Chapter 7

Oncology Nursing Care

Jennifer Frith and Nelson J. Chao

Cancer is a leading cause of death worldwide, accounting for nearly 10 million

deaths in 2020 [1]. This is due to many risk factors such as aging society, alcohol
abuse, smoking, obesity, and lack of physical activity [2]. It is essential to deliver
high-quality nursing care, from prevention and screening to end-of-life care. As
research and scientific discoveries are incorporated into cancer treatment, nurses
working in the oncology field should be well educated and be prepared to play an
integral role in delivering complex treatment regimens and targeted cellular thera-
pies. Therefore, focusing on specialized oncology nursing practice through advanced
education will ensure successful care delivery.
By utilizing established standards and competencies to provide oncology nursing
care, nurses will improve their knowledge and skill set. Nurses new to oncology, as
well as experienced nurses from other specialties, should receive the required com-
petencies to provide high-quality care to cancer patients. According to the Institute
of Medicine [3], these include leadership, health policy, system improvement,
research and evidence-based practice, teamwork and collaboration, community and
public health, geriatrics, and oncology. Documentation supporting the development
and validation of nursing competency is frequently required of accreditation agen-
cies, including the American College of Surgeons and The Joint Commission, as
part of the accreditation and reaccreditation process [4].
Any oncology setting should have policies to document any additional qualifica-
tions of specialized staff providing care to the cancer patient, especially regarding
chemotherapy administration and documentation. The 2016 updated American

J. Frith (*)
Inpatient Oncology and ABMT, Durham, NC, USA
e-mail: [email protected]
N. J. Chao
Division of Hematologic Malignancies and Cellular Therapy/BMT, Global Cancer/Duke
Cancer Institute/Duke Global Health Institute, Durham, NC, USA
e-mail: [email protected]

© The Author(s) 2022 57

M. Aljurf et al. (eds.), The Comprehensive Cancer Center,
https://doi.org/10.1007/978-3-030-82052-7_7
58 J. Frith and N. J. Chao

Society of Clinical Oncology/Oncology Nursing Society (ONS) chemotherapy

administration safety standards recommend a minimum expectation for ordering,
preparing, and administering chemotherapy [5]. There should be a comprehensive
program for initial and ongoing oncology education requirements for all staff and a
dedicated time frame for onboarding all new hires within the institution.
Oncology nursing continues to progress and can differ significantly across cul-
tures. Currently, oncology nurses work in diverse settings such as hospitals, private
physician clinics, outpatient infusions, radiation centers, home health agencies, and
community settings, supporting many oncology disciplines. The oncology nurse’s
roles vary from a community focus of screening, detection, and prevention to a
more intensive care focus such as blood and marrow transplantation. Regardless of
the setting, nurses working in cancer care are responsible for focusing on patient
assessment, management of symptoms, education, coordination, and support-
ive care.
According to the World Health Organization (WHO), there is a shortage of 7.2
million healthcare workers concerning health needs, whereas the report by the
“Third Global Forum on Human Resources for Health” estimates that by 2035, the
nursing deficit will reach 12.9 million [6]. With the growing shortages of health care
professionals skilled in providing cancer care, the focus should be on providing
oncology-specific training and competencies. Nursing staff shortages affect the
quality or quantity of healthcare and decrease nurses’ motivation regarding compre-
hensive care provision or care based on scientific principles [7]. This may lead to
work overload, burnout, and increased nursing turnover. It is imperative to assess
each clinical area’s nursing unit structure and staffing needs and develop a nursing
care model focused on evidence-based patient-centered care.

Oncology Inpatient Clinical Service Unit

Oncology nurses play a vital role in delivering high-quality care to patients hospital-
ized with a cancer diagnosis. The oncology care nurse needs to develop a collabora-
tive relationship with the physician to deliver exceptional comprehensive patient
care. Depending on the type of clinical service unit (CSU) being established or
maintained, the nurse–patient ratio must be assessed initially and again over time.
By benchmarking with other institutions, identifying an appropriate ratio and skill
mix can be validated for the individual unit type. Because of the increased acuity
and workload on an oncology inpatient unit, registered nurses (RN) are a critical
component of the healthcare delivery model. However, due to the limited number of
RNs in many countries around the world, it is suggested each institution assesses the
individual characteristics of their nurses, their work environments, and their patient
population [8] to ensure the appropriate skill mix has been identified. For example,
the inpatient blood and marrow transplant unit would use a primary model with
7 Oncology Nursing Care 59

highly trained nurses and a lower nurse–patient ratio due to the complexity of care
being delivered. In contrast, a medical oncology unit may have a higher nurse–
patient ratio but utilize non-licensed personnel to assist with care. Based on the
clinical unit’s care and scope, one must consider what their staff may require to
meet patient needs.
With the administration of antineoplastic agents occurring mostly on inpatient
units, a global standard is recommended to ensure safe handling and administration
for the care nurses by following the Oncology Nursing Society (ONS) guidelines.
Nurses working in cancer care are responsible for education before start of treat-
ment, safe drug handling; two-person independent verification of chemotherapy
with the calculation of drug dosage based on body surface area, insertion of intrave-
nous lines or accessing central venous devices; and continuous intense monitoring
to identify early recognition of oncologic emergencies. Nurses specifically working
in radiation oncology require an additional skill set. During basic nurse training,
many nurses do not have the opportunity to participate in any radiation-related
courses. To prevent nurses from exposure, it is necessary to provide the healthcare
nurse with the appropriate knowledge of radioactive contamination. The nurse will
also be responsible for symptom management assessment of skin rashes and com-
munication of any toxicities identified.

Ambulatory Setting

Although an inpatient care delivery model can be transitioned to an ambulatory model

easily, an assessment is imperative to understand the model’s cost-­effectiveness and
efficiency while supporting high-quality care and positive patient outcomes. With the
increased number of complex oncology patients transitioning to ambulatory care,
highly skilled nurses’ requirements are as crucial as in the inpatient setting. Choosing
the correct nursing care delivery model will need to include patient-centered care
while considering the increased complexity of nursing care requirements, monitoring
quality metrics and patient outcomes, and implementing cost-containment measures
such as drug costs. No standard staffing model or nurse-­to-­patient ratio exists for
ambulatory infusion or chemotherapy treatment and radiation centers [9].
With this fast-paced setting, including the rapid turnover of patients, experienced
nurses may be preferred. Ambulatory settings should consider many variables when
creating a staffing model, for example, the physical location assessment: freestand-
ing clinic versus attached to the hospital, types of service provided, hours of opera-
tion, patient population mix, and care needs. Acuity-based models should not be
based solely on the patient’s time in the treatment center and consider the complex
care being administered. Implementing supportive protocols such as electrolytes,
blood supplementation, and fever workups allow nurses’ autonomy and immediate
care delivery with minimal delay.
60 J. Frith and N. J. Chao

Oncology Role Outside of the Clinical Setting

With cancer care transitioning to the ambulatory setting, patients and caregivers
have to manage symptoms and side effects of treatment in their home. Many of
these patients travel from afar to receive cancer therapy. The nurse should serve as
the first line of communication. From the referral process to end-of-life care, the
patient and or/family should be able to contact an oncology nurse by phone during
their entire continuum of care. By developing a triage support system, the patient
will have consistent communication with their health care team, allow for emotional
support, and identify any emergencies. A nursing care triage model can support
various settings, including ambulatory clinics and outpatient infusion areas, sup-
porting increased patient satisfaction and positive patient outcomes. For example,
for a patient calling with a fever, an evidence-based protocol with a physician order
set embedded would reduce the time to receive antibiotics and potentially decrease
a patient’s length of stay in the hospital. It is also essential to assess hours of opera-
tion and a need for 24-hour access.
With global technology increasing and patients traveling from afar, is there an
opportunity, when able, to leverage telehealth for remote symptom management.
For some remote geographic areas, telecommunication technology may allow
nurses a vehicle to provide nursing care to patients in alternative care sites such as
patient homes, shelters, and nursing homes. Nurses can provide numerous services
in these areas, such as patient education, coordination of care, arranging appoint-
ments, and symptom management with physician resource support. Utilizing tele-
health and other types of remote technology, nursing can help eliminate barriers,
time, and distance a patient may experience living in remote areas and assess as part
of the care delivery model.

Survivorship/Palliative Care and Hospice

As cancer survivors grow, nurses often play a pivotal role during the survivorship
plan of care. Once a patient’s treatment regimen is completed, patients are often at
a loss of managing their long-term side effects, emotional distress, and economic
burden lacking the knowledge they can reach out to address these concerns. By
providing specialized training for long-term oncology care, nurses can deliver guid-
ance, education, and appropriate referrals to address various issues. These real-life
situations can help the cancer care community develop optimal care algorithms and
identify the interprofessional team members for survivorship care delivery [10].
Depending on how far the patient may travel for cancer survivorship care, a tele-
health platform may benefit a particular institution.
Palliative care is necessary to support comprehensive cancer care. As the trend in
healthcare moves from a fee-for-service model to a patient-centered, value-based
model, the expectation is that an increase will occur in the integration of palliative
7 Oncology Nursing Care 61

care into comprehensive oncology care [11]. Nurses have learned to incorporate
caregiver goals into the plan of care. A cancer diagnosis often results in distress in
the physical, psychosocial, spiritual, and emotional domains of care. Today, pallia-
tive care nursing focuses on care delivery to individual patients and families, within
specific disease populations, and palliative care issues within health care and soci-
ety as a whole entity. Proper training is essential to have the knowledge and skillset
to address the numerous facets of cancer. The Hospice and Palliative Nursing
Certification (CHPN) was developed in 1994 to support additional education and
guidance in this field of nursing. Once the care nurse has a few years of experience,
certification is recommended to support continued education in this field.
With the increased aging population in developed countries worldwide, patients
may choose to have end-of-life care in various settings such as a hospital, outpatient
facilities, or at home. Both new and seasoned oncology nurses need to be comfort-
able providing end-of-life nursing care. Training programs exist, End-of-Life
Nursing Education Consortium (ELNEC), focusing on nursing education to deliver
optimal end-of-life care to patients and their families [12]. Burnout is a significant
concern for the oncology nurse delivering end-of-life care. To support resilience and
sustain the workforce, oncology nurses need strategies on how to support these
complex patients, their families, and themselves to be successful in delivering high-­
quality end-of-life care.
In conclusion, the care nurse plays a vital role in delivering oncology care,
including administering multiple and complex treatment regimens. The coordina-
tion encompasses direct patient care, documentation in the medical record, partici-
pation in therapy, symptom management, organization of referrals to other
healthcare providers, family and patient education, and diagnosis, therapy, and fol-
low-­up. Providing continuous education and competencies to the care nurse, imple-
menting evidence-based practice, and identifying the appropriate nursing care
delivery model will support quality care delivery in these complex environments.

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