ONCOLOGY NURSING CARE STANDARDS

Oncology is the study of malignant neoplastic diseases generally referred to as cancer (Baldonado & Stahl, 1982: 1). Oncology nursing is the nursing of patients suffering from some form of neoplastic pathology. As a disease, cancer has been known thoughout r e ^ r d e d h isto ry . H ippocra tes h im self d ^ ^ ib e d many types of neoplasm and he probably coined the term carcinoma (Kahn, Love, Shermand & Chakravorty, 1983: 3). Until the late 1950’s, because of the apparently incurable nature of the disease, a diagnosis of cancer was viewed by both the patient and health care provider, as a death sentence. However, advances in surgical techniques, rad ia tio n th e ra p y , c h e m o th e ra p y and immunotherapy have greatly altered prognoses for the better. Today it is estimated that 40% of diagnosed neoplasms are curable and 15% of the remaining have a life expectancy greater than 15 years (Dietz, 1981: 3).

Oncology is the study of malignant neoplastic d iseases g en erally referred to as cancer (Baldonado & Stahl, 1982: 1).O ncology nursing is the nursing of patients suffering from some form of neoplastic pathology.As a disease, cancer has been known thoughout r e ^r d e d h isto ry .H ip p o c ra te s h im s e lf d ^^ib e d many types o f neoplasm and he probably coined the term carcinoma (Kahn, Love, Shermand & Chakravorty, 1983: 3).Until the late 1950's, because of the apparently incurable nature of the disease, a diagnosis of cancer was viewed by both the patient and health care provider, as a death sentence.However, advances in surgical techniques, ra d ia tio n th e ra p y , c h e m o th e ra p y and immunotherapy have greatly altered prognoses for the better.Today it is estimated that 40% of diagnosed neoplasms are curable and 15% of the remaining have a life expectancy greater than 15 years (Dietz, 1981: 3).
Therapy, however, may cause primary and/or secondary disabilities and the patient is exposed to many difficulties.Not only is his future unpredictable but the methods of treatment used to alleviate his condition are often very toxicand mav induce a variety of unpleasant side effects a^P^oblem s.Most patients receive a course of ch em o th erapeutic drugs and/or radiation therapy as part of their treatment regimen.Successful therapy depends upon meeting the individual needs and carrying out evaluation of the quality of care on an ongoing basis.This V aluation of the quality should take into consideration the potential course and outcome of the disease (Dietz, 1981: 172-173).
The oncology nurse plays an important role in the multiprofessional treatment regimen and is accountable for rendering quality nursing care.Nurses are, however, unable to objectively and formally evaluate the quality o f oncology nursing care due to a lack of standards and evaluation instruments in this regard.Standards guide the nursing practice and will help to monitor the quality of nursing care rendered in the oncological nursing unit.
The purpose of this study is to formulate oncology nursing care standards for a particular hospital.

LITERATURE REVIEW
O ncology nursin g care is a m ultifaceted speciality which deals with patients who may be at any point on the health-illness continuum ranging from the high risk patient needing information about prevention to the patient needing comfort and support duri ng dy i ng.Few medical diagnoses convey so dramatically and unambiguously the spectre of death as does cancer.From the moment of detection and diagnosis, the certainty of mortality influences the behaviour of both the patient and the medical care team.Consequently it is important that those involved in patient treatment and support examine their own attitudes toward cancer and death before attem pting to care for others (Portlock & Goffinet, 1986: 295).Oncology nursing care therefore requires special nurses.
The professional responsibilities of a registered nurse are em bodied in the South African Nursing Council (1984) regulation relating to the scope of practice of persons who are registered or enrolled under the Nursing Act (RSA, 1978).
T he re g iste re d nurse is resp o n sib le for sc ie n tific a lly b ased p h y sic al, chem ical, p s y c h o lo g ic a l, s o c ia l, e d u c a tio n a l and technological nursing care.This therefore requires specialised knowledge on the part of the nursing staff in an oncology nursing unit and meeting the basic health needs of the oncology patient becomes a specialised area of nursing.
The professional responsibilities also include p r e v e n tiv e , p r o m o tiv e , c u r a tiv e an d rehabilitative aspects of nursing care and the recognition o f the patient as part of a family and a community.The acts and interventions the nurse is expected to perform ensure that the patient is nursed in totality with his physical, social and psychological needs being met.The professional nurse is responsible too for the specific nursing care of patients at high risk, in this case the patient suffering from cancer.The objective of the health team is the rehabilitation of the patient, back into family and community life.In order to maintain control of their lives, many cancer patients need to change their habits, modify their normative prescribed social roles, redefine and reinterpret basic concepts such as health and illness.Thus the nurse's objectives are to assist the patient to adjust to d if f e r e n t w a y s o f m e e tin g h is d aily requirements, establishing new techniques of self care, modifying self-image, revising his routine of daily living, and developing a new life-style compatible with the effects of any disabilities (Dietz, 1981: 170).
On respecting the right of the patient to self-determ ination, his involvement in the planning and implementation of a nursing care programme is of paramount importance.The patient has the right to give informed consent regarding all medical and nursing interactions (Given & Given, 1984: 146).
In assessing the patient's health needs and p ro b le m s , th e n u rs e s h o u ld ta k e in to consideration his lifestyle, history, cultural background and self-care performance.The patient's abilities and disabilities which will determine the extent o f his engagement in self-care activities should also be assessed (Given & Given, 1984: 140).Problems most commonly experienced by the oncology patient are nutritional, psychological and com fort (pain) status, potential for infection and injury, knowledge of the disease process and the i mpl ications of the treatment modalities, as wel 1 as the ability to carry out activities necessary for daily living (Cox & Wark, 1980: 109-132).
T h e p r o g re s s iv e a n o r e x ia -c a c h e x ia accompanying advanced malignancy may be a major source of morbidity.Cachectic patients are often unable to tolerate the complications of cancer therapy and are more susceptible to infections (Pruitt, 1983: 370;Smith, 1975: 53).Fever as a manifestation of malignant disease may present a difficult diagnostic problem.While at least two-thirds of all cancer patients will have fever at some time during their iilness, in most instances this symptom is attributable to infection (Portlock & Goffinett, 1986: 37).It is th e re fo r e im p o r ta n t to u n d e rta k e a comprehensive patient history and physical examination regarding the patient's physical, social and psychological status.
Nursing a patient in totality implies that the psychological needs of the patient are being met.The importance of this aspect is highlighted in the SANC (1984) regulati o n :" moni tori ng o f the patient's reaction to disease conditions, trauma, stress, anxiety, medication and treatment."and the patient may experience certain emotional stages such as denial, anger, bargaining, depression and acceptance.Besides the fear of d y in g , p a tie n ts fe a r p a in an d b o d y disfigurem ent.The patien t's psychological response to body disfigurement depends upon his self-concept and body image, which are uniquely personal, so cial, em otional and psychological (B aldonado & Stahl, 1982: 134-147).
In assessing psychological status, the oncology nurse therefore needs to identify the patient's and family's coping mechanisms and meeting these needs requires a multi-professional team approach (Maguire, 1978: 33).
The relationship between patient and care-giver should be open, honest, and based on trust.G o als o f tre a tm e n t sh o u ld be re a listic , recognising that both quality and quantity of survival are important.Whatever therapy is chosen, the patient must be informed not only of its potential benefits but of its potential hazards as well.Although the patient may be anxious to begin treatment, he will also be r e lu c ta n t to s u f f e r its sid e e f fe c ts .Communication, accessibility, and consistent support assist in lessening this ambivalence.For those patients who are cured, stress and anxiety do not end with the completion of treatment but may be present continuously for many years to come.For those whose disease recurs or who cannot be cured, there is a p e rsis te n t c o n fro n ta tio n w ith m o rta lity .C a re -g iv e rs s h o u ld b ea r in m in d su c h fundamental features of human worth as respect for the individual, inclusion in a community, concern for the physical body, and personal meaning beyond the self (Portlock & Goffmet, 1986: 295).
Main physical problems to be considered are pain, nutritional status, haemoptysis, pleural e f f u s io n , p e r ic a r d ia l e ffu s io n , h e p a tic metastases, bowel obstruction, renal failure, bone metastases, and viral/fungal infections.Pain in a patient with cancer may be due to benign, unrelated causes, may be referred, and may be very difficult to control.The patient also needs to cope with fear, anxiety and depression of chronic pain (Portlock & Goffinet, 1986:297;Cox & Wark, 1980: 109-132;Hauck, 1986: 67).
Effusions may affect pulmonary and/or cardiac function which require many local, systemic or surgical therapeutic interventions.Metastases can result in severe pain and other complications increasing the mortality rate.Bowel obstruction is one of the most common gastrointestinal problems resulting in abdominal pain, emesis, and abdom inal distention.Infection is a common complication.As one of the side effects, chemotherapy causes a decrease in the leucocyte count.This increases the potential for infection.A nother cause o f leucopenia is metastatic involvement of the bone marrow ( P o r tlo c k & G o ff in e t, 1986: 2 9 5 -3 2 1 ; Speechley, 1985: 21-22).
There is also a potential for injury.T hrom bocytopenia is usually chemotherapy induced or as the result of bone marrow m etastasis and will cause haemorrhage.The nurse's role is confined mainly to early detection, by daily physical examination of the patient as well as testing faeces and urine for occult blood (Pruitt 1983: 374).
There are many specific problems related to specific cancer diagnoses.Specific signs and symptoms need to be detected by the nurse, for e x a m p le e x c e s s iv e b le e d in g , o ffe n s iv e d is c h a r g e s , e tc .T h e s id e e f f e c ts o f c h e m o th e ra p y an d ra d ia tio n s h o u ld be m o n ito re d and a p p ro p ria te ly ad d re ssed .Surgical interventions may lead to ostomies w hich also req u ire sp ecial n u rsin g care.R adiation therapy m ay cause acute skin reactions, cardiopulm onary com plications, gastrointestinal problems, and specific organ complications.Chemotherapy causes acute and chronic toxicides of which nausea and vomiting are m ost com m on and must be addressed appropriately (Portlock & Goffinet, 1986: 254-263).
O n co lo g y n u rsin g care is a sp e c ia lise d discip lin e req u irin g very special nurses.Oncology patients receive quality nursing care when the nurse rendering that care adheres to the scientific principles o f diagnosing the p a t i e n t s ' h e a lth n e e d s a n d p ro b le m s, formulating and implementing an appropriate n u rs in g c a re p la n an d e v a lu a tin g the effectiveness of her nursing interactions.The patient's response to the treatment modality is dependent upon such variables as the cancer diagnosis, the stage of the disease, health history, socio-economic status and motivation.Malignant diseases prevail in all organs and systems of the body and therefore the oncology nurse needs to be a specialist in all the different types of cancer.

D E F IN IT IO N O F T E R M IN O L O G Y Oncology nursing care
Oncology nursing care is the nursing of patients suffering from cancer and may be curative, restorative, palliative or supportive, depending upon the medical diagnosis o f the patient.

Standard
A standard is a descriptive statement of the expected level of performance againstwhich the quality o f oncology nursing care can be evaluated.

R E S E A R C H M E T H O D O L O G Y
A descriptive approach was followed whereby the dom ain variables related to oncology nursing care were explored, described and validated.A literature review was undertaken to ensure theoretical and content validity of the standards.American and British literature was utilised to identify the prerequisites of quatffc oncology nursing care.A specific approach™ standard formulation was utilised, focusing on the needs of a particular health institution.
The research hospital utilised in this study is the referral hospital for the Southern Transvaal for black patients requiringspecialist oncology care and is also a training hospital for the post-basic course in oncology nursing science.
In this contextual study the target population for the form ulation o f oncology nursing care s ta n d a r d s w e re o n c o lo g y n u rs in g ca re specialists working in the research hospital.C lin ic a l n u rse s p e c ia lis ts w ere selected purposefully according to their professional qualification in Oncology Nursing Science, as well as their experience in oncology nursing care.These clinical specialists served on a co m m ittee to fo rm u late and validate the standards.All committee members were nurses employed at the research hospital and consisted of the following members: * a clinical nurse educator for the post basic course of Oncology Nursing Science; * two chief professional nurses in charge of oncology wards in the hospital; * two senior professional nurses who had at least two years experience in specialised oncology nursing care; * two professional nurses who had at least two years experience in specialised oncology nursing care.
All the committee members held the post-basic registration o f the South A frican Nursing Council in Oncology Nursing Science.
The committee members were requested to formulate standards and criteria for oncology nursing care.They held weekly discussions for three months.Through group discussions and by reaching verbal consensus, standard care plans were drawn up for the common treatment modalities and medical diagnoses of patients nursed in the oncology wards.The formulated standard care plans were d rculated among other ^B te r e d nurses in oncology wards for their consideration and input and ratification and validation of standards was done verbally by these nurses.
From these standard care plans the committee members identified the patient problems that required the same nursing interventions.These problems were grouped together and formulated according to the scientific method of nursing care, namely assessment, nursing diagnosis, planning, implementation and evaluation.The terminology appearing on the standardised provincial nursing records was incorporated in the wording of the standards and criteria so as to prevent confusion.
No standard of nursi ng care was accepted by the committee unless full verbal consensus was reached among members and unless it was accepted by the registered nurses in the logy wards.Standards and criteria were idered and debated according to their appropriateness/applicability, com pleteness and clarity, as well as their realistic usefulness in the unit.
The final standards and criteria therefore had content validity based upon the literature and ratified by domain specialists/experts.

RESULTS
The follow ing standards and criteria were formulated; The nursing care regimen is continually evaluated and revised according to the changes in the patient's health status.
4.1 The data are collected to assess whether specific desired outcomes have been achieved.Local oncology nursing care standards were formulated and validated by oncology clinical ^are experts employed by the research hospital.These standards can serve as a guide to improve the quality of oncology nursing care in this hospital and can be used for the development of an evaluation instrument in this regard.
N ational v a lid a tio n o f the sta n d a rd s is recommended to prove statistically the validity of the standards.
O n co lo g y n u rsin g as a sp e cia lised nursing discipline has no p u b lish ed nursing care standards fo r South Africa.The purpose o f this study was to formulate o n c o lo g y n u rsin g s ta n d a r d s f o r a particular research hospital A specific approach was used and the oncology nursing experts in the research hospital compiled and formulated the standards.Group discussions and critical debating o f the standards followed.The standards w e re r a tifie d b y m e a n s o f v e r b a l co n sen su s b etw een th e ex p erts and professional nurses in the oncology unit.These standards could serve as a guide to ensure quality oncology nursing care.National validation o f the standards is recommended Uittreksel O n k o lo g ie s e v e r p le g in g , a s 'n gespesialiseerde verpleegdissipline, het g e e n fo r m e e l-g e p u b lis e e r d e verpleegstandaarde in Suid-Afrika nie patient interview regarding: * provide and teach measures to prevent or control side effects: nausea and vomiting; loss of appetite; stomatitis; weakness and fatigue; chills and fever; alopecia; gastrointestinal ulceration a n d /o r b le e d in g ; d ia rr h o e a and c o n s tip a tio n ; sk in c h a n g e s ; m y e lo s u p p r e s s io n ; in f e c tio n ; extravasanon; * intervention in the critical areas of patient care related to specific treatment sites.

4. 2
The collected data are compared with the stated desired outcomes.*•3 The patient/family and nurse(s) evaluate the achievement of stated desired outcomes.♦■4 All data concerning the patient's progress and nursing interventions are recorded.*■5 The nursing care regimen is reviewed and modified according to the patient's needs.*■6 The patient profile is updated as new information is received.Oc c l u s i o n a n d r e c o m m e n d a t i o n s