Oncology nurses in their professional life experience unique, challenging and rewarding relationships in a multidimensional way. The aim of this study was to describe, from their perspective, how they experience and react to this world and how much are they satisfied with their work. Through this study, I want the oncology nurse’s voice to be heard and that the derived data to be applied to the benefit of the field of oncology at least in the specific area where the study is performed. In-depth, semi-structured phenomenological interviews were done. Findings show that the oncology nurses, dealing with cancer patients and their families, experience many different relationships, rewarding experiences and stressors and a number of ways of their coping with them. The challenging interpersonal relationships with management and other members of the health care team are also highlighted. This enables the oncology nurse to be both on the giving and receiving end of the intensely emotional environment they work in.
LITERATURE REVIEW
According to World Health Organization, deaths from cancer are on a rise with an estimate of 12 million deaths in 2030. (Fact sheet, feb 2009). The majority of nurses, in all practice settings, will feel the impact of the disease at some time during their career and this impact affects the care they provide. According to Bott, M., Endacott, R., Watts, R. (2006), “The nurses in this study reported that they constantly faced a number of professional and personal issues when addressing the practical, emotional, and psychological demands of patients with cancer. There was a general recognition of the uniqueness of each patient’s needs and that these needs could change over time whether it be the timing of the provision of information or assisting the move from curative to palliative treatment”. According to Papadatou, D., Papazoglou, I., (2002), “It became apparent that health professionals’ grieving process was affected by how they perceived their role, interventions, and contribution in the care of the dying child, which in turn was influenced by the social and cultural context in which care is provided to children with cancer” (p.1).
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The oncology nurse is challenged by the fact that every cancer case, every type of cancer the course of every cancer illness and the way patients and families responds to this illness is different. Now, more than ever, competent nursing care is a basic right of cancer patients and their families alike. Every individual expresses grief differently and same is the case with health care providers of terminally ill patients. According to Papadatou, D., Papazoglou, I., (2002),”Physicians’ grief reactions involved crying, sadness, withdrawal, and recurring thoughts of the dying conditions and the death of the child. They frequently reported guilt feelings and an active search for philosophic explanations that would make their distress more tolerable. They rarely sought support among colleagues and experienced grief as a private affair”.
In addition to grieving, nurses undergo a number of stressors while working with dying patients and to cope up with them, supportive, constructive and understanding work environment is essential which would aid in improving job satisfaction. According to Bott, M., Endacott, R., Watts, R. (2006)., “The findings from this study suggest that professional support is an area that may be improved in an effort to improve job satisfaction”.
Besides this, it is important to note that professionals working with cancer patients will need the necessary knowledge and skills to acknowledge and explore patient’s feelings if they want to give them the reassurance and care they need. It then becomes obvious that significant demands are placed on nurse’s skills, knowledge and emotional resources. According to Bott, M., Endacott, R., Watts, R. (2006),”They found that nurses’ self-perceived educational needs in caring for patients with cancer included the need for more knowledge and skills in providing psychosocial care and communication”.
In order to provide holistic care, lots of things need to be born in mind. According to Rooven. V., Roux, D.L., & Kotze, W.J. (2008)., “the multifactorial effects of cancer have a serious impact on the psychological wellbeing of the oncology patient. For oncology nurses who want to render holistic care to patients and their family, these have important implications.”
The aim of the study is to explore the perceptions of oncology nurses and ruling out what affects the care they provide.
PROBLEM STATEMENT
Since I work at an Oncology Unit, I come across a number of terminally ill cancer patients regularly and I know that, in providing for the unique needs of cancer patients and their family, a broad variety of experiences and feelings are encountered. Therefore, I would like to explore that what do oncology nurses feel while caring for such patients and that whether their experiences are limited to extremely stressful feeling or it can be rewarding as well. These experiences, and how nurses cope with them, are illuminated in the interviews and their analysis.
In order to highlight the above problem statement, the research question is formulated as: What are the Oncology Nurse’s lived experiences and perspectives about end of life care of terminally ill Oncology patients?
The objective of this study was to accurately describe the lived experiences of the participating oncology nurses.
RESEARCH DESIGN AND METHODOLOGY
This study was based on a qualitative, explorative, and descriptive research design of inquiry. The focus of the study guided the selection of the participants. Purposive sampling design was used. All of the participants were, at the time of the research, working full time in the specified oncology unit. The sample included eight registered nurses with an experience of about two years or more.
Participants were informed about the aim of the study, the voluntary and confidential nature of their participation, as well as of the possible benefits and outcome of the study and permission to do this study. For this, informal informed consent was taken by all participants.
DATA COLLECTION
The data was analyzed and was initially systematized and then core themes and sub themes were identified. Semi structured interviews were conducted and open ended questions were asked. Questions focused around five major themes. These included their interest in Oncology (did they chose working in Oncology as their practice areas by themselves), their perspective about terminal illness, motivation to work in the field (what factors made them continue working in Oncology), major challenges and responses (how they managed with the stressors they come across while dealing with patients and the work environment) and satisfaction with work. These themes were based upon the research questions that guided the study. The sub themes included nurse’s personal experiences with death and illness, stressors and rewards, their coping mechanisms, their degree of satisfaction and whether they desire to stay or leave the unit.
DISCUSSION OF FINDINGS AND RESULT
The participants shared different experiences, both positive and negative. One central theme was common. All of the participants experienced that the field of Oncology, though challenging and highly demanding is very unique and rewarding as well. They dealt with difficulties and knew how to cope up with them. The analysis follows as:
Decision to work in the field of Oncology
All the participants had an experience of about more than two years, while it ranged from 2.1 to 12 years. Most of the nurses didn’t decided by themselves to join oncology. They were assigned by hospital administration (nursing services). The nurses reported that they were initially unhappy and anxious because it was not their prioritized area. However, within a short span of time, they reported to overcome their reservations.
Terminal illness
The analysis showed that a number of participants took terminal illness as a stressful event. They related terminal illness with poor prognosis, where no other treatment option works and when death is near. They reported that they associate terminal illness with hopelessness. They felt that when there is no hope of living and no cure could be done and when death is near, the stage is terminal illness. This feeling, they said is very upsetting because one knows that there is not a lot that could be done. Comfort care is the only cure for their patients at this stage of their disease.
Motivation to serve oncology
Despite a number of stressors, oncology nurses highlighted significant rewarding experiences as well that motivated them to work in oncology. These included caring for someone who is in much greater pain and discomfort than any other patient with any other form of illness. Participants reported that cancer is a suffering and is a disease that progresses gradually. When one sees their patient deteriorate slowly over time, losing their energies to fight back, it becomes a responsibility for them who know the required knowledge and skill to help alleviate their suffering and pain. A few also reported that they come across the feeling of sympathy when they see them suffer and this makes them work in every possible way they can. Others feel empathetic towards them. Some reported that caring in last days of suffering patients gives them a sense of satisfaction. One of them reported that it is like a worship to care for them.
Major stressors and challenges they encountered
Two main categories of stressors were highlighted. Firstly, difficulties related to the poor prognosis and death of cancer patients and secondly, work place stressors.
Findings reveal that the major stress resulted because the participants felt powerless and helpless because of their inability to decrease the pain and discomfort that resulted because of the course of disease and the side effects of the treatment modalities (chemotherapy and radiation). Other stressors included the denial of patients about their progressive disease and the denial of families at the announcement of death of their loved ones. Dealing with the grief the family members feel and their non acceptance becomes a challenge for the participants. The participants reported that they feel depressed and worried about uncertain situations that could happen any time with their patients. Sometimes, it is very difficult to explain patients and families about their disease prognosis as well as their treatment options because of their different level of intellectual understanding and because of their varied languages and multiple cultural influences. Responses to death differs form custom to custom. Few of the participants also reported that some times, on the announcement of death, families respond strangely and that their violent behavior becomes a threat to the security of other patients, their families and the working health care team. Besides, a few participants stated that after their patients depart, when they go back into the departed patient’s room or at their bed-side, they recall all the memories of them and become upset. Few participants reported that since they cannot directly help the families financially, seeing them suffer from economic crisis is also very difficult.
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Other findings reveal that there are other areas of concern that are challenges for the participants. These include shortage of nursing staff at the time of acute emergency. Because of the staff turnover, nurse’s retention is less which leads to heavy work load upon remaining working staff. The participants reported that since oncology is a critical area and is very demanding and challenging in terms of quality of time required by dying patients and their families, more of the skillful and competent nurses are needed to carry out the need. Others say that since nurses have been recruited in oncology not on the criteria of priority, they are less skillful and competent to deal with acute oncology emergencies and grieving processes. This becomes another big challenge. Interpersonal relationships with colleagues and other members of the multidisciplinary team is sometimes also a constraint in providing quality care to patients.
Coping strategies
There was a balanced response when the question regarding the impact of the care they provide under stress, was asked. Participants reported that it does not affect them at all, because they see patients as someone in dire need of their service and they do their best in all sorts of circumstances with their knowledge and skills. However, there were others who said that when mentally disturbed, care is affected. Cancer patients consume more time than other patients and in providing them so, rest of the patients gets less attention. On the question about how they cope up with these challenges and stressors, multiple responses were gathered. Participants reported that they seek in-depth knowledge on the specific disease and its management and practice more in order to remain confident while dealing with their patients and communicating with their families. Besides, they work with interdisciplinary team to approach positively to the patients. This includes seeking support and help from doctors, nutritionists, pharmacists, radiographers, pain management team etc. Some reported that since they know that there is no other who could take care of them competently, they are the only ones. This thought gives them motivation to move on and remain optimist and hopeful. Additionally, there were some, who said that they were fortunate enough to get such a huge opportunity to help the sufferers. There were some, who shared that the management personnel help them in managing their daily stressors. They counseled them with their knowledge and experience and guide them well. Few also mentioned that discussing issues with their colleagues and close friends in their available time helps reduce their stress. Few also shared that the more they communicate with patients and families, they more they feel relaxed and positive to move ahead.
Satisfaction
There are different responses over the question of degree of satisfaction while working in oncology. Few of the participants replied in assertion. They stated that they are very satisfied with the type of work they do. They justified this by giving reasons that they are blessed to have an opportunity to serve someone who needs them the most and since they have, with time, learnt the skills and have knowledge how to manage such patients, they have a desire to do more for them. There were others, who stated that they are not satisfied in oncology and feel that this domain of nursing is depressing, cancer is not curable despite you put in all your efforts and that life for these patients is miserable. A feeling that cancer patients will depend upon their families one day completely in doing all activities of daily living, is bad and they cannot see these patients suffer that badly.
Despite of all of whatever participants highlighted, no one reported to have a desire to leave the field of oncology. All reported that they have with time, adjusted in the field, caring for such patients and they never want to leave them. They said that despite of our dissatisfaction with the field, we have adjusted to work with the dissatisfaction and there still is feeling to work for them.
When asked, what should be done to improve job satisfaction, they enumerated a number of things. Motivation, positive feedback and appreciation from the management will help them a lot. Besides, staff counseling on a regular basis and frequently allowing staff members to ventilate their feelings will be of beneficence. Additionally, staffing should be adequate and more on that, competent, skillful and responsible staff nurses are needed and that nurses who are interested in joining oncology should be given priority by the nursing services to work in the field. Moreover, application of nursing theories should be included in practice. Management should give ample time to increase the knowledge, skills and application of the critical concepts of oncology.
LIMITATIONS OF THE STUDY
The specific limitations that enumerated below:
1. Because of the sample size and the nature of the study, generalizing the findings is difficult. However the richness of the data provides insight into the experiential world of the oncology nurses.
2. Interviews were conducted only in one teaching tertiary care hospital’s oncology unit. It did not included data from out-patient settings.
RECOMMENDATIONS FOR FURTHER RESEARCH
In the light of research findings and limitations, following recommendations for nursing practice, education and research is formulated:
1. A detailed support programme could be developed for oncology nurses in order to rule out their stressors and find ways to resolve them and that management needs to be sensitized regarding the unique needs and challenges of oncology. This can be done by organizing frequent meetings and discussion sessions with them, hence boasting up job satisfaction.
2. More emphasis should be given from the management side to assess and facilitate the nurses about core concepts of oncology and palliative care.
3. In-service programmes and workshops need to be developed to enhance the skills of nurses working with terminally ill patients.
4. The management should consider the need for increasing number of competent care providers for such a critical and demanding field of oncology.
5. Themes identified from the study could be explored more using quantitative research approach.
CONCLUSION
The study provided evidence that the field of oncology is a unique field that differs in many respects from other areas of nursing. Nurses in oncology, more than any other field, recognize the essence of giving. They recognize that an important dimension of being human is the lasting dignity that should be continued throughout the chronic illness of cancer. A lot needs to be done to soothe the dying clients. Field specific knowledge, hands-on skills and positive attitude is all that is required to meet the challenges of the filed.
REFERENCES AND BIBLIOGRAPHY
Bott, M., Endacott, R., Watts, R. (2006). Barriers in Providing Psychosocial Support for patients with cancer. Cancer Nursing. 29(4):309-316. Retrieved from http://www.medscape.com/viewarticle/543718.
Fact sheet, Feb 2009, World Health Organization. Retrieved from http://www.who.int/mediacentre/factsheets/fs297/en/.
Papadatou, D., Papazoglou, I., Bellai, T., & Patraki, D. (2002). Greek Nurse and Physician Greif as a result for caring for children dying of cancer. Pediatric Nursing.28 (4). Retrieved from http://www.medscape.com/viewarticle/442676_1
Rooven. V., Roux, D.L., & Kotze, W.J. (September 2008). The experiential world of the Oncology World. The free Library. Retrieved from http://www.thefreelibrary.com/The+experiential+world+of+the+oncology+nurse-a0184644146
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