Pediatric Cancer Nursing Research Priorities: A Delphi Study
Establishing
Pamela S. Hinds, RN, CS, PhD, Robbie Norville, RN, BSN, OCN, Lori K. Anthony, RN, BSN, Beverly W. Briscoe, RN, Jami S. Gattuso, RN, MSN, Alice Quargnenti, RN, BSN, Melinda S. Riggins, RN, BSN, Lisa A. Walters, RN, Lori J. Wentz, RN, BSN, Karen E. Scarbrough, RN, BSN, and Diane C. Fairclough, RN, DrPH
The purpose of this study was to have pediatric oncology nurses identify and rate topic priorities for clinical nursing research in the specialty and to determine if nurses in a pediatric cancer center identified different priorities than did nursing colleagues in other settings. The sample consisted of 44 nurses from a comprehensive pediatric cancer center and 43 nurses attending the 12th Annual APON Conference. A decision-making method, the classical Delphi technique, was used. Three rounds of soliciting opinions by questionnaires were completed. and data from each round were reviewed and categorized by a research team of six nurses until group consensus was achieved. The majority of priorities identified by both groups concerned nursing procedures, the pediatric oncology patient, and the specialty itself. The least number of priorities were in the categories of care delivery systems and families. One difference between the two groups was that professional issues dominated the cancer center sample, whereas psychosocial issues were more prominent in the APON sample. © 1990 by Association of Pediatric Oncology Nurses.
RECENT FOCUS in pediatric oncology is the development of clinical research nursing programs. Isolated and unrelated studies were previously conducted, which may have primarily reflected the interest of individual researchers and not necessarily those of the care setting. Perhaps because of this discrepancy, there are no aggregates of studies on the same topic. As a result, the research base for the specialty of pediatric oncology nursing consists of findings from studies on important but
A nursing
From St Jude Children’s Research Hospital, Memphis, TN. Supported by the 1988 APON/DAVOL Research Grant. Address reprint requests to Pamela S. Hinds, RN, CS, PhD, SL Jude Children’s Research Hospital, 332 N Lauderdale, Memphis, TN 38104. © 1990 by Association of Pediatric Oncology Nurses.
1043-4542/90/0703-0002$03.00/0
diverse topics that often do not
overlap.
This
that research findings of potential clinical usefulness are derived from a single study and are unlikely to be validated by repeated studies. Applicability of findings to patient care will be limited until validation studies can be commeans
pleted. Developing aggregates of studies on the same idea or problem is a logical next step in building the scientific knowledge base for pediatric oncology nursing. Aggregates of studies can result from a clinical nursing research program that has clearly defined research priorities. Institutional resources can then be allotted to support the research ideas in order of their priority. Clinical research programs receive stronger support from staff nurses when the nurses view the research topics as relevant to patient care.’ 2 Consequently, there is a need to develop
101
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102
.
programs of nursing research in care settings that contribute to the evolution of aggregates of same-topic studies and that are sensitive to the research ideas identified by nurses who provide
patient care.
Purpose The purpose of this study was to enlist pediatric oncology staff nurses in identifying and rating topic priorities for a developing clinical nursing research program in a pediatric comprehensive cancer center. A second purpose was to compare these priorities with those generated by a separate sample of pediatric oncology nurses from other geographic locales. While it is appropriate for an institution to develop its own nursing research priorities, it is of considerable importance that the priorities be similar to those of the larger practice world so that study findings have meaning to other practitioners and are generalizable to other settings. The study used a classical Delphi technique, which collects information from individuals who then refine it, with the result being a majority opinion.
Methodology A decision-making method called the classic Delphi technique was used. This technique is a group-process method that allows for ideas and information on a specific issue to be collected from individuals and subsequently refined by them, resulting in an informed majority opinion. Typically, questionnaires are used to solicit opinions in such a way that the respondents remain anonymous. A sequence of three or four rounds of data collection is used, with each successive round building on the results of the previous rounds. Between rounds, controlled feedback in the form of statistical analysis of the data is given to respondents.4.5 The technique is described as fast, inexpensive, understandable, versatile, and one that avoids &dquo;group think,&dquo; a situation where a dominant person may have undue influence
decision-making group.6-3 This technique nursing to identify staff develneeds,9 opment priorities for clinical nursing research,1,5 and priorities for cancer nursing reon a
has been used in
search in
Canada.10
Conceptual Framework
Sample and Setting
The conceptual model underlying the study decision making as adapted by Bailey and Claus3 from systems and decision theories. The model is based on a cybernetic systems model that consists of four interrelated parts: input (problem finding and definition); throughout. (evaluation of constraints, resources, and alternatives) ; output (action taking); and feedback (information about the outcomes of actions). Within this model, decision making is defined as the cognitive process of weighing alternatives and selecting a course of action from among them. The influence of human values, experiences, knowledge, and other factors upon decision making are recognized. When all model parts and sources of influence are considered, a
Respondents in a Delphi study are selected for their knowledge or expertise in a certain area. Respondents in this study were registered nurses who specialize in pediatric oncology nursing and who provide direct care to pediatric oncology patients at least 20 hours each week at the time of the study and had been doing so for a minimum of 6 consecutive months; they all volunteered to participate. The first study sample consisted of 44 nurses from a comprehensive pediatric cancer center. The comparison sample consisted of 43 nurses who attended the 12th Annual APOf‘I Conference. Three rounds of data were collected from 40 nurses (91 % ) in the cancer-center sample and from 35 nurses (81 % ) in the APON sample. The majority of nurses in the cancer-center sample were from the inpatient setting (n 28) and worked the shift The median (n 22). day length of experience as a pediatric oncology nurse was 31 months. The majority of nurses in the APON sample were also from inpatient settings (n 19) and worked the day shift (n 33). The median length of experience was 48 months in-
was
defensible decision, or one that can be explained and recalled step to step, results. The alternatives in this study were the identified research topics, and the action was prioritizing the topics in consideration of the nurses’ values, experiences, and knowledge as direct-care providers in pediatric oncology. A depiction of the Bailey and Claus decision-making model as it was applied to this study is depicted in Fig 1.
=
=
=
=
dicating that the APOI‘1 sample
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
as a
whole had
103
m
~b’ ul *0 0
0 CM
0
v (L)
-5 0
4.1
H a
a
r.L
tv M to m H
§u b
c at iv m
p 41 C6
0
t
’0
7a 0
r0) c
:
R
E c 0 .!2 u a7
4 a7
E-
. 0 - r_
si 0.2
vS’ . g~
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
104
TABLE 1.
Demographic Characteristics of the Two Samples
been involved in
pediatric oncology nursing longer than the cancer-center sample (Table 1). Procedure The study was approved by two institutional review boards. Potential respondents from the cancer-center sample were individually invited to participate in the study by one of six members of the center’s Nursing Research Advisory Committee. That same committee member re-
mained the respondent’s contact person for the final two rounds of data collection. Each respondent gave oral consent to participate. Potential respondents from the APON sample were informed of the study during a general session of the conference, and again individually when they consented to complete the first round of data collection at the conference site. Respondents in the APON sample completed the final two rounds using mailed questionnaires. For the first round, respondents in both samples were asked to identify three patient care problems or issues in pediatric oncology nursing that needed to be studied by nurses. These issues or problems were termed &dquo;research priorities.&dquo; Six members of the Nursing Research Advisory Committee analyzed the results from each sample separately. More than 160 priorities were identified by the cancer-center sample and more than 150 by the APON sample. The committee reviewed the items and classified them for content type (psychosocial, professional, and procedural) and focus (patient, family, and nurse). Committee members discussed and evaluated the priorities for overlap or similarity until consensus was achieved. Those priorities evaluated as similar or overlapping were condensed into a single priority that the panelists rated as accurately representing the merged priorities. All 68 resulting priorities for the cancer center and 58 for the APON sample
TABLE 2.
Categorization of Research Priorities Identified in Both Samples
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105
used to comprise the questionnaire for the second round of data collection. The majority of research priorities in both samples fell into the categories of nursing procedures and psychosocial care needs. The fewest priorities for both samples were in the caredelivery category (Table 2). Both samples rated their priorities using a five-point Likert scale with a rating of one meaning &dquo;of no importance&dquo; and a rating of five meaning &dquo;extremeiy important&dquo; Forty-one respondents in the cancer-center sample and 35 in the APON sample completed round two. All ratings were analyzed through a computer-based program that yielded descriptive statistics for each priority. Respondents were invited to provide written comments on the priorities. In the cancer-center sample, 36 respondents offered comments on all except four priorities. In the APON sample, 20 respondents commented on 17 priorities. For the third round, respondents in both samples were given the mean rating for each priority that was generated from their respective groups during the second round of data collection. The committee asked the respondents to rerate the priorities in consideration of how important (1) the respondent felt each priority to be, and (2) the entire study sample rated each priority in the second round of data collection. Forty nurses in the cancer-center sample and 35 in the APON sample completed round three.
were
_
Findings
studied or that an acceptable otherwise known, and (3) perceptions that the priority was not so much a research topic as a personal decision that varied with situations. Comments in the fourth category proposed having workshops for staff, creating a different patient appointment system, or establishing a different antibiotic schedule. The fifth category contained offers to join a research team to study a priority of particular interest to the nurse respondent. The majority of comments written on the second round questionnaire by nurses in the APON sample fell into one of three response categories : not a nursing priority; priority too difficult to study; or priority already being studied. Examples of priorities in the first category included identifying funding sources for patients’ health care costs and comparing survival rates of autologous bone marrow transplant patients versus those receiving donor marrow. Examples of the second category included evaluating methods for managing extravasation and evaluating the physiological and psychological effects of chemotherapy on the nurse. Examples of the third category included documenting the incidence of infection associated with entry techniques into venous access devices and evaluating skin care of central venous catheter sites. The top 10 rated research priorities of the cancer-center sample are listed in Table 3. The predominant focus of the top priorities was the
adequately
explanation was
nursing specialty itself, with priorities reflecting
Nursing Research Advisory Committee ’ categorized comments written on the secondround questionnaire by the two sample groups. The responses by the cancer-center nurses were categorized as follows: support for the research priority; broadening the focus of the priority; reasons against studying the priority; suggestions for solving a problem implicit in the priority; and volunteering to participate in studying the priority. An example of a comment in the first category was, &dquo;I think this is an extremely important topic because our unconscious feelings can affect care given to patients.&dquo; Included in the second category were comments that expanded the stated priority to reflect additional variables. Comments in the third category included (1) concerns with feasibility of studying the priority, (2) perceptions that the priority had already The
been
such as retention in the specialty, professional burn-out, and effects of handling antineoplastic agents. A second focus was the nursing role in helping families and patients deal with progressive disease. In the APON sample, the top 10 research priorities had a predominant focus on psychosocial issues (involving nursing support for patients and their families) and nursconcerns
ing procedures (Table 4). The top 10 research priorities for each sample were reexamined to determine if they varied by practice setting (inpatient, outpatient, and intensive care). In the cancer center sample, all three practice settings had the same top priority (retention of nurses) and shared four of the sample’s top priorities. Seven priorities were common to the inpatient and outpatient settings. Unique priorities for the intensive-care setting
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
106
TABLE 3.
Top
10 Research Priorikies Identified
by the
Cancer-Center Sample
included items related to continuity of care, patients’ difficulty accepting diagnoses, and the effect of certain hospital policies on patients and families. In the APON sample, eight top priorities were common to both the inpatient and outpatient samples. The inpatient sample had two priorities that were related to the treatment of mucositis and retention of registered nurses. The outpatient sample had two priorities related to needs of siblings and late effects of treatment.
TABLE 4. Top 10 Research Priorities Identified APON Sample
Other Delphi studies that had three rounds of data collection with cancer nurses had reported 11 participation rates of 44% and 84%.5 The higher participation rate for the cancer-center
sample may be related to the personal invitation extended to each nurse for each round by a known colleague who was a member of the Nursing Research Advisory Committee. Respondents in both samples readily identified nursing research priorities for the specialty. The most commonly identified types of priorities for both samples were nursing procedures, nursing professional issues, and psychosocial needs of patients and their family members. Individual research priorities across the two samples were similar, indicating that although the cancer center’s priorities reflect concerns specific to the center, those concerns do poscare
Discussion
Although both samples were small, the participation levels (91 % in the cancer-center sample and 81 % in the APON sample) were high.
by then
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107
degree of generalizability to other practicing n pediatric oncology settings. The two samples identified similar types of research priorities but rated them differently, with professional issues dominating the cancercenter list and psychosocial issues dominating sess some nurses
the APON list The difference may be related to sample differences. The APON sample is the more experienced in pediatric oncology nursing. The difference may also reflect sampling differences. The cancer-center nurses were well known to each other and that familiarity may have been a source of peer influence on their ratings, possibly involving them inadvertently in the previously referred to problem of &dquo;group
think.&dquo;
Alternatively, the location where respondents completed the priority ratings may have influenced outcomes. The cancer-center nurses completed their ratings at the work site where competing time demands and interruptions were common. In contrast, the APON respondents were more likely to complete their ratings away from the work setting. It is possible that events or other characteristics in the immediate environment as experienced by respondents may influence how they rate priorities. Another explanation for the difference is that the two samples experienced work events that, although external to the purpose of this study, may have
influenced
study findings. Examples of such during the study for the cancer-center sample include a restructuring of the care delivery system, changes in personnel at the level of direct nurse managers, and resignations of coevents
in definition to the category of &dquo;professional&dquo; priorities used in this study) included support
systems for staff, learning needs of
nurses,
oc-
cupational health hazards for cancer nurses, pain relief for cancer patients, and nursing strategies to assist grieving patients and families. The existence of these similarities indicates that these topics remain significant to the specialty of cancer nursing (both adult and pediatric) and have not yet been adequately addressed through research. Dissimilarities in the top professional practice priorities between Oberst’s study and this study are also important Oberst’s top priorities did not directly mention the issues of retention in the specialty, nurse burn-out, clinical preceptors, or ratios of nurse to patient and manager to nurse. It is probable that these issues were not as dominant at the time of Oberst’s study as they are now.
Similarities in
patient care issues between findings and this study’s findings included continuity of care from clinical settings to the home, treating chemotherapy-induced muOberst’s
use of antiemetics, and venous access. Dissimilarities were also noted. Oberst’s priorities did not include late effects of treatment, nursing strategies to decrease neutropenia, and use of sedation before initiating procedures. These may reflect new focuses in cancer nursing that were not a common concern a decade ago. It is interesting to note that the top priorities could be applicable for adult and pediatric cancer patients and their families and nurses.
cositis,
workers.
Conclusion
Priorities were quite similar between the inpatient and outpatient nurses of both samples. However, the priorities from the intensive care unit nurses did differ somewhat from those of
Areas of pediatric oncology nursing that are in need of additional research-based knowledge have been identified. A consensus regarding research priorities has been reached by nurses who provide direct care in one cancer center for pediatric oncology patients and their families. These consensus findings do have some degree of generalizability to other pediatric oncology nurses. By serving as a source of research ideas, the priorities have the potential to help generate and validate the needed knowledge. Study findings are being formally communicated to the nurses who practice in each of the treatment settings within the cancer center. Nurses in each setting are being encouraged to
’
the other two
care settings. This difference indiunique qualities of practice settings within a nursing department need to be considered when developing priorities for the entire de-
cates that
partment. Several of the top research priorities from both
are similar to those identithan a decade ago in 4berst’sll Delphi study of cancer nursing research priorities. Similar priorities on Oberst’s &dquo;list of items pertaining to the practicing nurse&dquo; (corresponding
fied
study samples
more
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
’
108
select a research priority from the top 10 priorities that could be the basis of a research program for that setting. Professional and psychosocial priorities are of particular concern for this nursing specialty. Researching these priorities must be facilitated. In addition, developing aggregates of studies on these priorities needs to be encouraged so that
validated research findings with applicability to direct patient-care, professional, and specialty concerns will result
Acknowledgment The authors acknowledge the editorial assistance of Ann Suttle and project assistance from Pam Maxey and Ralph Vogel. -,
References 1. Lindeman C: Delphi survey of priorities in clinical nursing research. Nurs Res 24:434-441, 1975
2. Hubbard S, Doneower M: The nurse in search setting. Semin Oncol 7:9-17, 1980 3. Bailey J, Claus K: Decision Making in for Change. St Louis, MO, Mosby, 1975
4. Lindeman C: care
a cancer re-
Nursing: Tools
Delphi study: Priorities within the health-
system. Report to the American Academy of Nursing,
1979 5. Ventura M, Waligora-Serafin B: Setting priorities nursing research. J Nurse Adm 1:30-34, 1981
for
6. Turoff M: The design of a policy Delphi. Technological Forecasting and Social Change 2:149-171, 1970
7. Rauch M: The decision Delphi. Technological Forecasting and Social Change 15:159-169, 1979 8. Couper M: The Delphi technique: Characteristics and sequence model. Adv Nurs Sci 6:72-77, 1984 9. Chaney J: Needs assessment A Delphi approach. J Nurse Staff Devel 3:48-53, 1987 10. Western Consortium for Cancer Nursing Research: Priorities for cancer nursing research: A Canadian replication. Cancer Nurs 10:319-326, 1987 11. Oberst M: Priorities in cancer nursing research. Cancer Nurs 3:281-290, 1978
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
Establishing
Pamela S. Hinds, RN, CS, PhD, Robbie Norville, RN, BSN, OCN, Lori K. Anthony, RN, BSN, Beverly W. Briscoe, RN, Jami S. Gattuso, RN, MSN, Alice Quargnenti, RN, BSN, Melinda S. Riggins, RN, BSN, Lisa A. Walters, RN, Lori J. Wentz, RN, BSN, Karen E. Scarbrough, RN, BSN, and Diane C. Fairclough, RN, DrPH
The purpose of this study was to have pediatric oncology nurses identify and rate topic priorities for clinical nursing research in the specialty and to determine if nurses in a pediatric cancer center identified different priorities than did nursing colleagues in other settings. The sample consisted of 44 nurses from a comprehensive pediatric cancer center and 43 nurses attending the 12th Annual APON Conference. A decision-making method, the classical Delphi technique, was used. Three rounds of soliciting opinions by questionnaires were completed. and data from each round were reviewed and categorized by a research team of six nurses until group consensus was achieved. The majority of priorities identified by both groups concerned nursing procedures, the pediatric oncology patient, and the specialty itself. The least number of priorities were in the categories of care delivery systems and families. One difference between the two groups was that professional issues dominated the cancer center sample, whereas psychosocial issues were more prominent in the APON sample. © 1990 by Association of Pediatric Oncology Nurses.
RECENT FOCUS in pediatric oncology is the development of clinical research nursing programs. Isolated and unrelated studies were previously conducted, which may have primarily reflected the interest of individual researchers and not necessarily those of the care setting. Perhaps because of this discrepancy, there are no aggregates of studies on the same topic. As a result, the research base for the specialty of pediatric oncology nursing consists of findings from studies on important but
A nursing
From St Jude Children’s Research Hospital, Memphis, TN. Supported by the 1988 APON/DAVOL Research Grant. Address reprint requests to Pamela S. Hinds, RN, CS, PhD, SL Jude Children’s Research Hospital, 332 N Lauderdale, Memphis, TN 38104. © 1990 by Association of Pediatric Oncology Nurses.
1043-4542/90/0703-0002$03.00/0
diverse topics that often do not
overlap.
This
that research findings of potential clinical usefulness are derived from a single study and are unlikely to be validated by repeated studies. Applicability of findings to patient care will be limited until validation studies can be commeans
pleted. Developing aggregates of studies on the same idea or problem is a logical next step in building the scientific knowledge base for pediatric oncology nursing. Aggregates of studies can result from a clinical nursing research program that has clearly defined research priorities. Institutional resources can then be allotted to support the research ideas in order of their priority. Clinical research programs receive stronger support from staff nurses when the nurses view the research topics as relevant to patient care.’ 2 Consequently, there is a need to develop
101
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
102
.
programs of nursing research in care settings that contribute to the evolution of aggregates of same-topic studies and that are sensitive to the research ideas identified by nurses who provide
patient care.
Purpose The purpose of this study was to enlist pediatric oncology staff nurses in identifying and rating topic priorities for a developing clinical nursing research program in a pediatric comprehensive cancer center. A second purpose was to compare these priorities with those generated by a separate sample of pediatric oncology nurses from other geographic locales. While it is appropriate for an institution to develop its own nursing research priorities, it is of considerable importance that the priorities be similar to those of the larger practice world so that study findings have meaning to other practitioners and are generalizable to other settings. The study used a classical Delphi technique, which collects information from individuals who then refine it, with the result being a majority opinion.
Methodology A decision-making method called the classic Delphi technique was used. This technique is a group-process method that allows for ideas and information on a specific issue to be collected from individuals and subsequently refined by them, resulting in an informed majority opinion. Typically, questionnaires are used to solicit opinions in such a way that the respondents remain anonymous. A sequence of three or four rounds of data collection is used, with each successive round building on the results of the previous rounds. Between rounds, controlled feedback in the form of statistical analysis of the data is given to respondents.4.5 The technique is described as fast, inexpensive, understandable, versatile, and one that avoids &dquo;group think,&dquo; a situation where a dominant person may have undue influence
decision-making group.6-3 This technique nursing to identify staff develneeds,9 opment priorities for clinical nursing research,1,5 and priorities for cancer nursing reon a
has been used in
search in
Canada.10
Conceptual Framework
Sample and Setting
The conceptual model underlying the study decision making as adapted by Bailey and Claus3 from systems and decision theories. The model is based on a cybernetic systems model that consists of four interrelated parts: input (problem finding and definition); throughout. (evaluation of constraints, resources, and alternatives) ; output (action taking); and feedback (information about the outcomes of actions). Within this model, decision making is defined as the cognitive process of weighing alternatives and selecting a course of action from among them. The influence of human values, experiences, knowledge, and other factors upon decision making are recognized. When all model parts and sources of influence are considered, a
Respondents in a Delphi study are selected for their knowledge or expertise in a certain area. Respondents in this study were registered nurses who specialize in pediatric oncology nursing and who provide direct care to pediatric oncology patients at least 20 hours each week at the time of the study and had been doing so for a minimum of 6 consecutive months; they all volunteered to participate. The first study sample consisted of 44 nurses from a comprehensive pediatric cancer center. The comparison sample consisted of 43 nurses who attended the 12th Annual APOf‘I Conference. Three rounds of data were collected from 40 nurses (91 % ) in the cancer-center sample and from 35 nurses (81 % ) in the APON sample. The majority of nurses in the cancer-center sample were from the inpatient setting (n 28) and worked the shift The median (n 22). day length of experience as a pediatric oncology nurse was 31 months. The majority of nurses in the APON sample were also from inpatient settings (n 19) and worked the day shift (n 33). The median length of experience was 48 months in-
was
defensible decision, or one that can be explained and recalled step to step, results. The alternatives in this study were the identified research topics, and the action was prioritizing the topics in consideration of the nurses’ values, experiences, and knowledge as direct-care providers in pediatric oncology. A depiction of the Bailey and Claus decision-making model as it was applied to this study is depicted in Fig 1.
=
=
=
=
dicating that the APOI‘1 sample
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
as a
whole had
103
m
~b’ ul *0 0
0 CM
0
v (L)
-5 0
4.1
H a
a
r.L
tv M to m H
§u b
c at iv m
p 41 C6
0
t
’0
7a 0
r0) c
:
R
E c 0 .!2 u a7
4 a7
E-
. 0 - r_
si 0.2
vS’ . g~
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
104
TABLE 1.
Demographic Characteristics of the Two Samples
been involved in
pediatric oncology nursing longer than the cancer-center sample (Table 1). Procedure The study was approved by two institutional review boards. Potential respondents from the cancer-center sample were individually invited to participate in the study by one of six members of the center’s Nursing Research Advisory Committee. That same committee member re-
mained the respondent’s contact person for the final two rounds of data collection. Each respondent gave oral consent to participate. Potential respondents from the APON sample were informed of the study during a general session of the conference, and again individually when they consented to complete the first round of data collection at the conference site. Respondents in the APON sample completed the final two rounds using mailed questionnaires. For the first round, respondents in both samples were asked to identify three patient care problems or issues in pediatric oncology nursing that needed to be studied by nurses. These issues or problems were termed &dquo;research priorities.&dquo; Six members of the Nursing Research Advisory Committee analyzed the results from each sample separately. More than 160 priorities were identified by the cancer-center sample and more than 150 by the APON sample. The committee reviewed the items and classified them for content type (psychosocial, professional, and procedural) and focus (patient, family, and nurse). Committee members discussed and evaluated the priorities for overlap or similarity until consensus was achieved. Those priorities evaluated as similar or overlapping were condensed into a single priority that the panelists rated as accurately representing the merged priorities. All 68 resulting priorities for the cancer center and 58 for the APON sample
TABLE 2.
Categorization of Research Priorities Identified in Both Samples
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
105
used to comprise the questionnaire for the second round of data collection. The majority of research priorities in both samples fell into the categories of nursing procedures and psychosocial care needs. The fewest priorities for both samples were in the caredelivery category (Table 2). Both samples rated their priorities using a five-point Likert scale with a rating of one meaning &dquo;of no importance&dquo; and a rating of five meaning &dquo;extremeiy important&dquo; Forty-one respondents in the cancer-center sample and 35 in the APON sample completed round two. All ratings were analyzed through a computer-based program that yielded descriptive statistics for each priority. Respondents were invited to provide written comments on the priorities. In the cancer-center sample, 36 respondents offered comments on all except four priorities. In the APON sample, 20 respondents commented on 17 priorities. For the third round, respondents in both samples were given the mean rating for each priority that was generated from their respective groups during the second round of data collection. The committee asked the respondents to rerate the priorities in consideration of how important (1) the respondent felt each priority to be, and (2) the entire study sample rated each priority in the second round of data collection. Forty nurses in the cancer-center sample and 35 in the APON sample completed round three.
were
_
Findings
studied or that an acceptable otherwise known, and (3) perceptions that the priority was not so much a research topic as a personal decision that varied with situations. Comments in the fourth category proposed having workshops for staff, creating a different patient appointment system, or establishing a different antibiotic schedule. The fifth category contained offers to join a research team to study a priority of particular interest to the nurse respondent. The majority of comments written on the second round questionnaire by nurses in the APON sample fell into one of three response categories : not a nursing priority; priority too difficult to study; or priority already being studied. Examples of priorities in the first category included identifying funding sources for patients’ health care costs and comparing survival rates of autologous bone marrow transplant patients versus those receiving donor marrow. Examples of the second category included evaluating methods for managing extravasation and evaluating the physiological and psychological effects of chemotherapy on the nurse. Examples of the third category included documenting the incidence of infection associated with entry techniques into venous access devices and evaluating skin care of central venous catheter sites. The top 10 rated research priorities of the cancer-center sample are listed in Table 3. The predominant focus of the top priorities was the
adequately
explanation was
nursing specialty itself, with priorities reflecting
Nursing Research Advisory Committee ’ categorized comments written on the secondround questionnaire by the two sample groups. The responses by the cancer-center nurses were categorized as follows: support for the research priority; broadening the focus of the priority; reasons against studying the priority; suggestions for solving a problem implicit in the priority; and volunteering to participate in studying the priority. An example of a comment in the first category was, &dquo;I think this is an extremely important topic because our unconscious feelings can affect care given to patients.&dquo; Included in the second category were comments that expanded the stated priority to reflect additional variables. Comments in the third category included (1) concerns with feasibility of studying the priority, (2) perceptions that the priority had already The
been
such as retention in the specialty, professional burn-out, and effects of handling antineoplastic agents. A second focus was the nursing role in helping families and patients deal with progressive disease. In the APON sample, the top 10 research priorities had a predominant focus on psychosocial issues (involving nursing support for patients and their families) and nursconcerns
ing procedures (Table 4). The top 10 research priorities for each sample were reexamined to determine if they varied by practice setting (inpatient, outpatient, and intensive care). In the cancer center sample, all three practice settings had the same top priority (retention of nurses) and shared four of the sample’s top priorities. Seven priorities were common to the inpatient and outpatient settings. Unique priorities for the intensive-care setting
Downloaded from jpo.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
106
TABLE 3.
Top
10 Research Priorikies Identified
by the
Cancer-Center Sample
included items related to continuity of care, patients’ difficulty accepting diagnoses, and the effect of certain hospital policies on patients and families. In the APON sample, eight top priorities were common to both the inpatient and outpatient samples. The inpatient sample had two priorities that were related to the treatment of mucositis and retention of registered nurses. The outpatient sample had two priorities related to needs of siblings and late effects of treatment.
TABLE 4. Top 10 Research Priorities Identified APON Sample
Other Delphi studies that had three rounds of data collection with cancer nurses had reported 11 participation rates of 44% and 84%.5 The higher participation rate for the cancer-center
sample may be related to the personal invitation extended to each nurse for each round by a known colleague who was a member of the Nursing Research Advisory Committee. Respondents in both samples readily identified nursing research priorities for the specialty. The most commonly identified types of priorities for both samples were nursing procedures, nursing professional issues, and psychosocial needs of patients and their family members. Individual research priorities across the two samples were similar, indicating that although the cancer center’s priorities reflect concerns specific to the center, those concerns do poscare
Discussion
Although both samples were small, the participation levels (91 % in the cancer-center sample and 81 % in the APON sample) were high.
by then
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degree of generalizability to other practicing n pediatric oncology settings. The two samples identified similar types of research priorities but rated them differently, with professional issues dominating the cancercenter list and psychosocial issues dominating sess some nurses
the APON list The difference may be related to sample differences. The APON sample is the more experienced in pediatric oncology nursing. The difference may also reflect sampling differences. The cancer-center nurses were well known to each other and that familiarity may have been a source of peer influence on their ratings, possibly involving them inadvertently in the previously referred to problem of &dquo;group
think.&dquo;
Alternatively, the location where respondents completed the priority ratings may have influenced outcomes. The cancer-center nurses completed their ratings at the work site where competing time demands and interruptions were common. In contrast, the APON respondents were more likely to complete their ratings away from the work setting. It is possible that events or other characteristics in the immediate environment as experienced by respondents may influence how they rate priorities. Another explanation for the difference is that the two samples experienced work events that, although external to the purpose of this study, may have
influenced
study findings. Examples of such during the study for the cancer-center sample include a restructuring of the care delivery system, changes in personnel at the level of direct nurse managers, and resignations of coevents
in definition to the category of &dquo;professional&dquo; priorities used in this study) included support
systems for staff, learning needs of
nurses,
oc-
cupational health hazards for cancer nurses, pain relief for cancer patients, and nursing strategies to assist grieving patients and families. The existence of these similarities indicates that these topics remain significant to the specialty of cancer nursing (both adult and pediatric) and have not yet been adequately addressed through research. Dissimilarities in the top professional practice priorities between Oberst’s study and this study are also important Oberst’s top priorities did not directly mention the issues of retention in the specialty, nurse burn-out, clinical preceptors, or ratios of nurse to patient and manager to nurse. It is probable that these issues were not as dominant at the time of Oberst’s study as they are now.
Similarities in
patient care issues between findings and this study’s findings included continuity of care from clinical settings to the home, treating chemotherapy-induced muOberst’s
use of antiemetics, and venous access. Dissimilarities were also noted. Oberst’s priorities did not include late effects of treatment, nursing strategies to decrease neutropenia, and use of sedation before initiating procedures. These may reflect new focuses in cancer nursing that were not a common concern a decade ago. It is interesting to note that the top priorities could be applicable for adult and pediatric cancer patients and their families and nurses.
cositis,
workers.
Conclusion
Priorities were quite similar between the inpatient and outpatient nurses of both samples. However, the priorities from the intensive care unit nurses did differ somewhat from those of
Areas of pediatric oncology nursing that are in need of additional research-based knowledge have been identified. A consensus regarding research priorities has been reached by nurses who provide direct care in one cancer center for pediatric oncology patients and their families. These consensus findings do have some degree of generalizability to other pediatric oncology nurses. By serving as a source of research ideas, the priorities have the potential to help generate and validate the needed knowledge. Study findings are being formally communicated to the nurses who practice in each of the treatment settings within the cancer center. Nurses in each setting are being encouraged to
’
the other two
care settings. This difference indiunique qualities of practice settings within a nursing department need to be considered when developing priorities for the entire de-
cates that
partment. Several of the top research priorities from both
are similar to those identithan a decade ago in 4berst’sll Delphi study of cancer nursing research priorities. Similar priorities on Oberst’s &dquo;list of items pertaining to the practicing nurse&dquo; (corresponding
fied
study samples
more
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’
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select a research priority from the top 10 priorities that could be the basis of a research program for that setting. Professional and psychosocial priorities are of particular concern for this nursing specialty. Researching these priorities must be facilitated. In addition, developing aggregates of studies on these priorities needs to be encouraged so that
validated research findings with applicability to direct patient-care, professional, and specialty concerns will result
Acknowledgment The authors acknowledge the editorial assistance of Ann Suttle and project assistance from Pam Maxey and Ralph Vogel. -,
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