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Meinir Krishnasamy, PhD, RN Winnie Kwok-Wei So, PhD, RN Patsy Yates, PhD, RN Luz Esperanza Ayala de Calvo, MEd, RN Rachid Annab, BSc (Hons) Tami Wisniewski, RN Sanchia Aranda, PhD, RN
The Nurse’s Role in Managing Chemotherapy-Induced Nausea and Vomiting An International Survey
K E Y
W O R D S
Background: Nurses play a substantial role in the prevention and management
Cancer
of chemotherapy-induced nausea and vomiting (CINV). Objectives: This study set
Chemotherapy-induced nausea and vomiting
out to describe nurses’ roles in the prevention and management of CINV and to
Education
was completed by 458 registered nurses who administered chemotherapy to
Nurses
cancer patients in Australia, China, Hong Kong, and 9 Latin American countries.
identify any gaps that exist across countries. Methods: A self-reported survey
Results: More than one-third of participants regarded their own knowledge of CINV as fair to poor. Most participants (965%) agreed that chemotherapy-induced nausea and chemotherapy-induced vomiting should be considered separately (79%), but only 35% were confident in their ability to manage chemotherapy-induced nausea (53%) or chemotherapy-induced vomiting (59%). Only one-fifth reported frequent use of a standardized CINV assessment tool and only a quarter used international clinical guidelines to manage CINV. Conclusions: Participants perceived their own knowledge of CINV management to be insufficient. They recognized the need to develop and use a standardized CINV assessment tool and the importance of adopting international guidelines to inform the management of CINV. Implications for Practice: Findings indicate that international guidelines
Author Affiliations: Peter MacCallum Cancer Centre and Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Victoria, Australia (Drs Krishnasamy and Aranda and Mr Annab); Nethersole School of Nursing, Chinese University of Hong Kong, China (Dr Kwok-wei So); School of Nursing and Midwifery, Queensland University of Technology, Queensland, Australia (Dr Yates); School of Nursing, Pontificia Universidad Javeriana, Bogota, Colombia (Ms de Calvo); Merck & Co Inc, Whitehouse Station, New Jersey (Ms Wisniewski); Cancer Institute New South Wales, Sydney, Australia (Professor Aranda).
Managing Chemotherapy-Induced Nausea and Vomiting
This study was supported through a collaboration between the International Society of Nurses in Cancer Care and Merck, Inc, through an unrestricted educational grant. The authors have no conflicts of interest to disclose. Correspondence: Meinir Krishnasamy, PhD, RN, Peter MacCallum Cancer Centre, St Andrew’s place, East Melbourne, Victoria, Australia 8006 (meinir [email protected]). Accepted for publication July 2, 2013. DOI: 10.1097/NCC.0b013e3182a3534a
Cancer NursingTM, Vol. 37, No. 4, 2014
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should be made available to nurses in clinically relevant and easily accessible formats, that a review of chemotherapy assessment tools should be undertaken to identify reliable and valid measures amenable to use in a clinical settings, and that a CINV risk screening tool should be developed as a prompt for nurses to enable timely identification of and intervention for patients at high risk of CINV.
C
hemotherapy-induced nausea and vomiting (CINV) is a common problem occurring in the absence of antiemetic drugs in up to 99% of patients treated with highly emetogenic chemotherapy (HEC) and in 30% to 90% of those receiving moderately emetogenic chemotherapy.1,2 If inadequately controlled, CINV may have severe clinical consequences, including physiological complications such as dehydration, electrolyte imbalance, and malnutrition.3 Several studies have investigated the effect of CINV on health-related quality of life and have demonstrated that CINV can have a profound effect on people’s experience of cancer treatment.4Y7 Despite the use of antiemetic prophylaxis (including 5-HT3 receptor antagonists), this area of cancer care remains one of importance to nursing. Cancer nurses play a key role in the care of patients receiving chemotherapy. However, to do so, they require access to the most recent guidelines, the latest developments in CINV therapy, and expanded knowledge of CINV pathophysiology. In addition, nurses need training to ensure appropriate screening to identify patients at risk of CINV before chemotherapy begins and the skills to undertake a comprehensive assessment of CINV once treatment has been initiated. Studies have reported that patients’ needs are more fully met and their symptoms are better addressed when nurses take a lead role in CINV management.7,8 Although it is understood that nurses play a substantial role in CINV management in North America and Europe, little is known about their roles in the Asia-Pacific and Latin American regions. The capacity of nursing roles to influence patient outcomes with regard to CINV may be due to many complex factors, including access to pertinent education resources. Although beyond the scope of this study, the impact of culture on nurses and nursing’s capacity to drive cancer practice improvement is an important consideration. Attempts to generate evidence to standardize and improve international cancer nursing practice have not fully addressed culture as an influencing variable. This important variable warrants further exploration and discussion. With the well-documented increase in the projected global incidence of cancer, particularly in low- and middle-income countries, the importance of ensuring access to best-practice symptom management and treatment-related care through appropriately educated nurses in these countries is an imperative. In response to this, an international survey was proposed to develop an understanding of nurses’ roles in the prevention and management of CINV.
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Aims and Research Questions
The aims of the study were to explore nurses’ roles in the prevention and management of CINV through an international survey of their attitudes, beliefs, knowledge, skills, and practices E28 n Cancer NursingTM, Vol. 37, No. 4, 2014
in that area and to identify any gaps that may exist in CINV management. Five study questions were set: 1. What role do nurses play in the prevention and management of CINV? 2. How do nurses assess CINV risk? 3. What are nurses’ perceptions of the most commonly used antiemetic prophylaxis and rescue medications in both first line and refractory settings? 4. What are the key influences on nurses’ CINV practice? 5. What educational needs do nurses have in relation to the prevention and management of CINV?
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Methods
Sample Registered nurses who at the time of completing the survey cared for and administered chemotherapy to cancer patients were eligible to participate. This study, guided by Benner’s9 conceptualization of novice to expert, had no exclusion criteria based on length of time in the profession or experience of delivering chemotherapy, as we sought to be inclusive of the views of nurses with a broad range of experience and knowledge. Potential participants were approached via national nursing groups or the networks of study investigators in each of the participating countries: Australia (The Cancer Nurses Society of Australia); Hong Kong Special Administrative Region (Hong Kong) and China (nurses were approached to participate via contact through senior hospital staff ); and Venezuela, Colombia, Argentina, Panama, Chile, Puerto Rico, Peru, Costa Rica, and Mexico (contacts were identified and approaches coordinated by a senior clinical contact based in Colombia who was also a member of the survey project team). In addition, considerable support was also provided by representatives from a pharmaceutical company in the Latin American regions to help identify contacts for the institutional review board approval processes and for distribution of the surveys. It was not possible at the outset of the project to estimate the total number of nurses available for recruitment to the study. Instead, a sample size of 30 nurses per country was set as a pragmatic recruitment target given the scope and resources available to undertake the study and as a minimum number to enable meaningful comparison of data across national data sets. No power calculation was set.
Procedures Ethics approval was sought according to the requirements of individual participating institutions. After ethics approval was
Krishnasamy et al
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obtained, approaches to take part in the survey were made by local study coordinators to national nursing groups or individual contacts in cancer units or centers, as described above. A convenience sampling method was used to recruit eligible subjects. Before data collection, members of the research team liaised with local study coordinators to identify the best way to recruit eligible subjects. Thus, in Australia, eligible subjects could be reached through electronic communication means. The same approach was used to recruit eligible subjects in Latin America. However, electronic communication was not feasible in Hong Kong or Mainland China. Instead, a hard-copy survey was identified as the best way to collect data from eligible participants. Therefore, 2 different methods were used for data collection reflecting optimal recruitment methods across the different regions. Study coordinators were not given access to participants’ names. All invitations to take part (hard copy or electronic) and accompanying study information were distributed to potential participants through the nursing groups. No identifying information was collected and all data were anonymous and remained confidential. Where direct electronic access to nurses was not available or possible, an e-mail invitation prepared by the research team was made available to the nursing groups for distribution to their members. The e-mail included details of the study aims and objectives, invited participation, and provided a Web link to the survey Web site, where nurses were able to complete the survey online. Where a participant needed to complete a hard copy of the survey, this was distributed along with the study information either via the local study coordinator or national nursing group. Completed hard-copy surveys were returned to local study coordinators or nursing groups in sealed envelopes. Participants were unidentifiable.
Data Collection INSTRUMENT
The survey instrument was developed after a comprehensive review of the literature to identify key issues pertinent to the role of nurses regarding CINV. The survey contained 51 multiplechoice and open-ended questions and took approximately 25 minutes to complete. Participants were also provided with opportunity to respond to an ‘‘other’’ category, where detailed qualitative responses could be inserted to add context-specific data. Benner’s novice to expert framework was used to structure questions about participants’ perception of their level of expertise in chemotherapy nursing to provide a standardized taxonomy for grading self-reported perception of capability.9 A copy of the survey is available from the authors on request. In this article, data collected from the following areas were used for analysis: (a) demographics; (b) participants’ knowledge, attitudes, and practice related to care of patients experiencing CINV; (c) assessment of risk factors for and occurrence of CINV; and (d ) CINV management. The survey was reviewed by the research team for clarity, consistency of terms, response categories, and ratings and to enable item reduction. Nine expert chemotherapy nurses attending a cancer nursing conference (Cancer Nurses’ Society of Australia Winter Congress,
Managing Chemotherapy-Induced Nausea and Vomiting
2009) were invited to participate in a focus group to review the relevance, clarity, comprehensiveness, and ease of completion of the survey. The 9 Australian nurses were all English speaking and had formal cancer nursing qualifications. Minimal changes were made to enhance the clarity of the survey after this expert review. Further piloting was undertaken with nurses working in the chemotherapy day unit of a cancer center in Australia to clarify wording of the survey and the time needed to complete it. All eligible participants in Hong Kong were fluent in English and, on a daily basis, administered chemotherapeutic agents whose instructions were printed in English. English was the language used for the survey in Hong Kong. Three clinical nurse specialists or managers in Hong Kong were invited to review the English version of the survey to ensure its clarity for local participants. A forward-translation procedure was used to translate the English-language survey into the respective languages of participants from Mainland China and Latin America. In addition, a face validity test was carried out with 10 experienced oncology nurses from Mainland China and 5 nurses specialized in oncology from Latin America to ensure that the survey was readable and understandable. Minor changes were made to enhance the clarity of the questions and response options. The terms usually used for positions and academic qualifications in different countries were adopted. A brief explanation was provided to clarify ‘‘formal oncology training’’ and ‘‘formal chemotherapy training.’’
Data Analysis E-survey data remained in Survey Monkey, and hard-copy survey data were entered into Survey Monkey by a research assistant. Data were downloaded from Survey Monkey into Excel and transferred to SPSS V610 for analysis. Descriptive statistics were applied to establish key trends in the data set and identify similarities and differences within and across data from participating countries. Descriptive statistics included number, percentage, cumulative percentage, median, and frequency breakdowns of response sets. To ensure transparency of reporting, a decision was made to report findings as valid percentages, with missing values excluded on a question-by-question basis and the average proportion of missing values reported for each section.
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Findings
Overall, 503 nurses initiated participation in the survey. However, 45 nurses dropped out after completing section 1 of the questionnaire (demographic data), leaving 458 nurses who went on to complete the remainder of the survey. As such, data reported below are based on these 458 nurses only. The characteristics of the 45 nurses who dropped out are reported below. There was a considerable amount of missing data after the first section of the survey (on average 100 per question), particularly from those completing the survey online. This was possibly because the survey was quite long (taking approximately 25 minutes to complete) and the Survey Monkey format did not allow participants to save and return to the survey at a later time. Cancer NursingTM, Vol. 37, No. 4, 2014
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Table 1 & Demographic Profile of the
Participants (Valid N = 458)
Country Australia China Hong Kong SAR Latin America Current position Head nurse/nurse coordinator Clinic/staff nurse Clinical nurse specialist/advanced practice nurse Nurse practitioner Other Years of experience in nursing e1 91Y2 92Y5 95Y10 910Y15 915Y20 920 Years of experience caring for chemotherapy patients e1 91Y2 92Y5 95Y10 910Y15 915Y20 920 Health sector Public Private Other Current place of work Hospital inpatient clinic Hospital outpatient clinic Hospital day-treatment unit Community/home-based care Combination of clinics, units, and wardsa Other
n
Valid %
57 247 103 51
12 53.90 20.5 11.1
41 242 92 58 18
9.1 53.7 20.4 12.9 4.0
13 19 65 110 91 65 90
2.9 4.2 14.3 24.3 20.1 14.3 19.9
29 32 91 131 85 54 36
6.3 7.0 19.9 28.6 18.6 11.8 7.9
404 44 9
88.4 9.6 2.0
329 42 49 4 10 20
72.5 9.3 10.8 0.9 2.2 4.4
Missing values are as follows: current position = 7, years of experience in nursing = 5, health sector = 1, current place of work = 32. Abbreviation: Hong Kong SAR, Hong Kong Special Administrative Region. a This category was not included in the original questionnaires but was added during the analysis according to a logical grouping of results in the ‘‘other’’ category.
Demographics The demographic details of the 458 participating nurses are presented in Table 1. Characteristics of the 45 nurses who withdrew after section 1 differed very little from those who went on to complete all sections of the survey. Of the 45, 28 were Australian, 6 were Chinese, and 11 were South American participants, and 7 were identified as a head nurse/nurse coordinator, 4 as a clinic or staff nurse, 17 as a clinical nurse specialist/ advanced practice nurse, 6 as a nurse practitioner, and 3 as other. Data were missing for 8. Of the 45 nurses (53%), 24 had more than 20 years of nursing experience; the remaining 21 were spread evenly across the range of years of experience. Of the E30 n Cancer NursingTM, Vol. 37, No. 4, 2014
45 who dropped out, 13 (28%) had 15 to 20 years’ experience of chemotherapy, 28 (62%) worked in the public sector, and 18 (40%) worked in hospital day treatment units. Most of the participants who completed the survey had received at least a bachelor’s degree, 44% reported lower levels of education (diploma or associate diploma), and 11% reported higher levels (Table 2). Of the 45 who dropped out, valid percentages for level of education, oncology training, chemotherapy training, training requirement, and rated experience closely matched those presented in Table 2. There were no statistically significant differences between participants who completed the survey and those who withdrew. For the nurses who went on to complete the survey, only 54% reported formal training in oncology, although 4 others reported alternative training consistent with specialist recognition such as Oncology Nursing Certification. Formal training in chemotherapy had been completed by 53%, such training being a requirement for administration of chemotherapy for 76% of the participants. Formal oncology and chemotherapy training was defined as ‘‘a course approved by the working institution or
Table 2 & Education Profile of the Participants (Valid N = 458)
Highest level of education Diploma Associate’s diploma Bachelor’s degree Master’s degree Doctorate Postgraduate certificate/diplomaa Other Completion of formal oncology training Yes No Unsure Other Completion of formal chemotherapy training Yes No Unsure Other Requirement for chemotherapy training Yes No Unsure Other Self-rating of expertise in chemotherapy nursing Beginner Competent Expert Unsure Other
n
Valid %
43 169 174 42 5 8 12
9.5 37.3 38.4 9.3 1.1 1.8 2.6
248 155 50 4
54.3 33.9 10.9 0.9
241 157 51 6
53.0 34.5 11.2 1.3
345 74 31 4
76.0 16.3 6.8 0.9
66 308 74 6 4
14.4 67.2 16.2 1.3 0.9
Missing values are as follows: highest level of education = 5, completion of formal oncology nursing = 1, completion of formal chemotherapy training = 3, requirement for chemotherapy training = 4. a This category was not included in the original questionnaires but was added during the analysis according to a logical grouping of results in the ‘‘other’’ category.
Krishnasamy et al
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Table 3 & The Top 5 Factors Influencing
Chemotherapy-Induced Nausea (CIN) and Chemotherapy-Induced Vomiting (CIV) Rank
Factors impacting on nausea Type of chemotherapy drug Dose of chemotherapy A history of CIN A history of CIV Anxiety Factors impacting on vomiting Type of chemotherapy drug Dose of chemotherapy History of CIN Route of administration Number of cycles of chemotherapy Factors Influencing CIN and CIV Drug addiction Psychiatric history Level of alcohol intake Gender Age Type of cancer History of nonYchemotherapy-related nausea Taste changes NonYchemotherapy-related vomiting
n (Valid %)
1 2 3 4 5
453 447 442 441 409
(99) (98) (98) (98) (93)
1 2 3 4 5
439 437 433 431 424
(85) (85) (84) (84) (83)
CIN, n (Valid %) 171 154 139 75 62 60 50
(38) (35) (31) (17) (14) (13) (11)
50 (11) 48 (11)
CIV, n (Valid %) 163 154 142 76 67 67 53
(38) (35) (33) (17) (15) (15) (12)
50 (11) 48 (11)
professional association; where participants obtained a certificate after completion and, the course undertaken provided evidence that the nurse had met the required competence.’’ Using Benner’s9 novice to expert framework, participants were asked to rate their level of expertise in chemotherapy nursing. Most (67%) rated themselves as ‘‘competent’’; 16%, as ‘‘expert’’; and 14%, as ‘‘beginners.’’ Of the 45 nurses who dropped out after section 1, 79% had received formal training in oncology. Formal training in chemotherapy had been completed by 84% and was a requirement for administration of chemotherapy for 79%. Most (51%) rated themselves as ‘‘expert’’; 36%, as ‘‘competent’’; and 11%, as ‘‘beginners.’’
Perceived Knowledge, Attitudes, and Management With Respect to CINV (n = 438Y448) Personal knowledge about CINV risk assessment was perceived to be adequate or advanced by most participants (57%), but more than 40% identified their risk assessment knowledge as only fair to poor. Similarly, a significant proportion of participants rated as fair to poor their knowledge of definitions of CINV (44%), antiemetic prophylaxis (33%), rescue medications (41%), and nonpharmacological interventions (58% chemotherapy-induced nausea [CIN] and 61% chemotherapy-induced vomiting [CIV]).
Managing Chemotherapy-Induced Nausea and Vomiting
Most participants (79%) agreed that CIN and CIV should be considered separately for assessment and management but disagreed (67% CIN and 73% CIV) that patients could largely manage CINV themselves with little intervention from healthcare staff. Most agreed (91%) that the recommended treatments used in their clinical areas were effective and that their patients took an active role in managing their own CINV (90%). Participants agreed or strongly agreed that the role of the nurse was important in assessing (82%), managing (76%), and educating patients about (81%) CINV. Most (965%) also agreed or strongly agreed that they were confident in their ability to assess CIN and CIV. However, fewer participants agreed or strongly agreed that they were confident in managing CIN (53%) or CIV (59%). Most (81%) reported that they provided patient education often or very often, but only 67% agreed or strongly agreed that they were confident with this aspect of their role.
Knowledge of Acute, Delayed, and Anticipatory Vomiting and Factors Impacting on CINV Most participants correctly identified acute vomiting as occurring within 24 hours of starting chemotherapy (94%; total valid response = 438Y448), delayed vomiting as occurring more than 24 hours after treatment (94%), and anticipatory vomiting as occurring before treatment (90%). Most nurses rated the chemotherapy dose, administration route, number of cycles of chemotherapy, history of nausea (nonYchemotherapy related), history of CIN, history of CIV, and anxiety as somewhat or very influential on the patient’s experience of CIN and/or CIV (Table 3). In contrast, a history of nonYchemotherapy-related vomiting, the type of cancer, age, gender, and taste changes received more mixed responses. Most participants were unsure that the level of alcohol intake, a history of drug addiction, and a psychiatric history were important influences on the patient’s experience of CIN and CIV (Table 3). Table 3 indicates that there was an important group of participants who were unsure about the influence of various factors on CIN and CIV. This is an important finding given that there is a considerable body of evidence to support the impact of such factors on the experience of CINV.
Assessment and Management of CINV Nurses reported being often or very often involved in CINV assessment of the occurrence of CINV (n = 435; 66%), with most (73%) indicating that their assessment distinguished between nausea and vomiting. However, only 20% of 356 participants reported often or very often using a standardized CINV assessment tool. International guidelines were reported as guiding assessment of occurrence of CINV assessment by 26% of the responding sample, whereas 45% used locally developed guidelines or protocols (Table 4).
Pharmacological Strategies to Manage CINV Where participants were asked to respond to questions relating to pharmacological strategies, they were provided with both group Cancer NursingTM, Vol. 37, No. 4, 2014
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Table 4 & Management of Chemotherapy-Induced Nausea and Vomiting (CINV) in the Workplacea
Management Guided by
n
Local clinical guideline/protocol International clinical guideline/protocol Unit-developed management plan Nurse clinician’s knowledge Physician’s preference
191 111 167 261 137
Valid % 44.6 25.9 39.0 61.0 32.0
a Of 458 respondents, 428 answered this question. Thus, 428 was used as a denominator to calculate valid %.
names and examples of the different drugs. The most common drugs used to treat both aspects of CINV were 5-HT3 receptor antagonists, corticosteroids, antihistamines, benzamides, and benzodiazepines (Table 5). However, there were high rates of uncertainty regarding some drugs used as part of CINV management regimens (Table 6).
CINV if it occurred away from the hospital (50%), and how to distinguish among anticipatory, acute, or delayed CINV (50%). Participants were asked to indicate the frequency with which they provided patients with self-care advice about a range of strategies. Overall, 234 (70%) participants reported often or very often providing self-care advice to patients receiving chemotherapy. However, a larger proportion of participants (n = 417Y377) answered the questions on the frequency of providing advice about specific self-care practices (Table 9). Participants who were rarely or never involved in patient education about CINV were asked to identify reasons. The most common reasons for influencing (sometimes, often, or very often) the nurse’s role in patient education were that it was provided by physicians (n = 58), the nurse’s knowledge was insufficient (n = 51), nurses did not have enough time to provide instruction (n = 70), printed information was provided in place of a nurse’s intervention (n = 64), or patient education was delivered elsewhere (n = 42).
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Nonpharmacological Strategies to Manage CINV When asked how often nonpharmacological methods were recommended for the management of CINV in their workplace, 48% of the 411 valid responses indicated often or very often. Table 7 lists the frequencies with which each of the nonpharmacological strategies was reported as being recommended, at either pretreatment or posttreatment stages, or for prevention of CINV.
Patient Education Participants (n = 438Y443) reported specific topics that they often or most often included in CINV patient education (Table 8). The 4 most common topics were antiemetic prophylaxis and how to take medications (98%), rescue medications and how to take them (91%), types of emetogenic agents used (84%), and how to identify any adverse effects needing to be reported to a health professional (84%). However, fewer participants taught participants about the pathophysiology of CINV (24%), how to record
Discussion
This article makes a valuable contribution to existing literature that continues to show that nurses need ongoing evidence-based education and ready access to resources to deliver optimal care for people experiencing CIN and CIV. The requirements for recognition of and education for the assessment and management of CIN and CIV as discrete problems has been strongly demonstrated through the survey findings. Overall, those responding to the survey were experienced oncology nurses working in public hospital environments. Most agreed that assessment and management of CINV were an important part of their role. There are limitations to the data, as described below, notably the number of participants who dropped out after completing section 1. In general, the participants demonstrated good general knowledge of CINV, but some important gaps were also identified, which provide useful information about how to improve nurses’ knowledge and delivery of education regarding CINV assessment and management. Specifically, many participants did not feel confident in their ability to assess and manage CINV, which might be because of
Table 5 & Common Pharmacological Agents to Manage Chemotherapy-Induced Nausea and Vomiting (CINV), by Rank
Rank
Pharmacological Agents to Manage CIN (n)
%
Rank
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
5-HT3 receptor antagonists (426) Corticosteroids (393) Antihistamines (382) Benzamides (371) Benzodiazepines (340) Neurokinin-1 antagonists (291) Domperiodone (266) Butyrophenones (264) Phenothiazines (254) Cannabinoids (228)
83 77 74 72 66 57 52 51 49 44
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Pharmacological Agents to Manage CIV (n)
%
5-HT3 receptor antagonists (395) Corticosteroids (395) Antihistamines (372) Benzamides (357) Benzodiazepines (330) Neurokinin-1 antagonists (281) Butyrophenones (254) Phenothiazines (247) Domperiodone (243) Cannabinoids (217)
77 73 73 70 64 55 49 48 47 42
Abbreviation: CIN, chemotherapy-induced nausea.
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Krishnasamy et al
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of knowledge and insufficient time were also reported as the commonest barriers to the delivery of nurse-led patient education.12 There was high level of use of 5-HT3 receptor antagonists among the respondents, in keeping with best-practice guidelines.1,2 Although it was not possible to deduce from the survey data whether the 5-HT3 agents were routinely used in combination with corticosteroids for high and moderate emetogenic chemotherapy regimens, the reportedly high use of both agents indicates that this may be the case in practice. Similarly, the high use of 5-HT3 agents and corticosteroids may indicate compliance with consensus guidelines for prevention of CINV for moderate and low emetogenic chemotherapy, where administration of a 5-HT3 agent or corticosteroid is recommended.1,2 Evidence to inform management of delayed CINV (2Y5 days after chemotherapy administration) is equivocal. However, the European Society for Medical Oncology and Multinational Association of Supportive care in Cancer guidelines1,13 is that a multiday oral corticosteroid (dexamethasone) should be prescribed for patients receiving chemotherapy who are at moderate emetic risk, whereas the NCCN recommends aprepitant with corticosteroids in the delayed phase for select patients receiving chemotherapies of moderate emetogenic risk2 or that a combination of dexamethasone and aprepitant should be used to prevent delayed CINV in patients receiving a combination of high emetogenic regimens. International consensus guidelines1 advocate the inclusion of a neurokinin-1 antagonist with a 5-HT3 receptor antagonist and corticosteroid when HEC agents are prescribed. The relatively low reporting of the use of neurokinin-1 antagonists in this survey (approximately 50%) may be indicative of the chemotherapy regimens being administered or of limited access to these relatively novel agents in diverse settings.
Table 6 & Participants Reporting Uncertainty
About Types of Pharmacological Agents Used in the Management of Chemotherapy-Induced Nausea (CIN)/Chemotherapy-Induced Vomiting (CIV) CIN
Agent Cannabinoids Phenothiazines Domperidone Butyrophenones Neurokinin-1 antagonists
CIV
n
Valid %
n
Valid %
207 191 157 110 97
91 75 59 42 33
189 182 136 108 91
87 74 56 43 32
the low proportion using a standardized CINV assessment tool, their reliance on clinical knowledge rather than international clinical guidelines, and the fact that almost half lacked formal chemotherapy training. Participants covered most of the essential CINV topics in patient education, but special attention should be paid to those topics covered by a lower proportion (differences between nausea and vomiting; distinguishing between anticipatory, acute, or delayed CINV; and the pathophysiology of CINV). Education of patients on the difference between antiemetic prophylaxis versus treatment is an important topic particularly for patients prescribed HEC.1 Educating patients about how to use their medication is essential to optimizing prophylaxis and treatment of CINV. Similarly, educating patients about how to record CINV occurring away from the hospital is essential to enable self-care and ensure that patients know to contact health professionals in a timely manner when adverse effects occur. Lack of clarity about their role as key providers of patient education was evident in the data reported and has been reported elsewhere as a factor impacting nurses’ contribution to patient education.10 Insufficient knowledge was also identified as a barrier to delivering patient education by nurses in this study, but heavy workload (previously cited by others11) and limited nursing time were also cited as key impediments. In a recent study to examine nurses’ perceived barriers to pain management, lack
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Limitations
This study had several limitations. Despite attempts to ensure a rigorous approach to translation of the English survey into Spanish, errors in translation occurred that led to the exclusion of responses from the Latin American participants to several items. The term pathophysiology was accidently mistranslated in
Table 7 & Use of Nonpharmacological Management Strategies for Chemotherapy-Induced Nausea and Vomiting (CINV)
Nonpharmacological Strategies Distraction Relaxation Visualization Massage Acupressure Aromatherapy Acupuncture Reflexology TENS
Valid N
Pre-Tx N
Post-Tx N
Prevention N
Total N
367 368 366 367 368 366 368 368 368
243 216 117 53 33 28 22 22 4
220 201 105 73 72 43 60 44 16
147 154 72 47 30 36 19 34 9
610 571 294 173 135 107 101 100 29
Abbreviation: TENS, transcutaneous electrical nerve stimulation; Tx, treatment.
Managing Chemotherapy-Induced Nausea and Vomiting
Cancer NursingTM, Vol. 37, No. 4, 2014
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Table 8 & Specific Chemotherapy-Induced Nausea and Vomiting (CINV) Topics That Nurses Taught Patients About Often or Very Often, by Rank
Rank 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. a
Specific Topic of CINV
N
%
Antiemetic prophylaxis and how to take medications Rescue medications and how to take them Types of emetogenic agents used How to identify side effects that need to be reported to a health professional Nonpharmacological and self-care strategies to reduce likelihood of developing CINV Nonpharmacological and self-care strategies to cope with CINV How to communicate with health professionals about CINV Discussing factors likely to increase CINV Discussing the difference between nausea and vomiting Distinguishing between anticipatory, acute, or delayed CINV How to record CINV if it occurs away from the hospital Providing education about the pathophysiology of CINVa
348 346 348 343 343 312 348 342 344 345 344 314
98 91 84 84 83 83 80 78 55 50 50 24
This question was wrongly worded in the Spanish survey and not used here.
the online Spanish version of the questionnaire as psychophysiology. The data for this question were therefore split into 2 variables, 1 for the English online version of the question and 1 for the Spanish online version, each of which was presented separately in the data analysis output. One option (relaxation) of nonpharmacological strategies to cope with CINV was missing in the Spanish online version of the questionnaire. Because of a typographical error, the Spanish version had an extra question presented to the respondents in the survey section relating to the ‘‘Clinic’’ environment. As a result, any response data to this question were removed from the data set. Response rates from Australia and the Latin American countries were low, with only 85 nurses participating in Australia and 62 from across Latin America. The back-translation method is a more respected translation process than the forward-translation used in this study, although both are commonly used methods to ensure conceptual and semantic equivalence. Although a sample size of 30 nurses per country was set as a pragmatic recruitment target, it proved impossible to achieve this because of contextual variations in access to nurses across the participating sites. Because of the low numbers responding from each of the Latin American countries, data were grouped and considered as a discrete data set. Large numbers of participants dropped out after completing section 1 (on average 100 per question). This hampered the capacity to undertake analysis beyond a descriptive reporting of the data set. Response rates may also have been affected to a lesser extent by the length of the survey, the repetitive nature of the questions (in an attempt to distinguish responses to nausea and vomiting as discrete problem), and inability to save responses and return to complete the survey at another time. There was evidence that participants responded inconsistently to several items, suggesting lack of understanding of the questions or nomenclature, for example, the high number of nurses identifying themselves as nurse specialist, advanced practice nurse, or nurse practitioners yet classing themselves as being only ‘‘competent’’ in chemotherapy administration. This serves to highlight the complexity of undertaking international surveys of this kind, where multiple translations are necessary and there is little consistency around nursing role, education, or training terminology across E34 n Cancer NursingTM, Vol. 37, No. 4, 2014
(and sometimes within) countries. For example, someone who calls himself/herself a nurse practitioner may in some countries be someone who practices as a nurse. Participants were accessed from national groups and networks known to the study team, potentially introducing a bias in the selection of nurses. However, individual participants and their level of skill, knowledge, and experience were unknown to the study team. In addition, demographic data indicated participation by nurses from diverse healthcare settings, including tertiary centers and general hospitals.
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Implications
Education for nurses is an essential strategy to enable best practice regarding CINV. The knowledge gaps identified demonstrate the need for the development of clinically relevant screening and assessment tools for use with patients experiencing CINV. Nurseled models of chemotherapy education have been shown to
Table 9 & Self-care Advice Given to Patients Rank
Self-care Advice
n (Valid %)
1. 2. 3.
Have small meals often. Prepare small meals and eat a little often. Avoid fried foods or those with a strong smell. Take frequent sips of fluid. Eat several small snacks/meals and chew food well. Sip drinks slowly. Avoid drinking before meals. Eat food warm or cold if the smell makes you feel sick. Ginger products can help. Take antacids. Use peppermint or peppermint tea. Take vitamin B6.
386 (93) 380 (93) 379 (91)
4. 5. 6. 7. 8. 9. 10. 11. 12.
335 (82) 277 (69) 239 (61) 208 (55) 220 (54) 156 147 139 91
(39) (38) (36) (24)
Krishnasamy et al
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reduce supportive care needs and enhance self-efficacy in patients undergoing cancer chemotherapy.12 Implementation of nurseled chemotherapy education programs has the potential to improve communication between nurses and patients, ensuring that patients receive essential and tailored information to meet their knowledge-based needs. Development of training programs for all nurses who deliver chemotherapy, with an emphasis on the implementation of best-practice as articulated in international clinical guidelines, is a priority if all patients are to receive quality cancer care. More attention should be given to the translation and interpretation of the international guidelines to ensure conceptual and semantic equivalence as well as relevance to a particular country or region.
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Conclusions
This study set out to examine the role of nurses in the management of CINV and to identify gaps that exist. Study participants demonstrated good general knowledge of CINV, but some important gaps were also identified. This survey has generated useful information to inform and prioritize the educational needs of nurses to optimize CINV assessment and management. Of note, our data indicate that more attention be given to the development and implementation of clinically applicable screening and assessment tools to help nurses identify patients at high risk of CINV and to help them better assess and manage CIN and CIV as a matter of urgency. Widespread adoption and promotion of international guideline recommendations for the prevention and management of CINV are highly recommended. Nurses undertake an extensive role in the assessment and management of CINV. Enabling them to do so to the best of their ability through adoption of evidence-based guidelines is essential to the delivery of quality cancer care.
Managing Chemotherapy-Induced Nausea and Vomiting
References 1. Multinational Association of Supportive Care in Cancer. MASCC/ESMO antiemetic guideline 2010. http://www.mascc.org/mc/page.do?sitePageId= 88041. Accessed November 17, 2010. 2. National Comprehensive Cancer Network. NCCN Practice Guidelines in Oncology: v.2.2010: Antiemesis. http://www.nccn.org/professionals/physician_ gls/pdf/antiemesis.pdf. Accessed August 2, 2013. 3. National Cancer Institute. Nausea and vomiting. 2011. http://www.cancer .gov/cancertopics/pdq/supportivecare/nausea/HealthProfessional. Accessed July 2, 2012. 4. Molassiotis A, Farrell C, Bourne K, Brearley SG, Pilling M. An exploratory study to clarify the cluster of symptoms predictive of chemotherapy-related nausea using random forest modeling [published online ahead of print June 5, 2012]. J Pain Symptom Manage. 5. Farrell C, Brearley SG, Pilling M, Molassiotis A. The impact of chemotherapyrelated nausea on patients’ nutritional status, psychological distress and quality of life [published online ahead of print May 19, 2012]. Support Care Cancer. 6. Ferna´ndez-Ortega P, Caloto MT, Chirveches E, et al. Chemotherapyinduced nausea and vomiting in clinical practice: impact on patients’ quality of life [published online ahead of print March 21, 2012]. Support Care Cancer. 2012. 7. Aranda S, Jefford M, Yates P, et al. Impact of a novel nurse-led prechemotherapy education intervention (ChemoEd) on patient distress, symptom burden, and treatment-related information and support needs: results from a randomised, controlled trial. Ann Oncol. 2010:23(1):222Y231. doi:10.1093/annonc/mdr042 8. Braud A-C, Genre D, Leto C, et al. Nurses’ repeat measurement of chemotherapy symptoms: feasibility, resulting information, patient satisfaction. Cancer Nurs. 2003:26(6):468Y475. 9. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley Publishing Company; 1984. 10. SPSS V6. SPSS Data Collection Desktop V6.0.1 (5725-A78). New South Wales: IBM Australia Ltd; 2011. 11. Turner S, Wellard S, Bethune E. Registered nurses’ perceptions of teaching: constraints to the teaching moment. Int J Nurs Pract. 1999;5:14Y20. 12. Elcigil A, Maltepe H, Esrefgil G, Mutafoglu K. Nurses’ perceived barriers to assessment and management of pain in a university hospital. J Pediatr Hematol Oncol. 2011;33(Suppl 1):S33YS38. 13. Schofield P, Jefford M, Carey M, et al. Preparing patients for threatening medical treatments: effects of a chemotherapy educational DVD on anxiety, unmet needs, and self-efficacy. Support Care Cancer. 2008;16:37Y45.
Cancer NursingTM, Vol. 37, No. 4, 2014
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Meinir Krishnasamy, PhD, RN Winnie Kwok-Wei So, PhD, RN Patsy Yates, PhD, RN Luz Esperanza Ayala de Calvo, MEd, RN Rachid Annab, BSc (Hons) Tami Wisniewski, RN Sanchia Aranda, PhD, RN
The Nurse’s Role in Managing Chemotherapy-Induced Nausea and Vomiting An International Survey
K E Y
W O R D S
Background: Nurses play a substantial role in the prevention and management
Cancer
of chemotherapy-induced nausea and vomiting (CINV). Objectives: This study set
Chemotherapy-induced nausea and vomiting
out to describe nurses’ roles in the prevention and management of CINV and to
Education
was completed by 458 registered nurses who administered chemotherapy to
Nurses
cancer patients in Australia, China, Hong Kong, and 9 Latin American countries.
identify any gaps that exist across countries. Methods: A self-reported survey
Results: More than one-third of participants regarded their own knowledge of CINV as fair to poor. Most participants (965%) agreed that chemotherapy-induced nausea and chemotherapy-induced vomiting should be considered separately (79%), but only 35% were confident in their ability to manage chemotherapy-induced nausea (53%) or chemotherapy-induced vomiting (59%). Only one-fifth reported frequent use of a standardized CINV assessment tool and only a quarter used international clinical guidelines to manage CINV. Conclusions: Participants perceived their own knowledge of CINV management to be insufficient. They recognized the need to develop and use a standardized CINV assessment tool and the importance of adopting international guidelines to inform the management of CINV. Implications for Practice: Findings indicate that international guidelines
Author Affiliations: Peter MacCallum Cancer Centre and Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Victoria, Australia (Drs Krishnasamy and Aranda and Mr Annab); Nethersole School of Nursing, Chinese University of Hong Kong, China (Dr Kwok-wei So); School of Nursing and Midwifery, Queensland University of Technology, Queensland, Australia (Dr Yates); School of Nursing, Pontificia Universidad Javeriana, Bogota, Colombia (Ms de Calvo); Merck & Co Inc, Whitehouse Station, New Jersey (Ms Wisniewski); Cancer Institute New South Wales, Sydney, Australia (Professor Aranda).
Managing Chemotherapy-Induced Nausea and Vomiting
This study was supported through a collaboration between the International Society of Nurses in Cancer Care and Merck, Inc, through an unrestricted educational grant. The authors have no conflicts of interest to disclose. Correspondence: Meinir Krishnasamy, PhD, RN, Peter MacCallum Cancer Centre, St Andrew’s place, East Melbourne, Victoria, Australia 8006 (meinir [email protected]). Accepted for publication July 2, 2013. DOI: 10.1097/NCC.0b013e3182a3534a
Cancer NursingTM, Vol. 37, No. 4, 2014
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should be made available to nurses in clinically relevant and easily accessible formats, that a review of chemotherapy assessment tools should be undertaken to identify reliable and valid measures amenable to use in a clinical settings, and that a CINV risk screening tool should be developed as a prompt for nurses to enable timely identification of and intervention for patients at high risk of CINV.
C
hemotherapy-induced nausea and vomiting (CINV) is a common problem occurring in the absence of antiemetic drugs in up to 99% of patients treated with highly emetogenic chemotherapy (HEC) and in 30% to 90% of those receiving moderately emetogenic chemotherapy.1,2 If inadequately controlled, CINV may have severe clinical consequences, including physiological complications such as dehydration, electrolyte imbalance, and malnutrition.3 Several studies have investigated the effect of CINV on health-related quality of life and have demonstrated that CINV can have a profound effect on people’s experience of cancer treatment.4Y7 Despite the use of antiemetic prophylaxis (including 5-HT3 receptor antagonists), this area of cancer care remains one of importance to nursing. Cancer nurses play a key role in the care of patients receiving chemotherapy. However, to do so, they require access to the most recent guidelines, the latest developments in CINV therapy, and expanded knowledge of CINV pathophysiology. In addition, nurses need training to ensure appropriate screening to identify patients at risk of CINV before chemotherapy begins and the skills to undertake a comprehensive assessment of CINV once treatment has been initiated. Studies have reported that patients’ needs are more fully met and their symptoms are better addressed when nurses take a lead role in CINV management.7,8 Although it is understood that nurses play a substantial role in CINV management in North America and Europe, little is known about their roles in the Asia-Pacific and Latin American regions. The capacity of nursing roles to influence patient outcomes with regard to CINV may be due to many complex factors, including access to pertinent education resources. Although beyond the scope of this study, the impact of culture on nurses and nursing’s capacity to drive cancer practice improvement is an important consideration. Attempts to generate evidence to standardize and improve international cancer nursing practice have not fully addressed culture as an influencing variable. This important variable warrants further exploration and discussion. With the well-documented increase in the projected global incidence of cancer, particularly in low- and middle-income countries, the importance of ensuring access to best-practice symptom management and treatment-related care through appropriately educated nurses in these countries is an imperative. In response to this, an international survey was proposed to develop an understanding of nurses’ roles in the prevention and management of CINV.
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Aims and Research Questions
The aims of the study were to explore nurses’ roles in the prevention and management of CINV through an international survey of their attitudes, beliefs, knowledge, skills, and practices E28 n Cancer NursingTM, Vol. 37, No. 4, 2014
in that area and to identify any gaps that may exist in CINV management. Five study questions were set: 1. What role do nurses play in the prevention and management of CINV? 2. How do nurses assess CINV risk? 3. What are nurses’ perceptions of the most commonly used antiemetic prophylaxis and rescue medications in both first line and refractory settings? 4. What are the key influences on nurses’ CINV practice? 5. What educational needs do nurses have in relation to the prevention and management of CINV?
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Methods
Sample Registered nurses who at the time of completing the survey cared for and administered chemotherapy to cancer patients were eligible to participate. This study, guided by Benner’s9 conceptualization of novice to expert, had no exclusion criteria based on length of time in the profession or experience of delivering chemotherapy, as we sought to be inclusive of the views of nurses with a broad range of experience and knowledge. Potential participants were approached via national nursing groups or the networks of study investigators in each of the participating countries: Australia (The Cancer Nurses Society of Australia); Hong Kong Special Administrative Region (Hong Kong) and China (nurses were approached to participate via contact through senior hospital staff ); and Venezuela, Colombia, Argentina, Panama, Chile, Puerto Rico, Peru, Costa Rica, and Mexico (contacts were identified and approaches coordinated by a senior clinical contact based in Colombia who was also a member of the survey project team). In addition, considerable support was also provided by representatives from a pharmaceutical company in the Latin American regions to help identify contacts for the institutional review board approval processes and for distribution of the surveys. It was not possible at the outset of the project to estimate the total number of nurses available for recruitment to the study. Instead, a sample size of 30 nurses per country was set as a pragmatic recruitment target given the scope and resources available to undertake the study and as a minimum number to enable meaningful comparison of data across national data sets. No power calculation was set.
Procedures Ethics approval was sought according to the requirements of individual participating institutions. After ethics approval was
Krishnasamy et al
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obtained, approaches to take part in the survey were made by local study coordinators to national nursing groups or individual contacts in cancer units or centers, as described above. A convenience sampling method was used to recruit eligible subjects. Before data collection, members of the research team liaised with local study coordinators to identify the best way to recruit eligible subjects. Thus, in Australia, eligible subjects could be reached through electronic communication means. The same approach was used to recruit eligible subjects in Latin America. However, electronic communication was not feasible in Hong Kong or Mainland China. Instead, a hard-copy survey was identified as the best way to collect data from eligible participants. Therefore, 2 different methods were used for data collection reflecting optimal recruitment methods across the different regions. Study coordinators were not given access to participants’ names. All invitations to take part (hard copy or electronic) and accompanying study information were distributed to potential participants through the nursing groups. No identifying information was collected and all data were anonymous and remained confidential. Where direct electronic access to nurses was not available or possible, an e-mail invitation prepared by the research team was made available to the nursing groups for distribution to their members. The e-mail included details of the study aims and objectives, invited participation, and provided a Web link to the survey Web site, where nurses were able to complete the survey online. Where a participant needed to complete a hard copy of the survey, this was distributed along with the study information either via the local study coordinator or national nursing group. Completed hard-copy surveys were returned to local study coordinators or nursing groups in sealed envelopes. Participants were unidentifiable.
Data Collection INSTRUMENT
The survey instrument was developed after a comprehensive review of the literature to identify key issues pertinent to the role of nurses regarding CINV. The survey contained 51 multiplechoice and open-ended questions and took approximately 25 minutes to complete. Participants were also provided with opportunity to respond to an ‘‘other’’ category, where detailed qualitative responses could be inserted to add context-specific data. Benner’s novice to expert framework was used to structure questions about participants’ perception of their level of expertise in chemotherapy nursing to provide a standardized taxonomy for grading self-reported perception of capability.9 A copy of the survey is available from the authors on request. In this article, data collected from the following areas were used for analysis: (a) demographics; (b) participants’ knowledge, attitudes, and practice related to care of patients experiencing CINV; (c) assessment of risk factors for and occurrence of CINV; and (d ) CINV management. The survey was reviewed by the research team for clarity, consistency of terms, response categories, and ratings and to enable item reduction. Nine expert chemotherapy nurses attending a cancer nursing conference (Cancer Nurses’ Society of Australia Winter Congress,
Managing Chemotherapy-Induced Nausea and Vomiting
2009) were invited to participate in a focus group to review the relevance, clarity, comprehensiveness, and ease of completion of the survey. The 9 Australian nurses were all English speaking and had formal cancer nursing qualifications. Minimal changes were made to enhance the clarity of the survey after this expert review. Further piloting was undertaken with nurses working in the chemotherapy day unit of a cancer center in Australia to clarify wording of the survey and the time needed to complete it. All eligible participants in Hong Kong were fluent in English and, on a daily basis, administered chemotherapeutic agents whose instructions were printed in English. English was the language used for the survey in Hong Kong. Three clinical nurse specialists or managers in Hong Kong were invited to review the English version of the survey to ensure its clarity for local participants. A forward-translation procedure was used to translate the English-language survey into the respective languages of participants from Mainland China and Latin America. In addition, a face validity test was carried out with 10 experienced oncology nurses from Mainland China and 5 nurses specialized in oncology from Latin America to ensure that the survey was readable and understandable. Minor changes were made to enhance the clarity of the questions and response options. The terms usually used for positions and academic qualifications in different countries were adopted. A brief explanation was provided to clarify ‘‘formal oncology training’’ and ‘‘formal chemotherapy training.’’
Data Analysis E-survey data remained in Survey Monkey, and hard-copy survey data were entered into Survey Monkey by a research assistant. Data were downloaded from Survey Monkey into Excel and transferred to SPSS V610 for analysis. Descriptive statistics were applied to establish key trends in the data set and identify similarities and differences within and across data from participating countries. Descriptive statistics included number, percentage, cumulative percentage, median, and frequency breakdowns of response sets. To ensure transparency of reporting, a decision was made to report findings as valid percentages, with missing values excluded on a question-by-question basis and the average proportion of missing values reported for each section.
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Findings
Overall, 503 nurses initiated participation in the survey. However, 45 nurses dropped out after completing section 1 of the questionnaire (demographic data), leaving 458 nurses who went on to complete the remainder of the survey. As such, data reported below are based on these 458 nurses only. The characteristics of the 45 nurses who dropped out are reported below. There was a considerable amount of missing data after the first section of the survey (on average 100 per question), particularly from those completing the survey online. This was possibly because the survey was quite long (taking approximately 25 minutes to complete) and the Survey Monkey format did not allow participants to save and return to the survey at a later time. Cancer NursingTM, Vol. 37, No. 4, 2014
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Table 1 & Demographic Profile of the
Participants (Valid N = 458)
Country Australia China Hong Kong SAR Latin America Current position Head nurse/nurse coordinator Clinic/staff nurse Clinical nurse specialist/advanced practice nurse Nurse practitioner Other Years of experience in nursing e1 91Y2 92Y5 95Y10 910Y15 915Y20 920 Years of experience caring for chemotherapy patients e1 91Y2 92Y5 95Y10 910Y15 915Y20 920 Health sector Public Private Other Current place of work Hospital inpatient clinic Hospital outpatient clinic Hospital day-treatment unit Community/home-based care Combination of clinics, units, and wardsa Other
n
Valid %
57 247 103 51
12 53.90 20.5 11.1
41 242 92 58 18
9.1 53.7 20.4 12.9 4.0
13 19 65 110 91 65 90
2.9 4.2 14.3 24.3 20.1 14.3 19.9
29 32 91 131 85 54 36
6.3 7.0 19.9 28.6 18.6 11.8 7.9
404 44 9
88.4 9.6 2.0
329 42 49 4 10 20
72.5 9.3 10.8 0.9 2.2 4.4
Missing values are as follows: current position = 7, years of experience in nursing = 5, health sector = 1, current place of work = 32. Abbreviation: Hong Kong SAR, Hong Kong Special Administrative Region. a This category was not included in the original questionnaires but was added during the analysis according to a logical grouping of results in the ‘‘other’’ category.
Demographics The demographic details of the 458 participating nurses are presented in Table 1. Characteristics of the 45 nurses who withdrew after section 1 differed very little from those who went on to complete all sections of the survey. Of the 45, 28 were Australian, 6 were Chinese, and 11 were South American participants, and 7 were identified as a head nurse/nurse coordinator, 4 as a clinic or staff nurse, 17 as a clinical nurse specialist/ advanced practice nurse, 6 as a nurse practitioner, and 3 as other. Data were missing for 8. Of the 45 nurses (53%), 24 had more than 20 years of nursing experience; the remaining 21 were spread evenly across the range of years of experience. Of the E30 n Cancer NursingTM, Vol. 37, No. 4, 2014
45 who dropped out, 13 (28%) had 15 to 20 years’ experience of chemotherapy, 28 (62%) worked in the public sector, and 18 (40%) worked in hospital day treatment units. Most of the participants who completed the survey had received at least a bachelor’s degree, 44% reported lower levels of education (diploma or associate diploma), and 11% reported higher levels (Table 2). Of the 45 who dropped out, valid percentages for level of education, oncology training, chemotherapy training, training requirement, and rated experience closely matched those presented in Table 2. There were no statistically significant differences between participants who completed the survey and those who withdrew. For the nurses who went on to complete the survey, only 54% reported formal training in oncology, although 4 others reported alternative training consistent with specialist recognition such as Oncology Nursing Certification. Formal training in chemotherapy had been completed by 53%, such training being a requirement for administration of chemotherapy for 76% of the participants. Formal oncology and chemotherapy training was defined as ‘‘a course approved by the working institution or
Table 2 & Education Profile of the Participants (Valid N = 458)
Highest level of education Diploma Associate’s diploma Bachelor’s degree Master’s degree Doctorate Postgraduate certificate/diplomaa Other Completion of formal oncology training Yes No Unsure Other Completion of formal chemotherapy training Yes No Unsure Other Requirement for chemotherapy training Yes No Unsure Other Self-rating of expertise in chemotherapy nursing Beginner Competent Expert Unsure Other
n
Valid %
43 169 174 42 5 8 12
9.5 37.3 38.4 9.3 1.1 1.8 2.6
248 155 50 4
54.3 33.9 10.9 0.9
241 157 51 6
53.0 34.5 11.2 1.3
345 74 31 4
76.0 16.3 6.8 0.9
66 308 74 6 4
14.4 67.2 16.2 1.3 0.9
Missing values are as follows: highest level of education = 5, completion of formal oncology nursing = 1, completion of formal chemotherapy training = 3, requirement for chemotherapy training = 4. a This category was not included in the original questionnaires but was added during the analysis according to a logical grouping of results in the ‘‘other’’ category.
Krishnasamy et al
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Table 3 & The Top 5 Factors Influencing
Chemotherapy-Induced Nausea (CIN) and Chemotherapy-Induced Vomiting (CIV) Rank
Factors impacting on nausea Type of chemotherapy drug Dose of chemotherapy A history of CIN A history of CIV Anxiety Factors impacting on vomiting Type of chemotherapy drug Dose of chemotherapy History of CIN Route of administration Number of cycles of chemotherapy Factors Influencing CIN and CIV Drug addiction Psychiatric history Level of alcohol intake Gender Age Type of cancer History of nonYchemotherapy-related nausea Taste changes NonYchemotherapy-related vomiting
n (Valid %)
1 2 3 4 5
453 447 442 441 409
(99) (98) (98) (98) (93)
1 2 3 4 5
439 437 433 431 424
(85) (85) (84) (84) (83)
CIN, n (Valid %) 171 154 139 75 62 60 50
(38) (35) (31) (17) (14) (13) (11)
50 (11) 48 (11)
CIV, n (Valid %) 163 154 142 76 67 67 53
(38) (35) (33) (17) (15) (15) (12)
50 (11) 48 (11)
professional association; where participants obtained a certificate after completion and, the course undertaken provided evidence that the nurse had met the required competence.’’ Using Benner’s9 novice to expert framework, participants were asked to rate their level of expertise in chemotherapy nursing. Most (67%) rated themselves as ‘‘competent’’; 16%, as ‘‘expert’’; and 14%, as ‘‘beginners.’’ Of the 45 nurses who dropped out after section 1, 79% had received formal training in oncology. Formal training in chemotherapy had been completed by 84% and was a requirement for administration of chemotherapy for 79%. Most (51%) rated themselves as ‘‘expert’’; 36%, as ‘‘competent’’; and 11%, as ‘‘beginners.’’
Perceived Knowledge, Attitudes, and Management With Respect to CINV (n = 438Y448) Personal knowledge about CINV risk assessment was perceived to be adequate or advanced by most participants (57%), but more than 40% identified their risk assessment knowledge as only fair to poor. Similarly, a significant proportion of participants rated as fair to poor their knowledge of definitions of CINV (44%), antiemetic prophylaxis (33%), rescue medications (41%), and nonpharmacological interventions (58% chemotherapy-induced nausea [CIN] and 61% chemotherapy-induced vomiting [CIV]).
Managing Chemotherapy-Induced Nausea and Vomiting
Most participants (79%) agreed that CIN and CIV should be considered separately for assessment and management but disagreed (67% CIN and 73% CIV) that patients could largely manage CINV themselves with little intervention from healthcare staff. Most agreed (91%) that the recommended treatments used in their clinical areas were effective and that their patients took an active role in managing their own CINV (90%). Participants agreed or strongly agreed that the role of the nurse was important in assessing (82%), managing (76%), and educating patients about (81%) CINV. Most (965%) also agreed or strongly agreed that they were confident in their ability to assess CIN and CIV. However, fewer participants agreed or strongly agreed that they were confident in managing CIN (53%) or CIV (59%). Most (81%) reported that they provided patient education often or very often, but only 67% agreed or strongly agreed that they were confident with this aspect of their role.
Knowledge of Acute, Delayed, and Anticipatory Vomiting and Factors Impacting on CINV Most participants correctly identified acute vomiting as occurring within 24 hours of starting chemotherapy (94%; total valid response = 438Y448), delayed vomiting as occurring more than 24 hours after treatment (94%), and anticipatory vomiting as occurring before treatment (90%). Most nurses rated the chemotherapy dose, administration route, number of cycles of chemotherapy, history of nausea (nonYchemotherapy related), history of CIN, history of CIV, and anxiety as somewhat or very influential on the patient’s experience of CIN and/or CIV (Table 3). In contrast, a history of nonYchemotherapy-related vomiting, the type of cancer, age, gender, and taste changes received more mixed responses. Most participants were unsure that the level of alcohol intake, a history of drug addiction, and a psychiatric history were important influences on the patient’s experience of CIN and CIV (Table 3). Table 3 indicates that there was an important group of participants who were unsure about the influence of various factors on CIN and CIV. This is an important finding given that there is a considerable body of evidence to support the impact of such factors on the experience of CINV.
Assessment and Management of CINV Nurses reported being often or very often involved in CINV assessment of the occurrence of CINV (n = 435; 66%), with most (73%) indicating that their assessment distinguished between nausea and vomiting. However, only 20% of 356 participants reported often or very often using a standardized CINV assessment tool. International guidelines were reported as guiding assessment of occurrence of CINV assessment by 26% of the responding sample, whereas 45% used locally developed guidelines or protocols (Table 4).
Pharmacological Strategies to Manage CINV Where participants were asked to respond to questions relating to pharmacological strategies, they were provided with both group Cancer NursingTM, Vol. 37, No. 4, 2014
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Table 4 & Management of Chemotherapy-Induced Nausea and Vomiting (CINV) in the Workplacea
Management Guided by
n
Local clinical guideline/protocol International clinical guideline/protocol Unit-developed management plan Nurse clinician’s knowledge Physician’s preference
191 111 167 261 137
Valid % 44.6 25.9 39.0 61.0 32.0
a Of 458 respondents, 428 answered this question. Thus, 428 was used as a denominator to calculate valid %.
names and examples of the different drugs. The most common drugs used to treat both aspects of CINV were 5-HT3 receptor antagonists, corticosteroids, antihistamines, benzamides, and benzodiazepines (Table 5). However, there were high rates of uncertainty regarding some drugs used as part of CINV management regimens (Table 6).
CINV if it occurred away from the hospital (50%), and how to distinguish among anticipatory, acute, or delayed CINV (50%). Participants were asked to indicate the frequency with which they provided patients with self-care advice about a range of strategies. Overall, 234 (70%) participants reported often or very often providing self-care advice to patients receiving chemotherapy. However, a larger proportion of participants (n = 417Y377) answered the questions on the frequency of providing advice about specific self-care practices (Table 9). Participants who were rarely or never involved in patient education about CINV were asked to identify reasons. The most common reasons for influencing (sometimes, often, or very often) the nurse’s role in patient education were that it was provided by physicians (n = 58), the nurse’s knowledge was insufficient (n = 51), nurses did not have enough time to provide instruction (n = 70), printed information was provided in place of a nurse’s intervention (n = 64), or patient education was delivered elsewhere (n = 42).
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Nonpharmacological Strategies to Manage CINV When asked how often nonpharmacological methods were recommended for the management of CINV in their workplace, 48% of the 411 valid responses indicated often or very often. Table 7 lists the frequencies with which each of the nonpharmacological strategies was reported as being recommended, at either pretreatment or posttreatment stages, or for prevention of CINV.
Patient Education Participants (n = 438Y443) reported specific topics that they often or most often included in CINV patient education (Table 8). The 4 most common topics were antiemetic prophylaxis and how to take medications (98%), rescue medications and how to take them (91%), types of emetogenic agents used (84%), and how to identify any adverse effects needing to be reported to a health professional (84%). However, fewer participants taught participants about the pathophysiology of CINV (24%), how to record
Discussion
This article makes a valuable contribution to existing literature that continues to show that nurses need ongoing evidence-based education and ready access to resources to deliver optimal care for people experiencing CIN and CIV. The requirements for recognition of and education for the assessment and management of CIN and CIV as discrete problems has been strongly demonstrated through the survey findings. Overall, those responding to the survey were experienced oncology nurses working in public hospital environments. Most agreed that assessment and management of CINV were an important part of their role. There are limitations to the data, as described below, notably the number of participants who dropped out after completing section 1. In general, the participants demonstrated good general knowledge of CINV, but some important gaps were also identified, which provide useful information about how to improve nurses’ knowledge and delivery of education regarding CINV assessment and management. Specifically, many participants did not feel confident in their ability to assess and manage CINV, which might be because of
Table 5 & Common Pharmacological Agents to Manage Chemotherapy-Induced Nausea and Vomiting (CINV), by Rank
Rank
Pharmacological Agents to Manage CIN (n)
%
Rank
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
5-HT3 receptor antagonists (426) Corticosteroids (393) Antihistamines (382) Benzamides (371) Benzodiazepines (340) Neurokinin-1 antagonists (291) Domperiodone (266) Butyrophenones (264) Phenothiazines (254) Cannabinoids (228)
83 77 74 72 66 57 52 51 49 44
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Pharmacological Agents to Manage CIV (n)
%
5-HT3 receptor antagonists (395) Corticosteroids (395) Antihistamines (372) Benzamides (357) Benzodiazepines (330) Neurokinin-1 antagonists (281) Butyrophenones (254) Phenothiazines (247) Domperiodone (243) Cannabinoids (217)
77 73 73 70 64 55 49 48 47 42
Abbreviation: CIN, chemotherapy-induced nausea.
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Krishnasamy et al
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of knowledge and insufficient time were also reported as the commonest barriers to the delivery of nurse-led patient education.12 There was high level of use of 5-HT3 receptor antagonists among the respondents, in keeping with best-practice guidelines.1,2 Although it was not possible to deduce from the survey data whether the 5-HT3 agents were routinely used in combination with corticosteroids for high and moderate emetogenic chemotherapy regimens, the reportedly high use of both agents indicates that this may be the case in practice. Similarly, the high use of 5-HT3 agents and corticosteroids may indicate compliance with consensus guidelines for prevention of CINV for moderate and low emetogenic chemotherapy, where administration of a 5-HT3 agent or corticosteroid is recommended.1,2 Evidence to inform management of delayed CINV (2Y5 days after chemotherapy administration) is equivocal. However, the European Society for Medical Oncology and Multinational Association of Supportive care in Cancer guidelines1,13 is that a multiday oral corticosteroid (dexamethasone) should be prescribed for patients receiving chemotherapy who are at moderate emetic risk, whereas the NCCN recommends aprepitant with corticosteroids in the delayed phase for select patients receiving chemotherapies of moderate emetogenic risk2 or that a combination of dexamethasone and aprepitant should be used to prevent delayed CINV in patients receiving a combination of high emetogenic regimens. International consensus guidelines1 advocate the inclusion of a neurokinin-1 antagonist with a 5-HT3 receptor antagonist and corticosteroid when HEC agents are prescribed. The relatively low reporting of the use of neurokinin-1 antagonists in this survey (approximately 50%) may be indicative of the chemotherapy regimens being administered or of limited access to these relatively novel agents in diverse settings.
Table 6 & Participants Reporting Uncertainty
About Types of Pharmacological Agents Used in the Management of Chemotherapy-Induced Nausea (CIN)/Chemotherapy-Induced Vomiting (CIV) CIN
Agent Cannabinoids Phenothiazines Domperidone Butyrophenones Neurokinin-1 antagonists
CIV
n
Valid %
n
Valid %
207 191 157 110 97
91 75 59 42 33
189 182 136 108 91
87 74 56 43 32
the low proportion using a standardized CINV assessment tool, their reliance on clinical knowledge rather than international clinical guidelines, and the fact that almost half lacked formal chemotherapy training. Participants covered most of the essential CINV topics in patient education, but special attention should be paid to those topics covered by a lower proportion (differences between nausea and vomiting; distinguishing between anticipatory, acute, or delayed CINV; and the pathophysiology of CINV). Education of patients on the difference between antiemetic prophylaxis versus treatment is an important topic particularly for patients prescribed HEC.1 Educating patients about how to use their medication is essential to optimizing prophylaxis and treatment of CINV. Similarly, educating patients about how to record CINV occurring away from the hospital is essential to enable self-care and ensure that patients know to contact health professionals in a timely manner when adverse effects occur. Lack of clarity about their role as key providers of patient education was evident in the data reported and has been reported elsewhere as a factor impacting nurses’ contribution to patient education.10 Insufficient knowledge was also identified as a barrier to delivering patient education by nurses in this study, but heavy workload (previously cited by others11) and limited nursing time were also cited as key impediments. In a recent study to examine nurses’ perceived barriers to pain management, lack
n
Limitations
This study had several limitations. Despite attempts to ensure a rigorous approach to translation of the English survey into Spanish, errors in translation occurred that led to the exclusion of responses from the Latin American participants to several items. The term pathophysiology was accidently mistranslated in
Table 7 & Use of Nonpharmacological Management Strategies for Chemotherapy-Induced Nausea and Vomiting (CINV)
Nonpharmacological Strategies Distraction Relaxation Visualization Massage Acupressure Aromatherapy Acupuncture Reflexology TENS
Valid N
Pre-Tx N
Post-Tx N
Prevention N
Total N
367 368 366 367 368 366 368 368 368
243 216 117 53 33 28 22 22 4
220 201 105 73 72 43 60 44 16
147 154 72 47 30 36 19 34 9
610 571 294 173 135 107 101 100 29
Abbreviation: TENS, transcutaneous electrical nerve stimulation; Tx, treatment.
Managing Chemotherapy-Induced Nausea and Vomiting
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Table 8 & Specific Chemotherapy-Induced Nausea and Vomiting (CINV) Topics That Nurses Taught Patients About Often or Very Often, by Rank
Rank 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. a
Specific Topic of CINV
N
%
Antiemetic prophylaxis and how to take medications Rescue medications and how to take them Types of emetogenic agents used How to identify side effects that need to be reported to a health professional Nonpharmacological and self-care strategies to reduce likelihood of developing CINV Nonpharmacological and self-care strategies to cope with CINV How to communicate with health professionals about CINV Discussing factors likely to increase CINV Discussing the difference between nausea and vomiting Distinguishing between anticipatory, acute, or delayed CINV How to record CINV if it occurs away from the hospital Providing education about the pathophysiology of CINVa
348 346 348 343 343 312 348 342 344 345 344 314
98 91 84 84 83 83 80 78 55 50 50 24
This question was wrongly worded in the Spanish survey and not used here.
the online Spanish version of the questionnaire as psychophysiology. The data for this question were therefore split into 2 variables, 1 for the English online version of the question and 1 for the Spanish online version, each of which was presented separately in the data analysis output. One option (relaxation) of nonpharmacological strategies to cope with CINV was missing in the Spanish online version of the questionnaire. Because of a typographical error, the Spanish version had an extra question presented to the respondents in the survey section relating to the ‘‘Clinic’’ environment. As a result, any response data to this question were removed from the data set. Response rates from Australia and the Latin American countries were low, with only 85 nurses participating in Australia and 62 from across Latin America. The back-translation method is a more respected translation process than the forward-translation used in this study, although both are commonly used methods to ensure conceptual and semantic equivalence. Although a sample size of 30 nurses per country was set as a pragmatic recruitment target, it proved impossible to achieve this because of contextual variations in access to nurses across the participating sites. Because of the low numbers responding from each of the Latin American countries, data were grouped and considered as a discrete data set. Large numbers of participants dropped out after completing section 1 (on average 100 per question). This hampered the capacity to undertake analysis beyond a descriptive reporting of the data set. Response rates may also have been affected to a lesser extent by the length of the survey, the repetitive nature of the questions (in an attempt to distinguish responses to nausea and vomiting as discrete problem), and inability to save responses and return to complete the survey at another time. There was evidence that participants responded inconsistently to several items, suggesting lack of understanding of the questions or nomenclature, for example, the high number of nurses identifying themselves as nurse specialist, advanced practice nurse, or nurse practitioners yet classing themselves as being only ‘‘competent’’ in chemotherapy administration. This serves to highlight the complexity of undertaking international surveys of this kind, where multiple translations are necessary and there is little consistency around nursing role, education, or training terminology across E34 n Cancer NursingTM, Vol. 37, No. 4, 2014
(and sometimes within) countries. For example, someone who calls himself/herself a nurse practitioner may in some countries be someone who practices as a nurse. Participants were accessed from national groups and networks known to the study team, potentially introducing a bias in the selection of nurses. However, individual participants and their level of skill, knowledge, and experience were unknown to the study team. In addition, demographic data indicated participation by nurses from diverse healthcare settings, including tertiary centers and general hospitals.
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Implications
Education for nurses is an essential strategy to enable best practice regarding CINV. The knowledge gaps identified demonstrate the need for the development of clinically relevant screening and assessment tools for use with patients experiencing CINV. Nurseled models of chemotherapy education have been shown to
Table 9 & Self-care Advice Given to Patients Rank
Self-care Advice
n (Valid %)
1. 2. 3.
Have small meals often. Prepare small meals and eat a little often. Avoid fried foods or those with a strong smell. Take frequent sips of fluid. Eat several small snacks/meals and chew food well. Sip drinks slowly. Avoid drinking before meals. Eat food warm or cold if the smell makes you feel sick. Ginger products can help. Take antacids. Use peppermint or peppermint tea. Take vitamin B6.
386 (93) 380 (93) 379 (91)
4. 5. 6. 7. 8. 9. 10. 11. 12.
335 (82) 277 (69) 239 (61) 208 (55) 220 (54) 156 147 139 91
(39) (38) (36) (24)
Krishnasamy et al
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reduce supportive care needs and enhance self-efficacy in patients undergoing cancer chemotherapy.12 Implementation of nurseled chemotherapy education programs has the potential to improve communication between nurses and patients, ensuring that patients receive essential and tailored information to meet their knowledge-based needs. Development of training programs for all nurses who deliver chemotherapy, with an emphasis on the implementation of best-practice as articulated in international clinical guidelines, is a priority if all patients are to receive quality cancer care. More attention should be given to the translation and interpretation of the international guidelines to ensure conceptual and semantic equivalence as well as relevance to a particular country or region.
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Conclusions
This study set out to examine the role of nurses in the management of CINV and to identify gaps that exist. Study participants demonstrated good general knowledge of CINV, but some important gaps were also identified. This survey has generated useful information to inform and prioritize the educational needs of nurses to optimize CINV assessment and management. Of note, our data indicate that more attention be given to the development and implementation of clinically applicable screening and assessment tools to help nurses identify patients at high risk of CINV and to help them better assess and manage CIN and CIV as a matter of urgency. Widespread adoption and promotion of international guideline recommendations for the prevention and management of CINV are highly recommended. Nurses undertake an extensive role in the assessment and management of CINV. Enabling them to do so to the best of their ability through adoption of evidence-based guidelines is essential to the delivery of quality cancer care.
Managing Chemotherapy-Induced Nausea and Vomiting
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