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November 2010, Volume 37, Number 6
Article
Oncology Nurses’ Use of National Comprehensive Cancer Network
Clinical Practice Guidelines for Chemotherapy-Induced and Febrile Neutropenia
Anita Nirenberg, DNSc, RN, NP, BC, AOCNP®, Nancy K. Reame,
BSN, MSN, PhD,
Kenrick D. Cato, RN, BSN, and Elaine L. Larson, PhD, RN
Purpose/Objectives: To describe oncology nurses’ use of National Comprehensive Cancer Network
(NCCN) clinical practice guidelines for chemotherapy-induced neutropenia (CIN) and febrile neutropenia
(FN).
Design:
Cross-sectional survey design; descriptive, correlational analysis.
Setting:
E-mail invitation to Web-based survey.
Sample:
Random sample of 309 Oncology Nursing Society (ONS) members with e-mail
addresses who provide care to adult patients receiving chemotherapy.
Methods: The
investigator-developed Neutropenia Oncology Nurses Survey™ was used.
Descriptive tests compared respondents’ personal and professional characteristics
to those of general ONS members; nonparametric chi-square and Kruskal-Wallis tests were used to correlate respondents’
survey subscale scores with demographic data. Significant associations were
entered into multiple logistic regression models.
Main Research Variables: The Neutropenia Oncology Nurses Survey’s subscales
measured subjective norm, attitude, perceived competence and confidence,
perceived barriers, and use of NCCN clinical practice guidelines for CIN and
FN.
Findings:
Response rate of nurses who opened the survey was 50%. Most
practiced in community versus academic centers. Eighty percent reported
using the NCCN clinical practice guidelines for CIN and FN. Respondents were
more likely to use clinical practice guidelines when they were expected to by
physician and nurse colleagues, they perceived fewer barriers, or they held
advanced oncology certification.
Conclusions:
This study was the first to assess oncology nurses’ reported use of NCCN
clinical practice guidelines for CIN and FN. It also demonstrated the
feasibility of partnering with ONS for Web-based survey research.
Implications for Nursing: The findings give insight into work-place barriers to
evidence-based practice in various settings. Expanding dissemination and implementation
of clinical practice guideline recommendations will support the development of
oncology nursing standards for risk assessment, management, and patient and
family education in CIN and FN.
Chemotherapy-induced neutropenia (CIN) is a serious toxicity of cancer
treatment. Life-threatening consequences include febrile neutropenia
(FN), increased risk of infection, prolonged hospitalizations for IV
antibiotics, delays in cancer therapy, and increased mortality (Crawford, Dale,
& Lyman, 2004; Crawford et al., 2008). CIN also is the most common
dose-limiting toxicity of cancer therapy (Crawford et al., 2004).
Multiple physician-generated
and directed risk models and clinical practice guidelines are available for
patient risk assessment and management of CIN and FN (Hughes et al., 2002; Klastersky et al., 2000; National Comprehensive Cancer
Network [NCCN], 2009; Ozer et al., 2000; Smith et
al., 2006; Talcott, Siegel, Finberg, & Goldman,
1992). The guidelines were developed by physicians in various medical
subspecialties for different aspects of risk assessment and management of CIN
and FN. The NCCN Clinical Practice Guidelines in Oncology™ are a composite,
providing a guide to clinicians to assess and manage patients. However, the
extent to which the guidelines are implemented and improve patient care is not
clear.
Because oncology nurses
deliver cancer treatments to patients who frequently receive therapies on an
outpatient basis (National Cancer Institute, 2006), nurses should identify
patient risk factors and instruct patients and their families about what to do
at home if disease symptoms or treatment-related toxicity occurs. Oncology
nurses need to know how to assess, understand, and use clinical practice
guidelines to provide patients with knowledgeable and clinically sound
practices. Although nurses have these important responsibilities, CIN and FN
clinical practice guidelines have not been widely disseminated directly to
oncology nurses through publication in nursing journals or continuing education
programs. In addition, no CIN and FN standardized curricula,
practice guidelines, standardized content, or evaluation of patient education
exists for nurses to use (Nirenberg et al., 2006a, 2006b). As a result, the
current study aimed to describe oncology nurses’ use of NCCN clinical practice
guidelines for CIN and FN.
Methods
Study Design
A cross-sectional survey
design was adopted to study selected factors affecting the reported use of NCCN
clinical practice guidelines for CIN and FN by nurses caring for adult patients
with cancer. The Theory of Planned Behavior (Ajzen,
2002) was used as the framework to guide the study and was adapted to develop
the survey instrument.
Sample
A purposive, random sample of
RNs who were licensed in the United States, were members of the Oncology
Nursing Society (ONS), and provided care to adult patients with cancer
receiving chemotherapy was surveyed with a Web-based questionnaire.
Procedures
The current study was
approved by the institutional review board of the Columbia University Medical
Center. The first author became a client of the ONS affiliate ONSEdge to disseminate the survey electronically to ONS
members and to preserve members’ confidentiality. Based on membership
information, e-mail invitations to participate in the study from the principal
investigator were sent by ONSEdge to 4,000 randomly
selected eligible members. Almost half of the total eligible ONS members (about
15,000 members) were nurses who provided care to adult patients receiving
chemotherapy (ONSEdge, personal communication, April
6, 2007); of them, about 8,700 members provided ONS with their e-mail
addresses. The participants were drawn from ONS cohorts of clinical nurses at
staff generalist (54% of ONS members) and advanced practice levels (4% and 6%
of ONS members are clinical nurse specialists and nurse practitioners,
respectively). The current study was the first research study conducted in this
manner; therefore, the pool of eligible respondents was over-sampled to ensure
an adequate response rate. A lottery incentive of $50 for 20 randomly selected
participants who completed and submitted the survey was described in the e-mail
invitation to increase the likelihood of participant responses (Dillman, 2007).
The survey was anonymous; the
principal investigator did not have access to member e-mail addresses or
information. The survey was available online for a period of two weeks. Within
three weeks of terminating online access, ONSEdge
delivered the Microsoft® Excel® files containing the raw data to the
investigator in a password-protected document.
Study Instrument
Inherent constructs of the
Theory of Planned Behavior are (a) beliefs about the likely outcomes of the
behavior, (b) beliefs about expectations of others and about the motivation to
adhere to those expectations, (c) beliefs about factors that may enhance or
impede the behavior, and (d) the perceived power to control these beliefs.
According to Ajzen (2002), additional predictors such
as age and educational preparation may influence individual variation in the
intention to perform the behavior or in the actual performance of the behavior.
Behavior is defined as the
conduct of intention and perceived behavioral control into performing an
action. Behavioral beliefs are ways of thinking about the behavior itself.
Behavior consists of action, target, context, and an element of time. The more
favorable the attitude about performing the behavior, the greater the
individual’s perception of positive opinions of others; the better the
perceived control over the behavior, the stronger the intention to perform the
behavior (Ajzen, 2002).
Actual behavioral control
refers not only to a person’s control over factors such as available resources
but also to one’s volitional control (i.e., willful control over the behavior).
Of interest is the study of aspects of behavior that are not entirely under
one’s volitional control. An individual may be motivated and have the knowledge
and the abilities to perform the desired behavior but may not have the
available resources to actually perform the task.
The Neutropenia Oncology Nurses Survey™ was developed by the researcher
to measure the constructs of the Theory of Planned Behavior: subjective norm
(six items), attitudes (four items), perceived confidence and competence
(perceived behavioral control, four items), perceived barriers (six items), and
reported use of NCCN clinical practice guidelines for CIN and FN (behavior, one
item) among nurses (see Figure 1).
Another nine items were used to record respondents’ personal and professional
demographics. In addition, seven statements on respondents’ barriers to the use
of the clinical practice guidelines for CIN and FN and 10 items that assessed
participants’ knowledge of evidence-based standards in CIN and FN risk
assessment and management were included.
Content validity was tested
by a panel of four oncology nursing experts in cancer chemotherapy and symptom
management who reviewed the Neutropenia Oncology Nurses Survey for clarity,
comprehensiveness, and relevance to oncology nursing three times. A cognitive-debriefing
session with the experts then was conducted to identify potential issues with
individual items and sequencing and structure of the entire instrument, which
resulted in an agreement rate higher than 80%. Reliability and internal
consistency coefficients of the Neutropenia Oncology Nurses Survey were
analyzed for the entire sample and demonstrated adequate psychometric
properties for a new instrument (overall internal consistency, Cronbach alpha = 0.84). The survey is available on request
to the author.
Data Analysis
Descriptive statistics for
the professional and personal characteristics of the sample were compared with
ONS member data. The scores for each subscale were summed, with higher mean
scores reflecting higher levels of agreement with the items. Associations among
scores on each of the five subscales (dependent variables) and professional and
personal characteristics (e.g., certification, practice setting, age) were
calculated with appropriate chi-square and Kruskal-Wallis
statistical tests. Variables that were found to be significant in bivariate analyses (p < 0.05) then were used as
predictor variables in several logistic regression models.
Responses to the 10 knowledge
items were scored as correct or incorrect for a total possible score of 100%.
In addition, the knowledge scores were tested for associations with demographic
characteristics. All analyses were conducted with SPSS® version 16 for Windows®.
Results
Of the 4,000 e-mail
invitations sent, 3,834 (96%) were deliverable and, of those, 644 (17%) were
opened. Of the nurses who opened the e-mails, 334 (52%) returned the completed
Neutropenia Oncology Nurses Survey; 25 (7%) were ineligible per the study’s
inclusion criteria. Therefore, the final sample of 309 oncology nurse respondents
constituted 8% of the eligible respondent pool (n = 3,834). The response rate
for those who opened the e-mail, responded, and submitted the Neutropenia
Oncology Nurses Survey was 50%.
Demographic Characteristics
Table 1 describes the demographic
characteristics of the study sample compared to ONS members. The respondents
were older, had more experience, and had higher levels of education. In addition, more practiced in community settings than in academic
centers.
Neutropenia Oncology Nurses Survey
The Neutropenia Oncology
Nurses Survey had two components. The first, based on Ajzen’s
(2002) Theory of Planned Behavior, included five subscales that related to the
theory’s constructs—attitudes, subjective norms, perceived competence and
confidence, perceived barriers, and use of NCCN clinical practice guidelines
for CIN and FN. Table 2
summarizes mean subscale scores. The second component included personal and
professional characteristics, experiences with perceived barriers to use of the
clinical practice guidelines, and 10 items related to participant knowledge of
CIN and FN.
Attitude:
Respondents felt that their assessment of patients for chemotherapy side
effects was essential (99%). Almost all respondents (99%) agreed that CIN may
lead to life-threatening complications, CIN may be a dose-limiting toxicity
(98%), and all patients receiving chemotherapy should be screened for neutropenia (97%).
Subjective norm: Regarding nurse and physician colleagues’ expectations, most
respondents reported that they were expected to use the NCCN clinical practice
guidelines for CIN and FN for patient education (65% and 63%, respectively) and
patient risk assessment (67% and 66%, respectively). More than 84% reported
that assessing patient risk for CIN and FN was a professional expectation
associated with their membership in ONS. Eighty-four percent also reported that
performing patient risk assessment and management as well as providing patient
education about the side effect were included as part of their job descriptions.
Nurses’ subjective norm mean
scores were significantly higher when they reported that both physicians and
nurses evaluated patients for CIN compared to those who said that either nurses
alone or physicians alone were responsible for evaluating patients for CIN (p =
0.03) (see Table 3).
Perceived confidence and competence: Almost all respondents (99%) felt competent about
their abilities to care for their patients, and 97% expressed confidence that
they provided patient education about neutropenia as
a chemotherapy side effect. Similarly, 97% reported that they felt able to
identify patient disease- and treatment-related risk factors for CIN and that they instructed patients and families about postchemotherapy home care (98%). Higher perceived competence
and confidence scores were significantly associated with advanced certification
levels (p < 0.001) and with older age (p = 0.02). Respondents who reported
that they were not certified had lower perceived competence and confidence
scores; higher perceived competence and confidence scores were associated with
more attendance at workshops and lectures on CIN (see Table 4).
Perceived barriers: Most nurse respondents (80%) reported that institutional CIN and FN
clinical practice guidelines were used in their practices and also that they
had access to the NCCN clinical practice guidelines most or all of the time. In
contrast, 56% reported that the decision to use the NCCN clinical practice
guidelines was theirs, and 54% reported they had time to access the guidelines.
Nine percent reported they were too busy to use the clinical practice
guidelines, and 10% reported not having access to educational materials for
help in using the guidelines. Nurses who reported experiencing fewer barriers
to using the clinical practice guidelines were more
likely to use online Web sites for professional education (p < 0.05) (see Table 5).
Clinical practice guidelines: More than 80% of the nurses responded that they used
the NCCN clinical practice guidelines for CIN and FN always (n = 249) or most
of the time (n = 309) in their practices. Regardless of whether respondents
reported using the guidelines, 37% said that using them was not their decision.
Fifty-six percent of respondents were almost three times more likely to use the
clinical practice guidelines when using them was their own decision (p ≤
0.001, 95% confidence interval 1.7–4.4).
Barriers to Use of Guidelines
To better elucidate
respondents’ perceived barriers to their use of the clinical practice
guidelines, an additional item presented statements adapted from Cabana, Rand, Becher, and Rubin (2001) that characterized seven barriers
to using clinical practice guidelines. Respondents were instructed to indicate
any or all of the listed barriers that applied to their experiences (see Table 6). Of the 299 multiple
responses to the statements, 111 (37%) reported, “It’s not up to me to use the
guidelines.”
Knowledge of Neutropenia
The results of the 10
knowledge items showed that a large majority of the nurses (86%) gave correct
answers to more than 70% of the knowledge items. A statistically significant
association (p < 0.001) was observed between respondents with bachelor’s
degrees or higher and higher knowledge scores (see Table 7). Sixty-one percent of the
nurses responded incorrectly to the item “patients who are receiving their
first cycle of chemotherapy are at greater risk of developing CIN and FN
complications.”
When significant associations
among the five subscales of the Neutropenia Oncology Nurses Survey were entered
into a multiple logistic regression model, two of the subscales, higher
subjective norm (expectations of colleagues) (p = 0.006) and lower perceived
barriers (p ≤ 0.01), were significantly related to oncology nurse
participants’ use of NCCN clinical practice guidelines for CIN and FN (see Table 8). The factors explained 24%
of the variance in the model (Nagelkerke R2). The
professional characteristic shown to predict use of the NCCN clinical practice
guidelines was holding an advanced oncology nurse certification versus
generalist or no certification (p ≤ 0.01).
Discussion
The current study was the
first to examine oncology nurses’ use of NCCN clinical practice guidelines for
CIN and FN. Myelosuppression is the most common
dose-limiting toxicity of cancer chemotherapy, and its complications are a
major cause of morbidity and mortality (Crawford et al., 2008). The results of
the current study are an important start to understanding nurses’ view of their
roles in using guidelines in their practices. The 309 respondents in the
current study had higher levels of education and more oncology nursing
experience than comparable ONS members who worked with adult patients receiving
chemotherapy. Significant differences also were observed in levels of ONS
certification between the study respondents and the ONS members, particularly
for those holding advanced oncology nursing certifications (e.g., advanced
oncology certified nurse practitioner, advanced oncology certified clinical
nurse specialist).
Of note, almost twice as many
study respondents reported practicing in community settings compared with the
general ONS members, who more typically worked in academic medical or
comprehensive cancer centers. According to the National Cancer Institute
(2006), 85% of patients receive cancer care at a local, community level.
Therefore, the respondents reported providing expert oncology nursing in a
setting that may be more representative of where patients with cancer in the
United States receive treatment. The finding suggests that the nurses who
responded to the survey may have greater influence on delivery of cancer care
for the large numbers of patients who receive treatment in community settings.
Eighty percent of the
respondents reported using the NCCN clinical practice guidelines for CIN and
FN, although only 56% reported that using them was their own decision.
Respondents who reported that using the clinical practice guidelines was their
decision were almost three times more likely to use them. The respondents felt
that they were expected to perform patient risk assessment for CIN and FN as
members of ONS. In addition, they reported that their job descriptions required
them to perform patient risk assessment and management and provide patient
education for CIN and FN. The respondents may not have known that they actually
were using the clinical practice guidelines’ content. Almost all respondents
felt that assessing patients for chemotherapy side effects was essential and
acknowledged that their practices may positively influence patient outcomes and
consequences.
Thirty-three percent of
participants responded to the seven statements about barriers to using the
clinical practice guidelines. The environment in which the nurses practice
seemed to influence their use of evidence- and consensus-based algorithms for
CIN and FN. According to Ajzen and Fishbein (1980), attitude, subjective norms, and perceived
behavioral control (perceived competence and confidence in the current study)
also may be influenced by reports of perceived barriers and are considered to
be objective environmental factors in the Theory of Planned Behavior.
Absent barriers, nurses
reported having greater control over their own behavior with the resources they
needed to perform assessment, management, and patient education. Although some nurses perceived barriers to their use of the clinical
practice guidelines for CIN and FN, associations revealed professional
collaboration in patient assessment for CIN. Respondents who reported
professional collaboration between doctors and nurses in patient assessments
described significant associations with fewer perceived barriers and greater
use of the NCCN clinical practice guidelines for CIN and FN. The finding was
supported by the demonstrated associations between fewer reported perceived
barriers to performing CIN risk assessment and increased use of Web sites for
professional oncology education.
Most nurses had high response
scores on the evidence-based knowledge items. However, 61% did not recognize
that patients who are receiving their first cycle of chemotherapy are at
greater risk for developing CIN and FN complications. Several studies have
identified that the first cycle of chemotherapy is the most common risk factor;
the information is included in most professional presentations about CIN and FN
(Crawford et al., 2004, 2008; Lyman et al., 2006). Further exploration of the
finding may be pertinent to establishing standards for nurses to provide and
reinforce patient and family education, particularly at the beginning of the
chemotherapy regimen.
Study Limitations
Targeting only a population
of computer-using ONS members for participation in a research study may have
biased the survey results. However, the ONS membership has a high proportion of
computer users, making computer use unlikely to have significantly distorted
findings. The study respondents also differed from general ONS RN members in
their personal and professional characteristics; respondents in the study
sample were more educated, were older, and had more oncology nursing
experience.
The decision to keep the
survey open for two weeks with a reminder invitation sent after one week was
made based on evidence that no significant increase in response rates to online
surveys occurs after two weeks (Dillman, 2007; Quiros, Lin, & Larson, 2007). During the two-week time
period that the Neutropenia Oncology Nurses Survey was available to the 4,000
eligible ONS members, ONS sent 25 other e-mails to its members, although not
all members received all 25 (n = 60–34,444 per e-mail). In addition, the
Neutropenia Oncology Nurses Survey was conducted in April, two weeks before the
annual ONS Congress was held in May 2008. Therefore, nurses who responded to
the study survey may have had a greater professional interest in the topic,
which, in turn, may have led to a sampling bias, as often is the case with
self-report survey responses.
The use of self-report may
have resulted in overestimation of the rate of guideline use and possibly
underestimation of the impact of barriers in the professional work environment.
Future studies of guideline use in clinical practice should incorporate medical
record documentation to verify self-report activities such as nursing
assessment, management, and patient education.
The response rate to surveys
mailed or electronically delivered always is an issue of concern. In the
current study, the overall response rate to the Neutropenia Oncology Nurses
Survey was only 9%, but the response rate for eligible nurses who opened the
e-mails (click-through) and then completed and submitted the survey was 50%. No
tracking mechanism was available to detect whether someone had actually read
the e-mail, only that the e-mail was opened. To what extent the e-mail delivery
may have been blocked by filters or other issues is not known.
Implications
for Nursing Practice, Research, and Policy
The use of clinical practice
guidelines in oncology practice has not been well studied. The Neutropenia
Oncology Nurses Survey provides new information about risk assessment,
management, and patient education in CIN and FN, as well as about some
workplace barriers to evidence-based practice experienced by oncology nurses in
various settings. A key finding was that nurses who reported fewer perceived barriers
also reported higher use of the clinical practice guidelines. To date, data are
limited on how use of clinical practice guidelines affects clinical decision
making and overall patient care. Findings from the current study may serve as a
basis to develop oncology nursing standards for CIN and FN risk assessment,
management, and patient education based on the NCCN clinical practice
guidelines.
Most of the current study’s
participants practice oncology nursing in community settings. Complex
professional and work relationships between oncology nurses and physicians may
influence the nurses’ abilities to change or adapt practices (Grol & Grimshaw, 2003). A
strength identified in the current study was the collaborative nature of
oncology practice, in which a strong association existed between subjective
norm and responses that both physicians and nurses evaluate patients for CIN
and FN. Studies related to the collaborative aspects of oncology practice may
provide rich information that may be used to recruit and retain oncology
clinicians. Research should focus on the best way to develop professional
collaborative efforts to ensure that the supportive care delivered by oncology
nurses in cancer screening, diagnosis, treatment, survivorship, palliation, and
end-of-life care—as the main outcome measures—is of the highest standard
possible.
Conclusion
The current study’s results
demonstrate the feasibility of conducting investigator-initiated research in
partnership with ONS to electronically survey eligible ONS members. As a
first-time effort, the current study provides some preliminary insights into
future membership surveys that have bearing on organizational policies for
nursing practice. Strategies to enhance participation rates in electronic
communication such as using local chapter meetings to encourage participation
are recommended.
The current exploratory study
addressed a serious gap in existing research and was the first to investigate
oncology nurses’ reported practices for risk assessment, management, and
patient education in CIN and FN. The results suggest the need to develop
resources such as standard nursing protocols that nurses in all oncology
practice settings may use. Identifying outcome measures in which oncology
nurses can play significant roles in the translation of evidence- and
consensus-based guidelines for CIN and FN in their practice settings would be
productive.
More cancer care in the
United States is shifting to community settings. The anticipated shortage of
medical oncologists, an increase in patients receiving supportive care, and the
aging population of patients with cancer suggest the need for educated and
knowledgeable oncology nurses to take bigger roles in providing supportive
cancer care. The expanding oncology nursing role will be a critical
contribution to cancer diagnosis, treatment, survivorship, and end-of-life care
in the United States.
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Anita Nirenberg, DNSc, RN, NP, BC, AOCNP®, is the William
Randolph Hearst Professor of Clinical Nursing in the Hunter-Bellevue School of
Nursing at Hunter College in New York, NY; and Nancy K. Reame,
BSN, MSN, PhD, is the director of the DNSc/PhD
program and leader of the pilot studies resource in the Irving Institute for
Clinical and Translational Research, Kenrick D. Cato,
RN, BSN, is a PhD student, and Elaine L. Larson, PhD, RN, is a professor of
pharmaceutical and therapeutic research and associate dean for research, all in
the School of Nursing at Columbia University in New York, NY. No financial
relationships to disclose. Nirenberg can be reached at anirenbe@hunter.cuny.edu,
with copy to editor at ONFEditor@ons.org. (Submitted October
2009. Accepted for publication December 10, 2009.)
