A Survey of Oncology Advanced Practice Nurses in Ontario ...fhsson.mcmaster.ca/apn/images/stories/pdfs/NL_vol20_no2_bryant1… · A Survey of Oncology Advanced Practice Nurses in

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A Survey of Oncology Advanced Practice Nurses in Ontario: Profile and Predictors of Job Satisfaction

Denise Bryant-Lukosius, RN, PhDAssistant Professor, School of Nursing, McMaster UniversityClinical Nurse Specialist, Juravinski Cancer CentreHamilton, ON

Esther Green, RN, MSc(T)Chief Nursing Officer, Cancer Care OntarioAssistant Clinical Professor, School of Nursing, McMaster UniversityToronto, ON

Margaret Fitch, RN, PhDHead of Oncology Nursing and Supportive Care, Toronto Sunnybrook Regional Cancer CentreProfessor, Faculty of Nursing, University of TorontoToronto, ON

Gail Macartney, RN, BScH, MSc(A), ACNPAdvanced Practice Nurse, Malignant HematologyThe Ottawa HospitalOttawa, ON

Linda Robb-Blenderman, RN, BScN, MSc Clinical Practice Leader, OncologyCancer Centre for South Eastern Ontario at Kingston General HospitalKingston, ON

Sandra McFarlane, RN, BScN, MHScDirector, Medicine Health Service Toronto East General HospitalClinical Lecturer, School of Nursing, McMaster UniversityToronto, ON

Kwadwo Bosompra, PhDResearch Associate, CHSRF/CHIR Chair in Advanced Practice Nursing ProgramMcMaster UniversityHamilton, ON

NURSING RESEARCH

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Alba DiCenso, RN, PhDCHSRF/CIHR Chair in Advanced Practice NursingProfessor, Nursing & Clinical Epidemiology & BiostatisticsMcMaster UniversityHamilton, ON

Susan Matthews, RN, PhDNational Executive Director, Disease Management and Chief of Practice for OntarioVON CanadaFormerly, Chief Nursing Officer, Ontario Ministry of Health and Long-Term Care

Harry Milne, RN, MScNManager, Regional Operations, Southwest Regional Cancer Service Alliance London Health Sciences CentreLondon, ON

AbstractThe purpose of this study was to examine role structures and processes and their

impact on job satisfaction for oncology advanced practice nurses (APNs) in Ontario.

APNs caring for adult, paediatric or palliative patients in integrated regional cancer

programs, tertiary care hospitals or community hospitals and agencies were invited to

complete a mailed self-report questionnaire. A total of 73 of 77 APNs participated in

the study. Most APNs (55%) were acute care nurse practitioners employed by regional

cancer programs or tertiary care hospitals. Adult patients with breast or haematological

cancers and those receiving initial treatment or palliative care were the primary focus

of APN roles. APN education needs related to specialization in oncology, leadership

and research were identified. Overall, APNs were minimally satisfied with their roles.

Role confidence (b=.404, p=.001) and the number of overtime hours (b=–.313, p=.008)

were respective positive and negative predictors of APN job satisfaction. Progress in

role development is described, and recommendations for improving role development

and expanding the delivery of oncology APN services are provided.

IntroductionWell-designed oncology advanced practice nursing (APN) roles have demon-strated significant improvement in patient and health systems outcomes related to access to care; coordination and continuity of care; satisfaction with care; and health outcomes and lower costs due to fewer hospitalizations and shorter lengths of stay (Bredin et al. 1999; Corner et al. 1996; Faithfull et al. 2001; Moore et al. 2002; Ritz et al. 2000). APN care is also associated with fewer deaths in elderly patients post cancer surgery (McCorkle et al. 2000). However, the successful intro-duction of APN roles is a complex and challenging process (Bryant-Lukosius et

A Survey of Oncology Advanced Practice Nurses in Ontario

52 Nursing Leadership Volume 20 Number 2 • 2007

al. 2004). Full role implementation depends on the extent of structures in place to support APN role development.

The Canadian Strategy for Cancer Control (2002) predicts the incidence of cancer will increase by 70% over the next 15 years. Several Ontario reports recommend the expansion of APN roles in the delivery of cancer services to ensure the province’s capacity for meeting the rising demands for care (Cancer Care Ontario 200la and b, 2004, 2006; Fitch and Mings 1999). The Canadian Nurses Association (CNA 2002) recognizes two types of APN roles: clinical nurse specialists (CNSs) and nurse practitioners (NPs). Hospital-based oncology CNS roles have existed for many years. However, in the last five years, Ontario has witnessed the introduction of an unprecedented number and new types of APN roles in various cancer settings.

This paper describes the first Canadian study to examine a provincial cohort of oncology APNs and their roles. The PEPPA Framework, outlining a participa-tory, evidence-based, patient-focused process for developing, implementing and evaluating the introduction of APN roles, was the conceptual guide for this study (Bryant-Lukosius and DiCenso 2004). The framework recommends formative evaluations examining the structures and processes of new APN roles to monitor progress in role development and to identify and address barriers to role imple-mentation. Structures refer to role resources, the physical and organizational environment and characteristics of APNs and patients (Sidani and Braden 1998). Graduate education, licensure and certification are other structures that affect role legitimacy, autonomy and the extent to which role competencies are fully realized (Brown 1998; Irvine et al. 2000; Woods 1998). Processes refer to the work or char-acteristics of what the APN does in the role. The ability to achieve desired goals or outcomes of new APN roles is dependent on core planning and provision of resources necessary for role implementation.

Study Purpose and MethodsThe purpose of this study was to conduct a formative evaluation to identify and describe role structures and processes and their impact on job satisfaction among oncology APNs in Ontario. Study results inform recommendations for how APNs, educators, administrators and policy makers can enhance the continued develop-ment of these and future oncology APN roles. This paper reports on the following:

1. Structural elements of the APN roles, including characteristics of the APN, APN education needs and patient characteristics;

2. Role processes or the work of the APN and focus of activities in five role domains: clinical practice, education, research, organizational leadership and scholarly/professional development;

3. Predictors of APN job satisfaction.

53A Survey of Oncology Advanced Practice Nurses in Ontario

Role structures and processes were examined within the context of the advanced oncology nurse as defined by the Canadian Association of Nurses in Oncology (CANO). The oncology APN is a “registered nurse, prepared with a minimum of a Master’s degree in nursing, who has acquired in-depth knowledge and clinical experience in oncology” (CANO 2001: 61). Role processes are characterized by the integration of five domains: direct patient care, education, research, organiza-tional leadership and scholarly/professional development (CANO 2001). A follow-up paper will report on administrative support, role barriers and role facilitators and their impact on APN job satisfaction.

DesignA mailed self-report questionnaire was developed for this descriptive study.

SettingThe study took place in all Ontario integrated regional cancer programs, tertiary care hospitals, community hospitals and community agencies where oncology APNs are employed.

ParticipantsStudy participants included all nurses working in a defined APN role that involved the care of adult, paediatric or palliative patients affected by cancer. APN roles included CNS, NP and other roles titled as advanced according to their job description. To ensure adequate familiarity with the APN role, eligibility was limited to nurses who had been in the position for six months or more.

Sample and participant recruitment The aim was to survey the entire population of oncology APNs in Ontario. We estimated there were about 50 oncology APNs in the province. Currently, there is no provincial system in place to document the number or types of oncology APN roles or where they exist. A snowball technique was used over a five-month period to identify eligible APNs. First, the research team generated a list of potential participants known to them through regional, provincial and national oncology nursing initiatives. This list was circulated to a provincial network, the Ontario Oncology APN Community of Practice (COP). COP members, representing APNs from various practice settings across Ontario, reviewed the list with local and regional colleagues to identify additional APNs. Other participants were iden-tified from Ontario members listed on the CANO website and through recruit-ment efforts at two conferences held by CANO and the Canadian Association of APNs. The research team and COP reviewed each updated list. The process concluded on a fifth review when no new participants were identified and all feasible strategies to identify APNs were exhausted. A total of 80 APNs were iden-tified, of which 77 were eligible for the study.


Methods for data collectionEthics approval for the study was obtained from McMaster University. Participants received written information about the study purpose, voluntary participa-tion, methods used to ensure confidentiality and plans for disseminating results. Participants were invited to complete a questionnaire consisting of closed and open-ended questions and the Misener (2001) Nurse Practitioner Job Satisfaction Scale. This scale is one of few valid and reliable instruments that measure job satisfaction (Misener 2001). Oncology nursing leaders from five provinces, with experience in managing APNs, gave feedback on the questionnaire content and format. A five-member expert panel of oncology APNs evaluated and piloted the questionnaire. Their feedback about face and content validity, readability, clar-ity and time to complete the questionnaire was documented on a review form and used to make revisions. On average, the questionnaire took 45 minutes to complete. Data collection occurred between October 2005 and January 2006. To minimize bias associated with poor response rates, several strategies to promote questionnaire return were employed (Edwards et al. 2001). A signed consent form was not requested; rather, return of the completed questionnaire signified consent to participate in the study.

Data AnalysisDescriptive statistics, including frequency counts, percentages and mean scores, were used to summarize quantitative data about APN and role characteristics. Paired t-tests were used to examine perceived differences in initial and current role confidence. APN and role variables were examined in bivariate correlation analyses, and those significantly associated with job satisfaction were entered in a multiple regression model to determine whether they were independent predic-tors of job satisfaction. The variables included age, acute care nurse practitioner (ACNP) education, years as an oncology nurse, years in a previous APN role, months in current role, role confidence and overtime hours worked per week.

ResultsAPN characteristicsA total of 73 out of 77 eligible APNs participated in the study, for a response rate of 94.8%. The mean age was 45.1 years, and 25% of respondents were over 50 years of age. While they had considerable nursing experience (mean, m=21.5 years), they had not much APN experience prior to their current role (m=2.7 years), and they had been in their current role for a mean of 3.6 years. For almost half the sample, this was their first APN role. Most were seasoned oncology nurses with a mean of 12 years in the specialty. However, 20% of APNs had zero to less than five years of oncology experience. Almost all APNs had a master’s degree, and 55% were graduates of an ACNP program. Another 18% were enrolled in master’s or doctoral programs. About half the APNs had basic certification in oncology or


palliative care, but just 5% had advanced certification. About 35% had completed an oncology or palliative care certificate program. (See Table 1.)

Table 1. APN characteristics

APN Characteristic Total (N = 73) Statistic SD

Females (%) 73 (100)

Mean age in years 45.13 .93

Ages 51 to 60 years (% of APNs) 18 (25)

Mean years as an RN (min – max) 21.45 (2.5–37) 1.0

Mean years in oncology (min – max) 12.22 (0–26.0) .76

Mean years in current APN role 3.62 2.90

Mean years in previous APN role 2.72 .46

Number in first APN role (%) 36 (49.3)

Completed education programs (%)• Master’s • PhD• Acute care nurse practitioner• Primary healthcare nurse practitioner• Oncology nursing certificate• Palliative care nursing certificate

6804051511

(93)(0)

(54.8)(6.8)(20)(15)

Currently enrolled in programs (%)• Master’s• PhD• Acute care nurse practitioner

634

(8.2)(4.1)(5.5)

National nursing certification – Total (%)• Basic oncology• Advanced oncology• Palliative care

363141

(49.3)(42.4)(5.5)(1.4)

SD: Standard deviation

APN perceptions of role preparedness, confidence and competenceUsing a Likert scale (scores = 0 to 4, with high scores reflecting better levels), APNs rated their preparedness for and confidence in the role at the time of hiring. While their education somewhat influenced their preparedness for the role (m=1.96, SD=0.12), the APNs scored previous nursing experience as a stronger influence on


preparedness (m=2.67, SD=.11). The APNs felt confident in their role at the time of hiring (m=2.27, SD=.71) and currently (m=2.8, SD=.55). There was perceived improvement between initial and current role confidence (t=–10.55, df=72, p<.001). At the time of hiring, APNs felt the least confident about their diag-nostic skills (m=1.63, SD=1.08), technical skills (m=1.32, SD=1.32), knowledge about medical interventions (m=1.82, SD=.94) and research (m=1.52, SD=1.08). Current areas where APNs felt less confident included technical skills (m=1.93, SD=1.35) and research (m=2.08, SD=1.10).

Based on Benner’s (1984) theory of nursing practice development, the APNs rated their competency (from novice = 1 to expert = 5) in five role domains defined by CANO (2001). They did not perceive themselves to be functioning at an expert level of practice, but felt the most competent or proficient in their clinical roles (m=4.0, SD=.70). For non-clinical activities, they felt competent in education roles (m=3.7, SD=.80), scholarly/professional development (m=3.4, SD=.84) and leadership (m=3.3, SD=.87). The APNs saw themselves functioning as advanced beginners in research (m=2.8, SD=.83).

Educational needsThe APNs identified strategies that would have helped to improve their initial educational preparation for the role (Table 2). Graduate oncology nursing courses, internship or fellowship programs, mentorship from a master’s-prepared oncology nurse and a research practicum were the most frequently reported strat-egies. Other strategies included access to oncology faculty, physician mentorship and postgraduate courses or practica. Respondents also identified strategies to support the continued development of their roles. Over 50% of APNs identified needs for continuing education courses and programs. Strategies similar to those for improving initial education were identified, but there was greater emphasis on education to develop research and leadership skills. Fewer APNs identified the need for extended clinical practica.

Role characteristicsTable 3 summarizes role characteristics related to employment. Most APNs were employed full time by integrated cancer programs and tertiary care hospitals, with a small proportion working in community hospitals or agencies. According to role title, the majority (42.4%) were in ACNP or NP roles and 22% were in a CNS role. Over a third of APNs were in roles that did not clearly identify them as an NP or CNS. These roles were generically titled as APN or other positions not formally recognized as an APN, such as professional practice leader, project leader or program coordinator. Just over a quarter of APNs were in palliative care–specific roles.


Patient characteristicsTable 4 describes the types of patients cared for by APNs. The majority of APNs cared for adults and estimated they saw slightly more female than male patients. Overall, APNs spent more estimated time with patients receiving care during the initial treatment and palliative stages and had less involvement with patients during the pre-diagnosis, diagnosis or post-treatment stages of the cancer contin-uum. The APNs also reported caring for more patients with locally advanced or advanced disease and those with haematological and breast cancers.

Table 2. Recommendations for improving initial and ongoing APN education

Education Strategy N = 73 %

Initial APN Education• Oncology graduate nursing courses• Internship or fellowship program• Mentorship from master’s oncology nurse• Research practicum• Access to faculty with oncology expertise• Mentorship from oncology physician• Leadership practicum• Post-master’s education• Longer clinical practicum

373232312827221614

514444433837302219

Ongoing APN Education• Continuing education courses or programs• Research practicum• Internship or fellowship program• Access to faculty with oncology expertise• Leadership practicum• Mentorship from oncology physician• Oncology graduate nursing courses• Mentorship from master’s oncology nurse• Longer clinical practicum

41322721211918154

56443729292625216

N: Number of APNs reporting.

Role implementation (role processes)Table 5 summarizes how APNs implemented their roles. Clinical practice, followed by education and leadership activities, accounted for the largest amount of estimated work time. Research and scholarly/professional development activi-ties each accounted for less than 10% of work time. The wide range of work time for each domain indicates a high degree of role variability. For example, the estimated work time providing direct clinical care ranged from 0 to 100%. Some APNs (21%) spent less than 50% of their time and others (27%) spent over 80%


of their time in this domain. Some APNs did not spend time in each of the five domains. About three-quarters (78%) of APNs worked overtime on a regular basis. The amount of overtime was substantial, on average 7.6 hours per week, with some APNs working up to 20 extra hours per week.

Table 3. APN role characteristics

Role Characteristics N = 73 %

Employer• Integrated cancer program• Tertiary care hospital• Community hospital• Community agency

323164

44.042.48.25.4

Full time 68 93.1

Role title• ACNP or NP• CNS• APN or other

311626

42.422.035.6

Role focus• Palliative care 19 26.0

The majority of APNs received patient referrals from hospital and cancer centre health providers. Just about one-third received referrals from community health providers or from patients themselves. Patient care was provided via telephone, inpatient visits, patient appointments with physicians and consultations. About one-third of APNs had independent clinics with scheduled patient appointments, and a small number made home visits to patients.

Most APNs perceived they functioned as collaborative rather than independent practitioners and worked with one or more healthcare teams. Within these teams, the majority of APNs were the primary provider responsible for coordinating the care of some or all of the patients. However, one-third of APNs had no respon-sibilities for coordinating patient care. Pain and symptom management were the primary focus of APN interventions, with less time providing care related to patient and family education, counselling or health promotion.

APN job satisfactionThe Misener (2001) NP Job Satisfaction Scale has scores ranging from zero (very dissatisfied) to six (very satisfied). The APNs were minimally satisfied (score of


Table 4. Patient characteristics

Patient Characteristics N Mean % Min–Max SD

Age (estimated % of patients in APN practice)

• Paediatric (birth to 17 years) 71 14.4 0-100 34.2

• Adult (18 years and older) 71 85.5 0-100 34.2

Female (estimated % of patients in APN practice) 70 53.2 10-100 17.3

Estimated % of clinical time spent across the cancer continuum

• Prevention 71 2.0 0-50 6.9

• Screening 71 1.7 0-50 7.2

• Genetic counselling 71 0.4 0-10 1.6

• Diagnosis 71 8.9 0-55 11.7

• Initial treatment 71 25.8 0-100 26.9

• Post-treatment follow-up 71 14.9 0-100 22.5

• Treatment for recurrence 71 15.4 0-100 16.2

• Palliation 71 32.6 0-100 33.7

Stage of Disease (estimated % of patients in APN practice)

• Pre-cancer 69 3.2 0-90 13.2

• Early/localized 68 11.8 0-70 16.3

• Locally advanced 68 32.0 0-90 25.5

• Advanced/metastatic 67 53.7 0-100 34.3

Cancer Type (estimated % of patients in APN practice)

• Haematological 69 30.2 0-100 40.1

• Breast 70 16.3 0-100 27.9

• Gastrointestinal 69 13.6 0-100 20.7

• Lung 69 12.2 0-100 20.3

• Genitourinary 69 5.5 0-85 11.5

• Gynecological 69 5.8 0-100 13.7

N: Number of APNs responding; Min–Max: Respondents’ actual minimum and maximum scores.


Table 5. Role implementation (processes)

Role Processess N Statistic Min–Max SD

% of estimated work time in each domain (mean %)

• Direct clinical care• Education• Organizational leadership• Research• Scholarly & professional development

7271717271

62.713.011.56.76.5

0-1000-600-800-300-20

22.610.613.66.84.5

Hours of overtime per week (mean) 57 7.6 2.5-20 3.5

Source of APN patient referrals (% of APNs)

• Cancer centre physician• Hospital healthcare providers• Cancer centre health team• Community health providers• Patient self-referral

7373737373

49.346.646.632.931.5

Ways in which patient care is provided (% of APNs)

• Telephone advice and support• In hospital• See patient during appointment with MD• Consultation for other providers• APN clinic• Home visits

737373737373

78.171.265.865.834.212.3

Interaction with health providers (% of APNs)

• Collaborate with 2 or more teams• Collaborate with 1 team• Function as an independent practitioner

46261

63.035.61.4

Care coordination (% of APNs)

• Responsible for all patients• Responsible for some patients• Not responsible • Missing responses

1526248

20.635.632.911.0

% of APN clinical time focused on nursing interventions (Mean%)

• Symptom management• Pain management• Patient education• Family education• Psychosocial counselling• Health promotion

717272717272

31.919.615.911.46.84.7

0-1000-800-500-430-300-30

18.317.89.68.06.75.9


4 to 4.9) with their jobs (m=4.5, SD=.61). Age (r=.099, p=.407), ACNP educa-tion (r=.110, p=.354), prior APN experience (r=.148, p=.214) and months in current APN role (r=.097, p=.418) were not significantly associated with job satisfaction. In contrast, years as an oncology nurse (r=.263, p=.025), hours of overtime worked per week (r=–.356, p=.007) and current level of overall confi-dence (r=.378, p=.001) were significantly correlated with job satisfaction. Table 6 summarizes the results of the multiple regression analysis examining these three variables as independent predictors of job satisfaction. Combined, these variables accounted for 28% of the variance in job satisfaction (p<.001). Two variables were predictive of job satisfaction. The number of overtime hours worked each week (b=–.297, p<.05) was negatively associated and current role confidence (b=.39, p<.01) was positively associated with job satisfaction. Years as an oncology nurse (b=.159, p=.17) was not a predictor of job satisfaction.

Table 6. Regression model of predictors of job satisfaction

Variables Entered Standardized Coefficients (b)

Adjusted R2

Degrees of Freedom

Significance

Years as an oncology nurse .157a 27.7% (3,53) .000

Number of overtime hours –.313b

Current role confidence .404c

a: p=.176; b: p=.008; c: p=.001.

When asked about their future, 67% of APNs reported they were satisfied with their current role and had no plans to seek new employment. However, 33% of APNs were thinking about or actively seeking new employment. Of the 24 APNs in this latter category, reasons for seeking new employment included insufficient administrative support (42%), insufficient resources to fulfill role expectations (36%), personal growth and/or career advancement (33%) and perceptions that the role demands were negatively affecting their health (25%).

DiscussionFull implementation of a new APN role takes time. Hamric and Taylor (1989) identified seven stages of role development and found it took three to five years for novice CNSs to achieve an expert level of practice. In our study, progress in APN role development seems appropriate given the average


length of time in the role (3.62 years) and the large number of respondents (49.3%) in their first APN role. APNs perceived their confidence improved with increasing time in the role and felt competent in most domains, particularly related to clinical practice. Other studies have noted that in the early stages of role implementation, APNs focus on developing their clinical role as a strategy for establishing credibility among stakeholders and to gain systems entry (Brown and Olshansky 1997; Kleinpell-Norwell 1999; Sidani et al. 2000).

Evidence suggesting that the roles are becoming integrated within the health system include the varied sources of patient referrals, different ways patients receive APN care and the high proportion of APNs collaborating with other health providers. Opportunities to increase patient access to APN care include expansion of services through home visits, patient self-referrals and linkages with community providers. Models of care that permit APNs to transition with the patient across health sectors promote continuity of care and are associated with improved patient outcomes and lower hospital costs (Brooten et al. 2002).

Important role development needs were identified related to specializa-tion in oncology nursing. A key feature of advanced nursing practice is specialization or expertise in a defined area of clinical practice (ANA 1995; CNA 2002). CANO (2001) also recognizes graduate education, oncology experience and advanced certification in oncology nursing as prerequi-sites for advanced practice. Yet, at the time of hiring, a substantial propor-tion of APNs lacked previous oncology nursing experience and only a few APNs were certified at an advanced level. In addition, only a small propor-tion of APNs had received oncology nursing education through certificate programs. The need for advanced specialty-based education and supports is further highlighted by the substantial number of APNs wanting access to graduate oncology nursing courses, oncology faculty and mentorship from master’s-prepared oncology nurses and oncologists. The APNs also identi-fied educational needs related to leadership and research. As in this study, research is often reported as the most underdeveloped aspect of APN roles (Bryant-Lukosius et al. 2004). The APNs spent the least amount of time in research-related activities and felt the least competent in this area.

The large variation in role activities and in APN work time spent in each role domain is expected and desirable (see Table 5). APN roles are dynamic and should be tailored and responsive to unique patient and health systems


needs in practice settings (Bryant-Lukosius and DiCenso 2004). However, a concerning feature is that not all APNs contribute work time to each domain of advanced nursing practice, including clinical practice, educa-tion, research, organizational leadership and scholarly/professional practice. Operationalization of each role domain, particularly related to direct patient care, is required to meet the definition of advanced practice (CANO 2001). The lack of APN involvement in all role domains suggests that some roles are not being fully implemented and may not reflect an advanced level of practice.

The reason is unclear, but underutilization of the full scope of APN expertise is a common role implementation problem (Bryant-Lukosius et al. 2004). Poor administrative support, lack of priority setting and competing clini-cal demands are frequent barriers to participation in education, research and leadership activities. In this study, over 78% of APNs reported working overtime hours, suggesting that time management, excessive role demands or both may be barriers to role implementation. Inconsistent and unclear role titling are also common barriers to role implementation associated with stakeholder confusion and lack of understanding about APN roles (Bryant-Lukosius et al. 2004). This confusion may lead to the development of roles lacking responsibilities in each role domain. Such may be the case in this study, where some roles had no clinical involvement and over 35% of roles were generically titled as APN or other role titles not formally recognized as advanced practice.

Another potential gap in role implementation is the low estimate of time spent in care coordination, patient/family education, psychosocial counsel-ling and health promotion. These interventions are considered the value-added features of advanced practice (Brooten et al. 2002). Furthermore, patients and families affected by cancer report significant unmet needs related to fragmentation of care, coping, information and psychosocial support (Canadian Cancer Society 2003).

Other points of discussion relate to resource planning and the effective use of APN roles. Considering that almost half of the APNs in this study were hired into new roles in the previous 3.6 years, there has been some success in recruitment. However, there is high competition for these roles, with many unfilled positions across the country. This finding may account for hiring APNs who lacked desired role requisites, including advanced certification and previous oncology experience. In addition, 25% of the population was between the ages of 50 and 60 years and therefore close to possible retirement.


Retention was also problematic, with one-third of APNs considering or seek-ing new employment owing to poor job satisfaction.

Finally, the implementation of these roles is clustered in the initial treatment and palliative stages of the cancer continuum. There is tremendous opportu-nity to expand the use of APN roles across the cancer continuum. Expansion of APN roles should be considered in areas of high provincial priority related to cancer prevention, early detection and screening; reduction of wait times; and access to post-treatment surveillance and supportive care (Cancer Care Ontario 2004). Currently, patients with haematological and breast cancers are the focus of almost 50% of existing APN roles. Future expansion of APN roles should consider other high-incidence and high-need populations, such as those with colorectal, lung and prostate cancer.

Study limitationsIt is possible that despite our comprehensive approach to recruitment, we did not identify all eligible APNs. However, as the number of identified APNs was much higher than expected, the number of missed APNs is likely small. Given that 95% of the sample took part in the study, we believe the results are representative of oncology APNs in Ontario. However, variability in education, roles and practice settings may limit the generalizability of results to oncology APNs in other provinces. An incomplete account of role implementation may also have occurred due to recall bias and retrospective APN estimates of role activities.

Implications for education and practiceThe mandate of all APN roles is to maximize, maintain or restore patient health through innovation in nursing practice and in the delivery of health services (CNA 2002; Davies and Hughes 2002; Hamric 2000; McGee and Castledine 2003). APNs enhance care delivery through flexible, expanded scopes of clinical practice; research; education; the advancement of evidence-based nursing practice; and leadership in implementing organizational and health system change. To achieve this potential for innovation in cancer care, strategies to enhance the full implementation of all five domains of oncology advanced nursing practice will be required.

There is a need to increase APNs’ access to graduate courses, continuing education and mentorship opportunities to further develop their roles, particularly related to oncology nursing practice, leadership and research. Given the high anticipated demand for oncology APN roles, the ideal solu-


tion would be to establish a graduate program designed specifically to produce oncology APNs for the province (Mitchell-DiCenso et al. 1996). Currently, only a small handful of Canadian universities offer limited elec-tive undergraduate or graduate courses, and none offer a comprehensive program in oncology nursing. Advanced oncology nursing certification is important for ensuring that APNs have the minimum level of specialty-based knowledge and skills required for the role. The lack of a Canadian examination is a major barrier for obtaining this credential. CANO and the CNA should establish a national advanced certification process and/or adopt existing examinations available in other countries.

The development of postgraduate certificate programs in oncology nursing may also be an effective strategy to meet the continuing role development needs of APNs. Strengthening collaborative links among academic institu-tions, oncology nursing faculty and practice settings may also provide APNs with increased access to specialty and research expertise. A provincial strat-egy to provide role development resources is now underway by the Oncology APN Community of Practice, sponsored by Cancer Care Ontario. A key feature of this strategy is to create an e-based mentorship, preceptorship and peer support program.

There is a need to implement a systematic provincial approach to nursing and health human resources planning for cancer care. This approach should examine how well the current complement and focus of APN roles are meeting patient, organization and health systems needs and determine the numbers and types of oncology APN roles required over the next five to 10 years. This plan should also include strategies to educate, recruit and retain highly qualified APNs with the expertise required to meet role demands. Targeted strategies to improve APN job satisfaction related to administra-tive support, practical resources, workload and career advancement are also required.

ConclusionsThe results of this study demonstrate the ad hoc implementation of oncol-ogy APN roles in Ontario. While progress in role development is being made, there are substantial opportunities to improve the implementation of these roles across the cancer continuum. There is agreement among provincial stakeholders that “new ways of working” are required to achieve a sustainable system of cancer services providing high-quality, efficient and patient-centred care (Cancer Care Ontario 2006: 4). Commitment on the


AcknowledgementsThis study was supported and funded by the Nursing Secretariat and the Ontario Ministry of Health and Long-Term Care. Recommendations from this study do not reflect government positions or policies. At the time of this study, Dr. Bryant-Lukosius held a Post Doctoral Fellowship Award from the Canadian Health Services Research Foundation and the Canadian Institute of Health Research. Our sincere thanks go to oncology APNs in Ontario for their commitment to improv-ing the health of patients with cancer through advances in nursing practice and care delivery.

Corresponding Author Info: Denise Bryant-Lukosius, RN, PhD, Assistant Professor and Senior Researcher for the CHSRF/CHIR Chair in APN, School of Nursing, McMaster University, Clinical Nurse Specialist, Juravinski Cancer Program, Faculty of Health Sciences, Room 3N25D, McMaster University, 1200 Main Street West, Hamilton ON. L8N 3Z5, e-mail: [email protected]

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A Survey of Oncology Advanced Practice Nurses in Ontario ...fhsson.mcmaster.ca/apn/images/stories/pdfs/NL_vol20_no2_bryant1… · A Survey of Oncology Advanced Practice Nurses in