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ONCOLOGY NURSING SOCIETY REPORT
ONLINE EXCLUSIVE
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The Oncology Nursing Society
Ambulatory Office Nurse Survey
Anne M. Ireland, MSN, RN, AOCN, Judith A. DePalma, PhD, RN,
Linda Arneson, BSN, RN, OCN, Laurel Stark, BSN, RN, OCN,
and Judy Williamson, MS, RN, AOCN
I
n the early 1990s, the Oncology Nursing Society (ONS)
provided by Gail Mallory, PhD, RN, CNAA, and Judith A.
published several reports of national surveys about salary,
DePalma, PhD, RN.
staffing, and professional practice patterns in office-based
The project team met in February 2002 to outline the key
nursing, infusion therapy centers, and ambulatory care oncol-
areas of practice related to ambulatory and office nurses
ogy clinics (ONS, 1990a, 1990b, 1992). These reports detailed
involved with chemotherapy administration. Content experts
the emerging role of the nurse in these various outpatient
reviewed the developed survey that was then pilot tested by 40
settings (ONS, 1990a, 1990b, 1992). Today, oncology care
randomly selected members of the Ambulatory/Office Nurs-
is delivered increasingly in outpatient, ambulatory, or office
ing ONS Special Interest Group (SIG). The mass distribution
settings in response to trends influenced by patient preference,
occurred in May 2002. Given the expanded and complex
improved supportive medications, and financial advantages.
roles of the oncology nurse in the ambulatory environment,
According to the ONS database, more than 10% of ONS
all aspects of clinical practice were deemed beyond the scope
members report that they work in ambulatory settings.
of one survey. Therefore, a decision was made to limit the
Recently, the ONS Workforce Survey reported that outpa-
definition of clinical practice to chemotherapy treatment
tient-based RNs were more likely than inpatient RNs to report
because it is the most frequent treatment currently supported
caring for an increased number of patients and that physi-
in ambulatory settings.
cians had delegated an increased number of tasks for them to
The survey included the broad practice areas of
perform (Lamkin, Rosiak, Buerhaus, Mallory, & Williams,
Clinical care
2002). Schim, Thornburg, and Kravutske (2001) reported sur-
Chemotherapy administration
vey findings that assessed practice patterns of RNs in a variety
Safety
of ambulatory care settings. Results revealed that ambulatory
Symptom management
RNs' perceptions of what they actually do in daily practice is
Outcomes
disconnected from what they believe is important to do. Sev-
Telephone triage
eral authors have reported the value of an expanded RN role
Patient education
in the ambulatory setting (Richter & Felix, 1999; Schroeder,
Delegation
Trehearne, & Ward, 2000a, 2000b) and have proposed nurse-
sensitive indicators of "quality" care (Mastal, 1999). Although
Anne M. Ireland, MSN, RN, AOCN  , is an oncology consultant in
these are not oncology-specific reports, the issues are pertinent
hematology and oncology at Fletcher Allen Health Care in Burling-
because they are based in the ambulatory setting.
ton, VT; Judith A. DePalma, PhD, RN, was a senior research associ-
The purpose of this survey was to determine which aspects
ate for the Oncology Nursing Society in Pittsburgh, PA, at the time
of care staff RNs were responsible for across a variety of am-
this article was written and currently is a professor in the School of
bulatory and office settings, whether the nurses believed that
Nursing at Slippery Rock University in Pennsylvania; Linda Arneson,
these aspects of care should be managed by an RN, and the
BSN, RN, OCN  , is the director of nursing at Oncology Associates
key issues related to practice that respondents believed needed
in Cedar Rapids, IA; Laurel Stark, BSN, RN, OCN  , is a traveling
nurse for RN Network and currently is working as a staff nurse at
to be addressed by the professional organization.
University Medical Center in Tucson, AZ; and Judy Williamson, MS,
The survey was developed by a project team led by Anne
RN, AOCN  , is a clinical nurse specialist in oncology and palliative
M. Ireland, MSN, RN, AOCN, and included Linda Arne-
care at OSF Saint Anthony Medical Center in Rockford, IL.
son, BSN, RN, OCN, Laurel Stark, BSN, RN, OCN, and
Judy Williamson, MS, RN, AOCN. ONS staff support was
Digital Object Identifier: 10.1188/04.ONF.E147-E156
ONCOLOGY NURSING FORUM VOL 31, NO 6, 2004
E147
Care delivery models
than $30 an hour, with 29% reporting more than $30 an hour
Staffing
and 36% reporting $24.01$30 an hour.
Patient scheduling
Approximately half (48%) of the respondents reported their
Clinical trials
highest level of education in nursing as a baccalaureate degree,
Reimbursement
18% had earned an associate degree, and 18% a master's degree.
Professional development
Seventeen percent reported no education in nursing beyond a
Legislative issues and policies
diploma. Certification as an Oncology Certified Nurse (OCN)
Nursing shortage
was held by 74% of the respondents, and 9% held Advanced
Key issues
Oncology Certified Nurse certification (see Table 1).
Practice and personal demographics.
Practice Setting
Most areas had questions that asked who had the primary
responsibility for specific aspects of care and how important
Respondents were divided evenly across settings with half
the respondent thought it was for the RN to have the primary
being employed in ambulatory or outpatient settings and half
responsibility for those particular aspects of care. The intent
in physician practice or office settings. More than half (56%)
was to determine which aspects of care nurses believed they
of the respondents reported working in a hospital or multi-
should be primarily responsible for and compare this with
hospital system, and 31% functioned in community cancer
the person in their settings who actually was responsible for
centers. Fifty-six percent identified their practice settings as
these particular aspects of care. Areas of practice with the
for-profit. Respondents represented 49 states and two prov-
greatest differences between value and actual responsibility
inces of Canada. Sixty respondents stated that their practice
will be emphasized in this article. These differences fell into
encompassed more than one state. The average number of
two categories.
treatment chairs in the practice setting was 12 (range = 1 45),
Highly important for RNs to have primary responsibility but,
and the average number of treatment beds was four (range =
in actual practice, other providers have that responsibility
150). Immediate supervisors most frequently were nurse
Minimally or not important at all for RNs to have primary
administrators (59%), followed by nonclinical administrators
responsibility, but, in actual practice, RNs are spending a
(21%) and physician administrators (20%). The presence of a
great deal of time performing
nurse in the practice setting was required after 5 pm by 55%
Other questions were asked using a Likert rating scale or
of the respondents, on weekends by 33%, and on holidays by
a list of options that could be checked, and comments were
26%. Sixty-four percent stated that the practice had one to
requested at the end of each topical section. Frequencies, per-
five physicians (range = 150), with 56% stating that one or
centages, ranges, and means were calculated for these results.
The voluminous narrative responses to the comment questions
Table 1. Sample Demographics
were reviewed for common themes or categories.
The survey was e-mailed to all ONS members who desig-
X
Range
Variable
nated their work settings as ambulatory or office and who had
e-mail addresses (N = 3,705). Seventy-six additional copies
44
2362
Age (years)
were e-mailed to members of the Ambulatory/Office Nursing
Practice years
and Chemotherapy SIGs who designated their work settings
20
0241
Years in nursing
as ambulatory or office but who did not appear on the former
14
0133
Years in oncology nursing
09
0128
Years in ambulatory or office nursing
list. Paper surveys were mailed to all members of the Ambula-
tory/Office Nursing and Chemotherapy SIGs who designated
n
%
Variable
work setting as ambulatory or office but did not have e-mail
addresses (N = 48). Total distribution was 3,829, and 325
Current primary position
completed surveys were returned (response rate of 8.5%). The
146
47
Direct patient care provider
low response was likely the result, in part, of the length of the
081
26
Nurse manager
021
07
survey questionnaire (18 pages) and its complexity. Each item
Nurse practitioner
017
05
had several response subsets (Who performs this task? How
Clinical nurse specialist
047
15
Other
important is it that an RN perform the task? Who do you feel
Salary range (per hour)
should perform the task?) that may have added to the complex-
013
04
$15.01$18
ity and discouraged participation.
018
06
$18.01$21
054
17
$21.01$24
Demographics
067
21
$24.01$27
047
15
$27.01$30
Sample
092
29
Above $30
Of the 325 respondents, 96% were female and 85% worked
022
07
No response
full-time (at least 30 hours per week). The average age of re-
Level of education
149
48
spondents was 44 years (range = 2362 years), and the average
Baccalaureate degree
057
18
Associate degree
years in nursing was 20 (range = 2 41 years). Respondents
056
18
Master's degree
averaged 14 years in oncology nursing (range = 133 years) and
052
17
Diploma
9 years in ambulatory or office nursing (range = 128 years).
Certification
Most frequently, the respondents' primary positions were
222
74
Oncology Certified Nurse
described as direct patient care providers (47%) or nurse
027
09
Advanced Oncology Certified Nurse
managers (26%). Current salary ranged from $15.01 to more
ONCOLOGY NURSING FORUM VOL 31, NO 6, 2004
E148
two offices were in the practice (range = 145). The number
The consensus was that as long as UAPs are well trained and
of RNs in the practice ranged from 140 (X = 9).
understand their duties, they can perform these tasks.
Fifty-two percent of the respondents stated that 80%100%
Chemotherapy Administration
of their practice was oncology. Two hundred sixty responded
that 100% of their patients were adults. Only three respon-
dents stated that 90%100% of their practice was pediatrics.
Chemotherapy administration was segmented into the most
The number of patients receiving chemotherapy during a week
important aspects, such as ordering and mixing of the medica-
averaged 101 (range = 1500).
tions, actual administration of the drugs, patient teaching, and
management of side effects. Primarily, RNs (49%) or phar-
Clinical Care
macists (35%) ordered chemotherapy drugs. Chemotherapy
was mixed and prepared by staff RNs (39%) or pharmacists
Clinical care, defined as the support of chemotherapy treat-
(55%). Staff RNs nearly always (99%) administered the che-
ment in the ambulatory or office settings, was approached
motherapy. Staff RNs also provided patient education about
with a list of relevant clinical activities to determine who had
95% of the time and symptom management for side effects
the primary responsibility for these activities in the clinical
97% of the time. The nurse manager of many facilities seemed
setting and which activities were valued as responsibilities
to be an extra pair of hands at times and also was responsible
for the nurses.
for chemotherapy administration, patient education, and
Although the task of putting the patients in the rooms was
symptom management when staffing required help. Generally,
considered "minimally or not at all important" for RNs to
the directors and nurse practitioners in the practices did not
do by 77% of the respondents, about 42% of the time RNs
administer chemotherapy.
escorted patients to their treatment or infusion rooms. Unli-
The respondents reported that it was minimally or not
censed ancillary personnel (UAPs) were responsible for this
very important for RNs to order (48%) and mix (56%) the
task 50% of the time. Approximately 43% of the time, RNs
drugs. These responses varied because not all facilities had
measured pretreatment weights and vital signs; UAPs did
pharmacists or pharmacy technicians available to order and
this 57% of the time. It was considered "minimally or not
mix the drugs. The administration of chemotherapy was con-
important" for RNs to do this by 64% of the respondents.
sidered important for RNs to do by 99% of the respondents.
Peripheral laboratory draws were considered "minimally or
The respondents also believed that RNs should be primarily
not important" for RNs to do by 70% of respondents, but the
responsible for patient teaching (99%) and symptom manage-
laboratory draws were done by RNs 55% of the time and by
ment of side effects (98%).
UAPs 42% of the time.
The majority of the respondents (68%) administered chemo-
With regard to more technical skills, importance and per-
therapy on a daily basis, 13% at least once a week, and 15% less
centage of time that the skill was performed by the RN had
than once a month. The respondents' comments indicated that
less of a difference. The majority of the time, the RN adminis-
many of the sites have nurses assigned to specific areas such
tered IV medications (99%), started peripheral IV lines (98%),
as physicians' offices and infusion areas. In some cases, staff
accessed and drew blood from vascular access devices (98%),
members appear to float between the areas depending on how
administered blood transfusions (97%), and gave intrathecal
busy the setting is. A variety of comments was made concerning
chemotherapy (97%). Nurses also primarily handled tele-
the size of the staff and frequency of chemotherapy adminis-
phone triage (92%), managed prescription refills (88%), and
tration. At some sites, chemotherapy was administered daily,
assisted with invasive procedures (83%). UAPs were, for the
whereas at others, chemotherapy was scheduled on specific
most part, used in limited numbers for such duties. They as-
days of the week and settings were staffed accordingly.
sisted with invasive procedures about 11% of the time, started
Safety
peripheral IV lines less than 1% of the time, renewed prescrip-
tions about 8% of the time, and managed telephone triage 4%
of the time. UAPs did not administer blood transfusions, IV
Safety issues included the policies and procedures in place
medications, or intrathecal chemotherapy. They very rarely
related to extravasation, hypersensitivity, double checking of
(1%) accessed and drew from vascular access devices. Gener-
chemotherapy prior to administration, use of infusion pumps,
ally, the respondents reported that they believed these more
recalculation of chemotherapy dosage and body surface area
technical skills should be performed by the RN staff, except
(BSA) calculations, and patient identification (see Table
for the intrathecal chemotherapy, where 30% believed that it
3). Almost all (94%) responded that they had a policy or
was not important at all for the RN to perform this clinical
procedure for extravasation, 88% had one for hypersensitiv-
skill. This disagreement may be because nurses believed that
ity reactions, 84% for double checking chemotherapy with
physicians should be performing intrathecal chemotherapy.
another RN prior to administration, and 81% had a policy or
Table 2 lists importance ratings for all areas surveyed.
procedure for use of infusion pumps. Recalculation of BSA
Many of the nurses commented that they thought ancillary
and dosage ordered was covered by policy in most practices
staff could reasonably get patients into rooms and take pread-
(71%). More than half (60%) had a policy or procedure for
mission weights and vital signs; however, others mentioned that
formal identification of the patient. Other policies mentioned
this was an important time for rapport building and assessment
in the comments section were numerous and most frequently
for RNs that UAPs might not be able to do. Budget constraints
included subcutaneous access devices, peripherally inserted
and staff shortages have dictated that many offices use medical
central catheters, declotting vascular access devices, control of
office assistants and phlebotomists to perform various tasks
chemotherapy hazards, patient assessment and reassessment,
such as drawing blood for laboratory work, putting patients
patient teaching, transportation, chemotherapy administration,
into rooms, or getting preadmission weights and vital signs.
total parenteral nutrition, evaluation of laboratory results,
ONCOLOGY NURSING FORUM VOL 31, NO 6, 2004
E149
Table 2. Performance and Importance of Clinical Care
Task
Who Is Performing?
0n (%)
How Important Is It That the RN Performs This Task?
0n (%)
IV medications
Staff RN
308 (99)
Very important
303 (97)
Staff licensed practical nurse (LPN)
Somewhat important
08 (3)
Pharmacist or pharmacy technician
Minimally important
02 (1)
Unlicensed ancillary personnel (UAP)
Not important at all
01 (0)
Nurse manager
02 (1)
Blood transfusions
Staff RN
207 (99)
Very important
217 (92)
Staff LPN
01 (1)
Somewhat important
13 (6)
Pharmacist or pharmacy technician
01 (1)
Minimally important
02 (1)
UAP
Not important at all
05 (2)
Nurse manager
01 (1)
Accessing and drawing from
Staff RN
296 (97)
Very important
268 (88)
vascular access devices
Staff LPN
03 (1)
Somewhat important
022 (7)
Pharmacist or pharmacy technician
02 (1)
Minimally important
08 (3)
UAP
02 (1)
Not important at all
06 (2)
Nurse manager
01 (0)
Peripheral IV starts
Staff RN
308 (98)
Very important
272 (87)
Staff LPN
02 (1)
Somewhat important
028 (9)
Pharmacist or pharmacy technician
01 (0)
Minimally important
07 (2)
UAP
02 (1)
Not important at all
07 (2)
Nurse manager
01 (0)
Telephone triage
Staff RN
272 (91)
Very important
261 (85)
Staff LPN
06 (2)
Somewhat important
035 (11)
Pharmacist or pharmacy technician
06 (2)
Minimally important
08 (3)
UAP
07 (2)
Not important at all
03 (1)
Nurse manager
07 (2)
Intrathecal chemotherapy
Staff RN
056 (97)
Very important
110 (58)
Staff LPN
Somewhat important
10 (5)
Pharmacist or pharmacy technician
Minimally important
12 (6)
UAP
Not important at all
057 (30)
Nurse manager
02 (3)
Prescription renewals
Staff RN
250 (88)
Very important
181 (58)
Staff LPN
08 (3)
Somewhat important
077 (25)
Pharmacist or pharmacy technician
12 (4)
Minimally important
036 (12)
UAP
11 (4)
Not important at all
18 (6)
Nurse manager
04 (1)
Assisting with invasive pro-
Staff RN
238 (82)
Very important
166 (54)
cedures
Staff LPN
16 (6)
Somewhat important
090 (29)
Pharmacist or pharmacy technician
14 (5)
Minimally important
036 (12)
UAP
19 (7)
Not important at all
15 (5)
Nurse manager
04 (1)
Pretreatment vital signs and
Staff RN
125 (43)
Very important
041 (13)
weight
Staff LPN
028 (10)
Somewhat important
073 (23)
Pharmacist or pharmacy technician
058 (20)
Minimally important
111 (35)
UAP
076 (26)
Not important at all
090 (29)
Nurse manager
01 (0)
Peripheral laboratory draws
Staff RN
094 (54)
Very important
038 (12)
Staff LPN
06 (3)
Somewhat important
056 (18)
Pharmacist or pharmacy technician
037 (21)
Minimally important
093 (30)
UAP
036 (21)
Not important at all
125 (40)
Nurse manager
02 (1)
Placing patient in room
Staff RN
122 (42)
Very important
20 (6)
Staff LPN
23 (8)
Somewhat important
053 (17)
Pharmacist or pharmacy technician
060 (21)
Minimally important
100 (32)
UAP
085 (29)
Not important at all
141 (45)
Nurse manager
ONCOLOGY NURSING FORUM VOL 31, NO 6, 2004
E150
sometimes" increased patient and family satisfaction (100%),
Table 3. Safety Policies and Procedures
affected quality of life and improved quality of care with
timely interventions (99%), increased their own job satisfac-
Policy in Place
n (%)
tion with timely and effective interventions (99%), prevented
Extravasation management
291 (94)
hospital admissions with timely symptom management (98%),
Hypersensitivity reactions
273 (88)
and decreased the cost of care (95%).
Double-checking of chemotherapy by RN prior to administration
261 (84)
The teaching that was done by nurses was considered very
Infusion pump programming
249 (80)
important, as was the support and counseling that nurses are
Recalculation of chemotherapy dosing
223 (72)
able to offer patients and families. Other benefits mentioned
Recalculation of body surface area and area under the curve
221 (71)
were more productive use of physician time, keeping patients
Patient identification prior to administration
183 (59)
to their schedules, and a better reputation for their institutions
N = 325
in the community. Safety also was mentioned because of the
nursing role in the monitoring of complicated chemotherapy
schedules, improved patient compliance and understanding,
intrathecal procedure and competency, area-under-the-curve
and increased accuracy of data collection for clinical trials.
calculation, oral chemotherapy, blood sampling from central
Financially, the nurses perceived that they decreased futile care
lines, mixing of chemotherapy, growth factor parameters,
by helping patients and families move toward hospice, secured
infusion of specific agents (paclitaxel, rituximab, infliximab,
compassionate assistance for pharmaceuticals, and helped fre-
and IV immunoglobulin), double check by RN of patient's
quently with insurance issues and case management questions.
performance status prior to chemotherapy, pain management,
The comments illustrated the nursing role as being integral
emergency events, cardiac arrest, symptom management, tele-
throughout the entire continuum of care from diagnosis through
phone triage, patient orientation, patient referral and screen-
treatment and then return to wellness or admission to hospice.
ing, double-check take-home or overnight infusions, standing
orders for Warfarin, bisphosphonates, absolute neutrophil
Telephone Triage
count calculation, patient consent and follow-up, nausea and
vomiting, and documentation standards.
Most of the nurses surveyed (93%) reported that they used
Chemotherapy orders were handwritten in 63% of the re-
a telephone documentation form to record telephone encoun-
spondents' settings, on preprinted order sheets in 38%, and
ters with patients and families. Of these, about 19% indicated
ordered by computer in 19%. Documentation of chemotherapy
that they used a written assessment guide with recommended
included name of drug (99%), dose of drug (99%), route of
questions based on the reason for the call. Additional written
administration (99%), site of administration (98%), presence of
comments suggested that several of the nurses work in envi-
blood return (94%), and patient education (90%) (see Table 4).
ronments where the content of phone calls is incorporated
Other facts that were required in documentation were start time
into the progress notes of patients' charts, into a triage book,
(85%), patient tolerance (84%), stop time (77%), and BSA
or dictated into the electronic record.
calculation (69%). Most of the respondents (98%) believed
The majority of ambulatory nurse respondents (54%) reported
that their methods of documentation were effective.
that telephone triage was part of every nurse's assignment; 27%
of the nurses reported that they had a designated "telephone tri-
Symptom Management
age nurse." Additional comments indicated that in some settings
nurses worked with a specific physician and triaged all phone
In regard to teaching materials available on symptom manage-
calls for those patients. In other settings, assignment to triage
ment, 74% used materials developed by external sources and
responsibilities rotated on a weekly basis.
68% used materials developed in their own organizations. The
comments reflected that a combination of materials was used
Patient Education
most commonly--materials from the National Cancer Institute
or other agencies, pharmaceutical company information, or
Once again, the approach to this area of clinical practice was
specific information developed in their own organizations. ONS
who was responsible for patient education and the importance
has identified several priority areas for symptom management.
of the RN having primary responsibility for patient teach-
When asked about these five top priority symptoms, respondents
reported that they needed to help their patients manage neutro-
Table 4. Chemotherapy Documentation
penia 84% of the time, pain 82% of the time, anorexia 67% of
the time, cognitive impairment 60% of the time, and insomnia
Type of Documentation
n (%)
56% of the time. Other symptom management areas mentioned
included bowel care, nausea and vomiting, oncologic emergen-
Name of drug
312 (99)
cies, neuropathy, stomatitis, dehydration, and fatigue. By far, the
Dose of drug
311 (99)
Route of administration
310 (99)
most frequent comments were related to improvement of patient
Site of administration
308 (98)
satisfaction and quality of life. Most discussed helping patients
Presence of blood return
295 (94)
and families cope with illness and treatment.
Patient education
281 (90)
Start time
267 (85)
Outcomes
Patient tolerance
264 (84)
Stop time
243 (77)
Nurses' perceptions of the influence that their interventions
Body surface area calculation
216 (69)
had on outcomes were determined for several nurse-sensitive
outcomes. Respondents perceived that they "frequently or
N = 325
ONCOLOGY NURSING FORUM VOL 31, NO 6, 2004
E151
The respondents reported that physicians or physician assis-
ing. Patient education on treatment and related side effects
tants (PAs) most commonly performed invasive procedures
(94%) and symptom management (94%) were the areas the
such as bone marrow aspirations and paracenteses (91%) and
respondents most strongly felt should be an RN responsibility.
administered intrathecal chemotherapy. However, 5% of the
The majority also felt strongly about nurses' responsibility
staff nurses performed invasive procedures and 11% of staff
for education about procedures (73%) and disease process
nurses administered intrathecal chemotherapy. The majority of
(69%). General orientation to the clinical space and patient
the nurses (86%) believed that doing invasive procedures was
flow processes was considered the least important for primary
minimally important or not important at all, and 78% believed
responsibility by nurses. Nurses actually had the primary re-
that administering intrathecal chemotherapy was minimally
sponsibility for patient education in all five areas, including
important or not important at all. As mentioned earlier, this
general orientation (see Table 5).
finding is possibly because the nurses believed that physicians,
The surveyed nurses used a variety of tools in their settings
NPs, or PAs should perform intrathecal chemotherapy.
to facilitate patient education. Almost all of the nurses (99%)
Other aspects of delegation--those not requiring a physi-
reported using printed materials that patients and families
cian order--also were explored. The respondents believed that
could take home. The majority (76%) stated that they used
it was very or somewhat important for RNs to be primarily
audiovisuals in their practice settings, 59% used teaching
responsible for decision making and ongoing management of
guidelines, 34% had established a formal patient education
palliative care. Currently, these two aspects of palliative care
class for patients receiving chemotherapy, and 15% said that
primarily are handled by physicians and PAs, but these may
they had a nursing position whose primary responsibility
be areas that need to be explored for further involvement by
was patient education. Sixty-nine percent of the respondents
nurses because they frequently assist or facilitate decision
reported that they had a documentation form to record the
making with patients and families.
completed patient education. Only 24% of the nurses surveyed
The respondents believed that it was less important for RNs
reported that their practice settings supported the practice of
to be responsible for ordering laboratory tests or notifying
billing for the patient education provided. Many respondents
patients with abnormal test results. This was indicated by the
reported using a low-level visit code to cover patient education
lower percentage of "very important" responses. But when
time; however, several nurses also commented that patient
"very" and "somewhat important" responses are combined,
education was integral to the care rendered, seen as a "safety
the numbers regarding laboratory test activities totaled ap-
measure," and perceived as "medically necessary."
proximately half of the respondents. In some settings or situ-
ations, nurses have the responsibility for ordering laboratory
Delegation
tests and notifying patients of results, whereas in others, this
is not as important (see Table 6).
The survey team perceived that delegation would be an area
where significant changes are occurring in ambulatory set-
Care Delivery Model
tings. Questions were included to elucidate areas of delegation
from others to the nurses as well as from the nurses to others.
Respondents were asked to define the care delivery model
used in their settings. The three models listed were functional
Table 5. Responsibility for 0   Importance of Patient
and
(providing nursing care as needed during client visits to a ran-
Education
dom group of clients depending on day's assignment), primary
care (providing nursing care to the same clients in a specified
How Important Is It That
group during each ambulatory visit), or medical (assisting the
Area of
Who Has the Primary
the RN Have the Primary
physician as needed, carrying out nursing aspects of medical
Patient Education
Responsibility?
Responsibility for Teaching?
care). Most nurses described their care delivery model as func-
tional (40%) or primary care (39%). Twenty percent reported
Treatment and re-
94% staff RN
94% very important
using the medical model of care. More than half (51%) stated
lated side effects
5% nurse manager
05% somewhat important
that they were satisfied with their model of care; 41% stated
2% staff licensed prac-
tical nurse (LPN)
that they were very satisfied with their model of care; and less
than 10% of the respondents reported being minimally or not
Symptom manage-
96% staff RN
94% very important
satisfied at all with their care delivery model.
ment
4% nurse manager
05% somewhat important
Procedures
93% staff RN
73% very important
Staffing
3% nurse manager
22% somewhat important
2% staff LPN
05% minimally important
Questions relating to staffing attempted to gain insight into
2% unlicensed ancil-
the number of patients that an RN, working in an outpatient
lary personnel (UAP)
area where chemotherapy is administered, treats in any given
Disease process
94% staff RN
69% very important
day, what percentage of the nurse's time is spent on specific
5% nurse manager
25% somewhat important
roles, and whether a staffing tool is available.
2% UAP
05% minimally important
Nurses were asked to indicate how many patients per day
General orientation
84% staff RN
49% very important
they provided care to, including providing treatment to new
9% UAP
28% somewhat important
chemotherapy patients, continuing chemotherapy patients,
5% nurse manager
18% minimally important
and nonchemotherapy or supportive care patients and pro-
2% staff LPN
06% not important at all
viding patient education. The majority of nurses (85%)
reported that they treated one to three new patients receiv-
Note. Because of rounding, percentages may not equal 100.
ONCOLOGY NURSING FORUM VOL 31, NO 6, 2004
E152
Table 6. Delegation
More than half the respondents believed that these tasks
were either "very important" or "somewhat important" for
How Important Is It That
the staff RN to be performing (see Table 7).
Who Has the Primary
the RN Have the Primary
Area of Delegation
Responsibility?
Responsibility?
Clinical Trials
Ongoing manage-
63% physician/physi-
35% very important
Clinical trials have become an integral part of oncology
ment of patients in
cian assistant (PA)
34% somewhat important
practice, especially related to chemotherapy treatment. This
palliative care
29% staff RN
15% minimally important
8% advanced practice
16% not important at all
section was intended to determine whether clinical trials were
nurse (APN)
performed in the practice setting, whether clinical trial nurses
were employed to carry out the trials, and what the staff RNs'
Facilitating the deci-
78% physician/PA
30% very important
roles were with clinical trials. Of the nurses surveyed, 86%
sion making to move
18% staff RN
38% somewhat important
reported that clinical trials were conducted in their practice
to palliative care
4% APN
18% minimally important
13% not important at all
settings with 75% reporting that clinical trial nurses were
available. The staff nurses' role in the context of clinical
Ordering lab tests
73% physician/PA
17% very important
trial care was primarily to follow protocols and collect data
21% staff RN
35% somewhat important
through documentation and blood draws. Two other roles seen
6% APN
27% minimally important
in almost half of the settings were managing investigational
22% not important at all
drugs and following patients who participated in the clinical
Calling patient with
72% physician/PA
16% very important
trials. Through comments, the respondents added the follow-
abnormal test re-
22% staff RN
24% somewhat important
ing roles: helping to prepare protocols for submission to fund-
sults indicating dis-
6% APN
26% minimally important
ing agency and the institutional review board, keeping study
ease progression
35% not important at all
books up to date, patient education, symptom management,
toxicity verification, and dose modification calculation (see
ing their initial cycle of a new regimen. More than a third
Table 8 for more details on other aspects of the RN role).
(35%) provided nonchemotherapy or supportive care for
one to five patients, 40% for 510 patients, 16% for 1120
Reimbursement
patients, and 7% for more than 20 patients. The number of
chemotherapy treatments varied considerably: 16% admin-
Reimbursement issues were explored in the survey as they
istered fewer than five treatments per day, 29% administered
related to the ambulatory setting. Nurses believed that the
510 treatments, 30% administered 1015 treatments, 10%
most important responsibilities for the RN were completion
administered 1520 treatments, and 13% administered more
of the billing ticket for services provided by the RN (44%)
than 20 treatments. In addition, the majority of the nurses
and the review of patient charges for accuracy (33%). In
surveyed also fielded 10 or more patient phone calls per day
actual practice, nurses were primarily responsible for these
(55%). Some nurses (14%) fielded 25100 phone calls per
two activities in 74% and 39% of the responding settings,
day. More commonly, nurses spent 10%30% of their time
respectively. In addition, 49% of the respondents stated
on specific roles such as symptom management, telephone
that nurses were responsible for procurement of drugs
triage, patient education, chemotherapy administration, case
for indigent patients, although only 23% of the respon-
management, assisting with clinical trials, or patient sched-
dents believed that this was very important (see Table 9).
uling. Many nurses commented that estimating the percent-
age of their time spent on each role was difficult because
Professional Development
these functions often overlapped with each patient. Another
common comment was that the survey did not provide a
Professional development included programs provided in the
column where they could specify the time commitment for
settings (i.e., orientation, maintenance of competencies, and a
mixing drugs. The majority of the nurses (76%) believed that
the nurse-to-patient ratio was reasonable in their practice.
Table 7. Scheduling
More than 80% of respondents replied that they did not use
any kind of staffing tool to assist with staffing decisions but
How Important Is It That
based their staffing on patient volume and types of treatment
Who Has the Primary
the RN Have the Primary
to be provided. Of the 20% who did use a tool, only four
Area of Scheduling
Responsibility?
Responsibility?
(6%) found the tool to be very useful, whereas 41% reported
Infusion room
42% unlicensed ancil-
33% very important
their tool was either useful or somewhat useful. Almost 10%
scheduling
lary personnel (UAP)
28% somewhat important
found the tool not useful at all.
41% staff RN
22% minimally important
12% pharmacist
17% not important at all
Patient Scheduling
3% staff LPN
1% nurse manager
Scheduling of patients in the ambulatory setting for the
Fixing scheduling
30% UAP
32% very important
infusion room was the primary responsibility of 41% of the re-
problems
54% staff RN
32% somewhat important
sponding nurses, and even more (54%) were fixing scheduling
10% pharmacist
22% not important at all
problems as they arose. Comments to clarify UAPs provided
2% staff LPN
14% minimally important
the following specific job titles: secretaries, administration
4% nurse manager
staff, clerks, and scheduling coordinator.
ONCOLOGY NURSING FORUM VOL 31, NO 6, 2004
E153
15 respondents were involved in the ONS ONStat program,
Table 8. Roles of the RN in Clinical Trials
and five of these were ONS state health policy liaisons.
Clinical Trial Task
0n (%)
Nursing Shortage
Follow protocols
240 (88)
Data collection (documentation, blood draws)
173 (63)
The shortage of nurses was apparent in ambulatory set-
Investigational drug management (storing, mixing, and
132 (48)
tings with 47% of the respondents reporting open positions.
administering)
Ambulatory settings were reacting to the lack of nurses to
Follow participating patients
125 (46)
fill their open positions by hiring less experienced nurses
Recruit sample (identify appropriate patients for the
093 (34)
(50%), asking nurses on staff to work overtime to fill the
trial)
Secure informed consent
070 (26)
needs (33%), or hiring an increased number of UAPs (11%).
Introduce clinical trials to appropriate patients
067 (25)
Twenty-three percent of the respondents reported an increase
Other
029 (11)
in the turnover of staff because of the shortage of nursing
staff. Several comments were made about giving rushed care
and working extra hours, especially in the settings affiliated
basic chemotherapy course) and support for external, informal,
with inpatient organizations. A small number of respondents
and formal continuing education. Eighty-five percent of the re-
(n = 20) stated that they were not yet affected by the shortage
spondents believed that professional development of the nursing
in their settings.
staff was very important in their settings.
Respondents reported some specific creative staffing strate-
Orientation programs were provided for 78% of the respon-
gies related to the shortage. These included
dents. These programs averaged 35 days in length (range =
Hiring critical care nurses (although not trained in oncology,
1180 days). Nearly half (43%) believed that the orientation
they adapted well)
"adequately" prepared them to practice in their settings,
Recruiting from local hospitals and nursing schools by
whereas 26% thought that the orientation program "very
nurses speaking to groups of personnel or students
adequately" prepared them for practice. Of the competencies
Providing flex hours
RNs reported they had in place in their clinical settings, those
Actively recruiting nurses now to fill the positions of sea-
that were listed by at least half of the respondents were che-
soned nurses when they retire in four to five years.
motherapy (95%), safety issues (94%), starting peripheral IVs
and doing blood draws (92%), symptom management (79%),
Table 9. Reimbursement Activities
oncologic emergencies (76%), ethical issues (61%), and ad-
ministration of blood products (50%). Cultural competency
How Important Is It That
(41%), clinical trials (35%), and traditional competencies of
Who Has the Primary
the RN Has the Primary
basic cardiopulmonary life support, fire safety, and disaster
Reimbursement Issue
Responsibility?
Responsibility?
training (0.6%) were expectations less frequently in the am-
Completion of billing
74% staff RN
44% very important
bulatory settings of the respondents. Clarification of other
ticket for services you
0% staff licensed
23% somewhat important
competencies included nutritional assessment, vascular access
provide
practical nurse/li-
16% minimally important
devices, charting, billing, filling of hepatic infusion pumps,
censed vocational
18% not at all important
and use of the specific computer system.
nurse (LPN/LVN)
Approximately 98% of the respondents had a chemotherapy
13% unlicensed ancil-
course available to them. The origin of the chemotherapy
lary personnel (UAP)
course was divided evenly among the specific setting, another
13% other personnel
organization, and ONS.
Review of patient charg- 39% staff RN
33% very important
The majority of respondents received time off for continu-
es for accuracy
1% staff LPN/LVN
23% somewhat important
ing education (CE) programs (80%), had their registration
29% UAP
22% minimally important
paid for the CE programs (74%), had certification examination
32% other personnel
23% not at all important
fees paid by their settings (64%), said their settings provided
Procurement of drugs
49% staff RN
23% very important
flexible scheduling so that personnel could attend academic
for indigent patients
1% staff LPN/LVN
30% somewhat important
programs (58%), and said their settings provided their own
14% UAP
25% minimally important
CE offerings, some on a monthly basis (52%). Only 5% re-
37% other personnel
23% not at all important
ported no current support at their organizations for CE. Some
Completing forms
31% staff RN
13% very important
respondents reported creative strategies they have been using
requesting diagnosis
1% staff LPN/LVN
19% somewhat important
to provide continuing nursing education.
codes or billing codes
39% UAP
36% minimally important
29% other personnel
32% not at all important
Legislative Issues and Policies
Counseling patients
11% staff RN
08% very important
and families regarding
0% staff LPN/LVN
17% somewhat important
Forty percent of the respondents reported that they de-
finances
33% UAP
31% minimally important
pended on the ONS Web site for the latest news related
56% other personnel
44% not at all important
to legislative issues. Another 40% said that they were not
Communication with
15% staff RN
05% very important
involved at all in such issues. Some of the other ways that
insurance companies
0% staff LPN/LVN
22% somewhat important
nurses stayed involved with legislative matters were attending
43% UAP
40% minimally important
related education programs, contacting local legislators about
42% other personnel
33% not at all important
issues, or accessing other legislative-related Web sites. Only
ONCOLOGY NURSING FORUM VOL 31, NO 6, 2004
E154
Clinical Care
Almost all of the respondents (85%) said that interaction
with patients kept them working in their particular practice
A difference existed between the importance of the RN
settings, and the majority (92%) responded that the nature of
performing some of the more basic clinical tasks and the per-
the job was what they liked. Job satisfaction (69%) and the
centage of nurses who actually were performing these tasks,
hours they worked (46%) were very high on the list as well.
such as placing patients in the room and doing pretreatment
Other aspects of the RN role in the ambulatory setting that
vital signs. The RN staff probably completed some of these
helped retention were the opportunities to improve the quality
tasks because of a high concentration of RNs on staff. General
of nursing care and increase the OCN role in the RN-physi-
agreement existed with the more skilled tasks as to importance
cian collaborative approach to patient care, as well as being
and RNs performing, with the greatest difference related to
involved in "cutting edge" research and the knowledge shared
intrathecal chemotherapy. This is postulated to be because
with oncologists.
nurses may believe that this invasive procedure should be
performed by physicians, NPs, or PAs.
Key Issues
Recommendation: This may offer an opportunity for pro-
fessional organizations to develop or revisit their standards
Patient education was the key issue that needed to be
of practice for the ambulatory or office nursing role and their
improved in nurses' own oncology practices, specifically
statements on UAPs.
more time for such education (59%) and recognition of the
Many of the nurse respondents (40%) reported that mixing
importance of patient education (36%). Other issues that
chemotherapeutic agents was their responsibility. This skill is
were rated as most important to be improved were salary and
presumed to be acquired with on-the-job training, and institu-
benefits (47%) and professional development (45%). Issues
tions are developing their own policies and procedures.
that were rated as important included staffing (37%), support
Recommendation: This is an opportunity for nurses and
for the expanded role of the nurse (31%), and standardization
pharmacists to develop collaborative guidelines related to
of documents across practice settings (30%). Delegation of
mixing techniques.
care was not as important as the other issues, with only 13%
Safety
of the respondents indicating a need for improvement with
what is delegated from physicians to nurses and 7% for care
Many respondents were willing to share existing resources
that is delegated from nurses to licensed practical nurses
from their practices such as forms and documentation tools.
(LPNs) and UAPs.
Recommendation: The ONS Ambulatory/Office Nursing
The most important issues for the professional organization
SIG may be a good repository of these valuable resources.
to address were very evenly distributed among helping nurses
Additionally, publication of model policies and procedures
keep abreast of new knowledge (39%), the nursing shortage
in an oncology clinical journal such as the Clinical Journal
(29%), new technologies (26%), the need for evidence-based
of Oncology Nursing would be a means to disseminate forms
guidelines and practice standards (25%), and reimbursement
and tools.
issues (23%). Other areas of interest were promotion of
The majority of nurses reported that they were using hand-
certification and specialty care, genetics technology, patient
written physician order forms in their practice settings.
advocacy, patient safety, and patient level of involvement in
Recommendations: A physician-order template would
treatment decisions.
benefit nurses in these settings to ensure thorough and clear
instructions for chemotherapy. A standard guide for chemo-
Discussion
therapy documentation is needed. An electronic documenta-
tion format could be developed in cooperation with vendors
The results of this survey confirm that ambulatory or office
of electronic charting systems to ensure comprehensive
oncology nurses are faced with increasingly complex clinical
documentation of chemotherapy administration.
care environments and that they have a broad range of respon-
Symptom Management
sibilities in their practice settings. Specific points from the
Nurses reported that patients require the most support
results are presented with either recommendations for action
around issues related to anorexia, cognitive impairment, and
by ONS or actions that are in progress by the organization or
sleep disturbances.
other relevant professional organizations.
Recommendation: These particular symptoms should be
Nearly 20% of the responding nurses reported caring for
given priority when developing evidence-based guidelines
patients in more than one state, giving rise to regulatory and
and outcomes projects.
licensure issues. These issues have been raised by other pro-
fessional organizations and need ongoing work for resolution
Outcomes
(American Academy of Ambulatory Care Nursing, 2004). As
Nurses believe that their interventions influence outcomes
of October 2004, 17 states have enacted the RN and LPN/Vo-
in oncology care.
cational Nurse Licensure Compact created by the National
Recommendations: Include ambulatory or office settings
Council of State Boards of Nursing (NCSBN) allowing nurses
in any outcomes projects. Encourage the use of such settings
in these states to provide nursing care in other states without
in funded outcomes research projects. Encourage the study
separate licensure (NCSBN, 2004). This compact is one
of the role of patient education with improved outcomes. En-
mechanism to allow nurses to provide care to patients resid-
courage the study of the role of specialized oncology nurses
ing in other states.
in ambulatory and office settings and outcomes, especially
The remaining discussion will deal with key points from
with some of the approaches being used to counter the nurs-
the main areas in the survey and recommendations based on
ing shortage.
the findings.
ONCOLOGY NURSING FORUM VOL 31, NO 6, 2004
E155
Telephone Triage
oncology nurses with a resource to assist in staffing plans.
Specifically, US Oncology has published a staffing model
A minimal number of respondents used a telephone assess-
based on patient acuity that could be tested in broader clinical
ment guide.
settings (Richardson, 2002).
Recommendation: This would be a valuable resource for
nurses with telephone triage responsibilities.
Clinical Trials
Patient Education
Clinical trials were conducted in the majority of the clinical
settings, and clinical trial nurses generally were employed in
The level of importance and actual percentage of nurses
these settings.
doing patient education were very consistent, denoting the
Recommendations: Promote collaborative programs or
need for this to be a primary responsibility of the nurse. The
educational opportunities with clinical trial nurses and am-
issue in this area appears to be with reimbursement for patient
bulatory or office nurses. Considering the high number of
teaching and the related issue of recognizing the importance
settings offering clinical trials, promoting the inclusion of
of patient education.
assessment needed for clinical trials onto nursing assessment
Recommendations: A need for evidence-based guidelines
flow sheets is reasonable.
for patient and family education continues to exist. Organiza-
tions need to promote reimbursement for patient education
Reimbursement
with third-party payers. This would be facilitated with more
Nurses were involved in many activities related to reim-
research that determines the time involved and the impact
bursement.
education has on outcomes.
Recommendation: Standards of practice for ambulatory or
Delegation
office nurses should include activities related to reimburse-
ment.
Differences did exist between what aspects of care were
considered important for RNs to be primarily responsible for
Legislative Issues and Policies
and the actual areas where nurses had responsibility. Nurses did
An apparent lack of involvement existed by RNs in legisla-
not believe that it was important for them to be responsible for
tive activities.
performing invasive procedures (e.g., bone marrow aspirations,
Recommendation: Ambulatory or office nurses should be
paracenteses) and intrathecal chemotherapy, yet a percentage of
included in any education or initiatives to promote involve-
nurses were. On the other hand, nurses believed that they should
ment in legislative activities.
be more responsible for facilitating decisions made to initiate
palliative care and ongoing management of such care.
Conclusion
Recommendations: A position paper or standard related
to RN involvement with invasive procedures and intrathecal
These results can be used to assist organizations in the
chemotherapy is needed. The development of education to
development of job descriptions for ambulatory oncology
support palliative care decisions and follow-up by nurses in an
nurses, further delineate the role of UAPs in ambulatory set-
advanced practice role would facilitate nurses having a more
tings, and assist the relevant professional organizations in
active role in this aspect of patient care.
setting priorities to meet the needs of this segment of their
Staffing
membership.
The majority of respondents reported that they did not use
a staffing tool to assist in planning.
Author Contact: Anne M. Ireland, MSN, RN, AOCN, can be
Recommendation: Development of a new tool or testing
reached at anne.ireland@vtmednet.org, with copy to editor at
or endorsement of an existing staffing tool would provide
rose_mary@earthlink.net.
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