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Practice Innovations

Immunotherapy Assessment: Using a Survey Instrument to Examine Oncology Nurses’ Confidence Levels With Administration and Management

Barbara J. Offner
Lisa Rinke
CJON 2021, 25(3), 343-346 DOI: 10.1188/21.CJON.343-346

Immuno-oncology is a complex treatment paradigm for many malignancies. As a result, nurses need to increase their knowledge awareness regarding safe, evidence-based care of patients who receive oncologic immunotherapy with their treatment regimen. This pilot study looks at nurse confidence levels specific to the challenges associated with this complex treatment. The Oncology Nurse Immunotherapy Confidence Survey, developed for this project, allowed for 28 confidence measurements, demographic collection, and a brief quasi-thematic analysis. The pre- and posteducation confidence scores demonstrated a 51% overall improvement.


  • Nursing confidence is improved with treatment-related, drug class–specific education.
  • As new, complex treatments enter the oncology landscape, continuing education is essential for optimal nursing care.
  • The complexity of care dictates a need to reevaluate not only the educational process, but also how the clinical environment is staffed and managed.

Immunotherapy is changing the standard of care for many malignancies and increasing the complexity of patient management across the spectrum of cancer care (Bayer et al., 2017; Chalmers et al., 2018; Clarke et al., 2018; Prettyman et al., 2018; Wang et al., 2019). The need for ongoing education for nurses providing the care is paramount for safe delivery of this treatment modality (Peek, 2015). However, as the complexity of cancer care shifts, questions arise. How is the education that is being provided perceived by the nurses delivering the care? How are nurse confidence levels affected as a result of the education that is received specific to the nurses’ perceived ability to provide the complex care that is expected?


The augmentation of antitumor immune activity, controversial during much of the 20th century, is demonstrating durable response in cancer treatment (Decker et al., 2017). This paradigm shift within the cancer treatment landscape has had an impact on how nurses are educated and how the patient’s care is managed (Madden, 2018). The unique immune toxicity profile associated with oncologic immunotherapy presents challenges with both identification and management of the immune-related adverse events that may occur (Brigden et al., 2016). Early recognition is critical to limiting the onset of serious sequelae, potentially leading to fatal outcomes (Brigden et al., 2016). An essential element in adverse event management is the appropriate education of the patient and the caregiver, a task often falling to the oncology nurse (American Nurses Association, 2015). Articulation of the information associated with immunotherapy cancer treatment is hindered when the nurses’ comprehension of the treatment is incomplete (Dine et al., 2017).


This research pilot study evaluated the confidence levels of nurses, who manage and administer immunotherapy to patients in the community oncology setting, after receiving an education intervention. Purposive sampling identified 10 oncology RNs working in the community setting throughout northern and eastern Texas. As a result of the COVID-19 pandemic, the project incorporated a mix of both live and virtual classrooms for the intervention.

Expedited institutional review board (IRB) approval was received from the Regis College IRB in Weston, Massachusetts. An IRB amendment was necessary because of COVID-19 pandemic restrictions. Established as a quantitative, correlational study, the outcome was a pilot study with a small sample, which was also related to pandemic restrictions.

Survey Instrument and Educational Intervention

The Oncology Nurse Immunotherapy Confidence Survey was developed for use with this study. Face and content validity was confirmed using five immuno-oncology expert volunteers. Reliability was determined using the test-retest reliability analysis with a separate group of five oncology nurse volunteers. The primary objectives were to evaluate the effect of an education intervention on nurse confidence regarding the management of patients with cancer receiving immunotherapy, and the perceived ability of the oncology nurse to identify and manage potential immune-related adverse events. Secondary objectives evaluated the effect of specific nurse demographics, including age, education, and experience, on nurses’ confidence levels.

The associated education intervention provided drug class–specific information on multiple types of oncologic immunotherapies. Monoclonal antibodies as a broad category, as well as immune checkpoint inhibitor therapy, cancer vaccines, interleukins, and interferons, were addressed specific to administration considerations, patient education, and adverse event identification and management. A course outline is provided in Figure 1.

The confidence survey, administered to participants before and after the education intervention, evaluated 28 confidence measurements based on Likert-type reporting. Questions translating confidence, specific to the following topics, were asked:

•  Understanding of specific immunotherapy mechanism of action, stability, administration considerations, and drug interaction concerns

•  Understanding of how immune-related adverse events occur and how the ability to perform appropriate patient assessments is associated with the identification and management of same

•  Ability to manage patient education specific to the immunotherapy being administered and the need for necessary communication with the healthcare provider

As a quasi-thematic analysis, three open-ended questions were asked following the education intervention specific to the immunotherapies used in cancer treatment, associated patient management, and identification and management of potential associated immune-related adverse events. Each participant was asked about area of greatest confidence, area of least confidence, and ongoing concerns or comments.


A pilot sample of 10 nurses evaluated the immunotherapy education program intervention. Table 1 presents the sample’s demographic data.

Based on Pearson correlation coefficient (p = 0.013) and Spearman’s correlation coefficient (p = 0.005) of pre- and posteducation program confidence survey data, the education program had a positive effect. In addition, the Friedman rank sum test, a nonparametric test useful to evaluate small samples, supports the correlation between pre- and posteducation intervention scores (p = 0.002). There were no correlations among degree status, age, experience, and posteducation scores.

According to survey findings, nurse posteducation program confidence scores improved 51% over pre-education scores (see Table 2). Based on a quasi-thematic analysis of three open-ended questions asked after the education program intervention, the pilot sample’s greatest confidence was in their ability to provide patient education and information to the patient and caregiver; least confidence was in the ability to perform adequate assessments and ensure continuity of care; and the area of most concern was in their ability to provide adequate assessments and ensure continuity of care.


The results of this quantitative, correlational pilot study demonstrate the positive effect of treatment-related education on nurse confidence specific to the management of patients who receive oncologic immunotherapies. Larger studies with the Oncology Nurse Immunotherapy Confidence Survey are needed. Nurses must understand the science behind the immunotherapy treatments being administered. Education regarding drug class facilitates nurse understanding of drug effect, as demonstrated with this study. The critical need for education associated with new and complex oncologic immunotherapy treatments will only continue to increase. Although the results of the survey demonstrate that education has a positive effect on nurse confidence, concerns remain about the ability to adequately provide ongoing nursing assessment and continuity of care. Additional large-scale studies are needed to confirm these results. Studies that address the clinical practices surrounding identification of immune-related adverse events should be considered along with the benefit of patient questionnaires (Bayer et al., 2017; Brigden et al., 2016; Ledezma & Heng, 2014). A review of acuity levels may be needed with the increasing complexity of the treatments being provided in the community setting (Bayer et al., 2017; Brigden et al., 2016; Ledezma & Heng, 2014). The ability to meet the standard of care expected is paramount to oncology nursing.

Continuing education is essential to demonstrate competency in a rapidly changing cancer treatment environment (Marvel, 2017). Current knowledge is necessary to keep pace with research, advancing technology, and innovative cancer treatments (Marvel, 2017). Cancer education shows an improvement in nurse knowledge, attitudes, and confidence with the delivery of cancer care. Through the enhancement of oncology nurse education, the potential for improved patient care may be realized.


Limitations to this study included the COVID-19 pandemic, which necessitated the IRB amendment allowing for changes from a live classroom to a virtual classroom for the education intervention. In addition, the resultant small sample size of 10 oncology nurses led to the modification of the project to a pilot study rather than the full quantitative, correlational analyses.


The Oncology Nurse Immunotherapy Confidence Survey allows for self-analysis of nurse confidence and the perceived ability to provide expected nursing care. The link between the immunotherapy treatment–specific education and nurse confidence is confirmed with this pilot study, although the participants did express specific concerns about the ability to provide adequate assessments and continuity of care. Additional research is needed to further evaluate the findings of this study.

The authors gratefully acknowledge Kimberly Shafer-Weaver, PhD, MBA, C. Andrew Martin, DNP, MS, RN, CNE®, ACRN, CHPN®, Karen Crowley, DNP, APRN-BC, ANP, WHNP, CNE, and Susan E. Fleming, PhD, RN, CNS, for their valuable advice, mentoring, editing, suggestions, and overall support.

About the Author(s)

Barbara J. Offner, DNP, RN, CRNI, is a senior oncology nurse educator at AstraZeneca in Montgomery, TX; and Lisa Rinke, DNP, APRN, FNP-BC, is an assistant professor and program director for the online DNP program at Regis College in Weston, MA. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Offner can be reached at barbara.offner@regiscollege.edu, with copy to CJONEditor@ons.org.



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