- Email: [email protected]
A Journey to Pediatric Chemotherapy Competence
A Journey to Pediatric Chemotherapy Competence Rachel Andam, BSN, RN, CPON Melissa Silva, MS, CPNP, CPON
Chemotherapy and biotherapy use has increased due to its effectiveness as a treatment for childhood cancer. Nurses need to demonstrate knowledge of these agents' mechanism of action, adverse effects, safe handling, and monitoring parameters. Competence of nurses administering chemotherapy and biotherapy needs to be assessed to ensure safety and quality care. Review of literature reveals that a comprehensive education program and skills validation are the most thorough means of assessing chemotherapy competency. The chemotherapy competency program at the Children's National Medical Center (CNMC) was evaluated and was noted to be inadequate. Although a self-learning module on intravenous push chemotherapy administration and a 1-hour lecture on chemotherapy administration were offered during orientation, there was limited reevaluation of competence at regular intervals. As a result of a literature review, multi-institutional surveys, and intensive review of the CNMC chemotherapy administration module, a comprehensive chemotherapy/biotherapy competency program was developed for nurses administering chemotherapeutic agents. The CNMC chemotherapy competency program was formed with a didactic content course utilizing the Oncology Nursing Society Chemotherapy/Biotherapy Provider Course combined with initial and yearly skills validation. After offering both the didactic portion and three-part competency skills set, nurses have indicated improved satisfaction with the methodology of achieving chemotherapy competency. © 2008 Elsevier Inc. All rights reserved. Key words: Pediatric chemotherapy administration; Competency; Performance evaluation
C
HILDHOOD CANCER IS rare, with approximately 1 in 7,000 children from birth to 14 years of age being newly diagnosed with cancer each year in the United States. Survival rates have improved dramatically since the 1960s, when the overall 5-year survival was estimated at 28%. “Improvements in survival rates have continued into the 1990s in the United States with a 3 year survival exceeding 75% for children and adolescents” (Smith & Ries, 2002, p. 8). The improved survival rates are largely due in part to chemotherapy and biotherapy treatments. “Chemotherapy is defined as drug therapy aimed at reducing tumor volume by cytotoxic effects and preventing tumor cell division and spread” (Kline, Echtenkamp, Norville, & Silva, 2004, p. 16). “Biotherapy refers to agents derived from biological sources and/or use of agents that affect biological responses. Biotherapeutic agents augment, modulate or restore the host's immune responses and provide direct antitumor activity” (Kline et al., 2004, p. 31). The use of these therapies has increased due its effectiveness as a primary treatment for cancer. Chemotherapy and biotherapy have a high level of toxicity, and it is required that nurses who administer these agents possess specialized knowledge and skills. Nurses caring for children with cancer are required to have knowledge of basic pediatric oncology. An
Journal of Pediatric Nursing, Vol 23, No 4 (August), 2008
understanding of cancer biology is necessary to comprehend the mechanism of action for the various treatments. “The pediatric oncology nurse must develop an understanding of the components of the immune system, the process of hematopoiesis, and the intimate interaction of biologic agents with each other and with other elements of the immune system” (Woolery-Antill, 2002, p. 178). Nurses administering chemotherapy and biotherapy need to have excellent assessment skills because they will need to assess the patients' and families' understanding of the disease and the treatment. Prompt identification of adverse effects of chemotherapy and biotherapy is also crucial (Bradshaw, 1997, 1998). Nurses are needed to be familiar with special pediatric considerations for administering cheFrom the Hematology/Oncology Care Unit, Children's National Medical Center, Washington, DC, and Department of Hematology Oncology, Children's National Medical Center, Washington, DC. Corresponding author: Melissa Silva, MS, CPNP, CPON, Department of Hematology/Oncology, 111 Michigan Avenue NW, Washington, DC 20010. E-mail: [email protected] 0882-5963/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2006.12.005
257
258
ANDAM AND SILVA
motherapy and biotherapy. These special considerations include child and family safety, education, support, data collection, and documentation. The child's developmental stage must also be taken into account so that the nurse can tailor his or her interventions to that child's level. Cancer treatment can disrupt normal developmental experiences by causing isolation and separation from family, peers, and school. It can also result in the child experiencing a loss of control and regressing to a more dependent role. Nurses can enlist the support of other disciplines such as pharmacy, social work, child life, chaplains, and psychology to assist the families in adapting to the diagnosis and treatment. A chemotherapy and biotherapy competency program at the Children's National Medical Center (CNMC) was developed to assist nurses to safely administer chemotherapy and biotherapy and to support and educate patients and families. The purpose of this article is to describe this institution's journey in developing a comprehensive program that includes both didactic and practical validation of chemotherapy administration in the pediatric population. BACKGROUND The initial education of nurses on the hematology/oncology care unit (HOCU) previously included a 1-hour orientation lecture on chemotherapy administration and a self-learning module addressing intravenous push (IVP) chemotherapy. The lecture was offered to new registered nurse (RN)-only staff. Content included brief discussion and overview of adverse effects and principles of chemotherapy. The lecture mainly focused on intravenous chemotherapy administration and included a few chemotherapy/biotherapy agents including their mechanism of action, their adverse effects, and their administration. The content lacked detailed information on issues related to other routes of administration (such as oral, intrathecal, and intramuscular). Other information pertinent to chemotherapy administration such as supportive care of patients was also lacking. As a supplement to the lecture, a self-learning module on IVP chemotherapy was distributed to new RN staff and was to be completed during clinical orientation over the orientation period of 8 to 12 weeks. The 17-page self-learning module consisted of two sections, “Introduction” and “Preparation and Administration of IVP Chemotherapy.” The introduction section included content covering general
considerations such as cell-cycle-specific and noncell-cycle-specific drug classes and rationale for drug dosing schedules. Section 2 addressed more role-specific information on the preparation and administration of IVP chemotherapy such as (a) calculation of chemotherapy doses, (b) drug preparation, (c) safe handling and administration of chemotherapy, (d) procedures for administration of IVP chemotherapy via a central venous access device, and (e) management of common side effects of IVP chemotherapeutic agents. In addition to these areas, other topics related to general chemotherapy administration and other routes of administration not directly related to IVP chemotherapy were included such as review of both cell-cycle-specific and non-cell-cyclespecific drugs, rationale of dosing schedules, and limited discussion of safe handling (Price & McShane, 2002). Once the participants had reviewed the selflearning module, competency was assessed with a return demonstration of IVP chemotherapy administration in the clinical setting. The participants were deemed competent after three observations by their preceptor or another experienced nurse on the unit. Competency assessment subsequent to the initial evaluation was not required. There was no core group of nurses identified to monitor staff competency at regular intervals nor was there a schedule to revise the module for updates (McMullen et al., 2003). The module and lecture did not address other areas of chemotherapy administration that are integral to safe administration such as detailed safe handling methods and accidental exposure management. In addition, childhood development issues and family/patient education related to chemotherapy administration were not addressed. Based on this comprehensive review of the module and lecture, it was evident that both components lacked clear focus and intent. The staff's education on other patient care areas where chemotherapy was administered, such as the pediatric intensive care unit (PICU) and medical care unit (MCU), was limited. The PICU nurses received a lecture on oncology emergencies and chemotherapy during their initial orientation. Futhermore, they had no skills validation. Nurses on the MCU where chemotherapy is given to patients with multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus received no formalized education or skills validation from clinical experts in chemotherapy administration.
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE
Because of the lack of adequate educational resources and training, a new program was developed. The CNMC chemotherapy competency program was formed with a didactic content course utilizing both the Oncology Nursing Society (ONS) Chemotherapy/Biotherapy Provider Course and Association of Pediatric Oncology Nurses (APON) Chemotherapy/ Biotherapy Provider Course. An initial and yearly skills validation was also incorporated into the program.
METHODS
Literature Review A review of the literature was conducted to assess the role of certification competency for nursing administration of chemotherapy and biotherapy. The literature was sparse and did not support certification as the only means to validate competency. The literature revealed that a comprehensive education program along with skills validation would be the most thorough means of assessing chemotherapy competency. In 1999, the ONS released a position paper regarding the preparation of a nurse who administers and cares for individuals receiving chemotherapy. This paper outlined the specialized RN preparation needed to administer chemotherapy that ensures a safe level of care. ONS recommends that nurses must have knowledge of agents, intravenous access, management of side effects, and appropriate patient teaching (Brown et al., 2001). The APON states, “safe and consistent administration of chemotherapy and biotherapy is a fundamental component of the care provided by pediatric oncology nurses” (Kline et al., 2004, p. 1). The Joint Commission on the Accreditation of Healthcare Organizations stresses the importance of maintaining competency in high-risk practice areas where one's knowledge base must be updated regularly, such as in chemotherapy administration (Kanaskie & Arnold, 1999). The American Society of Health-System Pharmacists has comprehensive recommendations for preventing errors with chemotherapy. Their guidelines recommend that “Nursing managers and supervisors require nurses to complete training and demonstrate nursing care related competencies” (Smith & Ries, 2002, p. 15). They also recommend that health care organizations periodically reassess the nurses' competencies related to their responsibilities (Wright, 1998).
259
Institutional Surveys Other East Coast pediatric hematology/oncology institutions were contacted to identify and evaluate the process of validation of competency in chemotherapy administration. Most institutions reported use of “homegrown” programs similar to ours, which involved a lecture or workshop with institutional competency checklists completed throughout orientation. Three of the six institutions had annual validation of competency. The APON was contacted to inquire about a chemotherapy certification course. At the time, no such program existed. However, APON did offer certification as a pediatric oncology nurse. This examination addresses some chemotherapy and biotherapy. The ONS offered a chemotherapy/ biotherapy program, largely adult-focused, with some pediatric content. Their program offered didactic information and examples of competency checklists. The ONS's program alone does not deem participants competent in chemotherapy administration. They recommend that the individual institutions measure competency using the ONS Chemotherapy and Biotherapy Guidelines, along with institution policies and procedures. DEVELOPMENT OF COMPETENCY PROGRAM As a result of the literature review, multiinstitutional surveys, and intensive review of the Table 1. ONS Chemotherapy and Biotherapy Course Objectives • Describe historical advances related to the use of cytotoxic therapeutic agents as treatment modalities. • Describe the investigational process all drugs undergo to gain U.S. Food and Drug Administration approval. • Define the role of the nurse who cares for a patient receiving standard therapy, high-dose or dose-intense regimens, and investigational cytotoxic drugs. • Identify the importance of the cell cycle and cellular kinetics as they relate to the various classifications of cytotoxic agents. • Explain the goals of cancer therapy. • Cite the methods to measuring tumor response to therapy and identify possible reasons for treatment failure. • Describe the safety precautions necessary when handling cytotoxic agents. • Identify the procedures for administering cytotoxic and therapeutic agents as part of cancer treatment. • Identify nursing interventions appropriate for a patient receiving cytotoxic therapies. • Identify acute, subacute, and chronic toxicities that can occur with the use of cytotoxic and therapeutic agents for cancer treatment. • Identify information pertinent to the comprehensive documentation of cytotoxic therapies.
260
CNMC IVP chemotherapy administration module, a comprehensive chemotherapy/biotherapy competency program was developed for nurses administering chemotherapeutic agents. The CNMC chemotherapy competency program was formed with a didactic content course combined with initial
ANDAM AND SILVA
and yearly skills validation (Gibson & Soanes, 2000; Hall, 1999).
Didactic Course Offering The first step in creating the CNMC chemotherapy competency program involved the development
Table 2. Chemotherapy Competency Checklist: Continuous Infusion of Chemotherapy
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE
261
Table 2 (continued )
of a comprehensive didactic course addressing chemotherapy mechanism of action, toxicities, management of toxicities, education, and administration. In December 2001, CNMC offered the ONS Chemotherapy/Biotherapy Provider Course to a small group of pediatric oncology, neonatal intensive care unit (NICU), PICU, and MCU nurses. The ONS provider course is a comprehensive chemotherapy/biotherapy lecture series with posttest that primarily covers adult cancer care. The ONS
Chemotherapy/Biotherapy Provider Course objectives are listed in Table 1. Evaluation of the course was positive; however, nurses found the program highly adult-focused with very little pediatric content. An evaluation of the program by the participants indicated that some of the areas that needed additional information were specific pediatric treatment protocols, growth and development concerns of the pediatric patient, and patient and family education.
262
To enhance the chemotherapy/biotherapy competency program at CNMC, the hematology/ oncology advanced practice specialist (APS) and Table 3. Chemotherapy Competency Checklist: Chemotherapy IVP Delivery
ANDAM AND SILVA
the clinical educator (CE) attended the ONS Chemotherapy/Biotherapy Provider Trainer Course, which was offered off-site. After the
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE
263
Table 3 (continued )
completion of the trainer course, the APS and CE then reviewed the provider curriculum and added additional pediatric content. In addition, case studies specific to pediatric oncology using the Children's Oncology Group (COG) treatment protocols were developed. The case studies included education related to pediatric dosing variations, toxicities, safe handling, documentation, and patient/family education. Unlike adult cancer treatment, childhood cancer treatment is primarily driven by protocols put forth by collaborative (multicenter and multidisciplinary) research groups such as the COG. Inclusion of case studies with COG protocols applicable to daily practice was used to emphasize didactic material after it was presented. The ONS provider course with the supplemental pediatric content became the didactic portion of the CNMC chemotherapy competency program and has been presented to pediatric oncology, NICU, PICU, and MCU nurses at CNMC. The course was offered to the NICU, PICU, and MCU nurses
because they also administer chemotherapy to their patients. We have also invited nurses from other local hospitals. Evaluations from 20 pediatric oncology course participants have been extremely positive. Participants have recommended that a hands-on demonstration or skills laboratory on IVP chemotherapy or safe handling be incorporated into the program.
Competency Skills Checklists After subsequent course offerings to address additional recommendations made by the staff, the APS and CE along with a group of staff nurses with 1 to 20 years of experience formed a chemotherapy competency team to update, revise, and develop competencies related to high-risk issues surrounding chemotherapy administration. Three subgroups of the competency team were formed to assess vulnerabilities surrounding chemotherapy administration, which included IVP chemotherapy, continuous intravenous infusion chemotherapy, and safe handling. Safe-handling
264
content included use of personal protective equipment, accidental hazardous drug exposure, and spill management. Further, the team developed test question items and informational posters addressing the three areas mentioned. Content was developed utilizing the ONS Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (Brown et al., 2001), as well as APON texts and
ANDAM AND SILVA
chemotherapy competency materials provided by other institutions. Three competency checklists were formulated as presented in Tables 2, 3, and 4. The first year of implementation of these checklists utilized two methods of validation for existing nursing staff. The IVP chemotherapy competency was validated by return demonstration at a skills station simulating a clinical scenario. Safe handling
Table 4. Chemotherapy Competency Checklist: Safe Handling of Hazardous Drugs
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE Table 4 (continued )
265
266 Table 5. IVP Chemotherapy Skill Station Script for Validating RNs Evaluator cheat sheet: Review the scenario and questions below and assist the RN by guiding them through the following. They must verbalize any answers (avoid prompting) and return demo with minimal prompting to complete the module successfully. Please initial Chemo Competency-IVP column next to RN name with your initials and date once the RN has completed the station. Scenario: Freddie is an 8-year-old with PICC line here for resolving F/L/N after ALL treatment last week. His ANC has recovered and is greater than 250. He is ready to be discharged. The fellow, however, has noted he is due for IVP Vincristine through his PICC line before he goes home. She writes the order and gives you a copy of his roadmap to ensure he receives his medication as ordered.
Questions and skills: 1. What preadministration documents do you need to ensure safe IVP chemo delivery? (Must name at least 2 of 3) • MD order • Roadmap • Chemo checklist 2. What patient information do you need to ensure safe IVP chemotherapy delivery? (Must list at least 3 of 5) • Patient height/weight • Allergy history • Nam/MR number • Lab results 3. Before giving the chemotherapy, the patient and family must be educated on the drug. What education can you provide on Vincristine? (Name two side effects or postadministration issues.) • Constipation, peripheral neuropathy, etc. • Clear drug • Extravasant/Irritant • APON drug sheet 4. You and the witnessing RN have verified the drug dose with the order. Before you administer it to the patient, you must verify patient identification modifiers. What is the process? • Check the modifiers, patient name and MR number, on the patient's ID band vs. drug label 5. Have the RN return demo the IVP drug delivery. Must demonstrate. • Gather and select supplies (chucks or gauze pads, alcohol, PPE, drug, flushes) • Set up area per poster/presentation • Assess for blood return • Trouble shoots and catches drops • Rate of administration • Signs/Symptoms of extravasation 6. You have successfully given the drug. The patient has a fever before discharge and has to stay the night. He becomes incontinent of urine and he and his bed sheets are wet. Describe your actions, what kind of precautions would staff take to minimize chemotherapy exposure? • Universal precautions with any patient waste, with gowns and/or gloves as needed • Move patient from area; cleanse skin with soap and water, until bed is remade 7. List two postadministration interventions. (What do you do when you are done?) • Dispose materials to yellow chemotherapy waste receptacles • Monitor for side effects • Documentation (FS, NPN, MAR)
and continuous intravenous chemotherapy infusion competencies were validated via written examination. Because it was identified that competencies were to be assessed annually, it was felt by the group that skills validation via return demonstration
ANDAM AND SILVA
should be rotated among the three areas of IVP, continuous chemotherapy, and safe handling competency. During the second year of implementation, return demonstration of spill management and safe handling was implemented; a written examination was distributed to address the areas of IVP and continuous infusion chemotherapy. These newly developed competency checklists were distributed to new RN staff during orientation and were to be completed during clinical orientation over a period of 8 to 12 weeks. Skills are evaluated by the CE, APS, preceptors, or members of the chemotherapy competency team or trained nurses. Validating RNs are provided with scripted scenarios to ensure consistent validation. A copy of the IVP chemotherapy skills station script for validating RNs is presented in Table 5. The return demonstration skills station included several highlighted features (Table 6). The current CNMC Chemotherapy Competency Program modules address these three chemotherapy competency skill sets and validate competency through return demonstration and written test. Nurses who administer chemotherapy or work with patients who have received chemotherapy review the modules annually. One area that continues to challenge this program is the education of RNs outside of the hematology/ oncology area, such as the PICU, NICU, and MCU. All the staff throughout the institution who administer chemotherapy are encouraged to attend the 2-day class and participate in the annual skills validation. Skills validation is not required for these areas at this time. The PICU has been most consistent in sending RN staff to the class and have had several RNs complete skills validation with the hematology/oncology staff. Generally, feedback from RNs from these areas has been positive. NICU and MCU staff, despite initial interest and participation in the classroom portion Table 6. Highlighted Features of the IVP Chemotherapy Skill Station Feature
Rationale
• To ensure standard validation technique among all evaluators Simulate central venous • Patient identification modifiers access device complete included to reflect patient with patient identification safety standards modifiers and blood return • Blood return important to reflect infusion-nursing standards Various supplies that may • To assess if RN is able to identify and or may not be used are select the appropriate supplies available at the station Return demonstration • To maintain adult learning principles Evaluator scripted scenario
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE Table 7. APON Pediatric Chemotherapy and Biotherapy Curriculum Cancer overview Describe the characteristics of the cancer cell. Identify differences between cancers in adults and cancers in children. List cancer treatment modalities and how response is measured. Chemotherapy overview Discuss the history of chemotherapy. Describe the development of the specialty in childhood cancer treatment. Identify principles for cancer research and informed consent and the role of the nurse. Legal and ethical issues Describe the ethical principles associated with clinical trials. Identify the nurse's role in informed consent. Discuss legal issues related to chemotherapy administration. Principles of chemotherapy Describe important principles of pharmacokinetics in chemotherapy administration. Discuss classes of chemotherapeutic agents. Define combination chemotherapy. List modes of chemotherapy delivery. Principles of biotherapy Identify biotherapeutic agents. Describe indications and actions of commonly used medications. Identify side effects and nursing interventions for specific biotherapy agents. Chemotherapy agents and classifications Recognize classifications for chemotherapeutic agents. Identify common side effects for individual medications. Describe nursing interventions for chemotherapy medications. Safe handling Describe the occupational exposure risks of chemotherapy. List components of safe handling and disposal practices. Identify components of personal protection equipment. Preadministration issues Identify components of pretreatment assessment. Calculate body surface area and confirm chemotherapy dosage. Describe required family teaching prior to chemotherapy administration. Chemotherapy administration and immediate postadministration issues Describe safety measures to verify chemotherapy orders. List steps in preparation of chemotherapy. Identify nursing measures for different routes of administration. Describe special considerations for vesicant chemotherapy. Toxicity and symptom management Identify common side effects of chemotherapy by organ systems. Describe nursing assessment and interventions for common toxicities. List expected medical interventions for each toxicity. Late effects of chemotherapy Define late effects. Describe examples of late effects by body system. Psychosocial issues Define quality of life in chemotherapy patients. Describe risk factors for adherence to therapy. Identify unique concerns for adolescents and young adults. Discuss how culture influences patient and family response to chemotherapy.
of the program, have not had RNs attend the skills validation component. RNs from the MCU have provided feedback that the 2-day course is excessively detailed for their limited use of chemotherapy in the their patient
267
population. The NICU has decreased their attendance to the program due to the rarity of chemotherapy administration in the neonate. As well, both units have the competency program available to them. The unit-based educator completes a modified skills validation on the MCU. The chemotherapy/biotherapy competency program at CNMC involving completion of both skills validation and completion of the 2-day didactic portion offered by the ONS (with supplemental pediatric content added by the APS and CE) has been extremely successful. During preparation of this article, the APON Pediatric Chemotherapy and Biotherapy Curriculum had become available. The CNMC chemotherapy competency program is now transitioning from the ONS to the APON course as the preferred course for the didactic portion of the CNMC program. APON Pediatric Chemotherapy and Biotherapy Curriculum objectives are listed in Table 7 to highlight the various content areas that enhance the program. Table 8. Chemotherapy Competency Module Evaluation Evaluation results following CNMC Chemotherapy Competency Module (N = 20) 1 To What Extent Have You Achieved Each Objective?
Question 1: The 2-day Chemotherapy Provider Course ⁎ provided me with the knowledge to administer chemotherapy safely. Question 2: The 2-day Chemotherapy Provider Course provided me with enough pediatric content. Question 3: The chemotherapy competencies at the unit-based competency fair reinforced the knowledge I gained from the course and provided another learning opportunity to administer chemotherapy safely. Question 4: Rate the overall level of satisfaction with the HOCU Chemotherapy Competency Program †.
None
2
3
4
Fair
5
6
Exceptional
No answer
–
– –
11 9
–
–
2 6
9
3
–
–
– 2
11 7
–
–
– 1
11 8
–
Note. Dashes indicate no response reported. ⁎ The 2-day Chemotherapy Provider Course refers to the ONS course, to which the APS/CE added additional pediatric content. † The HOCU Chemotherapy Competency Program consists of both the 2-day Chemotherapy Provider Course and the unit-based chemotherapy competencies.
268
ANDAM AND SILVA
The CNMC chemotherapy competency program's didactic course offering has evolved over the past 2 years. We have transitioned from a combination of 1-hour lecture and 17-page module, to an adultfocused chemotherapy course, and finally to a nationally recognized pediatric chemotherapy and biotherapy course with institution-specific competency checklists. Participants' evaluation of the APON pediatric course is currently being reviewed. EVALUATION After offering both the didactic portion and threepart competency skills set, nurses have indicated improved satisfaction with the methodology of achieving chemotherapy competency. They are more knowledgeable about the toxicities of these therapies (Table 8). Importantly, patients and families observe a nurse who is confident in his or her teaching of the action, toxicities, and management of the toxicities. Before administering chemotherapy/ biotherapy, the nurse will review the action and side effects of each agent using the APON Chemotherapy Fact Sheets. The nurse will then answer any question or provide more literature if families are in need of further information. Patients and families have verbalized in hospital surveys satisfaction with the education they have received. Future directions for the CNMC chemotherapy/ biotherapy competency program include continued yearly skills validations, independent provider
course renewal through either the ONS or APON depending on which course the participant was enrolled in, and continued transition from the ONS program to the new APON Chemotherapy/Biotherapy Provider program. Yearly skills validation will continue to include observation of skills competence and assessment of knowledge via the written examination component. As the body of knowledge of pediatric oncology treatment evolves, timely inservices as well as inclusion of new information into the competency presentations will be offered annually, nurses are ensured up-to-date information to maintain safe chemotherapy administration. Lastly, we will encourage nurses to become Certified Pediatric Oncology Nurses (CPON) because many components of the examination focus on chemotherapy/biotherapy toxicities and management of those toxicities. Completing the CNMC chemotherapy/biotherapy competency program will provide the nurse with the necessary preparation for the CPON examination. So far, 10 nurses that completed the CNMC chemotherapy/biotherapy competency program have successfully achieved CPON status. It is our hope that this description of our journey to pediatric chemotherapy competency will provide a program outline that other institutions/units can implement in their areas to ensure nurses are equipped with the knowledge and clinical competencies needed to administer chemotherapy safely to the pediatric patient.
REFERENCES Bradshaw, A. (1997). Defining competency in nursing (part 1): A policy review. Journal of Clinical Nursing, 6, 347−354. Bradshaw, A. (1998). Defining competency in nursing (part 2): An analytical review. Journal of Clinical Nursing, 7, 103−111. Brown, K., Esper, P., Kelleher, L., O'Neill, J., Polovich, M., & White, J. (Eds.). (2001). Chemotherapy and biotherapy: Guidelines and recommendations for practice (pp. 1−3). Pittsburgh, PA: Oncology Nursing Society. Gibson, F., & Soanes, L. (2000). The development of clinical competencies for use on a paediatric oncology nursing course using a nominal group technique. Journal of Clinical Nursing, 9, 459−469. Hall, J. L. (1999). Developing meaningful age-appropriate competencies for clinical services. Journal of Nurses in Staff Development, 15, 241−250. Kanaskie, M. L., & Arnold, E. (1999). New ways to evaluate chemotherapy competencies. Nursing Management, 30, 41−43. Kline, N. E., Echtenkamp, D., Norville, R., & Silva, M. (Eds.). (2004). The pediatric chemotherapy and biotherapy
curriculum (pp. 1−2). Glenview, IL: Association of Pediatric Oncology Nurses. McMullen, M., Endacott, R., Gray, M., Jasper, M., Miller, C., Scholes, J., et al. (2003). Portfolios and assessment of competence: A review of the literature. Journal of Advanced Nursing, 41, 283−294. Price, J., & McShane, B. (2002). Administration of chemotherapy: Evaluating a framework for developing practice. Paediatric Nursing, 14, 14−17. Smith, M. A., & Ries, L. A. (2002). Childhood cancer: Incidence, survival, and mortality. In P. A. Pizzo, & D. G. Poplack (Eds.), Principles and practice of pediatric oncology (pp. 1−13). Philadelphia, PA: Lippincott Williams & Wilkins. Woolery-Antill, M. (2002). Biotherapy. In C. Baggott, K. Kelly, D. Fochtman, & G. Foley (Eds.), Nursing care of the child with cancer (pp. 177−209). 2nd ed. Philadelphia: W.B. Saunders. Wright, D. (1998). The ultimate guide to competency assessment in healthcare. : PESI Healthcare, LLC.
Chemotherapy and biotherapy use has increased due to its effectiveness as a treatment for childhood cancer. Nurses need to demonstrate knowledge of these agents' mechanism of action, adverse effects, safe handling, and monitoring parameters. Competence of nurses administering chemotherapy and biotherapy needs to be assessed to ensure safety and quality care. Review of literature reveals that a comprehensive education program and skills validation are the most thorough means of assessing chemotherapy competency. The chemotherapy competency program at the Children's National Medical Center (CNMC) was evaluated and was noted to be inadequate. Although a self-learning module on intravenous push chemotherapy administration and a 1-hour lecture on chemotherapy administration were offered during orientation, there was limited reevaluation of competence at regular intervals. As a result of a literature review, multi-institutional surveys, and intensive review of the CNMC chemotherapy administration module, a comprehensive chemotherapy/biotherapy competency program was developed for nurses administering chemotherapeutic agents. The CNMC chemotherapy competency program was formed with a didactic content course utilizing the Oncology Nursing Society Chemotherapy/Biotherapy Provider Course combined with initial and yearly skills validation. After offering both the didactic portion and three-part competency skills set, nurses have indicated improved satisfaction with the methodology of achieving chemotherapy competency. © 2008 Elsevier Inc. All rights reserved. Key words: Pediatric chemotherapy administration; Competency; Performance evaluation
C
HILDHOOD CANCER IS rare, with approximately 1 in 7,000 children from birth to 14 years of age being newly diagnosed with cancer each year in the United States. Survival rates have improved dramatically since the 1960s, when the overall 5-year survival was estimated at 28%. “Improvements in survival rates have continued into the 1990s in the United States with a 3 year survival exceeding 75% for children and adolescents” (Smith & Ries, 2002, p. 8). The improved survival rates are largely due in part to chemotherapy and biotherapy treatments. “Chemotherapy is defined as drug therapy aimed at reducing tumor volume by cytotoxic effects and preventing tumor cell division and spread” (Kline, Echtenkamp, Norville, & Silva, 2004, p. 16). “Biotherapy refers to agents derived from biological sources and/or use of agents that affect biological responses. Biotherapeutic agents augment, modulate or restore the host's immune responses and provide direct antitumor activity” (Kline et al., 2004, p. 31). The use of these therapies has increased due its effectiveness as a primary treatment for cancer. Chemotherapy and biotherapy have a high level of toxicity, and it is required that nurses who administer these agents possess specialized knowledge and skills. Nurses caring for children with cancer are required to have knowledge of basic pediatric oncology. An
Journal of Pediatric Nursing, Vol 23, No 4 (August), 2008
understanding of cancer biology is necessary to comprehend the mechanism of action for the various treatments. “The pediatric oncology nurse must develop an understanding of the components of the immune system, the process of hematopoiesis, and the intimate interaction of biologic agents with each other and with other elements of the immune system” (Woolery-Antill, 2002, p. 178). Nurses administering chemotherapy and biotherapy need to have excellent assessment skills because they will need to assess the patients' and families' understanding of the disease and the treatment. Prompt identification of adverse effects of chemotherapy and biotherapy is also crucial (Bradshaw, 1997, 1998). Nurses are needed to be familiar with special pediatric considerations for administering cheFrom the Hematology/Oncology Care Unit, Children's National Medical Center, Washington, DC, and Department of Hematology Oncology, Children's National Medical Center, Washington, DC. Corresponding author: Melissa Silva, MS, CPNP, CPON, Department of Hematology/Oncology, 111 Michigan Avenue NW, Washington, DC 20010. E-mail: [email protected] 0882-5963/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2006.12.005
257
258
ANDAM AND SILVA
motherapy and biotherapy. These special considerations include child and family safety, education, support, data collection, and documentation. The child's developmental stage must also be taken into account so that the nurse can tailor his or her interventions to that child's level. Cancer treatment can disrupt normal developmental experiences by causing isolation and separation from family, peers, and school. It can also result in the child experiencing a loss of control and regressing to a more dependent role. Nurses can enlist the support of other disciplines such as pharmacy, social work, child life, chaplains, and psychology to assist the families in adapting to the diagnosis and treatment. A chemotherapy and biotherapy competency program at the Children's National Medical Center (CNMC) was developed to assist nurses to safely administer chemotherapy and biotherapy and to support and educate patients and families. The purpose of this article is to describe this institution's journey in developing a comprehensive program that includes both didactic and practical validation of chemotherapy administration in the pediatric population. BACKGROUND The initial education of nurses on the hematology/oncology care unit (HOCU) previously included a 1-hour orientation lecture on chemotherapy administration and a self-learning module addressing intravenous push (IVP) chemotherapy. The lecture was offered to new registered nurse (RN)-only staff. Content included brief discussion and overview of adverse effects and principles of chemotherapy. The lecture mainly focused on intravenous chemotherapy administration and included a few chemotherapy/biotherapy agents including their mechanism of action, their adverse effects, and their administration. The content lacked detailed information on issues related to other routes of administration (such as oral, intrathecal, and intramuscular). Other information pertinent to chemotherapy administration such as supportive care of patients was also lacking. As a supplement to the lecture, a self-learning module on IVP chemotherapy was distributed to new RN staff and was to be completed during clinical orientation over the orientation period of 8 to 12 weeks. The 17-page self-learning module consisted of two sections, “Introduction” and “Preparation and Administration of IVP Chemotherapy.” The introduction section included content covering general
considerations such as cell-cycle-specific and noncell-cycle-specific drug classes and rationale for drug dosing schedules. Section 2 addressed more role-specific information on the preparation and administration of IVP chemotherapy such as (a) calculation of chemotherapy doses, (b) drug preparation, (c) safe handling and administration of chemotherapy, (d) procedures for administration of IVP chemotherapy via a central venous access device, and (e) management of common side effects of IVP chemotherapeutic agents. In addition to these areas, other topics related to general chemotherapy administration and other routes of administration not directly related to IVP chemotherapy were included such as review of both cell-cycle-specific and non-cell-cyclespecific drugs, rationale of dosing schedules, and limited discussion of safe handling (Price & McShane, 2002). Once the participants had reviewed the selflearning module, competency was assessed with a return demonstration of IVP chemotherapy administration in the clinical setting. The participants were deemed competent after three observations by their preceptor or another experienced nurse on the unit. Competency assessment subsequent to the initial evaluation was not required. There was no core group of nurses identified to monitor staff competency at regular intervals nor was there a schedule to revise the module for updates (McMullen et al., 2003). The module and lecture did not address other areas of chemotherapy administration that are integral to safe administration such as detailed safe handling methods and accidental exposure management. In addition, childhood development issues and family/patient education related to chemotherapy administration were not addressed. Based on this comprehensive review of the module and lecture, it was evident that both components lacked clear focus and intent. The staff's education on other patient care areas where chemotherapy was administered, such as the pediatric intensive care unit (PICU) and medical care unit (MCU), was limited. The PICU nurses received a lecture on oncology emergencies and chemotherapy during their initial orientation. Futhermore, they had no skills validation. Nurses on the MCU where chemotherapy is given to patients with multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus received no formalized education or skills validation from clinical experts in chemotherapy administration.
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE
Because of the lack of adequate educational resources and training, a new program was developed. The CNMC chemotherapy competency program was formed with a didactic content course utilizing both the Oncology Nursing Society (ONS) Chemotherapy/Biotherapy Provider Course and Association of Pediatric Oncology Nurses (APON) Chemotherapy/ Biotherapy Provider Course. An initial and yearly skills validation was also incorporated into the program.
METHODS
Literature Review A review of the literature was conducted to assess the role of certification competency for nursing administration of chemotherapy and biotherapy. The literature was sparse and did not support certification as the only means to validate competency. The literature revealed that a comprehensive education program along with skills validation would be the most thorough means of assessing chemotherapy competency. In 1999, the ONS released a position paper regarding the preparation of a nurse who administers and cares for individuals receiving chemotherapy. This paper outlined the specialized RN preparation needed to administer chemotherapy that ensures a safe level of care. ONS recommends that nurses must have knowledge of agents, intravenous access, management of side effects, and appropriate patient teaching (Brown et al., 2001). The APON states, “safe and consistent administration of chemotherapy and biotherapy is a fundamental component of the care provided by pediatric oncology nurses” (Kline et al., 2004, p. 1). The Joint Commission on the Accreditation of Healthcare Organizations stresses the importance of maintaining competency in high-risk practice areas where one's knowledge base must be updated regularly, such as in chemotherapy administration (Kanaskie & Arnold, 1999). The American Society of Health-System Pharmacists has comprehensive recommendations for preventing errors with chemotherapy. Their guidelines recommend that “Nursing managers and supervisors require nurses to complete training and demonstrate nursing care related competencies” (Smith & Ries, 2002, p. 15). They also recommend that health care organizations periodically reassess the nurses' competencies related to their responsibilities (Wright, 1998).
259
Institutional Surveys Other East Coast pediatric hematology/oncology institutions were contacted to identify and evaluate the process of validation of competency in chemotherapy administration. Most institutions reported use of “homegrown” programs similar to ours, which involved a lecture or workshop with institutional competency checklists completed throughout orientation. Three of the six institutions had annual validation of competency. The APON was contacted to inquire about a chemotherapy certification course. At the time, no such program existed. However, APON did offer certification as a pediatric oncology nurse. This examination addresses some chemotherapy and biotherapy. The ONS offered a chemotherapy/ biotherapy program, largely adult-focused, with some pediatric content. Their program offered didactic information and examples of competency checklists. The ONS's program alone does not deem participants competent in chemotherapy administration. They recommend that the individual institutions measure competency using the ONS Chemotherapy and Biotherapy Guidelines, along with institution policies and procedures. DEVELOPMENT OF COMPETENCY PROGRAM As a result of the literature review, multiinstitutional surveys, and intensive review of the Table 1. ONS Chemotherapy and Biotherapy Course Objectives • Describe historical advances related to the use of cytotoxic therapeutic agents as treatment modalities. • Describe the investigational process all drugs undergo to gain U.S. Food and Drug Administration approval. • Define the role of the nurse who cares for a patient receiving standard therapy, high-dose or dose-intense regimens, and investigational cytotoxic drugs. • Identify the importance of the cell cycle and cellular kinetics as they relate to the various classifications of cytotoxic agents. • Explain the goals of cancer therapy. • Cite the methods to measuring tumor response to therapy and identify possible reasons for treatment failure. • Describe the safety precautions necessary when handling cytotoxic agents. • Identify the procedures for administering cytotoxic and therapeutic agents as part of cancer treatment. • Identify nursing interventions appropriate for a patient receiving cytotoxic therapies. • Identify acute, subacute, and chronic toxicities that can occur with the use of cytotoxic and therapeutic agents for cancer treatment. • Identify information pertinent to the comprehensive documentation of cytotoxic therapies.
260
CNMC IVP chemotherapy administration module, a comprehensive chemotherapy/biotherapy competency program was developed for nurses administering chemotherapeutic agents. The CNMC chemotherapy competency program was formed with a didactic content course combined with initial
ANDAM AND SILVA
and yearly skills validation (Gibson & Soanes, 2000; Hall, 1999).
Didactic Course Offering The first step in creating the CNMC chemotherapy competency program involved the development
Table 2. Chemotherapy Competency Checklist: Continuous Infusion of Chemotherapy
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE
261
Table 2 (continued )
of a comprehensive didactic course addressing chemotherapy mechanism of action, toxicities, management of toxicities, education, and administration. In December 2001, CNMC offered the ONS Chemotherapy/Biotherapy Provider Course to a small group of pediatric oncology, neonatal intensive care unit (NICU), PICU, and MCU nurses. The ONS provider course is a comprehensive chemotherapy/biotherapy lecture series with posttest that primarily covers adult cancer care. The ONS
Chemotherapy/Biotherapy Provider Course objectives are listed in Table 1. Evaluation of the course was positive; however, nurses found the program highly adult-focused with very little pediatric content. An evaluation of the program by the participants indicated that some of the areas that needed additional information were specific pediatric treatment protocols, growth and development concerns of the pediatric patient, and patient and family education.
262
To enhance the chemotherapy/biotherapy competency program at CNMC, the hematology/ oncology advanced practice specialist (APS) and Table 3. Chemotherapy Competency Checklist: Chemotherapy IVP Delivery
ANDAM AND SILVA
the clinical educator (CE) attended the ONS Chemotherapy/Biotherapy Provider Trainer Course, which was offered off-site. After the
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE
263
Table 3 (continued )
completion of the trainer course, the APS and CE then reviewed the provider curriculum and added additional pediatric content. In addition, case studies specific to pediatric oncology using the Children's Oncology Group (COG) treatment protocols were developed. The case studies included education related to pediatric dosing variations, toxicities, safe handling, documentation, and patient/family education. Unlike adult cancer treatment, childhood cancer treatment is primarily driven by protocols put forth by collaborative (multicenter and multidisciplinary) research groups such as the COG. Inclusion of case studies with COG protocols applicable to daily practice was used to emphasize didactic material after it was presented. The ONS provider course with the supplemental pediatric content became the didactic portion of the CNMC chemotherapy competency program and has been presented to pediatric oncology, NICU, PICU, and MCU nurses at CNMC. The course was offered to the NICU, PICU, and MCU nurses
because they also administer chemotherapy to their patients. We have also invited nurses from other local hospitals. Evaluations from 20 pediatric oncology course participants have been extremely positive. Participants have recommended that a hands-on demonstration or skills laboratory on IVP chemotherapy or safe handling be incorporated into the program.
Competency Skills Checklists After subsequent course offerings to address additional recommendations made by the staff, the APS and CE along with a group of staff nurses with 1 to 20 years of experience formed a chemotherapy competency team to update, revise, and develop competencies related to high-risk issues surrounding chemotherapy administration. Three subgroups of the competency team were formed to assess vulnerabilities surrounding chemotherapy administration, which included IVP chemotherapy, continuous intravenous infusion chemotherapy, and safe handling. Safe-handling
264
content included use of personal protective equipment, accidental hazardous drug exposure, and spill management. Further, the team developed test question items and informational posters addressing the three areas mentioned. Content was developed utilizing the ONS Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (Brown et al., 2001), as well as APON texts and
ANDAM AND SILVA
chemotherapy competency materials provided by other institutions. Three competency checklists were formulated as presented in Tables 2, 3, and 4. The first year of implementation of these checklists utilized two methods of validation for existing nursing staff. The IVP chemotherapy competency was validated by return demonstration at a skills station simulating a clinical scenario. Safe handling
Table 4. Chemotherapy Competency Checklist: Safe Handling of Hazardous Drugs
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE Table 4 (continued )
265
266 Table 5. IVP Chemotherapy Skill Station Script for Validating RNs Evaluator cheat sheet: Review the scenario and questions below and assist the RN by guiding them through the following. They must verbalize any answers (avoid prompting) and return demo with minimal prompting to complete the module successfully. Please initial Chemo Competency-IVP column next to RN name with your initials and date once the RN has completed the station. Scenario: Freddie is an 8-year-old with PICC line here for resolving F/L/N after ALL treatment last week. His ANC has recovered and is greater than 250. He is ready to be discharged. The fellow, however, has noted he is due for IVP Vincristine through his PICC line before he goes home. She writes the order and gives you a copy of his roadmap to ensure he receives his medication as ordered.
Questions and skills: 1. What preadministration documents do you need to ensure safe IVP chemo delivery? (Must name at least 2 of 3) • MD order • Roadmap • Chemo checklist 2. What patient information do you need to ensure safe IVP chemotherapy delivery? (Must list at least 3 of 5) • Patient height/weight • Allergy history • Nam/MR number • Lab results 3. Before giving the chemotherapy, the patient and family must be educated on the drug. What education can you provide on Vincristine? (Name two side effects or postadministration issues.) • Constipation, peripheral neuropathy, etc. • Clear drug • Extravasant/Irritant • APON drug sheet 4. You and the witnessing RN have verified the drug dose with the order. Before you administer it to the patient, you must verify patient identification modifiers. What is the process? • Check the modifiers, patient name and MR number, on the patient's ID band vs. drug label 5. Have the RN return demo the IVP drug delivery. Must demonstrate. • Gather and select supplies (chucks or gauze pads, alcohol, PPE, drug, flushes) • Set up area per poster/presentation • Assess for blood return • Trouble shoots and catches drops • Rate of administration • Signs/Symptoms of extravasation 6. You have successfully given the drug. The patient has a fever before discharge and has to stay the night. He becomes incontinent of urine and he and his bed sheets are wet. Describe your actions, what kind of precautions would staff take to minimize chemotherapy exposure? • Universal precautions with any patient waste, with gowns and/or gloves as needed • Move patient from area; cleanse skin with soap and water, until bed is remade 7. List two postadministration interventions. (What do you do when you are done?) • Dispose materials to yellow chemotherapy waste receptacles • Monitor for side effects • Documentation (FS, NPN, MAR)
and continuous intravenous chemotherapy infusion competencies were validated via written examination. Because it was identified that competencies were to be assessed annually, it was felt by the group that skills validation via return demonstration
ANDAM AND SILVA
should be rotated among the three areas of IVP, continuous chemotherapy, and safe handling competency. During the second year of implementation, return demonstration of spill management and safe handling was implemented; a written examination was distributed to address the areas of IVP and continuous infusion chemotherapy. These newly developed competency checklists were distributed to new RN staff during orientation and were to be completed during clinical orientation over a period of 8 to 12 weeks. Skills are evaluated by the CE, APS, preceptors, or members of the chemotherapy competency team or trained nurses. Validating RNs are provided with scripted scenarios to ensure consistent validation. A copy of the IVP chemotherapy skills station script for validating RNs is presented in Table 5. The return demonstration skills station included several highlighted features (Table 6). The current CNMC Chemotherapy Competency Program modules address these three chemotherapy competency skill sets and validate competency through return demonstration and written test. Nurses who administer chemotherapy or work with patients who have received chemotherapy review the modules annually. One area that continues to challenge this program is the education of RNs outside of the hematology/ oncology area, such as the PICU, NICU, and MCU. All the staff throughout the institution who administer chemotherapy are encouraged to attend the 2-day class and participate in the annual skills validation. Skills validation is not required for these areas at this time. The PICU has been most consistent in sending RN staff to the class and have had several RNs complete skills validation with the hematology/oncology staff. Generally, feedback from RNs from these areas has been positive. NICU and MCU staff, despite initial interest and participation in the classroom portion Table 6. Highlighted Features of the IVP Chemotherapy Skill Station Feature
Rationale
• To ensure standard validation technique among all evaluators Simulate central venous • Patient identification modifiers access device complete included to reflect patient with patient identification safety standards modifiers and blood return • Blood return important to reflect infusion-nursing standards Various supplies that may • To assess if RN is able to identify and or may not be used are select the appropriate supplies available at the station Return demonstration • To maintain adult learning principles Evaluator scripted scenario
A JOURNEY TO PEDIATRIC CHEMOTHERAPY COMPETENCE Table 7. APON Pediatric Chemotherapy and Biotherapy Curriculum Cancer overview Describe the characteristics of the cancer cell. Identify differences between cancers in adults and cancers in children. List cancer treatment modalities and how response is measured. Chemotherapy overview Discuss the history of chemotherapy. Describe the development of the specialty in childhood cancer treatment. Identify principles for cancer research and informed consent and the role of the nurse. Legal and ethical issues Describe the ethical principles associated with clinical trials. Identify the nurse's role in informed consent. Discuss legal issues related to chemotherapy administration. Principles of chemotherapy Describe important principles of pharmacokinetics in chemotherapy administration. Discuss classes of chemotherapeutic agents. Define combination chemotherapy. List modes of chemotherapy delivery. Principles of biotherapy Identify biotherapeutic agents. Describe indications and actions of commonly used medications. Identify side effects and nursing interventions for specific biotherapy agents. Chemotherapy agents and classifications Recognize classifications for chemotherapeutic agents. Identify common side effects for individual medications. Describe nursing interventions for chemotherapy medications. Safe handling Describe the occupational exposure risks of chemotherapy. List components of safe handling and disposal practices. Identify components of personal protection equipment. Preadministration issues Identify components of pretreatment assessment. Calculate body surface area and confirm chemotherapy dosage. Describe required family teaching prior to chemotherapy administration. Chemotherapy administration and immediate postadministration issues Describe safety measures to verify chemotherapy orders. List steps in preparation of chemotherapy. Identify nursing measures for different routes of administration. Describe special considerations for vesicant chemotherapy. Toxicity and symptom management Identify common side effects of chemotherapy by organ systems. Describe nursing assessment and interventions for common toxicities. List expected medical interventions for each toxicity. Late effects of chemotherapy Define late effects. Describe examples of late effects by body system. Psychosocial issues Define quality of life in chemotherapy patients. Describe risk factors for adherence to therapy. Identify unique concerns for adolescents and young adults. Discuss how culture influences patient and family response to chemotherapy.
of the program, have not had RNs attend the skills validation component. RNs from the MCU have provided feedback that the 2-day course is excessively detailed for their limited use of chemotherapy in the their patient
267
population. The NICU has decreased their attendance to the program due to the rarity of chemotherapy administration in the neonate. As well, both units have the competency program available to them. The unit-based educator completes a modified skills validation on the MCU. The chemotherapy/biotherapy competency program at CNMC involving completion of both skills validation and completion of the 2-day didactic portion offered by the ONS (with supplemental pediatric content added by the APS and CE) has been extremely successful. During preparation of this article, the APON Pediatric Chemotherapy and Biotherapy Curriculum had become available. The CNMC chemotherapy competency program is now transitioning from the ONS to the APON course as the preferred course for the didactic portion of the CNMC program. APON Pediatric Chemotherapy and Biotherapy Curriculum objectives are listed in Table 7 to highlight the various content areas that enhance the program. Table 8. Chemotherapy Competency Module Evaluation Evaluation results following CNMC Chemotherapy Competency Module (N = 20) 1 To What Extent Have You Achieved Each Objective?
Question 1: The 2-day Chemotherapy Provider Course ⁎ provided me with the knowledge to administer chemotherapy safely. Question 2: The 2-day Chemotherapy Provider Course provided me with enough pediatric content. Question 3: The chemotherapy competencies at the unit-based competency fair reinforced the knowledge I gained from the course and provided another learning opportunity to administer chemotherapy safely. Question 4: Rate the overall level of satisfaction with the HOCU Chemotherapy Competency Program †.
None
2
3
4
Fair
5
6
Exceptional
No answer
–
– –
11 9
–
–
2 6
9
3
–
–
– 2
11 7
–
–
– 1
11 8
–
Note. Dashes indicate no response reported. ⁎ The 2-day Chemotherapy Provider Course refers to the ONS course, to which the APS/CE added additional pediatric content. † The HOCU Chemotherapy Competency Program consists of both the 2-day Chemotherapy Provider Course and the unit-based chemotherapy competencies.
268
ANDAM AND SILVA
The CNMC chemotherapy competency program's didactic course offering has evolved over the past 2 years. We have transitioned from a combination of 1-hour lecture and 17-page module, to an adultfocused chemotherapy course, and finally to a nationally recognized pediatric chemotherapy and biotherapy course with institution-specific competency checklists. Participants' evaluation of the APON pediatric course is currently being reviewed. EVALUATION After offering both the didactic portion and threepart competency skills set, nurses have indicated improved satisfaction with the methodology of achieving chemotherapy competency. They are more knowledgeable about the toxicities of these therapies (Table 8). Importantly, patients and families observe a nurse who is confident in his or her teaching of the action, toxicities, and management of the toxicities. Before administering chemotherapy/ biotherapy, the nurse will review the action and side effects of each agent using the APON Chemotherapy Fact Sheets. The nurse will then answer any question or provide more literature if families are in need of further information. Patients and families have verbalized in hospital surveys satisfaction with the education they have received. Future directions for the CNMC chemotherapy/ biotherapy competency program include continued yearly skills validations, independent provider
course renewal through either the ONS or APON depending on which course the participant was enrolled in, and continued transition from the ONS program to the new APON Chemotherapy/Biotherapy Provider program. Yearly skills validation will continue to include observation of skills competence and assessment of knowledge via the written examination component. As the body of knowledge of pediatric oncology treatment evolves, timely inservices as well as inclusion of new information into the competency presentations will be offered annually, nurses are ensured up-to-date information to maintain safe chemotherapy administration. Lastly, we will encourage nurses to become Certified Pediatric Oncology Nurses (CPON) because many components of the examination focus on chemotherapy/biotherapy toxicities and management of those toxicities. Completing the CNMC chemotherapy/biotherapy competency program will provide the nurse with the necessary preparation for the CPON examination. So far, 10 nurses that completed the CNMC chemotherapy/biotherapy competency program have successfully achieved CPON status. It is our hope that this description of our journey to pediatric chemotherapy competency will provide a program outline that other institutions/units can implement in their areas to ensure nurses are equipped with the knowledge and clinical competencies needed to administer chemotherapy safely to the pediatric patient.
REFERENCES Bradshaw, A. (1997). Defining competency in nursing (part 1): A policy review. Journal of Clinical Nursing, 6, 347−354. Bradshaw, A. (1998). Defining competency in nursing (part 2): An analytical review. Journal of Clinical Nursing, 7, 103−111. Brown, K., Esper, P., Kelleher, L., O'Neill, J., Polovich, M., & White, J. (Eds.). (2001). Chemotherapy and biotherapy: Guidelines and recommendations for practice (pp. 1−3). Pittsburgh, PA: Oncology Nursing Society. Gibson, F., & Soanes, L. (2000). The development of clinical competencies for use on a paediatric oncology nursing course using a nominal group technique. Journal of Clinical Nursing, 9, 459−469. Hall, J. L. (1999). Developing meaningful age-appropriate competencies for clinical services. Journal of Nurses in Staff Development, 15, 241−250. Kanaskie, M. L., & Arnold, E. (1999). New ways to evaluate chemotherapy competencies. Nursing Management, 30, 41−43. Kline, N. E., Echtenkamp, D., Norville, R., & Silva, M. (Eds.). (2004). The pediatric chemotherapy and biotherapy
curriculum (pp. 1−2). Glenview, IL: Association of Pediatric Oncology Nurses. McMullen, M., Endacott, R., Gray, M., Jasper, M., Miller, C., Scholes, J., et al. (2003). Portfolios and assessment of competence: A review of the literature. Journal of Advanced Nursing, 41, 283−294. Price, J., & McShane, B. (2002). Administration of chemotherapy: Evaluating a framework for developing practice. Paediatric Nursing, 14, 14−17. Smith, M. A., & Ries, L. A. (2002). Childhood cancer: Incidence, survival, and mortality. In P. A. Pizzo, & D. G. Poplack (Eds.), Principles and practice of pediatric oncology (pp. 1−13). Philadelphia, PA: Lippincott Williams & Wilkins. Woolery-Antill, M. (2002). Biotherapy. In C. Baggott, K. Kelly, D. Fochtman, & G. Foley (Eds.), Nursing care of the child with cancer (pp. 177−209). 2nd ed. Philadelphia: W.B. Saunders. Wright, D. (1998). The ultimate guide to competency assessment in healthcare. : PESI Healthcare, LLC.