All qualitative research studies were rated as medium to high quality. According to the critical appraisal tool,28 limitations for qualitative studies were the lack of a clear philosophical perspective and statements of reflexivity. Quantitative studies were ranked as either medium or high quality using a critical appraisal tool29 specific for descriptive/correlational studies. As all the research questions were aimed at yielding descriptive findings, some quantitative research studies did not meet the criteria of hypothesis formation, random sampling, comparative analysis, or having findings that were statistically significant.
In the quantitative research studies, data were collected using self-report surveys, and the sample sizes ranged from 89 to 615 oncology nurse participants. For the qualitative research studies, individual interviews or focus groups were conducted, and the sample sizes ranged from 3 to 91 oncology nurses. Participants in the research studies were predominantly staff nurses providing direct care to cancer patients. One study included oncology nurse executives along with staff nurses in the sample, and another study included exclusively nurses working in cancer clinical trials.
The Context of Oncology Nursing
The theoretical and empirical literature reviewed provided descriptions of settings where oncology nurses work and forces influencing the settings. Several themes were identified in the extracted data that reflect the surroundings or background (structural environment, world of cancer care) as well as conditions and circumstances (organizational climate, nature of oncology nurses’ work, and interactions and relationships) of oncology nursing practice settings.
THE STRUCTURAL ENVIRONMENT
The theme structural environment described physical and structural elements such as location, models of care delivery, and resources within oncology nursing practice settings in 9 countries. The types of care settings included acute care units within hospitals, ambulatory clinics in cancer centers or hospitals, and hospice, palliative care, and home-care/community settings. In most settings, the model of care delivery included nurses working as part of a multidisciplinary health team or as primary nurses or case managers. One article43 described nurse-led clinics where nurses had primary responsibility for the follow-up care of cancer patients. In community settings, nurses were part of the health team, but worked more independently coordinating and accessing services for cancer patients living at home.10,37
The structure of oncology work settings varied from highly specialized environments40,46 in urban settings that had modern up-to-date equipment and computers to rural and remote settings that had limited basic equipment and resources.10,37,40 Settings where chemotherapy and radiotherapy were administered reflected high technological cancer treatment environments18,38,40 but also were recognized as environments that exposed nurses to toxic chemicals and safety risks.16,34,40 Two studies17,19 emphasized that the location of the cancer clinic/ward and its physical features can convey a powerful symbolic meaning. For example, in one study,17 evidence of neglect for the physical environment, limited space available for personal and private interactions, and a staff that was not easily accessible relayed a message of not caring for people. Thus, the physical environment can either ease or impose suffering by presenting an atmosphere of openness and involvement or secrecy and noninvolvement.17
With respect to human resources, almost all articles indicated that cancer care settings were functioning with not enough registered nurses (RNs) to provide quality care. Registered nurse staffing inadequacies were attributed to a number of factors that included the layoff of nurses that occurred through healthcare restructuring in the 1990s, the replacement of RNs with unregulated healthcare workers in an effort to cut costs, the global shortage of nurses, difficulty retaining experienced oncology RNs in chaotic work environments with increased patient workloads, and difficulty recruiting RNs with expertise in the knowledge and skill of oncology nursing.7–10,12,16,35,38,40 The literature revealed that the oncology nursing workforce was predominantly a mature experienced nurse group with few younger novice nurses.7–10,12,15 Furthermore, decreased RN staffing was most notable on inpatient units,7–10,12,35 where oncology nurses were required to work double shifts or overtime hours, and staff were temporarily hired from employment agencies or float pools or reassigned from other departments in order to meet patients’ needs. These human resource strategies were perceived by nurses to result in an inadequate and less qualified oncology nursing staff8–10 that negatively influenced the quality of cancer care. In studies that measured nurses’ perceptions of staffing levels and workloads, the overall responses indicated moderate to high levels of dissatisfaction with these workplace characteristics.7–9,12,15
THE WORLD OF CANCER CARE
The literature emphasized that cancer control continues to be a top priority healthcare issue around the world.7,35,39,42,44,45 Many articles38,39,42–46 reported that factors such as new technology and scientific advances transforming cancer care management, the demographics of an aging population, the increasing incidence and prevalence of cancer cases, and the trend toward administering cancer treatments in outpatient settings emphasize the need for the specialized knowledge and skills of oncology nurses across the entire spectrum of cancer control. Oncology nurse leaders from several countries39,41–43,45 addressed social, economic, and political issues relating to the care of cancer patients, the impact of the global nursing shortage, and the need to develop new and innovative nursing roles to meet current and future cancer control needs.
The literature described organizational circumstances and conditions that contributed to the climate of oncology practice environments. In particular, the literature emphasized that irrespective of care setting and geographical location, patient acuity and patient volumes were on the rise. Such conditions along with the inherent unpredictability of cancer as a disease contributed to oncology care settings being busier and less predictable than in the past.32
The research literature also provided descriptions of organizational climate through surveying oncology nurses’ perceptions about the attributes, policies, and practices of their workplaces. Five studies7–10,35 reported that oncology nurses’ workplaces were affected by widespread hospital restructuring throughout the 1990s. System changes created stressful work conditions that were characterized by fiscal restraint, increased workloads (including both nursing and nonnursing functions), and lack of visible nursing leadership. These conditions were associated with nurse job dissatisfaction, burnout, and a perceived decrease in the quality of patient care.
Some of these studies8,9,35 compared oncology care settings with other nursing workplaces. The findings indicated that nurses working on dedicated oncology units or in cancer clinics perceived their practice environments to have a more positive climate than that experienced by nurses working on mixed patient units, primarily because of the presence of collegial nurse-physician relations and workloads that included fewer patients. Studies16,34 conducted in Turkey, however, revealed a more negative workplace climate for cancer nurses than for nurses working with other patient populations. This negativity stemmed from poor working conditions due to organizational noncompliance with national labor laws and regulations about the safe preparation and administration of cytotoxic drugs.
NATURE OF ONCOLOGY NURSES’ WORK
Although the literature acknowledged that cancer nursing traditionally has held a negative image associated only with suffering, death, dying, and toxicity of treatments, it also provided evidence of oncology nursing as a specialized field where nurses experienced both rewards and challenges. The challenges included daily exposure to pain, suffering, and loss30–32 and trying to achieve a balance between personal and professional life.7,30,44 One article described oncology nursing as “being on the frontlines of a war against death, disfigurement, and intense human suffering,”31(p1485) whereas another article identified the moral distress that can arise caring for vulnerable patients.36 Although cancer nurses recognized that the nature of their work could be stressful and emotional, overall they described their work as satisfying, rewarding, and meaningful. Satisfaction came from the close nurse-patient relationships that were established, and the validation received from patients and families that nursing knowledge and skills contributed positively to making a difference in patients’ quality of care.10,19
The literature delineated that, within the context of a specialization, oncology nursing requires specialized knowledge and skill in complex procedures and protocols of cancer control, competency in the assessment and management of physiological and psychosocial patient health concerns, ability to coordinate patient care across the continuum of cancer control, effective interpersonal and communication skills, and use of therapeutic presence or “being there” for patients and families.39,40,44,46 In addition, with the emergence of new innovations in cancer management and increasing cancer workloads, additional professional role expectations for cancer nurses included more responsibility and autonomy in patient care, self-direction in continuing education, the ability to integrate new technology and research evidence with clinical decision making, a more collaborative and consultative role within multidisciplinary teams, and leadership in patient advocacy and supportive care.10,13,18,19,32,33
RELATIONSHIPS AND SUPPORT
As nursing is an interpersonal event,19 the context of oncology nursing relies on an intricate matrix of therapeutic, collegial, and professional relationships. Several articles described the therapeutic relationship established between oncology nurses and cancer patients as “unique”10 and “unlike the relationship with any other patient.”19 The nurse-patient relationship is intense and of long duration and includes connecting with and navigating patients and families through their cancer journey from diagnosis through to death or survivorship.32 Oncology nurses reported that relationships with patients and families were the rewards of their work and often served to buoy and sustain them within chaotic workplaces.10 However, relationships with patients could also be challenging when patients as healthcare consumers vented their frustrations about the healthcare system and expected more than the system could provide.10,30
Professional relationships were most often described in terms of nurse-physician collaboration. In studies8,9,12 that measured relational aspects of the work environment, oncology practice environments scored positive ratings on collegial nurse-physician relations and in comparative studies8,9 had more superior ratings than did non–oncology practice environments. However, it was noted that oncology nurses also faced some challenges articulating their specific role within interdisciplinary teams. In particular, several articles emphasized that oncology nurses need to more effectively demonstrate new and advanced practice roles for nurses, which encompass increased patient care responsibilities in order to meet patients’ needs and achieve higher national and international standards in cancer control.39,42,43
Many articles7–10,12–15,18,19,33,38 addressed leadership within oncology nursing. The overall message was that work environments “were managed, but leadership for nurses in cancer care was lacking.”13(p208) Nurses reported little support for their work from top-level administrative officers including senior nursing administrators. The unique and complex demands of caring for oncology patients were underestimated by organizational management, resulting in insufficient staff allocation and support for continuing education. The lack of visible nursing leadership and attention paid to nursing work-life issues were attributed to healthcare restructuring and the dismantling of nursing departments from organizational charts.10,14
Relationships with nurse peers were viewed as the main professional support system for both patient care and work environment issues.10,19,30 Nurses described a sense of community and cohesiveness with their coworkers. The perceived lack of support from managers and administrators resulted in nurses seeking peer-to-peer acknowledgement and feedback about their contributions and concerns related to patient care and the workplace. Nurse colleagues reported they were able to support one another in their shared passion for the oncology patient because they were attuned to coworkers’ emotional needs within an oncology care setting.19
Forces Shaping the Context of Oncology Nursing
The literature described external and internal forces that influenced the practice environment. External forces evolved from social, political, and economic events. The complex nature of cancer control was a predominate social force that influenced the way oncology nursing care was organized and delivered in all care settings as well as the day-to-day practice of individual oncology nurses.7,9,15,32 The profile of cancer patients presented both positive and negative contextual forces. Increased patient acuity was described to have a direct impact on cancer nurses’ work in terms of the level of education, knowledge, and skill required to meet patients’ needs in both hospital and community settings. The increased patient volume created system demands for appropriate staffing and resource allocation. As well, advances in science, technology, and cancer control were influential in emphasizing the need for oncology nurses to learn and master skills to administer complex therapies, gain computer literacy, and interpret and use research generated evidence in everyday practice.7,33,41,42,46
The literature reported on the political and economic forces in many countries that stimulated widespread healthcare system restructuring over the past 2 decades.7–10,15,16,34,45 These forces resulted in organizations reducing healthcare expenditures by cutting programs and personnel, despite increases in cancer patient volumes and acuity. In many cases, the economic forces took precedence over social forces and were perceived to have a negative impact on both the quality of oncology nurses’ work life and patient care.
Internal contextual forces surfaced from the organizational and professional cultures within the institution or agency. As stated above, external political and economic factors were major influences in determining the administrative frameworks of organizations and thus contributed to the underlying values, beliefs, and assumptions of the organizational culture. Many articles7,10,16,34 described organizational cultures as having business-oriented values that emphasized efficiency, prioritization, and service outcomes. “Time was a central metaphor,”32(p38) and how time was managed either facilitated or hindered the quality and quantity of oncology nurses’ work. Nurses indicated their workplace stress did not evolve from interacting with cancer patients or dealing with death or dying but rather from juggling the pressures of time and balancing professional and personal demands.10,18,30–32
The literature also identified that the professional culture of oncology nursing, which emphasized values of specialization, holistic care, advocacy, and collaboration, was a strong force influencing oncology nurses’ daily practice and the way nurses interacted with patients, families, and other health professionals. Several articles10,18,19,30 described how the cultural norms of oncology nursing, which focused on a patient-centered philosophy of care, were not always compatible with the economic and political values underlying the culture of healthcare organizations. Cancer nurses described the context of their work as unique within the nursing profession because it offered “a personal journey with incredible emotional enrichment”19(p23) and that this experience created a sense of commitment in which the “the care of the patient is a bigger priority… than the routine or structure of the ward.”19(pp23–24)
The core question for this integrative review was “What is the context of oncology nursing practice?” The term context as it relates to healthcare practice is identified as an important concept to examine for the purpose of gaining insight into the structures, processes, and forces that influence healthcare outcomes and healthcare professional productivity.47
In their PARIHS framework, Kitson et al,22 McCormack et al,23 and Rycroft-Malone24 propose that context constitutes 3 elements: an understanding of the prevailing culture, the nature of human relationships as summarized through leadership, and the organization’s evaluation or monitoring of systems and services. They also acknowledged that defining the context of practice is complex because of the many factors or forces that can interact to determine its characteristics and personality. The specific themes and forces identified in this integrative review were examined considering the context dimension of the PARIHS framework22–24(Figure 2).
For oncology nursing, the culture element included 2 cultures that represented different values or worldviews. The professional culture of oncology nursing reflected a philosophy of caring that was patient-centered and emphasized beliefs and values such as being present in the patient’s experience, acting on the patient’s behalf, and individualizing care to support the patient and family in finding meaning throughout their cancer journey.19–31 These values and attributes are reflected in the role descriptions for oncology nurses promoted by national (eg, Canadian Association of Nurses in Oncology) and international oncology nursing societies (eg, International Society of Nurses in Cancer Care). In contrast, organizational culture reflected a philosophy of service that emphasized time management and goals of efficiency, keeping systems running smoothly and moving patients through the system.16,18,39 As culture is socially constructed, evolving from shared experiences, the interplay of a professional subculture (oncology nurses) that embraces assumptions, beliefs, and rituals differing from the overall organizational culture can create tensions.25 These tensions can influence perceptions about how the organization (work environment) values and supports the practice and goals of the professional group.
The element of leadership included the therapeutic and professional relationships that underlie day-to-day oncology nursing as well as the organizational and educational supports needed to sustain, promote, and value the role oncology nursing plays in cancer control. Organizational climate was mapped onto the evaluation element as it represented findings from studies that were conducted to measure nurses’ opinions about the atmosphere and conditions of their practice environments. Other findings were mapped onto the overall dimension of context and included features of the structural environment, the world of cancer control, and external forces. In summary, the findings revealed that the context within which oncology nursing practice takes place is a complex, multifaceted environment that is characterized by the location and structure of the care setting and its resources, the nature and demands of cancer patients and cancer care, and organizational and professional cultural and relational elements, as well as external social, political, and economic events.
The findings from this integrative review portray that the context of oncology nursing is similar yet different from other nursing contexts. Similarities include the social, political, and economic forces that have shaped the healthcare milieu in many countries over the past decades. Like nursing workplaces in general, oncology nursing practice environments have experienced healthcare restructuring that has influenced both how nursing care is delivered and the quality of nurses’ work lives. As well, the social demographics of an aging population, the epidemiology of chronic disease, and innovations in medical treatments are forces that have increased the demand for nursing services and increased professional accountability not only within the cancer patient population but also for other patient populations.
However, within the oncology nursing literature, there is a recurrent theme that oncology nursing is unique and different from other nursing specialties.10,19,30–32,39,42,44 This uniqueness has been attributed to such factors as the dynamic and complex world of cancer control; the diversity of cancer care settings; the intense and longstanding relationships with cancer patients and their families; and the self-awareness and personal growth gained through connecting, caring, and advocating for patients and families coping with bad news, suffering, death and dying, and/or survivorship. Oncology nurses have likened their work to the “cancer experience” in terms of the uncertainty and emotional demands they experience. They have expressed that the therapeutic nurse-patient relationships they establish are learning experiences that change their lives and evoke passion.30
Implications for Practice, Policy, and Research
The primary reason for studying the context of oncology nursing lies with the growing evidence that the quality of nursing work environments has a significant impact on both nurses’ quality of work life and the quality of patient care.20,21 Thus, research examining the contextual features and forces of the oncology work environment can help to identify facilitators and barriers to nursing practice, patient safety, and health outcomes.
This integrative review included articles about oncology nursing practice in 9 countries having different healthcare systems, and it is interesting that there were similar contextual features and concerns that gave oncology nursing its look and feel. These features included the complex world of cancer control, the nature of oncology nursing, increasing patient volume and acuity, decreased qualified nursing staff and support staff, the need for continuing education and specialty recognition for oncology nursing, and lack of strong nursing leadership.
Albeit, social, political, and economic events are dominant factors in setting national and regional healthcare agendas and outcome goals, healthcare administrators also need to recognize that quality patient care depends on developing positive practice environments and retaining quality healthcare providers. Thus, greater efforts are needed to utilize the growing body of evidence about what organizational or workplace attributes can be modified to develop positive practice environments that recruit and retain nurses. Factors shown to influence nurses’ decisions to remain or leave their positions include job satisfaction, management style and supervisory support, the work environment, and personal issues.47 With respect to the specialty of oncology nursing, visible/relational leadership and positive relationships among nurses, managers, and physicians have been shown to contribute to nurses’ job satisfaction and quality oncology nursing environments.14 In addition, recent systematic reviews provide evidence about the positive influence of nursing leadership on nurse performance and work environment.48,49 Nurse leaders with an inclusive leadership style have the ability to promote workplace empowerment50 so that nurses’ performance and patient outcomes align with both a culture of caring and a commitment to the organization. Thus, organizational efforts to develop transformational and relational nurse leaders within oncology settings have the potential to enhance nurse satisfaction, recruitment, and retention and positively affect work environments.
The mapping of findings onto the PARIHS framework illuminated specific factors and forces relevant to oncology nursing and helped to identify contextual features that either were not highlighted in the reviewed literature or required further examination. For example, a few articles identified the importance of oncology nurses’ interactions with patient families; however, the concept of family-centered care did not emerge as a predominant relational theme. Recent research on family nursing51,52 in oncology emphasizes that a cancer diagnosis affects not only the patient but the entire family dynamics and that the movement toward ambulatory cancer care relies on family involvement for the support and care of cancer patients in the community. Thus, oncology nurses need to regularly assess family members’ needs for information and their ability to cope with new responsibilities and demands.51,52 Furthermore, findings from these studies indicate that organizational features can create barriers that isolate families from being “partners of care.”52(p65) Evidence gleaned from this integrative review provides information about organizational features (space, location, human resources) and forces (organizational philosophy and culture) that could be targeted for change and evaluation in order to support family-centered care.
In addition, our findings indicate that information technology and evidence-informed practice were not perceived by nurses as being dominant forces influencing individual nursing practice. As information technology and evidence-informed practice are both prominent features of 21st-century healthcare settings, it is important that research studies be conducted to determine how these contextual features can best support oncology nursing practice and quality of work life. Whereas the research studies reviewed in this integrative review provided descriptions of aspects of the context of oncology nursing, it is important that future research studies be designed to move beyond the descriptive level to investigations that test relationships among contextual features and/or the impact of specific internal or external forces on oncology nursing practices and processes including nurse recruitment and retention.
The terms context, culture, and climate are used in the business literature to describe factors that influence employees’ behavior and performance.25,26 However, the terms are used inconsistently and have not been clearly defined to differentiate how they relate to organizational attributes or features within healthcare practice environments. This ambiguity in terminology can pose a challenge when examining nurse practice environments. For this integrative review, the definition of context was adapted from the work of Kitson et al,22 McCormack et al,23 and Rycroft-Malone24 as the setting where oncology nursing is practiced and the forces shaping that environment. Because the term context is used within the nursing literature interchangeably to refer to the nurse practice environment, clinical practice environment, and/or nurses’ work environment,25 the literature search was guided using these multiple key words in order to capture published theoretical and empirical literature that provided descriptions of the attributes of oncology nursing practice, the structure and processes making up cancer care practice settings, and the conditions and circumstances influencing practice. The terms climate and culture were used as descriptors of the work environment based on rationale outlined in the organizational literature.25,26
As the population ages, the number of people with or at risk for cancer will also grow, placing increased demands for oncology nursing care. Thus, recruitment and retention of nurses with specialized knowledge and skill in the care of cancer patients and their families will continue to be a major health human resource issue over the next decades. To achieve quality cancer care, healthcare administrators need to better understand the contextual attributes and forces that can be modified to both improve the context of oncology nursing and effectively meet the care needs of cancer patients and their families.
The authors thank Esther Green of Cancer Care Ontario, Toronto, for her insight and ongoing support of this work and Ann Barrett, librarian at W.K. Kellogg Health Science Library, Dalhousie University, Halifax, Nova Scotia, and Kimberly Hancock, librarian at the Health Sciences Library, Western Health, Corner Brook, Newfoundland, for their expertise and assistance in searching the literature.
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Keywords:© 2013 Lippincott Williams & Wilkins, Inc.
Cancer control; Nurses’ workplace; Professional practice; Oncology nursing; Organizational climate; Organizational culture; Work environment