts of Survivorship.”82 She
provided, by word and example, a mechanism to combine the challenges of life into a cohesive plan
for living.

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Summary
The progress of professional oncology nursing parallels the progress made in the surgical,
radiologic, and medical approaches to the treatment of cancer. The oncology nurse has become an
integral component of the cancer-care team. Oncology nurses have earned the respect of physicians,
other health-care professionals, and, most importantly, of patients and their families. Oncology
nursing will continue to develop as a dynamic element within the health-care delivery process as the
number of these nurses increases and their levels of knowledge, experience, and expertise advance.