Barriers and Promoters for Nurses' Participation in Cancer Treatment Decision Making Process and Patient Satisfaction with Treatment Decision

Title:Barriers and Promoters for Nurses' Participation in Cancer Treatment Decision Making Process and Patient Satisfaction with Treatment Decision

Purpose:

To examine the barriers and promoters for nurses' participation during cancer treatment decision making (TDM) process and to describe the nurse and nurse practitioner's (NP) perspectives on their personal beliefs, values, and attitudes relevant to their participation in cancer TDM.

Methods:

Study Design:  Descriptive, cross-sectional study using a semi-structured interview schedule.

Setting: Inpatient and outpatient oncology settings.

Sample: The study sample consisted of thirty nurses and nurse practitioners who are actively involved in direct patient care (see Table 1 for further demographic description). All thirty participants have completed the interviews, but only 21 interviews have been transcribed and verified and they are included in this preliminary analysis. Complete analysis of data from all thirty participants is expected to be completed in March 2015 and full data analysis and findings will be reported in the July 2015 conference.

Main Research Variables: Barriers and promoters for nursing participation in cancer TDM, nurse's values, beliefs, attitudes related to participation in the decision making process.

Analytic Procedure:Directed content analysis procedures were used to develop major themes from the nurse and nurse practitioner participant interviews. Initial categories and their definitions were developed based on a literature review on factors influencing cancer treatment decisions and integrative review on barriers for nursing advocacy. Transcriptions of digital audio files were completed by three trained graduate students, SPM, NYS, EM and transcription verification was conducted by the lead researcher, JDT.   Interview text was read line by line by JDT and then imported to NVivo 10 (QSR International, Victoria, Australia), a qualitative data software analytic program. Initial categories and definitions were also imported to NVivo. Data coding were performed by two trained graduate students, SPM and NYS. Initial and emerging categories were reviewed and discussed again among four members of the research team, JDT, SPM, NYS and EM after coding 50% of the preliminary data.  Coding comparison query was completed to check for at least 80% agreement between two coders as required by consensual validation process. Full agreement between SPM and NYS in terms of coding scheme and their definitions was reached utilizing the process of consensual validation. The overall project coding agreement was excellent at 94.3%. Ongoing in-depth discussions and agreement about the wording of final themes, factors encompassed by major themes and definitions were carried out by the entire research team.

Results:

The following major themes relate to the barriers for nurses and NPs' participation in cancer TDM:

1. Practice barriers - non-nursing responsibilities take away time from patient; no representation of nursing in tumor boards or grand rounds; lack of uniform practice standards for nursing participation in cancer TDM; participation varies from one practice to another practice; nursing perspective is not being seek out by other health care team members; not having enough nursing input in treatment decision making.

2. Patient barriers - lack of patient's emotional and mental readiness to participate in cancer TDM; patient's high anxiety level due to new diagnosis of cancer makes it difficult for patient to participate in TDM process; patient simply lacks willingness to learn.

3. Institutional policy barriers - presence of institutional policy that restricts the role of nurse practitioners in relation to clinical and treatment decision making; policy requiring physician supervision instead of collaboration between physician and nurse practitioner. Existence of policy that represents misinterpretation of scope of practice for NP. Lack of institutional policy that allows specific block of time for nurses to provide patient education about therapy.

4. Professional barriers - lack of professional training and experience; when nurse practitioners are not having formal training regarding their job and lack professional experience, they are less likely to participate in cancer TDM; nursing colleagues holding nurse practitioners back from being autonomous practitioners; nurses not fully understanding the advanced role of nurse practitioners. When nurses are less valued by other health professionals and their opinions are dismissed because they are not evidence-based.

5. Scope of practice barriers - when nurse practitioners can't initiate new cancer therapy due to state or federal laws prohibiting it; when scope of nursing practice for NP is not autonomous and requires physician's supervision; when state or federal laws limit prescriptive authority for NP.

6. Insurance coverage as a barrier - when insurance does not cover certain therapies; when insurance does not reimburse or provide payment for nurses providing treatment education; when insurance payment for service is low, NP has to see more patients and will be forced to spend less time with patients due to high patient load.

7. Administration as a barriers - when administration does not provide adequate support staff to nurses and nurse practitioners; administration limiting the scope of practice of NPs.

The following major themes relate to promoters for nurse and NP's participation during cancer TDM:

1. Multidisciplinary or team approach - nurses and NPs participate more in cancer TDM when there is consistent multidisciplinary or team approach in the practice.

2. Nurses having a voice - when nurses and NPs believe they have a voice and feel that they could have an influence with the physician who ultimately makes the treatment decision, they are more likely going to participate in the decision making process.

3. Level of knowledge about the disease and its therapy - when nurses have adequate level of knowledge about the disease and its therapy, they are more likely going to have active, participatory role in decision making.

4. Nurse's personal value influences participation in cancer TDM - nurses who personally value participation in cancer TDM are more actively involved in the decision making process.

 

Conclusion:

There are many barriers to the nurse and nurse practitioner's participation during cancer TDM. Nurses and NPs must continue to work rigorously in removing these barriers and they must strive to attain full level of participation during cancer TDM.

Barriers must be addressed regularly to improve clinical outcomes related to cancer TDM, especially patient's satisfaction with treatment decision. Nursing interventions, nursing staff education and training, and policies that address these barriers must be developed in order to improve the level of participation among nurses and NPs during cancer TDM.

 Table 1. Demographics of Participants  (N=21)

Category	Response	%*	N=*
Gender	Male Female	9.5 90.5	21
Work status	Full-time Not Working	90.5 9.5	21
Age	30-39 40-49 50-59 60+	4.8 42.9 42.9 9.5	21
Years of practice experience	3-5 years 6-9 years 10 years and above	4.8 19.0 76.2	21

Education (highest complete)	Associate Bachelor Master Doctoral	4.8 33.3 52.4 9.5	21
Job title	OP NC NP CNS Research RN OP RNC Inpatient RN clinician	9.5 42.9 9.5 19.0 14.3 4.8	21

Abbreviations:

OP – outpatient

NC – nurse clinician

NP – nurse practitioner

CNS – clinical nurse specialist

RNC – registered nurse coordinator