Background: A project team was formulated to create evidence-based oncology nurse generalist competencies (ONGCs) to establish best practices in competency development, including high-risk tasks, critical thinking criteria, and measurement of key areas for oncology nurses.
Objectives: This article aims to describe the process and the development of ONGCs.
Methods: This article explains how the ONGCs were accomplished, and includes outcomes and suggestions for use in clinical practice.
Findings: Institutions can use the ONGCs to assess and develop competency programs, offer educational strategies to measure proficiency, and establish processes to foster a workplace committed to mentoring and teaching future oncology nurses.
Oncology nurses play a crucial role in delivering quality care to patients with cancer. Given the intricate healthcare needs of people with cancer, comprehensive knowledge, high-level engagement with interprofessional teams, self-reflection, critical thinking, and clinical skills are essential to ensuring the safe delivery of high-quality nursing care in the healthcare environment. Nurses are equipped to provide safe, proficient, and effective interventions to people with cancer across the disease trajectory, from preventive screening to end-of-life care. The complex technological environment, coupled with the ever-evolving science and rapid assimilation of research into practice in the oncologic specialty, requires oncology nurses to attain and maintain a high level of competency to adequately and safely care for people with cancer. The Oncology Nurse Generalist Competencies (ONGC) (Oncology Nursing Society [ONS], 2016) provide a framework to ensure quality outcomes.
As noted in ONGC (ONS, 2016), the Institute of Medicine ([IOM], 2011), now referred to as the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine, published The Future of Nursing: Leading Change, Advancing Health, which offers recommendations for improving nursing practice. IOM (2011) capitalized on the necessity of educating nurses and assessing their competency over time to ensure high-quality care. In 2016, IOM published an update to the report, stating that, although improvements had been made, more were needed. In addition, they described the nurse’s responsibility of providing a “continuum of services” (National Academies of Sciences, Engineering, and Medicine, 2016, p. 1), including delivering direct patient care, promoting health, educating patients, and coordinating care (ONS, 2016).
In Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM (2001) identified several components to a high-quality cancer care delivery system, including engaged patients, an adequately trained and educated staff, a coordinated workforce, translation of evidence into clinical practice, quality measurement and performance improvement, evidence-based cancer care, a learning healthcare information technology system, and accessible, affordable cancer care (ONS, 2016).
To provide high-quality care to patients with cancer, nurses new to oncology, including seasoned nurses from other specialties, should acquire the necessary competencies. According to IOM (2011), these include competencies in leadership, health policy, system improvement, research and evidence-based practice, teamwork and collaboration, community and public health, geriatrics, and oncology. Documentation supporting the development and assessment of nursing competency is frequently required of accreditation agencies, including the American College of Surgeons and the Joint Commission, as part of the accreditation and reaccreditation process (ONS, 2016).
The terms competence and competency are often used interchangeably; competence is a person’s ability or capability to act in a situation, whereas competency is a person’s actual performance (ONS, 2016). As a result, a person needs competence before he or she can achieve competency (ONS, 2016; Schroeter, 2008). Nurses’ technical skills, critical thinking skills, reflection, and interpersonal strategies can be assessed to determine their level of competency. Roach (2002) stated, “Compassion without competence is a meaningless, if not harmful, intrusion into the life of a person needing help” (p. 54). Training programs that focus on increasing and building competency can strengthen and multiply the workforce of nurses who deliver high-quality care to patients with cancer (ONS, 2016; Smith & Lichtveld, 2007).
A sound transition into entry-level practice serves to facilitate the novice nurse’s success. Components such as orientation, coaching, precepting, lifelong learning, team-based skills building, career development planning, and introduction to the value of specialty certification are necessary. Measurement and documentation of competency in nursing care is critical to assure the public that cancer nursing care is rendered in a safe and evidence-based approach (Randolph et al., 2012).
As noted in ONS’s (2016) ONGC, Benner (1982) proposed that nurses progress through five stages of learning, from novice to expert. According to Benner (1982), the novice nurse is a nursing student in his or her first year of clinical education who is not trained to determine what might happen in a clinical situation. Advanced beginners are new graduate nurses in practicing in their first job. They have more knowledge than novices but lack in-depth nursing experience (Benner, 1982). Through education and practice, they can progress to the latter stages of learning: competent, proficient, and expert (Benner, 1982).
Oncology Nurse Generalist Practice
Although the Oncology Nursing Certification Corporation (2017) has established key areas of study for the examination, the oncology nurse generalist core competencies further define and provide areas of measurement to apply in daily practice. ONS’s (2016) ONGC “provide[s] the fundamental knowledge, skills, and expertise required for oncology nurses to perform proficiently in their roles” (p. 6). ONS developed the oncology nurse practitioner and clinical nurse specialist core competencies (ONS, 2007, 2008), as well as specialty competencies for clinical trials nurses, leaders, and oncology nurse navigators (ONS, 2010, 2012, 2013, 2016). ONGC was developed to support institutions with competency validation and to engage the oncology nurse generalist in a professional development plan for lifelong learning. ONGC (ONS, 2016) defines a novice as an oncology nurse with one or two years of experience, based on Brenner’s model. The competencies are intended to build on nurses’ academic preparation and basic nursing knowledge.
In August 2014, ONS put together a project team of eight nurses specializing in administration, education, and clinical practice, whose goal was to define the core competencies for the oncology nurse generalist caring for adult patients with cancer. The focus was on the knowledge and skills that could be reasonably attained by novice oncology nurses after their first year of practice.
To develop the initial working draft of the competencies, the project team reviewed the literature and other resources. The following key terms were used to identify articles in CINAHL®, Ovid, MEDLINE®, and PubMed: nursing, clinical practice, education, competence, competency, health care, financial acumen, teaching strategies, best practice project articles, and scopes and standards. The articles, findings, applicability, and traits of each competency were outlined in a table (see Table 1). Randomized, controlled trials and meta-analyses on nurse generalist competencies were lacking. Other authors have implemented processes surrounding nursing competencies, such as simulation, shadowing programs, and dedicated education nursing inpatient units (Dean et al., 2013; Messmer, Jones, & Taylor, 2004; Muehlbauer, Parr, & Perkins, 2013). The project team identified a need for competencies to describe the role and skills of oncology nurse generalists. Novice nurses can attain these competencies in one to two years in most environments (ONS, 2016).
Measuring competencies is essential. As shared in ONS’s (2016) ONGC, Wright (2012) wrote about the importance of measuring competency not by what education a nurse receives but by how he or she demonstrates competencies through skills, behaviors, and knowledge. Using themes and traits identified through the literature review, the project team developed the competencies and methods for measuring them and categorized them with subject headers (ONS, 2016).
The Zarca web-based survey tool was used to gather public comments for six weeks from June to July 2015. An email with a link to the survey was sent to more than 1,200 ONS members, who identified themselves as managers, administrators, clinical nurse specialists, and staff educators. The email explained the purpose and background of the project and asked those who worked with novice oncology nurses to complete the survey. The survey was also posted on the ONS website for other nurses to complete. The participants were asked whether the competency statements were easy to understand, whether the generalist behaviors and skills described the core duties of the job, and if they were applicable to novice oncology nurses (ONS, 2016). In addition, the participants were asked which competencies should be kept and how the competencies could be improved (ONS, 2016). Forty-nine survey responses were received, representing a diverse sample (see Table 2). The public comments were used to further edit the competencies.
Because oncology nurses work in multiple settings, the ONGC was created to address core work beyond chemotherapy and biotherapy administration. A five-expert review panel assessed the document prior to publication for flow, clarity, completeness, and appropriateness. In addition, the panel was asked to provide feedback on the individual competency statements. More edits were made based on expert reviewer responses. The project team finalized the document with five key competency domains that included 37 competency statements accompanied by tools for measurement and methods of competency verification (see Table 3). ONGC was published in March 2016 and is available on the ONS website.
Dissemination and Application
Following public comment and expert peer review, the ONGC was posted online and promoted in ONS member emails and website banners. An abstract of the competencies was published and presented at the ONS 42nd Annual Congress in 2017.
ONGC articulates the knowledge and skills required of oncology nurse generalists to proficiently manage the complexities of cancer care, including the disease process, modes of cancer treatment, interprofessional care teams, and patients’ psychosocial and symptom management needs. The competency framework is built on the knowledge that nurses follow pathways of learning that progress through levels of knowledge and experience (Benner, 1982). The competencies are beyond what is taught in prelicensure nursing programs regarding the care of patients with cancer and can be applied to various practice settings, including inpatient and ambulatory (ONS, 2016).
ONS members, particularly those in leadership roles, are professionally responsible for sharing and using the ONGC to outline the role and performance of oncology nurse generalists. Measurement is required to evaluate competency and, in some cases, must be conducted annually per organizational policies and procedures (ONS, 2016). The ONS project team used Wright’s (2012) Ultimate Guide to Competency Assessment in Health Care to select competency measurement methods. Recommended methods include evidence of daily work; presentations; case studies; peer review; self-assessments; discussion; reflective groups; exemplars; engagement in councils, forums, and committees; functioning in expert roles like charge nurse or preceptor; technical skills; reflection; journaling; critical thinking; quality monitoring; return demonstration; and interpersonal strategies. The competencies can be applied in many ways, such as the following:
• Developing job description
• Assisting in recruitment by defining expected oncology nurse generalist qualifications and skills
• Increasing the quantity and quality of the nursing workforce through a competency-based training program (Smith & Lichtveld, 2007; Wright, 2012)
• Providing orientation and guidance for preceptors with novice oncology nurses
• Establishing benchmarks for performance expectations
• Developing skills checklists in clinical practice
• Identifying gaps and resources needed to develop educational programs
• Promoting staff development through learning pathways
• Planning career development goals
• Assisting nurses in progressing from a novice to an expert
• Promoting lifelong learning
ONGC was developed in a consistent fashion with other ONS competencies. Although they are evidence-based, they have not been studied in the clinical setting. They should be used as a tool for the novice nurse to successfully obtain the level of needed competency to care for patients with cancer. It is unclear if nurses who are new to oncology but who have experience in other areas of nursing practice will achieve competence sooner than graduate nurses without experience.
Oncology nurses practice in a variety of settings, including inpatient, ambulatory, radiation, infusion, general medical-surgicalunits, and specialized oncology units, such as stem cell transplantation. Therefore, development of competencies specific to a clinical practice setting or patient population, such as patients with cancer, may be needed. Some nurses who care for patients with cancer may not self-identify as oncology nurses. This may contribute to a disconnect or gap related to nonrecognition of applicability to practice. The attainment of competencies within one to two years may be challenging in practice settings with a low volume of patients with cancer.
Integration of the competencies may be more difficult if individuals responsible for the development of the onboarding and orientation of new nurses do not have oncology background, requiring oversight by an experienced oncology nurse under the supervision of a clinical nurse specialist, educator, manager, or preceptor.
Specific competencies were developed with a broad, overarching focus to allow for differences in oncology nursing practice and across settings. Therefore, specific items, such as preparation and administration of chemotherapy, were not included in the list. Those responsible for coordinating the training and orientation of the oncology nurse generalists should expand on the competencies by including items specific to their roles and responsibilities.
Implications for Nursing
ONGC is a result of extensive literature review, member comments, and expert review. Those results guided next steps, including development of competency statements, identification of measurement methods, and delineation of each competency into five categories (teamwork, professional development, clinical care, financial, and quality). They were designed to achieve wide-ranging applicability in multiple practice settings for experienced nurses who are new to oncology and nurses who are beginning their careers in the oncology specialty, and to further define the role of the practicing oncology nurse. The competencies can be used by oncology nurses in a variety of ways, including new hire training, benchmarks for performance evaluation measures, identification of potential leaders, and development of skills checklists, educational programs, and learning pathways. New oncology nurses may use the competencies to evaluate and plan their personal and professional development.
ONGC is a valuable tool for assessing, addressing, measuring, and documenting competent clinical practice for novice nurses and nurses new to cancer care. The competencies lend themselves to use in diverse work environments, such as in inpatient and ambulatory departments. Demonstrating strong competency in nursing practice is crucial for many institutions seeking accreditation by national agencies. In addition, meeting the public’s cancer care needs is paramount. As care continues to evolve and patient care becomes more complex, the public needs competent nurses who can provide safe care, whether in a surgical suite or infusion center. Every patient deserves a competent nurse.
About the Author(s)
Michele E. Gaguski, MSN, RN, AOCN®, CHPN, NE-BC, APN-C, is the administrator for the Cancer Program at Jefferson Health in Sewell, New Jersey; Kim George, MSN, APRN, ACNS-BC, OCN®, is the assistant director of advanced practice providers in the Office of Health System Affairs at the University of Texas Southwestern Medical Center in Dallas; Susan D. Bruce, MSN, RN, OCN®, AOCNS®, is a clinical nurse specialist at the Duke Cancer Center Raleigh in North Carolina; Edie Brucker, MSN, MPH, AGPCNP-BC, is a lead advanced practice provider in oncology at the University of Texas Southwestern Medical Center; Carol Leija, MSN, RN, OCN®, is an oncology nurse navigator at the University of California Davis Comprehensive Cancer Center in Sacramento; Kristine B. LeFebvre, MSN, RN, AOCN®, is an oncology clinical specialist at the Oncology Nursing Society in Pittsburgh, PA; and Heather Thompson Mackey, RN, MSN, ANP-BC, AOCN®, is an nurse practitioner at the Cone Health Cancer Center at Wesley Long in Greensboro, NC. The authors take full responsibility for this content. Gaguski has previously consulted for Carevive. Bruce has received support from and is a member of the Oncology Nursing Certification Corporation Nominating Committee Board. LeFebvre is an independent contractor for the American Nurses Credentialing Center and has previously received support from the National Institute for Occupational Safety and Health. Mackey is an independent education contractor for the Oncology Nursing Society and, during the writing of this article, was supported by a scholarship from the ONS Foundation. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Gaguski can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org. (Submitted January 2017. Accepted April 12, 2017.)
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