The influence of technology on cancer nursing

S e m i n a r s in Oncology Nursing, Vol 16, No 1 (February), 2000: pp 3-11

3

THE INFLUENCE OF TECHNOLOGY

lite (in the ~ontext qfoneOlogy) over the last 25years. and to presen~ projections of pos~ble technology in thefuture of oncology nursing.

DATASOURCES:

ON CANCER

(1982 tO presenO; MED(1976 m i1984) and ~ t h o r iden~fic.a~n of articles.

NURSING

CONCLUSIONS: Technology has greatly influenced the evolution of 0neology nursing, particularly concerning treatment (chemotherapy, radiation therapy, biotherapy, marrow and blood transplantation), access devices, and genetic and information technologies.

IMPLICATIONS FOR NURSING PRACTICE: Nurses must be prepared to deal with how technology affects their philosophical perspective of nursing and the challenges presented by technology.

From the University of Arizona, Arizona Cancer Center, Cancer Prevention and Control, Tucson, AZ. Supported in part by a National Institutes of Heahh/National Cancer Institute Cancer Prevention and Control predoctoral fellowship (NIH 1 R25 78447-01), an Individual National Research Service Award predoctoral fellowship from the National Institute of Nursing Research (1 F31 NR07235), and an American Cancer Society Cancer Nursing doctoral scholarship. Lois J. Loescher, PhD: Senior Research Specialist, Cancer Prevention and Control Fellow, University of Arizona, Arizona Cancer Center, Cancer Prevention and Control, Tucson, AZ. Address reprint requests to Lois J. Loescher, PhD, Arizona Cancer Center, Salmon Bldg Room 2964D, 1515 N Campbel !Ave, PO Box 245024, Tucson, AZ 85724,5024,

Copyright ©2000 by W.B. Saunders Company 0749-2081/00/1601-000151& 00/0

Lois J. LOESCHER

T

he literature first began to recognize oneology nursing as a nursing subspecialty around 1975.1 A reader of early oncology nursing literature garners that technology (although not always identified as "technology" per se) has played a direct or indirect role in oneology nursing over the past 25 years. Any nurse who has been actively involved in oneology during those years can identify with these other observations of technology: (1) oneology nurses have been instrumental in advancing technology in oncology and (2) advances in technology continue to change the scope of oneology nursing research, education, and practice. Indeed, medical technology is now so rapidly evolving and advancing that many nurses struggle to keep up with changes, both philosophically and in a practical sense. This article presents an overview of the interaction of technology and oneology nursing, beginning with a philosophical commentary on nurses' views of technology in general. Also summarized are some technologies that have been described in nursing literature (in the context of oneology) over the last 25 years. Most of these technologies are medically based. Finally, some projections of possible future technology in this new millennium of oncology nursing are presented. PHILOSOPHICAL PERSPECTIVE: |S NURSING AT ODDS WITH TECHNOLOGY?

p

aradigms of nursing have, and will continue to be, debated in the literature. 2-s Common to most perspectives are elements of earing, health, health experience, 4 well-being, and the uniqueness and autonomy of human beings. 2 Teehnology's position in the

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L O I S J. L O E S C H E R

philosophical underpinnings of nursing (and vice versa) has only begun to receive attention in these debates. 6 The word "technology" often conjures visions of mechanical devices, laboratory testing, and other highly technical images, images that reflect a more mechanistic, rather than humanistic, focus. 7 The origins of technology, however, are not purely mechanistic. Technology is defined as the braneh of knowledge that deals with the creation and use of technical means and their interrelation with life, society, and the environment. The Greek word stem "teehno" means "art" and "skill. ''s Technology in this sense "fits" with the humanistic focus of nursing. 7 Wiehowski9 defined medieal technology as "drugs, devices, medical and surgieal procedures used in medical care, and the organizational and supportive systems within which it is provided." That definition c a n b e slightly refined for ontology nursing: technology is the creation and use of technical means (ie, drugs, devices, medical and surgical procedures, molecular techniques) to prevent, treat, and control cancers. Embedded in this definition is the interrelation of technology with the art and science of oneology nursing: research, education, and praetiee. Nurses historically have held one of two contrasting views of teehnology: (1) technology enhances nursing and empowers nurses (labeled "technological optimism ''1° or "technological utopia 'ul) or (2) technology disrupts the holistie foundations of nursing and is an intrinsically regressive social force that is detrimental to nursing (labeled "technological romanticism 'u° or "technological dystopia'Ul). Advocates of technologic optimism view technology as enabling nurses to become more knowledgeable about the biological and engineering sciences and improving the sensory and physical capabilities of nurses. For example, nurses may have more expertise with machine technology, in a mechanistic and intuitive sense, than physicians. Advocates of technologic romanticism contend that teehnology decreases the "humanism" in nursing both philosophieally and in dealing with patients. They view that technology has "reinforced the subordination of nursing to medicine and impeded the development of nursing as a valued province of knowledge and practice."1° According to Purnell, 11neither perspective of teehnology addresses nursing's implicit values nor does it acknowledge the expert nurse.

She comments that "technology within the nursing situation is artistically transformed, and parameters are redefined. ''11 Although technology itself is considered to be value neutral, its uses are not. The nurse is responsible for the application and outcomes of technology placed within the nursing arena for nursing use. As such, the nurse becomes an interpreter of technology and the bridge between the technology and the patient. However, in the role of interpreter, the nurse may experience technologic dissonance when attempting to transform the reductionistic aspects of medical technology into holistie nursing teehnology.11 Sandelowski, 12 who has published widely on technology, summarizes another view, based largely on Ihde's 13 view of instrumental realism. In this view, nature (or reality of the world) is transformed by the technology used to reveal it. Essentially, science is a product of the technology that reveals what science ultimately deems as nature (reality); ie, science is teehnologieally embodied. Nature does not mirror science; rather, it is the product of technology-dependent science; ie, nature is found and made. Technology both reveals and transforms nature; the very act of using technology to reach nature changes nature and loses it as it was) 2 Viewing technology through this lens lends eredenee to the notion that nursing, as a science, also embodies technology. As such, technologic advances will continue to occur and become a part of nursing as nursing becomes a part of technology.

METHODS t is beyond the scope of this article to review

I every technologic advance in oneology nursing. Equally informative, perhaps, is an overview of categories of technologic advanees (primarily medically based technology) published in the nursing literature. To identify nursing journal articles that focused on ontology nursing and teehnology, the MEDLINE and CINAHL databases were searched. Because CINAHL listings are from 1982 to present, articles predating 1982 were identified using MEDLINE (1976 to 1984). The initial MEDLINE search parameters were "neoplasms" + "technology" + "nursing"; however, this search yielded only five articles. A second MEDLINE search for the same period used the parameters "neo-

INFLUENCE

plasms" + "nursing" + " t r e a t m e n t " b e c a u s e in the early years of oneology nursing, technology was highly associated with t r e a t m e n t . This search yielded 34 citations, 19 of which were publications in nursing journals. The CINAHL search used the categories and key words o f " c a n e e r " + "nurses" + "technology" ("cancer" + "technology" yielded a large n u m b e r of n o n n u r s i n g references). The search covered the period between 1982 and 1999 and identified 32 articles. Articles predating 1982 and t h a t were not published in journals listed in Index Medicus were individually identified b y the author as appropriate for describing the evolution of technology in oneology nursing. DESCRIPTIONS OF ONCOLOGY-RELATED TECHNOLOGY IN TttE NURSING LITERATURE

Year

Technology

1976 1978 1979

Bone marrow transplantation 1" Chemotherapy (side effects) 15.16 Radiotherapy (implants, dosimetry, simulators, ultrasound, radioisotopes 17-21 Chemotherapy administration 22 Infection conlrolaa Chemotherapy (side effects) 24,25 Ommaya reservoir26 Biologic response modifiers (interferon) 27 Monoclonal antibodies 28 Venous access devices 29 Biotherapy (i nterleukin-2) 3o Animal research 31 Biotherapy (interleukin-2. interferon) 32.33 Chemotherapy (safe handling) 34 Hi-tech patient education 35 Radiation therapy 36 Outpatient infusion service 37 Impact of technology on cancer nursing 38 Laser treatment 39 New approaches/innovations in cancer prevention, diagnosis, treatment, and support 4° Cancer critical care 41 Gene therapy 42 AIIogeneic bone marrow transplantation 43 Autologous bone marrow transplantation 44 Genetics (predisposition testing, gene therapy)"5,46

1980 1981 1982

1983 1984 1986 1987 1988 1989 1990

Chemotherapy

1997

1992 1993 1994

1995

Waiter's 2s words still ring true for nurses eurrently involved in the varied uses of c h e m o t h e r apy. T h r o u g h o u t the last two decades, nurses have been i n s t r u m e n t a l in advancing the use of these technologies through i n v o l v e m e n t in monitoring of clinical trials, side effects m a n a g e m e n t , and,

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Access devices 47-49

1996

In 1982, Walter 2s p r e s e n t e d an a p p r o a c h to viewing c h e m o t h e r a p y as a technology: "Caring for patients who receive ehemotherapeutie agents is among the most challenging and potentially rewarding dimensions of oneologie nursing practice. The nurse must possess sound knowledge of not only the biologic and behavioral seienees, but also of current oneologie nursing practices, pathology, and the pharmaeeuties of antineoplastie drugs. However, comprehensive nursing care must eounterbalanee clinical expertise with sensitivity to the unique problems patients with cancer and their families experience."

ON CANCER NURSING

in the Nursing Literature*

ased on the above criteria, Table 1 s u m m a rizes types of technology described by nurses in nursing literature published between 1976 and 1998.14-64 Seleeted categories reflecting the evolution of technology in oneology nursing include c h e m o t h e r a p y and radiation therapy, m a r r o w and blood transplantation, access devices, biotherapy, genetic technology, and information technology. In the early years of ontology nursing (ie, from 1976 to 1980), descriptions of technology in the nursing literature c e n t e r e d around e a n e e r treatm e n t , primarily c h e m o t h e r a p y and radiation therapy. This focus is not surprising in that these therapies r e p r e s e n t e d the standard c a n c e r treatm e n t modalities used during that period.

B

OF TECHNOLOGY

1998

Reproductive tech nology for patients with cancer 5o Hematopoeitic growth factors 51 Biotherapy (future projections) 52,53 Telephone support groups s4 Monoclonal antibody therapy 55 Cancer prevention technology 5~ Cancer genetics (educational issues) 57 Computer use for cancer pain management 58 Blood cell transplantation 59 Cancer genetics (DNA testing) 6°,61 Information technology 62"64

*Sources: MEDLINE (1976 to 1984), CINAHL (1982 to 1999), and author selection of articles.

m o r e recently, the identification of late and long-term effects of e h e m o t h e r a p y . Because of nurses' insistence, vigilance, and dedication, standards of practice for c h e m o t h e r a p y a d m i n i s t r a t i o n have b e e n created and endorsed, standards that p r o t e c t b o t h nurses and patients from possible h a r m resulting from the technology. C h e m o t h e r apy certification courses also have helped nurses

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administer and handle drugs safely. Viewing chemotherapy as a technology, oncology nurses have been technologic optimists but also have used their role as expert nurses in this area to become the bridge between the technology and the patient. 1°,11 Despite the persistent efforts of oncology nurses to maintain the pace of chemotherapy technology, the technology itself continues to present problems. Viewing chemotherapy through the lens of Ihde 13 (technology both reveals and transforms nature), chemotherapy has cured many cancers, but advances in chemotherapy continue to create a host of new side effects and symptommanagement problems for nurses to deal with.

Radiation Therapy Early descriptions of radiation therapy centered around the mechanistic aspects of the therapy: implants and applicators, dosimetry, simulators, and use of ultrasound and radioisotopes in tumor localization. 17-21 Stroh136 furthered this discussion in her extensive review of half-body radiation, total skin electron therapy, hyperfractionation, intraoperative radiation, advances in brachytherapy, hyperthermia, and chemical modifiers influencing radiation response. In the early years of radiation therapy for cancer, nurses learned the technology and assimilated it into their role by becoming licensed radiation therapy technologists (RN/RT[T]). These nurses were trained to operate the treatment machines and deliver the radiation treatments. The intertwining of the RN/RT role enabled nurses to integrate nursing into the more technologic aspect of radiation therapy. However, economic constraints and government regulations led to the current separation of the roles. 65 Stroh166 pointed out the challenges of viewing radiation therapy technology within nursing when nurses do not personally administer the treatment, a challenge that could represent some cognitive dissonance of radiation technology and nursing. 11 Shepard and Kelvin65 reviewed the multifaceted role of oncology nursing in relation to radiation therapy and stated that although the role "has been defined and implemented with success in the last 20 years, the future development of the role is uncertain." These investigators suggested that oncology nurses need knowledge and skills in the areas of case management and information systems to deal with radiation therapy technology in this new century.

Marrow and Blood Transplantation Schwitter and Beach's 14 description of bone marrow transplantation (BMT) was one of the first

articles published in the nursing literature about the "new concept" of leukemia treatment. These investigators stated that: "the nurse not only acquires skill in caring for a patient with leukemia and aplastie anemia, but also becomes knowledgeable in infectious diseases, immunology, fluid and eleetrolyte balance, and cardiae, respiratory, and renal diseases. ''14

In less than 30 years, oneology nursing has seen allogeneic BMT evolve from an experimental therapy fraught with serious side effects to a standard treatment for several diseases. Autologous BMT now relies on a variety of purging techniques to decrease the potential for marrow contamination. 44 Better success with BMT in general is largely attributed to technologies such as use of HLA antigen typing, hematopoietic growth factors, changes in antibiotics, and advances in parenteral nutrition and transfusion therapy, as well as how nurses integrate this technology into their nursing practice. 43 Blood cell transplantation (BCT) for the use of selected leukemias and solid tumors has rapidly evolved over the past 10 years and has become the primary source of stem cells. Allogeneic BCT sometimes is a treatment option for patients not eligible for BMT. The success of BCT lies in the ability to identify stem cells using techniques such as culture assays. Unheard of 25 years ago, BCT can be administered on an outpatient basis. 59 Umbilical cord blood transplantation may be more common in the future, as well as umbilical cord blood stem cells as vectors for gene transfer. 67 Use of both these technologies in oncology has evolved largely during the era of the professional oncology nurse. Nurses, therefore, have been instrumental in recognizing and dealing with the often-serious complications of BMT and BCT. Nursing input into the development of clinical trials, procedure guidelines, and standards of care for these technologies as been invaluable. Nurses have been proactive in designing the settings for transplantation, such as inpatient units or outpatient specialty clinics. The challenge for nurses who are involved in BMT and BCT will be to better define how these technologies interface with nursing's implicit values and acknowledge the expert nurse. 11

Access Devices Two decades ago, short-term venous access devices (VADs) enabled oncology nurses to deliver drugs with fewer chances of extravasation and with

I N F L U E N C E OF T E C H N O L O G Y O N CANCER N U R S I N G

less trauma to the patient. 29,4r In 1984, Goodman and Wiekham 29 exemplified how nurses could enhance VAn technology for oneology patients: "The problem of continued venous access is common to all nurses involved in the administration of cancer therapy ... because nurses most often administer the drugs, it seems appropriate that they participate in identifying patients who also could benefit from a VAn and the type of device best suited to the patient." Early VAns included single- or double-lumen silicone silastie catheters (eg, Hickman/Broviae catheters, Bard Access Systems, Murray Hill, NJ), small-gauge central venous catheters, and implanted ports (eg, Port-a-Cath, 8 i n s Deltee, Ine, St Paul, MN). 29 Similarly, c u r r e n t VAns consist of peripherally inserted central catheters, tunneled catheters, and implanted ports. However, these are made with silicone elastomere or elastomerie hydrogel, which greatly decreases the complications seen with early c a t h e t e r s . 4s T o d a y ' s access devices can be used for intravenous drug and nutritional therapy, blood product administration, and blood withdrawal 4s and inelude short- and long-term devices for accessing the intraspinal, arterial, peritoneal, and intraventrieular body spaces. 4r Additionally, over 600 models of ambulatory pump systems are currently available to access body spaces by peristaltic, syringe-driven, or elastomerie (balloon) mechanisms .49 Access devices have revolutionized patient treatment over the past 25 years. Camp-Sorrell 4r summarized evolving nursing trends reflecting the technologic aspects of access devices: "First, access devices are no longer reserved for inpatients • . . as o u t p a t i e n t u s e increases, so h a s the d e m a n d for safe

and reliable devices . .. Second, routine care and dealing with complications, once the responsibility of the oneology nurse, are now responsibilities of the patient and family ... Third, oneology nurses are challenged to maintain current knowledgeof the differences between the devices, the patient criteria for selecting a device, maintenance protocols, and monitoring for complications. Troubleshooting problems occurs more frequently over the telephone than in the clinic or hospital... Oneology nurses have become recognized authorities on access device care..."

Biotherapy The last two decades bear witness to the identification and use of biological agents to affect a h o s t - t u m o r response. Use of interferons-~ and -[3 predominated early discussions of biotherapy in the nursing literature. 27,33 In 1982, Seogna and

7

8 c h o e n b e r g e r 27 discussed biotherapy as a "last c h a n c e " treatment: "Patients m a y view it as t h e 'magic bullet' a n d m a y find it attractive b e c a u s e it is 'natural' or biological. Patients receiving t h e s e agents often have unrealistic expectations, despite information given t h e m . We m u s t n o t d e n y patients of hope b u t should t e m p e r it realistically. Patients who are no longer responsive to s t a n d a r d t h e r a p y m a y view the o p p o r t u n i t y to receive s u c h an investigational agent as their 'last chance.' "

R e c o m b i n a n t DNA technology provided the means for using another eytokine, interleukin-2, as biotherapy. 3°,32 Hybridoma technology enabled the p r o d u c t i o n of monoelonal antibodies, two of which have received regulatory approval: murom o n a b - C D 3 and s a t u m o m a b pendetide. 2s,32,s3 Monoelonal antibodies are now used in c a n c e r histopathology, detection, and monitoring for c a n c e r r e c u r r e n c e and metastases. 55 More recently, molecular biology technology has isolated hematopoietie growth factors such as granuloeytem a c r o p h a g e colony-stimulating factor, granuloeyte colony-stimulating factor, and erythropoietin. sl,s3 All these growth factors affect the process of hematopoiesis. In 1996, Rieger 6s considered the future of biotherapy and elucidated how the status of biotherapy has evolved since early reports of the technology: "Ongoing discoveries in the basic sciences will c o n t i n u e to fuel innovative strategies against c a n c e r u s i n g biotherapy in increasingly complex c o m b i n a t i o n s with o t h e r modalities. The o n t o l o g y n u r s e m u s t keep abreast of t h e s e n e w a n d increasingly sophisticated d e v e l o p m e n t s to lead t h e way in developing n u r s i n g m a n a g e m e n t strategies for patients with cancer."

Genetic Technology Although work on gene therapy began in the mid-1980s, somatic cell gene therapy for c a n c e r has been discussed in the nursing literature only over the last decade. In 1994, Jenkins et al 4a posed the following question: "Will gene therapy be validated as a treatment in cancer care or find its best application in genetic diseases? While this question is being answered, the challenge for nurses both in the United States and internationally will be to understand gene therapy and to educate patients and their families about this new technology." Two types of gene transfer are used in the clinical setting: gene labeling (eg, eytokine labeling and labeled autologous bone m a r r o w cells) and gene t h e r a p y (interleukin-4 t u m o r vaccines, tu-

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L O I S J. LOESCHER

mor necrosis factor directly targeted to tumor, suicide gene, multidrug resistance gene, genes that enhance antigenicity).46 Another focus of genetic technology, identification of gene mutations predisposing to cancer and the testing for those mutations, also has been only recently reviewed in the nursing literature. Loescher45 reviewed inherited mutations in tumor suppressor genes implicated in several cancers and later described DNA testing for cancer and implications for oncology nurses. 6° As with biotherapy, nurses working with genetic technology must have knowledge of basic molecular and cellular biology. In a sense, nurses provide the technologic bridge for successful clinical implementation of translational research. Additionally, genetic technology has ushered a new responsibility and subspecialty for oncology nurses: cancer genetic risk counseling. 69-71

Information Technology The availability and accessibility of computer technology has begun to affect many aspects of oncology nursing. For example, Frandsen 5s indicated that the availability of computer resources for cancer pain and nursing are limited. He suggested that the application of computer technology to cancer pain management potentially might improve delivery of patient care, educate both health care professionals and consumers, and improve outcome measures. Recent development of Internet cancer support groups (ICSG) have brought computer technology into the realm of cancer information and psychosocial support for patients and their families. 63 Advantages of this technology are cited by Klemm and Nolan63: "Eleven percent of American households currently have Internet access, and the number of computers in the United States will reach 40 million in the near future . . . An ICSG addresses many of the traditional barriers of attending support groups. It is an option for patients who are too ill to travel and family members who are too busy taking care of ill people to attend. In addition, they are low in costs (no travel costs or time away from work), support is always available online, and the relative anonymity may increase participation."

Disadvantages are potential legal and ethical implications of conducting research with this patient population. Gomez and King64 identified additional uses of computer technology in nursing, including use of e-mail, the Internet as a cancer information resource, virtual classrooms to en-

hanee distance learning, sharing of research databases, and the burgeoning specialty of nursing informatics. ONCOLOGY TECHNOLOGY IN THE NEW

MILLENNIUM: FUTURE PREDICTIONS o the probable chagrin of technologic romanticists, 1° rapidly evolving technologies critical for cancer care, such as computer information systems and molecular biology, inevitably will change the traditional "hands-on" nurse-patient relationship. Technologic advances will eliminate or modify some activities and responsibilities traditionally considered in the realm of nursing. An example of this change is patient education. In the future, most patient education will be accomplished by interactive computer programs rather than face-to-face by a nurse. Touchscreen computer programs will allow patients to learn about cancer prevention, diagnosis, treatment, and survivorship in a self-paced, user-friendly way. Programs using comprehensive videos and graphics will detail risks and benefits of procedures and treatments while also testing the patient's understanding of the information. The patient's path through the program will be saved and printed out in a transaction report seen and signed by both the patient and the health care provider. 72 Although this education method results in less nurse-patient face-to-face contact, nurses will play a pivotal role in developing the content for computer programs and evaluating them for utility, validity, and reliability. Molecular technology will continue to have an enormous impact on cancer prevention, diagnosis, and treatment. For example, biochips (microarrays, DNA array) can provide a grand view of the human genome or narrow in-depth looks, such as screening for several hundred genes that are associated with breast cancer. Biochips can identify these genes at a rate 25 times faster than currently used gene-sequencing methods. Following cancer diagnosis, biochips can then be used to check several other genes; such as those that determine how fast the body metabolizes anticancer drugs. 73 Table 2 lists other technology-related projections that could ring true this millennium. The list is not exhaustive and nurses are encouraged to use

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A Few Projections of Influences of Technology on OnCology Nursing Type of Technology Information (patient)

Information (professional)

Diagnosis and treatment

Prevention and early detection

Projection Nurses will use their expertise as consultants for touchscreen computer programs used for teaching patients about cancer prevention, diagnosis, treatment, and survivorship 72 The Internet will become the mare source of patient information Nurses will provide outreach consultation to 0atients via personal computer camera telecommunications software Nurses will participate in virtual training and human simulation systems to learn new skills before patient contact Curricula on informatics and technology will become standard offerings in nursing colleges: cognitive and practical knowledge of computer systems will be required for graduation and licensure Wireless or radio frequency technology (the norm) will facilitate computerized nursing care planning systems TM Telenursmg will be a standard means of educating nurses in rural areas Technology will not replace "intuitive knowledge" as a part of nursing knowledge Biochips (microarrays, DNA array) will be used to diagnose cancer, then to check several other genes, such as those that determine how fast the body metabolizes anticancer drugs The field of pharmacogenetics will use genetic diagnostics to determine which patients should take which drugs 73 Photonic (light) technology (lasers, optics, detectors, etc) will allow cancer to be diagnosed or treated through a minimally invasive technique and will become a widely used method for diagnosing and treating breast and ovarian cancer 7s More treatments will be administered transdermally or transnasally 40 Most patients will receive chemotherapy as outpatients; portable, disposable infusion pumps with drug-mixing capability will be pocket-sized or smaller7e Organs destroyed by cancer will be cloned and replaced in patients without evidence of disease Gene mutations predisposing to cancer will be manipulated to a lower likelihood of cancer development Biologic markers will be routinely used to identify carcinogenic changes early in life; resultant use of chemopreventive agents will be based on their biologic activity and the affected phase of carcinogenesis or mutagenesis

their own creative imaginations to ponder what the technologic future could hold. CONCLUSION echnology clearly has been a significant force in the evolution and advancement of oneology nursing to a professionally recognized subspeeialty in nursing. Many of the technologic advances described in this article could not have happened without the close involvement of oneology nurses. In this sense, oncology nurses have been, and continue to be, technologic optimists. The articles cited in this overview also illustrate how oneology nurses have become interpreters of technology and act as the bridge between

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the technology and the patient. Not only have many of the technologies deseribed made certain procedures less cumbersome for the oneology nurse, they also have enhanced the quality of life of patients. As certain technologies become more widespread in use, they could trim some health eare costs, benefiting both the health care system and patients. Viewed in the spirit of instrumental realism, 13 as technology shapes nursing so do nurses shape technology. Technology will continue to "change the way that nurses relate to each other, the content of professional practice, and relationships with patients. ''77 On a positive note, technology may provide nurses with the ability to do what they have always wanted to do: spend more time with patients. 74

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