Cancer Nursing in NSW

Transcription

1 Cancer Nursing in NSW June 2010 Philippa Cahill, Gaynor Heading, Cynthia Lean, Sue Sinclair in collaboration with Ipsos-Eureka Social Research Institute i

2 TABLE OF CONTENTS List of figures List of tables Glossary of Abbreviations (iv) (v) (vi) EXECUTIVE SUMMARY INTRODUCTION METHODS Overview Description of study phases Quantitative data analysis Qualitative data analysis RESULTS AND DISCUSSION What Defines Cancer Nursing in NSW? 3.1 Profile of the cancer nurse in NSW Gender Age Geographical location and role Experience, employment and education Profile of facilities, services, staffing and skill mix Facilities Services Cancer nurse classification Place of work Additional staffing Attrition Links with other services and sectors Staffing and skill mix Models of care 29 What do Cancer Nurses in NSW value? 3.4 Recruitment 33 ii

3 3.4.1 Facility recruitment strategies Key recruitment factors for cancer nurses Qualitative recruitment themes Retention Facility retention strategies Key retention factors for cancer nurses Analysis of priorities for retention Drivers for retention Satisfaction Satisfaction with current role Satisfaction with working in cancer nursing Satisfaction with quality of care Satisfaction with aspects of working environment Analysis of priorities for satisfaction Drivers of satisfaction Drivers of dissatisfaction Professional development, clinical practice and career progression Professional development initiatives Practice development initiatives Career progression 70 What are the Challenges for Cancer Nurses in NSW? 3.8 Workload and emotional strain Workload Emotional strain Bullying 76 What is different about Cancer Nursing? 3.9 Positive and negative differences Differences in recruitment and retention Positive differences abut cancer nursing Negative differences abut cancer nursing CONCLUSIONS REFERENCES 85 APPENDICES 90 Appendix A: Total FTE for each role by type of setting 100 Appendix B: % Total FTE for each role by type of setting 101 Appendix C: Total FTE for each role by type of care/treatment 102 Appendix D: % Total FTE for each role by type of care/treatment) 103 iii

4 LIST OF FIGURES Figure 1: Cancer nursing in NSW study phases 9 Figure 2: Survey sample age 13 Figure 3: Positions held 14 Figure 4: Employment status by ARIA+ 15 Figure 5: Time in nursing across various settings 16 Figure 6: All nursing qualifications completed (multiple response) 17 Figure 7: Place of work 24 Figure 8: Community cancer services provision by ARIA+ 27 Figure 9: Models of care 30 Figure 10: Appropriateness of models of care 30 Figure 11: Advantages of models of care 31 Figure 12: Disadvantages of models of care 32 Figure 13: Facility recruitment strategies (prompted response) 33 Figure 14: Facility recruitment strategies (unprompted response) 34 Figure 15: Reasons for becoming a cancer nurse 35 Figure 16: Reasons why others might become a cancer nurse 36 Figure 17: Cancer nursing specific recruitment strengths 37 Figure 18: Cancer nursing specific recruitment challenges 38 Figure 19: Facility retention strategies 42 Figure 20: Reasons why you continue working in cancer nursing 43 Figure 21: Encouraging others to stay in cancer nursing 45 Figure 22: Priorities analysis - Likelihood of staying in current position 46 Figure 23: Priorities analysis - Likelihood of staying in cancer nursing 47 Figure 24: Satisfaction with time spent on administrative tasks by ARIA+ 56 Figure 25: Priorities analysis - Satisfaction with cancer nursing 57 Figure 26: Priorities analysis - Satisfaction with current role 58 Figure 27: Priorities analysis - Satisfaction with quality of care 59 Figure 28: Professional development initiatives 66 Figure 29: Professional development initiatives available to individuals 67 Figure 30: Professional development needs 68 Figure 31: Practice development initiatives 69 Figure 32: Availability of practice development initiatives 70 Figure 33: Leadership programs and career development opportunities 70 Figure 34. Frequency of workload issues 72 Figure 35: Frequency of emotional strain 74 Figure 36: Frequency of stress working with cancer patients and families/friends 75 Figure 37: Frequency of bullying 76 iv

5 LIST OF TABLES Table 1: Age of cancer nurses compared to profile of nursing workforce in NSW.. 13 Table 2: Ward, unit or service (setting and care/treatment type) Table 3: Breakdown of units (setting) by status Table 4: Breakdown of units (care/treatment) by status Table 5: Cancer nurse FTE by classification Table 6: Cancer nurse FTE per classification by unit status Table 7: Additional staff in cancer nursing:agency, casual and overtime Table 8: Agency, casual and overtime staff by unit status Table 9: Turnover rates 26 Table 10: Breakdown of model of care by unit status Table 11: Quantitative drivers for retention Table 12: Mean scores-satisfaction and adequacy cancer nurses environment..53 Table 13: Quantitative drivers for satisfaction Table 14: Focus group structure and venue 89 v

6 GLOSSARY OF ABBREVIATIONS Abbreviation AHS AIN ARIA+ CNC CNE CNS CSDM CSO EAG EN EEN FT FTE n N/A or NA NE NFP NP NSW NM NUM PhD PT RN RN Year 1 Referent Area Health Service Assistant in Nursing Accessibility-Remoteness Index of Australia Plus Clinical Nurse Consultant Clinical Nurse Educator Clinical Nurse Specialist Cancer Services Development Manager Clinical Support Officer Expert Advisory Group Enrolled Nurse Endorsed Enrolled Nurse Full-time Full-time equivalent Number of participants (sample size or base ) Not applicable Nurse Educator Not-for-profit Nurse Practitioner New South Wales Nurse Manager Nursing Unit Manager Doctorate of Philosophy Part-time Registered Nurse Registered Nurse during first year following nursing registration vi

7 Abbreviation RN Years 2-4 RN Years 5-8 RN 9+ Referent Registered Nurse during second, third or fourth year post registration Registered Nurse during fifth, six, seventh or eighth year post registration Registered Nurse who is not Year 1, Year 2-4, Year 5-8 and does not have a specific clinical or industrial classification vii

8 EXECUTIVE SUMMARY 1. Introduction Comprehensive cancer care includes many phases: initial contact and referral, including screening and diagnostic services; treatment; monitoring and follow-up after treatment; survivorship; and palliative/end of life care. Cancer nurses comprise a significant proportion of the skilled cancer professionals who contribute to the care of cancer patients during all stages, providing services in different facilities including public and private hospitals, community and outreach services and speciality settings. Given the significant contribution of cancer nurses to the care of cancer patients throughout the cancer journey it is important to understand this key group of professionals. This report presents the results from a state-wide study examining cancer nursing in NSW. It aims to provide a comprehensive description of cancer nursing, to identify key factors and initiatives that influence recruitment and retention of cancer nurses and to distinguish any factors that are important or unique to cancer nursing. 2. Research Design The study incorporated six sequenced phases of research using mixed methods including: 1. Literature review 2. Ten exploratory stakeholder interviews 3. Four group discussions with cancer nurses 4. Facility (site) data collection from 67 sites 5. Survey of cancer nurses 6. Seventeen explanatory stakeholder interviews and two group discussions. Data were collected from facilities identified as providing cancer nursing services in the public, private and not-for-profit (NFP) sectors. The facilities were asked to include nurses who worked in speciality cancer wards or units, specialist cancer nursing programs, or wards that care for cancer patients on a regular basis. Generalist community nurses that care for cancer patients were excluded. The full range of nursing classifications was included. 3. Results and Discussion The following sections focus on the state-wide findings which can be grouped into four main concepts: what defines cancer nursing in NSW what cancer nurses in NSW value what are the challenges for cancer nurses in NSW what is different about cancer nursing. 1

9 What defines cancer nursing in NSW? Cancer nurses are predominantly female and 56 per cent were 40 years or older. In regional and remote areas 82 per cent of the total full-time equivalent (FTE) was aged 40 years or older. The survey sample (n=221) was comprised primarily of nurses working full-time (FT) in cancer nursing on weekday day duty. These nurses reported an average of 23 years nursing experience with an average of 11 years in cancer nursing. Two-thirds had completed a cancer nursing qualification. The data from the 67 facilities (94% response rate) were analysed at the individual unit level, with the number of cancer-related wards, units or services totalling 162. The majority (70%) of cancer nursing facilities were in the public sector, 27 per cent were private facilities, and the remaining three per cent were NFP. Speciality cancer units (82%) dominated where cancer nurses worked. Inpatient wards comprised 86 per cent of the general units which included general medical and general surgical wards. The total number of cancer nurses working across NSW was reported as 1,344 FTE. There were greater proportions of higher grade classifications of cancer nurses working in outpatient units/clinics and ambulatory units, with a higher percentage of Clinical Nurse Specialist (CNS) FTEs in chemotherapy and radiotherapy units/services compared to other cancer units/services. Inpatient units had the highest proportion of Registered Nurses (RNs) Years (18%) and Endorsed Enrolled Nurses (EENs) (12%). There was a greater proportion of specialised nursing roles e.g. CNSs than the overall nursing profile in NSW, which might be expected given the complexities related to cancer patients diagnosis, treatment and supportive care. The most commonly reported model of care was team nursing. The study results did not confirm, however, the appropriateness of a particular model of care as skill mix, patient acuity and other factors appeared to influence attitudes related to a model s appropriateness. What do cancer nurses in NSW value? Key reasons for survey respondents becoming a cancer nurse included: the interesting nature of the work (22%); making a difference to patients and/or their families (18%); and relationships and contact with patients and the nature of patients (22%). Most cancer nurses saw a genuine need to promote cancer nursing by focusing on the positive rewards of the job such as the satisfying patient relationships and the challenging and rewarding nature of the work. Cancer nurses who responded to the survey indicated high mean satisfaction with their roles, cancer nursing in general, and the quality of care provided (> 7 on a 0-10 point satisfaction 1 RNs were defined by their year of service since registration and grouped into four categories: RNs Year 1, RNs Years 2-4 and RNs Years 5-8. Other cancer nurses were categorised according to their professional classification (e.g. CNS) or role (Cancer Nurse Coordinator). 2

10 scale where 10 was extremely satisfied). Eighty four per cent of respondents rated their satisfaction with cancer nursing as greater or equal to seven and 77 per cent rated their satisfaction with their current role as greater than or equal to seven. Satisfaction with current role and the quality of care provided were positively correlated with the length of time in the ward/unit and position. Cancer nurses were also satisfied with other work-related aspects including their sense of accomplishment, degree of challenge, opportunities to use skills and knowledge, and level of autonomy. The results indicated satisfaction with professional relationships such as peer support from other nurses, working relationships with medical staff, teamwork across disciplines and support/leadership from nursing line managers. Cancer nurses were less satisfied with nursing staff levels, level of sufficiently experienced nursing staff, time available to get through the work, opportunities for career advancement and the amount of time spent on administrative tasks. Professional development was taken seriously by cancer nurses and was linked to job satisfaction. Facilities reported the availability of professional development initiatives including leave for postgraduate study (84%), access to other forms of professional development/education programs (93%) and annual performance reviews (95%). Cancer nurse survey respondents reported lower levels of availability to some of these initiatives. Facilities also reported the availability of career development opportunities (60%) and leadership programs (74%). Recruitment strategies reported by facilities included return to work programs (70%), undergraduate placements (46%), access to education, training and professional development (37%), and availability of new graduate position rotations (33%). Facilities also reported using professional development and educational initiatives (82%), financial assistance and leave (45%), flexible hours (22%) and good/supportive management (18%) as retention strategies. The main positive influences for retention of cancer nurses were: making a difference to patients and families (30%); rewarding role (27%); the nature of patients (21%); and having good staff/teamwork (20%). The survey results indicated that 59 per cent of respondents were extremely unlikely to leave cancer nursing within the next 12 months. Factors important in recruitment were also key in retaining nurses. Almost all sites (96%) indicated that cancer nurses had support for quality improvement initiatives. There was also support for participative management such as inclusion of staff in management decisions (91%) and involvement of cancer nurses in the development of evidence based practice (87%) and in clinical research (59%). These strategies are likely to further enhance the opportunity for cancer nurses to develop their clinical autonomy and experience a sense of accomplishment and utilise their skills and knowledge reported as factors contributing to their role satisfaction. 3

11 What are the challenges for cancer nurses in NSW? Some cancer nurses expressed concerns about workload with just under one-third indicating that they worked too hard at least once a week. These nurses were less satisfied with their current role and quality of care given and more likely to indicate they were thinking of leaving their role or cancer nursing in the next 12 months. Those nurses who felt used up at the end of the day or emotionally drained at least once a month were significantly less satisfied with their current role, cancer nursing and the quality of care provided and were more likely to be thinking of leaving their current role or cancer nursing in the next 12 months. Bullying was not widespread, but when experienced at least monthly was negatively associated with satisfaction and linked with a greater likelihood of leaving their current role or cancer nursing. Other challenges included the availability of sufficiently experienced nurses and inappropriate ratios of junior to more senior staff. Rural nurses found these problems more acute, and exacerbated by the amount of time spent on administrative tasks and the lower adequacy ratings for allied health and medical staff availability. What is different about cancer nursing? New developments in cancer treatments and improvements in patient care and outcomes have resulted in a stimulating and rewarding work environment. Cancer nurses thought they possessed a greater degree of technical competence compared to nurses in other areas and believed that their skills led to a greater level of autonomy and responsibility, which they saw as a unique benefit of the speciality. Cancer nursing was seen as offering a wide diversity of opportunities and work settings for nurses with varying interests at different stages in their life. Patient relationships were widely viewed as one of the most positive aspects of cancer nursing. Cancer nursing provided more personal patient contact which was sustained over a longer period of time. Nurses reported that being able to make a difference along the patient s journey was particularly rewarding and fulfilling. However, many cancer nurses acknowledged the emotional strains of their work. Providing appropriate, accessible emotional support for cancer nurses, and communicating its availability and importance, were identified as issues for recruitment and retention. While complexity was generally a positive aspect of the job, it was also reported as a negative aspect when there was insufficient workload planning which did not keep pace with the increased complexity of care, the need to treat comorbidities, and the rising patient acuity. There was a clear divide between how cancer nurses saw their jobs and how they thought other nurses saw the speciality. Cancer nurses viewed the contact and relationships with patients as positive, but believed other nurses viewed this as depressing as there was a perception that some patients will die while in their care. Nurses suggested marketing the positive aspects of 4

12 cancer nursing so that external perceptions match the experiences of cancer nurses and to assist with recruitment. Conclusions The majority of the cancer nursing workforce is 40 years or older. This percentage (56%) is lower than the equivalent cohort for the NSW nursing workforce which comprise 71 per cent nurses aged 40 years or older. It is estimated that there will be a 30 per cent increase in the number of cancer cases in the next 10 years, which suggests future challenges to balance the service demands of cancer care with the resources available to provide the care. It is important for policy makers and nursing leaders to consider and establish strategies to recruit to and retain the current workforce, to support specific needs of older nurses who may remain in the workforce, and to attract and support nurses returning after a career break. Cancer nurses identified the need to provide opportunities for students and new graduates to experience cancer nursing, and the positive aspects of the speciality. Given the complex nature of malignant disease and treatments, and the specialised care that patients require, it is notable that cancer nursing in NSW had a greater proportion of specialised nursing roles than the overall nursing profile in NSW. The survey respondents have an average of 11 years cancer nursing experience and have completed a cancer nursing qualification, which results in well educated and experienced nurses providing care to cancer patients. The survey results also indicate the majority of respondents are extremely unlikely to leave cancer nursing within the next 12 months. Methods to encourage the recruitment of new entrants to the system, who will become the experienced nurses of the future, should be considered and could include harnessing the expertise of experienced nurses who are likely to stay in their current roles. There are greater proportions of experienced nurses in clinics, outpatient and ambulatory care units. Organisational reporting structures may have skewed this result as some of these nurses for example Clinical Nurse Consultants (CNCs) may have been included in the outpatient/ambulatory nursing profiles rather than the inpatient nursing profile. The skill mix reported may be quite appropriate in units where a high degree of clinical expertise is required and where patients previously managed in the inpatient environment now receive care in the ambulatory setting. There are greater proportions of lower nursing classifications in inpatient wards and it is important to consider the most appropriate models of care to support the varied and less experienced skill mix of cancer nurses providing care for high acuity cancer patients. Particular reference to the RN/Enrolled Nurse (EN) skill mix and suitable models of care to support the use of ENs in cancer nursing should be considered. This would help to address some cancer nurses concerns about the scope of EN practice and possible increase in RNs workload, and to foster effective utilisation of ENs in contributing to safe patient care. The cancer education and skill development needs of less experienced cancer nurses should also be considered. There is an opportunity to leverage off the variation in skill mix between inpatient wards and clinics, 5

13 outpatient and ambulatory care units and use experienced cancer nurses to support skill development and learning opportunities for the less experienced nurses. There are specific rural issues including an older workforce (82% of cancer nurse aged 40 years or older), part-time staff, administrative overload, and lack of professional development support. Strategies to manage these issues need to be developed to ensure adequate workforce in these geographical areas, particularly where regional cancer centres are established or proposed. The creation and recruitment of Clinical Support Officers is a recommendation from Caring Together: The Health Action Plan for NSW (NSW Health 2009) which should address the administrative burden on nurses. Education, training and professional development were valued by cancer nurses to maintain the skills and knowledge required by this speciality. Professional development initiatives including leadership programs, clinical supervision and mentoring were offered at a facility level, although cancer nurses perceive accessibility to these initiatives to be lower than the facilities that offer them. Implementation of the NSW Health Take the Lead - The Nursing/Midwifery Unit Manager Project will support cancer nurses in the development of their leadership skills. The education and training of skilled cancer nurses should acknowledge the skills, knowledge and competencies required for quality nursing care and include specific core competencies, for example those required for administration of chemotherapy medication. The National Professional Development Framework for Cancer Nursing Education Project (EdCaN 2008) provides competency standards for specialist cancer nurses and core capabilities for Registered Nurses working in cancer control. Barriers to access and support for professional development need to be addressed. Appropriate strategies for providing training and education should be identified in consultation with nursing leaders and educators, tertiary providers, the Academic Chairs in Cancer Nursing and Palliative Care Nursing and other key stakeholders. Blended models of professional development using multiple methods could be developed such as on-site training with skilled educators, in combination with the utilisation of the Cancer Institute NSW eviq website as an e-learning platform. Workload and emotional strain are challenges, and the development of new models of peer support and clinical supervision could address this issue. Given the increase in cancer incidence it is important to explore the current models of care and appropriate skill mix in cancer settings to assess their efficacy and the contribution they make to satisfactory patient outcomes while maintaining the satisfaction of the current workforce. Such examination may identify appropriate models of care and skill mix for the current workforce within the context of cancer care delivery, and provide information for future changes that may be required. Key recommendations of NSW Health s Nursing Models of Care Project should also be considered. Workforce planning needs to consider current and future cancer incidence, current skill mix and age, rural issues, volume of patients, changing models of service delivery e.g. ambulatory units, and the skills and competencies required by cancer nurses to meet patient needs and deliver quality patient care. 6

14 The results indicated that there is much to value about cancer nursing. The perception is that cancer nurses tend to stay in cancer nursing because it is rewarding. Cancer nurses exhibit a high degree of dedication, pride and enthusiasm associated with their speciality. Cancer nursing is appreciated for its dynamic and challenging nature and opportunities to develop satisfying relationships with patients. These are factors in cancer nurses ongoing professional commitment. It is important to recognise and value the positive aspects of cancer nursing to maintain the current workforce, while addressing the identified challenges to meet future patient needs. 7

15 1. INTRODUCTION Demands on cancer treatment and care are expected to rise with cancer cases estimated to increase by 30 per cent over the next 10 years in NSW (Tracey et al., 2005). Cancer services will require a sustainable workforce of skilled professionals to provide services to and care for cancer patients to ensure optimal patient outcomes and meet the increasing demand for care. Comprehensive cancer care includes many phases: initial contact and referral, including screening and diagnostic services; treatment; monitoring and follow-up after cancer treatment; survivorship; and palliative/end of life care. Cancer nurses comprise a significant proportion of skilled cancer professionals who contribute to the care of cancer patients during all stages, providing services in many different settings including public and private hospitals, community and outreach services. They provide direct patient care in speciality oncology/haematology units or wards or in general wards on a regular basis. Current NSW workforce data provide information about the numbers of RNs and ENs working in oncology, haematology and palliative care services in the public and private sectors. However specific demographic data, geographical location of work, areas of practice, and length of service for cancer nurses in NSW are not included. In addition, factors that influence recruitment and the attributes that support and retain cancer nurses in NSW are not known. Given the significant contribution of cancer nurses to the care of cancer patients throughout the cancer journey it is considered important to have a full understanding of this key group. This study was undertaken to provide a comprehensive description of cancer nursing in NSW, including key factors and initiatives that influence recruitment and retention and factors that are considered important or unique to cancer nursing or create challenges. 8

16 2. METHODS 2.1 Overview The study (Figure 1) was guided by an Expert Advisory Group (EAG) and incorporated six phases as displayed in Figure 1 below. Figure 1: Study phases 1. Literature review 2. Exploratory stakeholder interviews n=10 3. Cancer nurses focus group discussions n=4 4. Site data collection n=67 5. Survey questionnaire of cancer nurses n= Explanatory stakeholder interviews n=17 and focus groups n=2 2.2 Study phases Phase 1 Literature review A literature review was conducted at the outset of the study to: ensure full appreciation of the current context; identify gaps in the existing body of research; assist with the development of the data collection tools; and assist with data interpretation. The review centred on cancer nursing (although sometimes included broader nursing or other health professionals) with a focus on the following core topic areas: nursing profile; recruitment and retention; care/service models; and skill mix. It targeted recent literature (primarily 2005 onwards) with some earlier literature included where it yielded particularly valuable information. A number of gaps were identified in the literature including characteristics of cancer nursing that are different from other specialties or nursing in general and evidence to support different models of care. Phase 2 Exploratory stakeholder interviews Exploratory semi-structured interviews guided the development of the site data collection tools to ensure that data requests to facility representatives were clear and achievable, and to 9

17 increase the effectiveness of this phase. The aim was to understand what cancer nursing information was available, the best way to capture it, the best contact point at facilities and barriers to data collection. Ten semi-structured interviews were conducted with key stakeholders with an understanding of data availability and collection issues. The sample was based on purposive sampling and incorporated representation from various facilities and a range of roles across all Area Health Services (AHSs) and the private sector. The semistructured interviews were conducted over the telephone, and ranged from 30 to 60 minutes. Key questions were ed to stakeholders in advance. The questions acted as a general guide for interviewers, but participants were encouraged to raise any other pertinent issues. The primary questions covered the format of existing data, the best contact person to collate the data, and any barriers envisaged in obtaining the data. Interviews were recorded where consent was provided. Phase 3 Focus group discussions This phase explored the experiences and ideas about recruitment, retention, job satisfaction, models of care and skill mix. The findings were used in developing the subsequent survey and in interpreting its results. Four focus group discussions were conducted with cancer nurses drawing from a wide variety of roles (from EN to Director of Nursing). Each group involved between eight to 12 participants. Recruitment was based on purposive sampling and groups had representation from all AHSs and metropolitan private facilities. A discussion guide based on the study aims and the literature was developed to assist facilitators. Each group discussion ran for about two hours and followed a semi-structured format. Participants were encouraged to introduce any other issues considered pertinent. Where appropriate, notepad exercises were used at the outset whereby participants answered some general questions in writing. The discussion started with broad questions, leading to more specific issues. Group discussions were audio taped where consent was provided by all participants. Phase 4 Site data collection The aim of this phase was to build a profile of cancer nursing in NSW by undertaking data collection at the facility (and individual unit) level. The main unit of analysis for this profiling phase was the facility ; although multiple units, wards, and services were typically included within each facility. The objectives of the site data collection tool were to: provide a baseline description of cancer nursing and related services identify cancer services strategies to recruit and retain cancer nurses identify professional development activities across NSW cancer services. 10

18 The data collected provided the means for comparative analysis of cancer nursing across the different ward/unit and service sectors and for the different types of treatment and care provided. Site data were collected from facilities identified as providing cancer nursing services. Site tools were distributed to 71 facilities, with a response rate of 94 per cent. The four facilities which were unable to participate in the site data collection exercise included one metropolitan public facility, one rural public facility and two metropolitan private facilities. The site tool used an Excel spreadsheet designed for efficient entry of relevant data. The tool development was informed by the earlier phases and input from the EAG. A pilot version of the tool was field tested using service data from a case study prior to finalisation. The site tool included closed and open-ended questions about: facility location and type organisational structure links between cancer nursing services and other services models of care recruitment and retention initiatives attrition. The site tool was distributed via to a nominated facility representative. Most site tools were completed by a single facility representative, although some were completed by multiple representatives within a given facility. The accuracy of the data provided was largely taken at face value, although basic integrity checks and questioning of outliers were conducted. Phase 5 - Survey The objective of this phase was to collect primarily quantitative data from cancer nurses across NSW in relation to the key areas of interest. The target sample came from the public, private and NFP sectors. The total sample size attained was 221 and of these, 35 cancer nurses completed the survey in hard copy. An online survey based on the key areas of interest was developed and included questions from previous studies (Barrett and Yates, 2002 and NSW Health 2003). Selected managers from each facility were asked to circulate and promote the survey to all cancer nurses using wherever possible. Where participants could not easily access the web-based online survey, hard copy and ed versions were made available. The questionnaire was informed by the project scope, the literature review, earlier study findings and EAG input. The questionnaire covered: 11

19 level of satisfaction (overall and aspects of the work environment) educational, professional developmental and support opportunities and related needs models of care factors that attract participants to cancer nursing factors that keep participants in cancer nursing likelihood of staying in current role, or cancer nursing in general perceived differences between cancer nursing and other nursing specialties demographics (e.g., role, facility, gender, age, qualifications). Phase 6 Explanatory stakeholder interviews The objective of this phase was to consider the study findings in light of the experience of key stakeholders and to assist data interpretation. Recruitment was based on purposive sampling. Senior stakeholders represented various facilities across all AHSs and the private sector. Respondents covered a wide variety of roles, including the Chief Nursing Officer, Nurse Academic, Nurse Manager (NM), Nurse Practitioner (NP), CNCs and Cancer Services Development Managers (CSDMs). Less senior respondents included RNs and ENs. Semistructured interviews (n=17) were conducted by telephone taking generally one hour. Two focus group discussions were conducted by teleconference or face-to-face, and were up to two hours duration and provided an efficient data capture method (Tolhurst and Dean, 2004). An interview guide was developed reflecting study objectives, including interim survey findings considered worthy of further exploration. Participants were encouraged to raise additional pertinent issues. Discussion started with broad/unprompted questions, followed by detailed discussion of more specific issues. Interviews were audio taped where consent was provided and transcribed. 2.3 Quantitative data analysis Results were reported for public facilities/units that completed the site tool and for NSW in total including data from all participating public, private and NFP facilities/units. The site tool provided reliable population data so generalisations were possible when considering survey responses against site tool data. Data collected via the site tool and survey were analysed using SPSS version 15. Percentages shown in tables and figures have been rounded to the nearest whole integer (that is, anything less than X.5 is rounded down, and anything greater than or equal to X.5 is rounded up). Any discrepancies that may appear when percentages are summed, are due to rounding (for example, rounded percentages may appear to sum to 99% or 101% when, in fact, the raw unrounded percentages sum to exactly 100%). Percentages have been rounded to the nearest whole integer with the exception of two types of data: (a) proportions relating to FTE, and (b) proportions relating to 0-10 rating scales, where the raw data were reported to 12

20 one decimal place and therefore corresponding percentages have also been reported to one decimal place Statistical analysis Statistical analysis included: inferential statistics (including chi-square tests for categorical data, Kendall s Tau-B for ordinal data, and t-tests for other data), to identify statistically significant differences between responses across the grouping variables including: age, gender, AHS, public/private/not-for-profit sector, the high likelihood of leaving segment, and geographic location (ARIA+ category) correlation analysis (using linear regressions), to compare stated satisfaction with various aspects of the working environment to the importance of each aspects in determining five key variables of interest: overall satisfaction with cancer nursing; satisfaction with current role; satisfaction with quality of care; likelihood of leaving current role in the next 12 months; and likelihood of leaving cancer nursing in the next 12 months factor analysis, to understand the satisfaction and adequacy items, using a varimax rotation method. Factors with eigenvalues greater than one were considered significant, resulting in seven factors or drivers being identified (reduced from 25 items). Satisfaction and adequacy items with a loading of greater than 0.40 onto a driver were considered significant. 2 All satisfaction and adequacy items had a significant correlation with at least one driver, and none had a significant loading on more than two drivers. Analysis of priorities for improving retention and satisfaction was undertaken using strategic matrices. A strategic matrix is an analytical tool that compares and plots: x-axis: respondents mean (average) satisfaction or adequacy ratings for a given aspect of their working environment or item 3 (measured on a 0-10 scale, where higher numbers indicate higher satisfaction ratings); against y-axis: the importance (i.e., correlation) of a given item in determining responses to a key variable of interest (i.e., likelihood of staying in one s current position, or cancer nursing in general, as measured on 0-10 scales, where higher numbers indicate higher likelihood of staying. 2 Guideline from Hair, et al (1998) Multivariate Data Analysis, 5 th Edition, p 112. Significance is based on a.05 significance level, a power level of 80 per cent, sample size of n=200, and standard errors assumed to be twice those of conventional correlation coefficients. 3 These items refer to various aspects of the working environment, based on survey questions 27 and

21 For the purpose of the priority quadrant analysis, scores for likelihood of leaving were reversed to represent likelihood of staying, such that strong positive correlations indicate that a particular item is important in encouraging cancer nurses to stay. The importance of an item (represented on the y-axis) is derived by correlation analysis. This form of analysis results in a two-dimensional plot of the items, which can be divided into four quadrants that categorise items into those that have: Y: Importance lower mean satisfaction and strong correlation with likelihood of staying lower mean satisfaction and weak/no correlation with likelihood of staying higher mean satisfaction and strong correlation with likelihood of staying higher mean satisfaction and weak/no correlation with likelihood of staying X: Satisfaction The intersection of the two axes, marking the threshold for high or low importance (correlation) and high or low satisfaction or adequacy scores, is the median for each distribution of scores. 2.4 Qualitative data analysis The data gathered from the focus group discussions and explanatory stakeholder interviews were coded and thematically analysed. Written answers to open-ended questions were coded and entered in Excel. Coding lists and coded data were reviewed by a second researcher. Frequencies were calculated on the coded data. Key themes and preliminary findings related to the discussion/interview guide were developed by each facilitator. Emergent themes were discussed and consensus reached about the overall findings. 14

22 3. RESULTS AND DISCUSSION What Defines Cancer Nursing in NSW? Key summary points Cancer nurses are predominantly female. More than half of cancer nurses (56%) are 40 years or older. Cancer nurses (n=221) report an average of 23 years experience in nursing and 11 years experience in cancer nursing. Cancer nurses report high levels of specific cancer nursing qualifications (66%). 3.1 PROFILE OF THE CANCER NURSE IN NSW Gender Females make up the majority of cancer nurses (83%) although 10.6 per cent of the total staffing FTE did not specify gender. When missing data were excluded, females comprise 93 per cent of the workforce. This was similar to the NSW nursing profile (NSW Health 2006b) which reported gender distribution as 91 per cent females. The gender distribution of cancer nurses was similar for cancer speciality and general units. Ninety two per cent of the cancer nurse survey respondents (n=221) were female Age Forty seven facilities (70%) provided data on the age distribution of cancer nurses. Fifty six per cent of these nurses were 40 years or older (Table 1). In regional and remote areas (n=22 facilities) cancer nurses aged 40 years or older made up 82 per cent of the total FTE, compared with 49 per cent of the total in major cities (n=25 facilities). The survey data supported this finding with 71 per cent of cancer nurses aged 40 years or over (Figure 2), which indicated that a perhaps more noticeable trend towards older age groups (NSW Health 2006b). The higher figure reported from the survey may be explained by the skew in survey respondents towards older nurses. 4 All nursing classifications and roles of cancer nurses working in the public, private or NFP facilities providing cancer nursing services were included in the site data collection, including generalist staff providing care for cancer patients. Generalist community nurses providing care to cancer patients were not included. Palliative care nursing was excluded for the site data as it had been included in a previous study, however the study s survey component was extended to these nurses. 15

23 Table 1: Age of cancer nurses compared to profile of nursing workforce in NSW Age (years) n (headcount) 5 Age of cancer nurses (%) Age of nursing workforce (%) <20 0 0% -* % 3% % 6% % 9% % 11% % 13% % 20% % 18% % 12% % % 8% Total % 100% *NSW Health (2006b) data was not available for nurses aged under 20 years, or for year olds specifically (instead using a combined category for nurses aged 60+ years). Figure 2: Survey sample age Not specified, 0.5% >65, 1% 60 64, 4% 25 29, 4% 20 24, 0.5% % % % % % % Source: survey, Base: n=221 5 n=146 units, as 16 units did not provide FT or PT data 16

24 3.1.3 Geographical location and role Almost two-thirds (64%) of survey respondents were cancer nurses working in major cities. Twenty two per cent were from inner regional areas, 11 per cent from outer regional areas and the remaining three per cent from remote areas. No survey respondents were from very remote areas. The majority of respondents (87%) worked in the public sector, with the remaining working in the private (9%) and NFP sectors (4%). There was a high proportion of nurses in senior roles among survey respondents (Figure 3). The proportion of junior nurses (e.g. RNs Year 1 or Years 2-4) was low. Figure 3: Positions held 6 Nurse Practitioner 1 1 Clinical Nurse Consultant Cancer Nurse Coordinator Clinical Nurse Specialist Nurse Manager 3 3 Nursing Unit Manager Nurse Educator Clinical Nurse Educator 2 2 Clinical Trials Nurse 2 Registered Nurse Years 5-8+ Registered Nurse Years Registered Nurse Year Endorsed Enrolled Nurse Enrolled Nurse 3 3 Trainee Enrolled Nurse 0 0 Assistant in Nursing Other Multiple response Single response (main role) % Source: survey, base: n=221 Respondents from major cities were more likely to include CNCs than nurses from more remote areas (p=0.002, p<0.01). Almost half of all respondents (49%) had one FT cancer nursing role and 11 per cent of the FT cancer nurses were employed in more than one role. Nurses from major cities were more likely (55%) than other nurses (41% on average) to be employed fulltime in cancer nursing in one position (Figure 4) (p=0.025, p<0.05). 6 The figure above presents some percentages to one decimal place. This is to enable the reader to distinguish between results of exactly zero (shown as 0) and results of (shown as 0.5, rather than rounding down to 0 which would make these results indistinguishable from genuine zero results). 17

25 Figure 4: Employment status by ARIA+ 7 17% 55% 42% 46% 49% 21% 33% 25% 50% 24% FT cancer nurse (1 position) PT cancer nurse FT cancer nurse (>1 position) FT (PT cancer nurse) Casual Other Agency 4% 10% 11% 12% 33% 21% 10% 10% 9% 1% 2% 3% 2% 3% 2% 4% 0.5% Major City Inner Regional Outer Regional Remote TOTAL Source: survey, base: Major City n=140; Inner Regional n=48; Outer Regional n=24; Remote n=6; TOTAL n=221 Comparison of the survey and site tool classification data indicated that the survey results were largely representative in terms of the public/private sectors. RNs Years 5-8 and lower nursing classifications were however underrepresented in the survey sample (32% of FTE) compared to the site tool (68% of FTE). The high representation of more senior classifications of nurses in the survey sample may have been partly due to a greater awareness and access to the online survey Experience, employment and education The survey respondents indicated that the length of time working as a nurse across various settings was an average of 23 years with an average of 11 years in cancer nursing (Figure 5). 7 ARIA+ (Accessibility-Remoteness Index of Australia Plus) is the standard Australian Bureau of Statistics endorsed geographic measure of remoteness. It is derived from measures of road distance between populated localities ( where someone is coming from ) and service centres ( where someone may need to travel to obtain services ). These distance measures are used to generate a remoteness score for any given location (e.g. a specific postcode). On a scale from 0 to 15, higher index scores indicate greater remoteness. There are five ARIA+ categories based on these scores: Major City (0 to 0.2), Inner Regional (>0.2 to 2.4), Outer Regional (>2.4 to 5.92), Remote (>5.92 to 10.53), and Very Remote (>10.53). 18

26 Figure 5: Time in nursing across various settings Average years Nursing Cancer nursing Current main facility Current main ward/unit Source: survey, base: Nursing n=220; Cancer nursing n=220; Facility n=216; Ward n=194; Nursing n=220; Cancer nursing n=220; Facility n=216; Ward n=194; Position n=219 Current main position Analysis of geographic location and experience revealed that cancer nurses from inner/outer regional areas had fewer years experience in cancer nursing (8.8 and 8.9 years, respectively) than nurses from major cities (12.4 years) or remote areas (15.3 years) (p=0.004, p<0.01). Nurses from inner regional areas had fewer years experience in their current position (3.4 years) (p=0.0042, p<0.01) than those in other areas (major cities: 5.3 years, outer regional: 4.2 years, remote: 6 years). The majority of cancer nurses (78%) reported that they worked Monday-Friday day duty. The next most common pattern of work was rotating shifts (12%). On average, cancer nurses worked 32 paid hours per week, with a median of 38 hours 8. Most respondents (61%) worked between paid hours per week. Nurses from major cities were more likely (68%) to work hours per week than other areas (p=0.004, p<0.01). Eighty seven per cent of the survey sample completed their initial qualification in Australia. The next most common regions were the United Kingdom (7%) and New Zealand (3%). The majority of nurses (53%) had at least completed a Registered Nurse certificate. The next most common qualifications were a Bachelor Degree (42%), Post-graduate Certificate (38%) and Graduate Certificate in Nursing (36%) (Figure 6). 8 Note that 38 hours per week was considered a full-time week, based on the relevant award. In this study less than 38 hours was considered part-time. 19

27 Figure 6: All nursing qualifications completed, not cancer specific (multiple response) RN Certificate 53 Bachelor (Nursing) 42 Post-graduate Cert. (Nursing) Graduate Cert. (Nursing) Diploma (Nursing) 19 Other Master of Nursing EN Certificate 9 Post-graduate Dip (Nursing) Other Masters (nursing/health) 4 7 AIN Certificate % source: survey, base: n=221 Sixty six per cent of respondents (n=146) had completed a specific cancer nursing qualification including a Graduate Certificate (42%), Post-Graduate Certificate (38%), Masters of Nursing (7%), Post Graduate Diploma (7%) and other (6%). Forty respondents (18%) were currently undertaking cancer nursing qualifications including Graduate Certificate (40%), Post-graduate Certificate (25%), Master of Nursing (23%), PhD (3%) and Post-graduate Diploma (3%). 20

28 3.2 PROFILE OF FACILITIES, SERVICES, STAFFING AND SKILL MIX Key summary points Cancer speciality units are the dominant cancer nursing service (82%). Outpatient, ambulatory and day only settings comprise 61 per cent of speciality units. Inpatient wards comprise 86 per cent of general units. There is a greater proportion of specialised nursing roles in cancer nursing in comparison to the NSW nursing profile. There are greater proportions of higher grade classifications of cancer nurses FTE in outpatient/clinics, day only and ambulatory units. There are greater proportions of lower grade classifications e.g. RNs Years 1-4 and EENs in inpatient wards. Chemotherapy and radiotherapy units have the greater proportions of CNSs. General medical wards have the greatest proportion of EENs. The total number of cancer nurses in NSW is reported as 1,344 FTE. Staffing levels impact on ability to access professional development and may lead to decreased job satisfaction and retention issues Facilities The majority (70%) of cancer nursing facilities were in the public sector and 27 per cent in the private sector, with the remaining three per cent in the NFP sector. This finding comprised data collected from 67 public, private and NFP facilities identified as providing cancer services Services 9 Facilities were asked to describe the units, in which cancer nurses worked in terms of two dimensions: 1. type of setting (inpatient, outpatient, day only, etc), and 2. type of care or treatment provided (e.g. chemotherapy, mixed cancer, surgical) Nursing services included speciality units and general units or wards that care for cancer patients on a regular basis. Services included oncology/haematology wards, ambulatory or outpatient units, radiation oncology units or centres, specialist cancer nursing programs (e.g., outreach programs), or other wards that include care for cancer patients on a regular basis. Speciality units included chemotherapy/clinics, mixed cancer, haematology, radiation oncology, medical oncology and designated cancer surgical units. General units include general medical and general surgical units and other. 21