Palliative radiotherapy is an effective modality of treatment for patients with advanced cancer for a wide range of distressing symptoms such as painful bone metastases, bleeding from tumour sites, dyspnoea caused by central airway obstruction and neurological compromise caused by spinal cord compression and brain metastases (Lutz, 2016). However, in reality, palliative radiotherapy continues to be underused (Lutz et al, 2004) and is frequently offered at too late a stage in the disease trajectory to realise the benefits intended (Berger et al, 2014). Lutz and Chow (2014) deemed research and education in palliative radiation oncology essential to maintain the connection between advanced radiation technology and the humanitarian skills required for palliative care. Ireland's Health Service Executive (Hollywood, 2003) recognised that oncology and palliative care nurses are vital multidisciplinary team members in the provision of radiation treatment, and have an integral part to play in the clinical care of patients who are both receiving and recovering from radiation. Likewise, Berrang and Samant (2008) acknowledged that nurses are the health professionals who care for patients on a day-to-day basis and therefore require the knowledge and skills to identify those that may benefit from referral. While nurses are not permitted as yet to independently refer patients for radiotherapy, as members of the multidisciplinary team, they can advocate for a patient who may benefit from palliative radiotherapy and use their knowledge to contribute to a registered medical practitioner's decision to refer them to radiation oncology.
Of all patients who undergo radiotherapy, approximately half are treated with palliative intent (Hoskin et al, 2013). Although palliative radiotherapy is most often used to manage symptoms caused by metastatic disease, it also has a role in the control of incurable disease which can potentially increase long-term survival (Aggarwal and Hughes, 2016).
The aim of this study was to assess if nurses who care for patients with cancer have adequate knowledge of palliative radiotherapy.
Study objectives were to:
Methods and materials
To obtain an accurate representation of what is understood about palliative radiotherapy, a purposive sample of nurses who worked in oncology and palliative care specialist areas was selected. An invitation to participate in the study was sent to all 162 registered general nurses who were employed in the oncology and palliative care departments of the selected research sites. This was the only criteria set in the recruitment of participants. Considering a 95% confidence level and a 5% margin of error, the total sample size required was estimated to be 115.
The study was conducted in three clinical sites in Dublin, Ireland; two were specialist palliative care units and the other an academic teaching hospital. The specialist units provide palliative care through inpatient, day unit and community services. While no radiotherapy facility is available at either site, there are close links to radiotherapy services at a nearby radiation oncology centre. The third research site, a large university training hospital with over 450 inpatient beds provides oncology, palliative care and radiation specialist services.
The design of this study was informed by a previous study that employed a quantitative method of research using an existing validated questionnaire. The research tool developed by Berrang and Samant (2008) to assess knowledge of palliative radiotherapy among community family physicians and nurses encompassed the key elements that this study aimed to examine. Permission to adapt the questionnaire for this study was sought and granted, and it was subsequently reviewed by a panel of experts.
The five-page questionnaire consisted of 38 items to examine participants' experience and knowledge of palliative radiotherapy. Just under half of all items were set in the format of multiple choice questions to assess overall knowledge of radiotherapy and its use in palliative care. Demographic questions to collect information about the respondents' experience, training and specialty were also included. To determine nurses' self-rated levels of knowledge and whether they considered their knowledge was adequate for their needs, they were asked to choose answers from a four-point Likert scale ranging from ‘very little knowledge’ to ‘extremely knowledgeable’. Actual knowledge of palliative radiotherapy was assessed through a calculation of correct responses given to a list of clinical indications using a Likert scale of answer choices of ‘not effective’, ‘somewhat effective’, ‘very effective’ and ‘don't know’.
Nurses were asked to rate a list of seven factors, such as age of the patient or concern about side effects, which influenced their decision to recommend referral of a patient for palliative radiotherapy. The questionnaire offered respondents the option of ticking a ‘yes’, ‘no’ or ‘unsure’ response in a list of 10 possible conditions to evaluate knowledge of which clinical indications radiotherapy could be considered useful for. A blank space was also included where nurses were asked to list indications for which urgent radiotherapy should be considered. Participants were asked if they had ever been educated in palliative care or radiation oncology in their nurse training and if they had received any training after qualification.
Nurses were assured their participation was entirely voluntary and their identities would remain anonymous. An information sheet in each questionnaire pack informed the participant that completion and return of the questionnaire implied consent. Nominated gatekeepers at each site were responsible for the distribution and collection of the questionnaire packs.
Descriptive and inferential statistical analyses of questionnaires were completed using the Statistical Package for Social Science (SPSS) Version 21. A Mann-Whitney U test was run to identify statistically significant differences between oncology and palliative care nurses in terms of actual knowledge scores.
Results and discussion
A total of 80 questionnaires were returned, which demonstrated a response rate of 49.38%. Two questionnaires were considered ineligible because they were returned late so the final sample size was 78. Table 1 shows participant profiles and self-assessment of radiotherapy educational needs.
| Characteristic | Response |
|---|---|
| Median age in years (range) | 38 (23–61) |
| Female (%) | 89.5 |
| Involved with care of cancer patients? (% yes) | 100 |
| Knowledge of palliative radiotherapy adequate for needs? (% yes) | 45.5 |
| Would you like to learn more about palliative radiotherapy? (% yes) | 84 |
The majority (89.5%; n=70) of respondents were female with an average of 10 years' nursing experience within their clinical specialty. Twenty-four nurses reported they worked in an oncology setting and a further two were working in oncology-related areas (haematology and surgical). Fifty-one nurses described themselves as working within palliative care areas; 29 on inpatient areas, eight within community palliative care and 14 who did not specify. Most (89.5%; n=70) of the nurses surveyed reported that they were often involved in palliative care management and 94.7% (n=72) of nurses had experience of patients who had been referred for palliative radiotherapy.
The study participants were a well-experienced cohort of nurses and therefore deemed to be representative in the assessment of what nurses know about palliative radiotherapy.
Assessment of clinical indications
To determine the current level of understanding among nurses about for which conditions palliative radiotherapy may be useful, 10 clinical indications were listed and participants were instructed to tick which answer applied. The list included situations in which radiotherapy would not be useful, for example hypercalcaemia and febrile neutropenia. Figure 1 shows a selection of the conditions in which palliative radiotherapy would be indicated.
Almost all nurses, 96.2% (n=75) and 76.9% (n=60) respectively correctly specified that bone metastases and diffuse brain metastases were clinical conditions for which palliative radiotherapy may be indicated. However, fewer than half (39.5%) were aware that palliative radiotherapy could be a useful modality in the management of ulcerating or painful skin metastases. Palliative radiotherapy is not a treatment for the oncologic emergency of febrile neutropenia, but 17.9 % (n=14) of nurses reported they were ‘unsure’ and 2.6% (n=2) incorrectly selected ‘yes’. Almost 17% (n=13) of nurses incorrectly stated that palliative radiotherapy was useful in the treatment of hypercalcaemia and more than 20% (n=16) indicated that they were unsure. Just 61.8% (n=47) of nurses identified that radiotherapy was effective in the management of superior vena cava obstruction.
Similar results were identified by Fairchild et al (2012), who demonstrated significant inconsistencies in the knowledge of the correct indications for radiotherapy in particular with regard to hypercalcaemia and febrile neutropenia. This would suggest that indications for palliative radiotherapy should be a specific area of focus for future education.
Misconceptions of radiotherapy administration
The questionnaire included general questions pertaining to treatment times, side effects and conditions necessary for treatment (Table 2).
| Survey | No (%) | Yes (%) | Depends (%) | Unsure (%) |
|---|---|---|---|---|
| Is radiotherapy painful? | 60.3 | 5.1 | 26.9 | 7.7 |
| Does palliative radiotherapy (PR) usually cause nausea or vomiting? | 23.1 | 9.0 | 60.3 | 7.7 |
| Does PR usually cause hair loss? | 39.7 | 3.8 | 50.0 | 5.3 |
| Are patients receiving PR usually significantly immunocompromised or at high risk of infection? | 51.3 | 24.4 | 16.7 | 7.7 |
| Do patients usually become radioactive after PR? | 47.4 | 17.9 | 17.9 | 16.7 |
Fewer than half of nurses (47.4%; n=37) surveyed accurately responded that patients did not usually become radioactive after radiotherapy treatment and 19.2% (n=15) of nurses were unclear if patients were a danger to those around them. Nurses were asked to indicate what the minimum life expectancy of a patient with cancer should be before they should be considered a candidate for radiotherapy (Figure 2).
The number of nurses who identified the correct answer as greater than one month was just 17.9% (n=14). More than half of the nurses surveyed accurately described the usual side effects of palliative radiotherapy to be none or mild, the remainder inaccurately choosing the descriptor of moderate or severe. Nurses were asked to select which factors precluded a patient from receiving radiotherapy from a list of six. The two correct factors were ‘actively vomiting’ and ‘delirium’; 64.1% (n=50) and 71.8% (n=56) respectively of nurses correctly identified this. However, 15.4% (n=12) of nurses incorrectly indicated that a patient with a pacemaker in situ was unable to undergo radiotherapy. Regarding the treatment benefit time for painful bone metastases, just over half (55.1%) of the nurses surveyed identified the correct response of 1-3 weeks after treatment.
It is worth noting that Berrang and Samant (2008) cautioned that treatment may be perceived to have failed if the timing of treatment benefit was underestimated. Knowledge of palliative radiotherapy must be accurate and evidence based to manage the complexities associated with advanced disease and to ensure that it is delivered both on time and appropriately (Aggarwal and Hughes, 2016).
Results of the study being reported here highlight several areas of misconceptions relating to palliative radiotherapy that may affect its utilisation and potentially have a negative impact on the patients' quality of life.
Self-assessment of palliative radiotherapy knowledge
Just under half (45.5%; n=35) of nurses indicated their knowledge of radiotherapy was adequate for their needs. When asked to rate their knowledge of the general aspects of radiotherapy using a Likert scale, fewer than half of them described themselves as being ‘moderately knowledgeable’ about the potential benefits of palliative radiotherapy, 15.85% said they had ‘very little knowledge’ relating to potential side effects and only 2.6% (n=2) declared themselves as ‘extremely knowledgeable’ in the management of side effects. A majority (84%; n=66) of nurses agreed they would benefit from more education in palliative care and almost all (94.8%; n=73) said they would benefit from more education in radiotherapy and its use in oncology. Olsen et al (2012), in their examination of the relationships between family physicians' knowledge of the indications for radiotherapy, previous training and referrals to palliative radiotherapy, found that higher self-rated knowledge was positively associated with referral rates of palliative radiotherapy.
Radiation education
Participants were first asked to indicate ‘yes’ or ‘no’ if they had received any formal training in radiation oncology during their nursing education, to which just 15.6% (n=12) answered ‘yes’. The same question was posed in relation to education after completing nurse training, to which 25.6% (n=20) of participants indicated they had received further training in radiation oncology. Just over half of the nurses surveyed (57.7%; n=45) had visited a radiotherapy department.
These results were surprisingly low, considering the majority of nurses surveyed (94.7%) had cared for patients who had been referred for palliative radiotherapy and on average had been working within a clinical specialty of either oncology or palliative care for more than 10 years. It is worth noting that Aggarwal and Hughes (2016) highlighted the necessity of providing palliative radiotherapy training to both oncology and palliative care teams and that continuing education remained key to the optimal use of palliative radiotherapy.
Barriers to radiotherapy referral
An initial assessment of overall knowledge was calculated to examine if a lack of knowledge was a barrier to recommending patients for referral for palliative radiotherapy. This was achieved by analysing the results of a set of specific questions pertaining to radiotherapy, with a possible correct score of 30. The lowest score calculated was 6 and the highest 28. The mean score of the sample was 18.22 (SD=4.41); 7.7% (n=6) scored 0–10, 64.1% (n=50) scored 11–20 and 28.2% (n=22) scored 21–30. Participants were asked how much a particular factor influenced their decision to recommend referral of a patient for radiotherapy. The Likert scale of tick-box answers available were ‘not at all’, ‘a little’, ‘somewhat’ or ‘a lot’. Of the total sample (n=78): six nurses (7.8%) reported that uncertainty about the benefits of radiotherapy had not influenced their decision to recommend referral of a patient for radiotherapy at all; 19 nurses (24.4%) indicated that it had influenced their decision a little; just over half (n=39) agreed that it had somewhat influenced their decision; and 16.7% (n=13) that it was a major factor.
Almost half of those surveyed (47.4%; n=37) indicated that the age of the patient would somewhat influence their decision to recommend them for referral for radiotherapy, 14.3% (n=11) a little and 24.7% (n=19) of nurses would be influenced a lot. To assess the knowledge of the clinical conditions that constitute an urgent referral for radiotherapy, participants were asked to list the indications they considered emergent. More than one in four (26.9%; n=21) correctly identified either of the two main urgent indications for radiotherapy: spinal cord compression; and superior vena cava syndrome.
Participants were asked to rate the effectiveness of radiation treatment from a list of seven possible manifestations of cancer using a Likert scale of ‘not effective’, ‘somewhat effective’, ‘very effective’ or ‘don't know’. Almost all participants (96.1%; n=75) recognised the effectiveness of radiotherapy to treat painful bone metastases. In relation to the use of radiation for the treatment of haematuria or haemoptysis, fewer participants identified its effectiveness; 16% (n=12) indicated that it was not effective for haemoptysis and 26.7% (n=20) said they didn't know. With regard to haematuria, just over a quarter of participants (26.7%; n=20) stated that radiotherapy was not an effective treatment, with a further quarter (24.4%; n=19) stating that they did not know. For the treatment of an airway obstruction caused by a tumour, 17.9% (n=13) did not recognise radiotherapy as a possible modality of care.
Olson et al (2012) demonstrated a correlation between knowledge of palliative radiotherapy and increased rates of referral. This is noteworthy, considering the results of the study reported here show that more than half of all nurses stated their knowledge of radiotherapy was inadequate for their needs and almost all agreed they would benefit from more education on this topic. Continuing education for professional development would ensure that the nurse, as a member of the multidisciplinary team caring for patients with cancer, would recognise the importance of knowledge to facilitate timely referrals to radiation oncology (Berrang and Samant, 2008).
Knowledge comparison
Because the sample size was relatively small, the non-parametric Mann-Whitney U test was run to examine statistically significant differences between oncology and palliative care nurses in terms of general knowledge scores. A statistical significant difference (U=386; P<0.01) demonstrated that palliative care nurses had a higher mean knowledge score (mean=19.12; SD=4.22) than oncology nurses (mean=16.50; SD=4.57).
This statistical difference in knowledge between the specialties suggests that the curriculum for oncology training may require more content on radiation oncology.
Conclusion
It is evident from this study of palliative radiotherapy knowledge that additional training is required for nurses caring for patients with advanced cancer. Findings were consistent with those of Berrang and Samant (2008) concerning inaccuracies in the ability to correctly identify clinical indications for palliative radiotherapy, and with the findings of Fairchild et al (2012) and Olsen et al (2012) with regard to lack of knowledge regarding the haemostatic properties of radiotherapy. The benefits of palliative radiotherapy are generally negated for patients with a prognosis of less than one month and mistimed treatment could potentially delay the delivery of supportive measures that focus on end-of-life planning and optimising quality of life (Jones et al, 2014; Kress et al, 2015).
Fewer than a quarter of nurses were able to recognise the appropriate minimum life expectancy of a patient before a referral for radiotherapy should be considered. Lack of knowledge is recognised as a barrier to radiotherapy use (Fairchild et al, 2012); in this study, the majority of nurses reported that uncertainty about the benefits of radiotherapy and concern about side effects would influence their decision to refer patients for radiotherapy. Although all of the nurses surveyed cared for patients with cancer, only slightly more than half had ever visited a radiotherapy department. Only a minority of nurses had received training in radiation oncology during their nurse education and only a quarter had received any training after registration.
Optimal use of palliative radiotherapy relies on the knowledge of health professionals involved in the care of the patient. The findings from this quantitative study have demonstrated a significant gap in nurses' knowledge of palliative radiotherapy and identified specific areas of focus for developing future radiotherapy educational programmes. To add to the understanding of nurses' knowledge regarding palliative radiotherapy, a qualitative component should be considered for future research in this area.