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Registered Nurses’ Perspectives of the Impact of a Post-registration Education Qualification on Patient Care and Clinical Practice in Cancer Care: a Qualitative Study

Registered Nurses’ Perspectives of the Impact of a Post-registration Education Qualification on... Student evaluation of teaching is routinely completed as modules and programmes of study at higher education institutions conclude. The evaluations are often focused on the educational value and experience. For programmes with healthcare professionals as students, the impact of the learning on patient care and clinical practice is not routinely captured in these student evaluations. These insights are crucial as the definitive impact of learning for many educational programmes of study for healthcare professionals is to enhance patient outcomes. The aim of this qualitative research study was to capture the impact of a post-registration Specialist Practice in cancer pathway for registered nurses in the context of Northern Ireland following completion of the programme. Eleven participants engaged in interviews in 2021 who had completed the educa- tion programme from 2013 to 2021. Two themes inductively emerged from the data which provided insights into the specific impact of the education programme on patient care and clinical practice. Theme one identified patient outcomes improved, and was related to five sub themes; development of nurse’s clinical knowledge; enhanced awareness of the holistic impact of cancer; greater understanding of patient services available; development of clinical networks; and greater decision-making ability. Theme two related to the impact of the qualification on clinical practice through an increase in their professional credibility within the multidisciplinary team in cancer services. The debate on how to capture the impact of education on patient care and clinical practice in cancer care, should consider how to routinely capture this data. Keywords Nursing · Cancer education · Post-registration education · Impact on patient care Introduction at a higher level [3]. Advanced Practice Nursing includes advanced nursing interventions ‘that influence clinical From nursing’s inception as a profession approximately one healthcare outcomes for individuals, families and diverse century ago, there has been an ongoing appraisal of the pro- populations’ [1, p.6]. The key aim of Advanced Practice fession in response to changes in health and society [1]. One Nursing is to improve patient outcomes [1]. One aspect of aspect of this appraisal is the global interest in supporting Advanced Practice Nursing is the availability of Advanced nurses to extend their practice beyond the level of initial reg- Practice Nurse roles. An ‘Advanced Practice Nurse is a istration [2]. Advanced Practice Nursing, sometimes abbre- generalist or specialised nurse who has acquired, through viated to APN, is an umbrella term for nurses practicing additional graduate education, the expert knowledge base, complex decision-making skills and clinical competencies for Advanced Practice Nursing’ [1 p. 6]. There are multiple * Helen Kerr Advanced Practice Nurse roles with one study identifying 52 h.kerr@qub.ac.uk different roles in 26 countries [4 ]. Roles include the Clini- Oonagh McSorley cal Nurse Specialist (CNS), Nurse Consultant and Nurse o.mcsorley@qub.ac.uk Practitioner. Studies report positive patient outcomes asso- Monica Donovan ciated with these roles in cancer services such as increased m.donovan@qub.ac.uk patient satisfaction, improvements in psychological support 1 for patients, and better symptom management [5, 6]. School of Nursing and Midwifery, Queen’s University Belfast, Northern Ireland, UK Vol.:(0123456789) 1 3 Journal of Cancer Education Education has a key role in developing knowledge, skills educational quality, and student experience [11]. However, and expertise related to Advanced Practice Nursing. There the impact of this post registration education programme on are a suite of post registration programmes available across patient care and clinical practice, is not routinely gathered. the globe in higher education institutions (HEI) which aim Standardised module evaluations are often used across HEIs to equip nurses to advance their evidence-based knowledge [13] with recommendations for the development of national and skills beyond initial registration, to improve patient education metrics in the UK which provides educational data outcomes. In the context of the UK, the regulatory body, that is linked to patient outcomes [14]. Questions in SET the Nursing and Midwifery Council (NMC), is currently tools often focus on whether educational materials supported reviewing the standards for post registration specifically for learning, what worked well in the module and programme, the NMC recordable qualification in Specialist Practice with and recommendations for improvements. As post registra- the outcome of the review due in 2022. At the School of tion programmes of study for healthcare professionals ulti- Nursing and Midwifery, in a HEI in Northern Ireland (NI), mately aim to improve patient outcomes, the primary aim the Specialist Practice programme is available with seven of this research was to evaluate the impact of the education pathways, one of which is cancer nursing, leading to a NMC programme on patient care and clinical practice, after the Specialist Practice recordable qualification. The definition completion of the education programme. of Specialist Practice is a registered nurse who can exercise ‘higher levels of judgement, discretion and decision-making in clinical care’ relating to four broad areas; clinical practice; Methods care and programme management; clinical practice develop- ment; and clinical practice leadership [, p. 4–5]. Nurses with Setting the Specialist Practice qualification often progress to work in Advanced Practice Nurse roles such as a CNS. Working Two of the five HSCTs in NI were selected as the two set - within a specialism such as cancer, involves nurses develop- tings for data collection. The rationale for this selection ing and expanding their knowledge and skills in a selected was that 79% of nurses commissioned by the Department area within the discipline of nursing [7, 8]. In NI, to use the of Health, NI, onto the Specialist Practice in cancer pro- terminology ‘specialist’ in a nursing role title, a Specialist gramme at a HEI in Northern Ireland from 2013 to 2018, Practice qualification is recommended [ 9]. The Specialist were employed at these two HSCTs. Data collection was due Practice programme in NI is commissioned by the Depart- to commence in May 2019 with ethical approval secured ment of Health in the five Health and Social Care Trusts (HKerr.SREC_May19_V2), however, due to the COVID19 (HSCTs) and is a 2-year part time, or 1-year full time educa- global pandemic, a decision was made to delay data collec- tion programme. The programme involves a 50% academic tion. Amendments were submitted to the University Fac- component and a 50% clinical component. The academic ulty Research Ethics Committee and to the two HSCTs for component involves six modules completed in the univer- research governance approval to undertake data collection sity setting and the clinical component involves each stu- in 2021, and these amendments were approved. dent being allocated a Practice Assessor, a registered nurse who is clinically based, and an Academic Assessor based Study Design at the university to support the student to meet the clini- cal competences. Another aspect of the clinical component A phenomenological qualitative approach was adopted as involves clinical placements, the quantity and location of this study aimed to capture the individual’s lived experiences which is based on the student’s previous clinical experience. within their world [15]. To achieve this, questions such as The clinical component involves the completion of a clinical ‘what is this experience like?’ and ‘what does this experi- portfolio to demonstrate that students have met the compe- ence mean?’ were asked [16] in semi-structured interviews. tences associated with the clinical component. Inclusion criteria included registered nurses who were cur- Student evaluation of teaching (SET) is common practice rently working in one of two HSCTs and had completed the in HEI’s globally to gather information about teaching ee ff c - Specialist Practice programme, cancer pathway, leading to tiveness [10, 11]. There are ongoing debates about various the NMC recordable qualification from 2013 to 2021. 9–18 aspects of SETs such as student motivation to complete [10], participants were anticipated as the sample size in which if SET are used to improve teaching [12], and incentivising data saturation was anticipated to be achieved. students to complete SET [11]. Evaluating the Specialist Practice in cancer pathway education programme is com- Sampling pleted by students informally throughout, and formally at the completion of the six academic modules through an online Purposive sampling was adopted applying the inclusion questionnaire in the university setting, to determine the criteria. Nurses who completed the education programme 1 3 Journal of Cancer Education in another HEI between this timeline and currently work- among three researchers (HK, MD, OMcS) to validate inter- ing in one of the two HSCTs, could be recruited through pretation in the data analysis process with consensus being snowball sampling. An email of invitation and Participant reached on the themes emerging. Information Sheet were forwarded to potential participants using their university student email by the lead researcher Ethical Considerations (HK), although it was recognised that previous students may no longer be accessing their university email accounts. To There are four main guiding ethical principles when to con- enhance recruitment, a gatekeeper at the two HSCTs for- sider when conducting research; autonomy, beneficence, warded invitations to participate and a Participant Infor- non-maleficence and justice [18]. These ethical princi- mation Sheet to registered nurses who met the inclusion ples were considered and implemented at all stages. Elec- criteria, using their work email address. Interested poten- tronic written informed consent was secured prior to data tial participants were invited to contact the lead researcher collection. directly with questions and/or arrange a time for the inter- view. If there was no response within 10–14 days, a reminder email was forwarded to the nurse’s work email account and Results university student email account. To facilitate a cooling off period, after initial contact via email or telephone, potential Eleven registered nurses consented to participate, and data participants were provided with one further week prior to saturation was considered to have been achieved. Descriptive the interview date. data on the participants is captured in Table 1. No partici- pants were recruited through snowball sampling and all par- Data Collection and Analysis ticipants consented for the lead researcher (HK) to facilitate the interview. Interviews lasted an average of 45 min with Data collection involved online semi-structured audio- a range of 31 and 71 min. Two themes inductively emerged recorded interviews using the Microsoft Teams platform from the data; theme one is associated with the impact of in July and August 2021. An online platform was selected the post registration qualification on patient care, and theme to avoid face to face contact with frontline nurses due to two related to the impact on clinical practice. the Covid-19 pandemic. Interviews were planned to last approximately 60  min. Electronic informed consent was Themes obtained prior to the commencement of the interview after addressing any questions. Interviews were facilitated by the Theme One: Impact on Patient Care lead researcher (HK). To minimise any potential conflict of interest, participants were also given the option of inter- Theme one relates to the impact of the Specialist Practice views being completed by a co-researcher (OMcS), as the qualification on patient care with five subthemes identified: lead author was the Pathway Lead for the programme, for development of clinically relevant knowledge; enhanced cohorts completing after 2019. Following a scoping review awareness of the holistic impact of cancer; greater under- of the literature, the interview schedule was co-produced standing of patient services available; development of clini- with the research team and a previous student. Braun and cal networks; and greater decision-making ability. Clarkes six staged framework was used for data analysis [17]. A descriptive thematic analysis was adopted. The Development of Clinically Relevant Knowledge All partici- NVIVO computer package assisted in the organisation and pants reported a development in their clinical knowledge. coding of data. Independent blind analysis was completed This included, but was not limited to, the range and detail Table 1 Descriptive data Years qualified Four to 23 years Years working in cancer care Four to 20 years Current role Clinical Nurse Specialist × 6 Oncology Nurse Practitioner × 1 Clinical educator × 1 Cancer clinical trials × 1 Acute Oncology and Haematology Service × 1 Outpatient setting × 1 Years working in current role Four months to six years Year completed Specialist Practice qualification 2014 × 2 2019 × 3 2020 × 5 2021 × 1 1 3 Journal of Cancer Education of cancer treatments available and symptom management. ‘I’m able to navigate now, and it really informed me of the role of all the CNSs and what their job consisted This new knowledge was reported to enhance patient care by providing a concrete evidence-base to support patients with of, because sometimes you get zoned in, in the role that you are doing, and you don’t understand maybe what information on the effects and potential side effects of cancer treatments, and a greater capacity to assess and manage dis- everybody else is doing.’ (04). ease and treatment related symptoms, leading to a reported Development of Clinical Networks Participants shared the increase in the nurses’ level of competence and confidence. education programme contributed to developing important networks which led to a more streamlined and time efficient ‘… it has given me a lot more knowledge and insight approach when referring patients and their carers to other into even just cancer and treatments and symptoms. services. These networks were developed with peer students And it just gave me that more in depth knowledge that in clinical roles throughout NI, and through meeting other I wouldn’t have had, and hadn’t necessarily already practitioners while on clinical placements. got in my job. And then obviously the more I know, the ‘…it allows you to meet people and to create those more information I can give to my patient.’ (07). links and to actually know the other CNSs in other areas.’ (07). As the participant’s knowledge developed, their com- petence was enhanced leading to their sense of confidence Greater Decision‑making Ability Participants reported their growing in providing patient care. Nurses reported they ability to critically think in practice was enhanced which were more confident in communicating with multidiscipli- led to a greater capacity to make evidence-based complex nary team members and their sense of self-efficacy grew in decisions related to patient care. advocating for patients. ‘You are critically thinking about things all the time. ‘…If maybe medical staff have wanted to do some- You are applying your knowledge base from what you thing and I don’t really think it’s the best thing for the learned…I think the critical thinking before you do patient, I would certainly have the confidence … not things, and thinking, why am I doing this? (11). to challenge them in a bad way, but just to say, would you think…we might be able to do it this way? Or the rationale for maybe doing it this way.’ (05). Theme Two: Impact on Clinical Practice Enhanced Awareness of the Holistic Impact of Cancer The Increased Professional Credibility Theme two focused on the nurse’s ability to assess and provide holistic care was enhanced as a result of the education programme. Content impact of the education programme on clinical practice. Par- ticipants shared the qualification increased their professional on the holistic impact of a cancer diagnosis and person-cen- tred care was provided by services users in the education credibility within the multi-disciplinary team as it provided evidence that they had the knowledge and skills required to programme, and supplemented by academics and clinically based healthcare professionals, which enhanced the nurse’s occupy an Advanced Practice Nurse role. ability to more accurately empathise with patients and appre- ciate the holistic and individual impact of a cancer diagnosis. ‘It’s …like a rite of passage…It’s like, I’ve done it. ‘…that really helped give you insight into understand- I’ve done specialist practice. I feel worthy to be here ing their [patient] journey and I think then you are now…’ (09). able to care for them better as a result.’ (05). ‘I feel confident and able to call myself a Clinical Nurse Specialist and know that, yes, that is what I am, ‘If you can holistically assess your patient, and I think the modules certainly help you to think more holisti- and I have done everything that I need to do, to achieve that, and to be called that..’ (07). cally, and if you are looking at your patient from more of a holistic perspective, I think the patient care is defi- This enhanced sense of professional credibility increased nitely enhanced’ (11). their professional and personal confidence as they had dem- Greater Understanding of Patient Services Available Par- onstrated resilience to overcome the academic and time chal- ticipants shared they were more informed of the range of lenges to complete the education programme. statutory and non-statutory services available which was ‘[There is] value added for the organisation itself as shared with patients and their carers, enhancing the quality being a nurse with a specialist practice qualification, of care provided. These insights were also provided through but also the value that it had on me as a person, is the clinical placement component. me being able to grow and develop as a person, and 1 3 Journal of Cancer Education improve my confidence and my competence and being state that specialist practice nurses should exercise higher able to be a safe and effective practitioner.’ (08). levels of discretion, judgement and decision-making [7]. These ‘higher levels’ required for safe and effective patient care, involve critiquing skills and corroborate their impor- Discussion tance in education programmes. This study demonstrates the transferability value of critiquing skills beyond the edu- Two themes emerged from the data associated with the cational environment, into the clinical setting in improving impact of the post-registration nurse education programme, patient outcomes. These specific insights crystallise how which related to the impact on patient care and clinical learning from education programmes seamlessly translates practice. Theme one demonstrated that nurses reported into improvements in patient care and clinical practice and there were improvements in patient outcomes as a result should be of interest to educators developing and delivering of the education programme for registered nurses working education programmes to healthcare professionals in cancer in cancer services related to five key areas, highlighting services. The second theme related to the impact of the edu- the mechanisms of how the education programme was of cation programme on clinical practice with nurses reporting value in improving patient care. Education programmes in a greater sense of validation in the role they occupied, often HEIs are revalidated approximately every 5 years, provid- Advanced Practice Nurse roles. This was borne out with ing an opportunity to review and update content to ensure reports of improved competence in their clinical role and it aligns to current evidence-based practice, research and enhanced confidence in advocating for patients. This is in policy. One relevant example in this education programme keeping with results from a research study which reported is the European Oncology Nursing Society (EONS) Educa- a cancer education course improved nurses’ confidence in tion Framework which also outlines that specialist cancer caring for patients, highlighting the far-reaching benefits of nursing programmes provide added value in terms of patient education, beyond knowledge development [20]. The impact outcomes [19]. The revalidation process involves represen- of education programmes on registered nurses in cancer tation from patients, carers, students, educationalists, ser- services is currently an understudied area in comparison to vice providers and researchers. If the revalidation process is numerous studies published on the impact of education on robust and rigorous, with effective teaching methodologies undergraduate nursing students. employed, then findings related to theme one are not unex- pected with regards a development in the student’s knowl- Limitations and Strengths edge, enhanced awareness of the holistic impact of cancer, and a greater understanding of patient services available, as One of the limitations of this study related to data collection these relate specifically to the module and programme learn- being undertaken in two HSCTs in the context of NI so there ing outcomes for this education programme. These findings should be caution in the transferability of these findings. To align to results from a quasi-experimental research study support transferability, demographic data has been provided. which reported an increase in registered nurses knowledge The strength of this study was the in-depth exploration of the and perceived skills in the psychosocial care of individuals components of educational programmes which specifically with cancer, following engagement in a cancer education impact patient care and clinical practice in cancer services. programme [20]. However, in returning our attention to the These insights will support educationalists to develop aims, findings in this research, what was interesting were reports learning outcomes, and module content to best support stu- that patient care was enhanced by the development of clini- dents who are healthcare professionals, to improve patient cal networks with other nurses on the education programme, outcomes. and through contacts initiated in clinical placements. These To conclude, SET’s are routinely completed throughout, new insights identify how education programmes meet and at the completion of modules and education programmes additional outcomes not included in programme and mod- at HEI’s, which should be used to not only evaluate teach- ule aims and learning outcomes, which in this study, were ing, but improve teaching [12]. For education programmes attributed to improving patient outcomes. Furthermore, this with students as healthcare professionals, the ultimate aim study reported that nurse’s ability to think critically in the of these education programmes are often to improve patient clinical setting was developed as a result of the education outcomes. Despite this, this data is not routinely captured in programme, which enhanced their decision-making ability HEI SETs. This seems an important omission. If this data related to improving patient care. The association between is gathered, it will shape the content and delivery of edu- critical thinking and improved decision-making in clinical cational programmes to ensure they are fit for purpose. The practice has been established [21]. Criticality is often associ- rationale for this research was to capture this data retrospec- ated as an academic writing skill; however, it is also a funda- tively, however, this approach would not be feasible to glob- mental component of the advanced nurse’s role as the NMC ally implement in HEI’s due to the time required to secure 1 3 Journal of Cancer Education 5. Kerr H, Donovan M, McSorley O (2021) Evaluation of the role ethical and research governance approvals. Consequently, of the clinical Nurse Specialist in cancer care: an integrative lit- we recommend that educationalists review question items in erature review. Eur J Cancer Care 30(3):1–13 module and programme SET to ensure there is a focus on the 6. Jeyarajah S, Adams KJ, Higgins L et al (2009) Prospective evaluation of impact of education programmes on patient care and clinical a colorectal cancer nurse follow-up clinic. Colorectal Dis 13:31–38 7. Nursing and Midwifery Council (2001) Standards for specialist practice, rather than the narrower focus on the educational education and practice. NMC, London experience. Whilst the data collected is often through a ques- 8. Hamric AB, Tracy MG (2019) A definition of advanced practice tionnaire and limited to one point in time, it will still capture nursing. In: Tracy MF, O’Grady ET (eds) Hamric and Hanson’s useful insights into the present and anticipated outcomes advanced practice nursing: an integrative approach, 6th edn. Else- vier, Missouri, pp 202–251 in applying learning to practice, focusing on the impact on 9. Department of Health (2018) Career framework for specialist patient care and clinical practice. This data could be supple- nursing roles. Belfast: DoH mented with discussions with students to capture the appli- 10. Hoel A, Dahl TI (2019) Why bother? Student motivation to participate in cation of learning to practice. The debate on how to capture student evaluations of teaching. Assess Eval High Educ 44(3):361–378 11. Gordon H, Stevenson E, Bookhart A et al (2018) Grade incentive the impact of education on patient care in cancer care, should to boost course evaluation International. J Nurs Educ 18(1):1–5 consider how to routinely capture this data, as this must be a 12. Golding C, Adam L (2016) Evaluate to improve: useful approaches more accurate measurement of learning. to student evaluation. Assess Eval High Educ 41(1):1–14 13. Wiley C (2010) Standarised module evaluation surveys in UK Acknowledgements Thank you to the study participants for their time higher education: establishing students’ perspective. Available as they were frontline nursing staff providing care over the Covid19 at: https:// s3. eu- centr al-1. amazo naws. com/ eu- st01. ext. exlib risgr pandemic. oup. com/ 44SUR_ INST/ s t or a g e/ alma/ EB/ CF/ 90/ 4C/ 20/ 99/ 1B/ 04/ 11/ 48/ 76/ 98/ 47/ 85/ 8D/ 8A/ Wiley% 2C% 20Chr istop her% 20% 282019% 29.% 20Sta ndard ised% 20mod ule% 20eva luati on% 20sur Author Contribution All authors contributed to the study conception ve y s% 20in% 20UK% 20hig her% 20edu cation% 20-% 20Es t ablis and design. Data analysis were performed by Helen Kerr, Oonagh hing% 20s tu dents% E2% 80% 99% 20per spect ives. pdf? r espo nse- McSorley and Monica Donovan. The first draft of the manuscript was conte nt- type= appli cation% 2Fpdf &X- Amz- Algor ithm= AWS4- written by Helen Kerr and all authors commented on versions of the HMAC- SHA25 6&X- Amz- Date= 20220 511T0 85138 Z&X- Amz- manuscript. All authors approved the final manuscript. Signe dHead ers= hos t&X- Amz- Expir es= 119&X- Amz- Cr ede ntial=AKIAJ N6NPM N GJALPPW AQ%2F202 20511% 2F eu-centr Funding Burdett Trust for Nursing. al-1% 2Fs3% 2F aws4_ r eq ue s t&X - Amz- Signa tur e= 0a6f3 ab736 dfb2954927 eeeb4 45235 d29e3 def38 6d10c aec7c da9f7 3888b b866 Declarations Accessed: 9 May 2022 14. Illing J, Corbett S, Kehoe A et al (2018) How does the education and training of health and social care staff transfer to practice Ethics Approval Ethical approval was secured at the university (code: and benefit patients? A realist approach. Final report. Available HKerr.SREC_May19_V). Research governance approval was secured at: https:// eprin ts. ncl. ac. uk/ file_ store/ produ ction/ 250597/ 0918B at the two HSCTs (code: 269931). E55-648C- 439F -8706- 49932 29060 59. pdf . Accessed 7 Aug 2022 15. Neubauer BE, Witkop CT, Varplo L (2019) How phenomenology can Conflict of Interest The authors declare no competing interests. help us learn from the experiences of others. Perspect Med Ed 8:90–97 16. Rodriguez A, Smith J (2018) Phenomenology as a healthcare Open Access This article is licensed under a Creative Commons Attri- research method. Evid Based Nurs 21(4):96–98 bution 4.0 International License, which permits use, sharing, adapta- 17. Braun V, Clarke V (2006) Using thematic analysis in psychology. tion, distribution and reproduction in any medium or format, as long Qual Res Psychol 3:77–101 as you give appropriate credit to the original author(s) and the source, 18. Beauchamp TL, Childress JF (2001) Principles of Biomedical provide a link to the Creative Commons licence, and indicate if changes Ethics, 6th edn. Oxford University Press, London were made. The images or other third party material in this article are 19. European Oncology Nursing Society (2018) The European Oncol- included in the article's Creative Commons licence, unless indicated ogy Nursing Society Cancer Nursing Education Framework. otherwise in a credit line to the material. If material is not included in Available at: https://z2y .621. m yftpupload. com/ wp- conte nt/ uploa the article's Creative Commons licence and your intended use is not ds/ 2020/ 05/ EONSC ancer Nursi ngFra mewor k2018-1. pdf? time= permitted by statutory regulation or exceeds the permitted use, you will 16021 63080. Accessed 7 Aug 2022 need to obtain permission directly from the copyright holder. To view a 20. Steginga SK, Dunn J, Dewar AM et al (2005) Impact of an inten- copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . sive nursing education course on nurses’ knowledge, confidence, attitudes and perceived skills in the care of patients with cancer. Oncol Nurs Forum 32(2):375–381 21. Heidari M, Ebrahimi P (2016) Examining the relationship between References critical thinking skills and decision-making ability of emergency medicine students Indian. J Crit Care Med 20(10):581–586 1. International Council of Nurses (2020) Guidelines on advanced practice nursing. Switzerland: ICN Publisher's Note Springer Nature remains neutral with regard to 2. Dowling M, Beauchesne M, Farrell F et al (2012) Advanced prac- jurisdictional claims in published maps and institutional affiliations. tice nursing: a concept analysis. Int J Nurs Pract 19:131–140 3. Sheer B, Wong FKY (2008) The development of advanced nursing practice globally. J Nurs Scholarsh 40(3):204–211 4. Heale R, Buckley C (2015) An international perspective of advanced practice nursing regulation. Int Nurs Rev 62:421–429 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cancer Education Springer Journals

Registered Nurses’ Perspectives of the Impact of a Post-registration Education Qualification on Patient Care and Clinical Practice in Cancer Care: a Qualitative Study

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10.1007/s13187-022-02205-4
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Abstract

Student evaluation of teaching is routinely completed as modules and programmes of study at higher education institutions conclude. The evaluations are often focused on the educational value and experience. For programmes with healthcare professionals as students, the impact of the learning on patient care and clinical practice is not routinely captured in these student evaluations. These insights are crucial as the definitive impact of learning for many educational programmes of study for healthcare professionals is to enhance patient outcomes. The aim of this qualitative research study was to capture the impact of a post-registration Specialist Practice in cancer pathway for registered nurses in the context of Northern Ireland following completion of the programme. Eleven participants engaged in interviews in 2021 who had completed the educa- tion programme from 2013 to 2021. Two themes inductively emerged from the data which provided insights into the specific impact of the education programme on patient care and clinical practice. Theme one identified patient outcomes improved, and was related to five sub themes; development of nurse’s clinical knowledge; enhanced awareness of the holistic impact of cancer; greater understanding of patient services available; development of clinical networks; and greater decision-making ability. Theme two related to the impact of the qualification on clinical practice through an increase in their professional credibility within the multidisciplinary team in cancer services. The debate on how to capture the impact of education on patient care and clinical practice in cancer care, should consider how to routinely capture this data. Keywords Nursing · Cancer education · Post-registration education · Impact on patient care Introduction at a higher level [3]. Advanced Practice Nursing includes advanced nursing interventions ‘that influence clinical From nursing’s inception as a profession approximately one healthcare outcomes for individuals, families and diverse century ago, there has been an ongoing appraisal of the pro- populations’ [1, p.6]. The key aim of Advanced Practice fession in response to changes in health and society [1]. One Nursing is to improve patient outcomes [1]. One aspect of aspect of this appraisal is the global interest in supporting Advanced Practice Nursing is the availability of Advanced nurses to extend their practice beyond the level of initial reg- Practice Nurse roles. An ‘Advanced Practice Nurse is a istration [2]. Advanced Practice Nursing, sometimes abbre- generalist or specialised nurse who has acquired, through viated to APN, is an umbrella term for nurses practicing additional graduate education, the expert knowledge base, complex decision-making skills and clinical competencies for Advanced Practice Nursing’ [1 p. 6]. There are multiple * Helen Kerr Advanced Practice Nurse roles with one study identifying 52 h.kerr@qub.ac.uk different roles in 26 countries [4 ]. Roles include the Clini- Oonagh McSorley cal Nurse Specialist (CNS), Nurse Consultant and Nurse o.mcsorley@qub.ac.uk Practitioner. Studies report positive patient outcomes asso- Monica Donovan ciated with these roles in cancer services such as increased m.donovan@qub.ac.uk patient satisfaction, improvements in psychological support 1 for patients, and better symptom management [5, 6]. School of Nursing and Midwifery, Queen’s University Belfast, Northern Ireland, UK Vol.:(0123456789) 1 3 Journal of Cancer Education Education has a key role in developing knowledge, skills educational quality, and student experience [11]. However, and expertise related to Advanced Practice Nursing. There the impact of this post registration education programme on are a suite of post registration programmes available across patient care and clinical practice, is not routinely gathered. the globe in higher education institutions (HEI) which aim Standardised module evaluations are often used across HEIs to equip nurses to advance their evidence-based knowledge [13] with recommendations for the development of national and skills beyond initial registration, to improve patient education metrics in the UK which provides educational data outcomes. In the context of the UK, the regulatory body, that is linked to patient outcomes [14]. Questions in SET the Nursing and Midwifery Council (NMC), is currently tools often focus on whether educational materials supported reviewing the standards for post registration specifically for learning, what worked well in the module and programme, the NMC recordable qualification in Specialist Practice with and recommendations for improvements. As post registra- the outcome of the review due in 2022. At the School of tion programmes of study for healthcare professionals ulti- Nursing and Midwifery, in a HEI in Northern Ireland (NI), mately aim to improve patient outcomes, the primary aim the Specialist Practice programme is available with seven of this research was to evaluate the impact of the education pathways, one of which is cancer nursing, leading to a NMC programme on patient care and clinical practice, after the Specialist Practice recordable qualification. The definition completion of the education programme. of Specialist Practice is a registered nurse who can exercise ‘higher levels of judgement, discretion and decision-making in clinical care’ relating to four broad areas; clinical practice; Methods care and programme management; clinical practice develop- ment; and clinical practice leadership [, p. 4–5]. Nurses with Setting the Specialist Practice qualification often progress to work in Advanced Practice Nurse roles such as a CNS. Working Two of the five HSCTs in NI were selected as the two set - within a specialism such as cancer, involves nurses develop- tings for data collection. The rationale for this selection ing and expanding their knowledge and skills in a selected was that 79% of nurses commissioned by the Department area within the discipline of nursing [7, 8]. In NI, to use the of Health, NI, onto the Specialist Practice in cancer pro- terminology ‘specialist’ in a nursing role title, a Specialist gramme at a HEI in Northern Ireland from 2013 to 2018, Practice qualification is recommended [ 9]. The Specialist were employed at these two HSCTs. Data collection was due Practice programme in NI is commissioned by the Depart- to commence in May 2019 with ethical approval secured ment of Health in the five Health and Social Care Trusts (HKerr.SREC_May19_V2), however, due to the COVID19 (HSCTs) and is a 2-year part time, or 1-year full time educa- global pandemic, a decision was made to delay data collec- tion programme. The programme involves a 50% academic tion. Amendments were submitted to the University Fac- component and a 50% clinical component. The academic ulty Research Ethics Committee and to the two HSCTs for component involves six modules completed in the univer- research governance approval to undertake data collection sity setting and the clinical component involves each stu- in 2021, and these amendments were approved. dent being allocated a Practice Assessor, a registered nurse who is clinically based, and an Academic Assessor based Study Design at the university to support the student to meet the clini- cal competences. Another aspect of the clinical component A phenomenological qualitative approach was adopted as involves clinical placements, the quantity and location of this study aimed to capture the individual’s lived experiences which is based on the student’s previous clinical experience. within their world [15]. To achieve this, questions such as The clinical component involves the completion of a clinical ‘what is this experience like?’ and ‘what does this experi- portfolio to demonstrate that students have met the compe- ence mean?’ were asked [16] in semi-structured interviews. tences associated with the clinical component. Inclusion criteria included registered nurses who were cur- Student evaluation of teaching (SET) is common practice rently working in one of two HSCTs and had completed the in HEI’s globally to gather information about teaching ee ff c - Specialist Practice programme, cancer pathway, leading to tiveness [10, 11]. There are ongoing debates about various the NMC recordable qualification from 2013 to 2021. 9–18 aspects of SETs such as student motivation to complete [10], participants were anticipated as the sample size in which if SET are used to improve teaching [12], and incentivising data saturation was anticipated to be achieved. students to complete SET [11]. Evaluating the Specialist Practice in cancer pathway education programme is com- Sampling pleted by students informally throughout, and formally at the completion of the six academic modules through an online Purposive sampling was adopted applying the inclusion questionnaire in the university setting, to determine the criteria. Nurses who completed the education programme 1 3 Journal of Cancer Education in another HEI between this timeline and currently work- among three researchers (HK, MD, OMcS) to validate inter- ing in one of the two HSCTs, could be recruited through pretation in the data analysis process with consensus being snowball sampling. An email of invitation and Participant reached on the themes emerging. Information Sheet were forwarded to potential participants using their university student email by the lead researcher Ethical Considerations (HK), although it was recognised that previous students may no longer be accessing their university email accounts. To There are four main guiding ethical principles when to con- enhance recruitment, a gatekeeper at the two HSCTs for- sider when conducting research; autonomy, beneficence, warded invitations to participate and a Participant Infor- non-maleficence and justice [18]. These ethical princi- mation Sheet to registered nurses who met the inclusion ples were considered and implemented at all stages. Elec- criteria, using their work email address. Interested poten- tronic written informed consent was secured prior to data tial participants were invited to contact the lead researcher collection. directly with questions and/or arrange a time for the inter- view. If there was no response within 10–14 days, a reminder email was forwarded to the nurse’s work email account and Results university student email account. To facilitate a cooling off period, after initial contact via email or telephone, potential Eleven registered nurses consented to participate, and data participants were provided with one further week prior to saturation was considered to have been achieved. Descriptive the interview date. data on the participants is captured in Table 1. No partici- pants were recruited through snowball sampling and all par- Data Collection and Analysis ticipants consented for the lead researcher (HK) to facilitate the interview. Interviews lasted an average of 45 min with Data collection involved online semi-structured audio- a range of 31 and 71 min. Two themes inductively emerged recorded interviews using the Microsoft Teams platform from the data; theme one is associated with the impact of in July and August 2021. An online platform was selected the post registration qualification on patient care, and theme to avoid face to face contact with frontline nurses due to two related to the impact on clinical practice. the Covid-19 pandemic. Interviews were planned to last approximately 60  min. Electronic informed consent was Themes obtained prior to the commencement of the interview after addressing any questions. Interviews were facilitated by the Theme One: Impact on Patient Care lead researcher (HK). To minimise any potential conflict of interest, participants were also given the option of inter- Theme one relates to the impact of the Specialist Practice views being completed by a co-researcher (OMcS), as the qualification on patient care with five subthemes identified: lead author was the Pathway Lead for the programme, for development of clinically relevant knowledge; enhanced cohorts completing after 2019. Following a scoping review awareness of the holistic impact of cancer; greater under- of the literature, the interview schedule was co-produced standing of patient services available; development of clini- with the research team and a previous student. Braun and cal networks; and greater decision-making ability. Clarkes six staged framework was used for data analysis [17]. A descriptive thematic analysis was adopted. The Development of Clinically Relevant Knowledge All partici- NVIVO computer package assisted in the organisation and pants reported a development in their clinical knowledge. coding of data. Independent blind analysis was completed This included, but was not limited to, the range and detail Table 1 Descriptive data Years qualified Four to 23 years Years working in cancer care Four to 20 years Current role Clinical Nurse Specialist × 6 Oncology Nurse Practitioner × 1 Clinical educator × 1 Cancer clinical trials × 1 Acute Oncology and Haematology Service × 1 Outpatient setting × 1 Years working in current role Four months to six years Year completed Specialist Practice qualification 2014 × 2 2019 × 3 2020 × 5 2021 × 1 1 3 Journal of Cancer Education of cancer treatments available and symptom management. ‘I’m able to navigate now, and it really informed me of the role of all the CNSs and what their job consisted This new knowledge was reported to enhance patient care by providing a concrete evidence-base to support patients with of, because sometimes you get zoned in, in the role that you are doing, and you don’t understand maybe what information on the effects and potential side effects of cancer treatments, and a greater capacity to assess and manage dis- everybody else is doing.’ (04). ease and treatment related symptoms, leading to a reported Development of Clinical Networks Participants shared the increase in the nurses’ level of competence and confidence. education programme contributed to developing important networks which led to a more streamlined and time efficient ‘… it has given me a lot more knowledge and insight approach when referring patients and their carers to other into even just cancer and treatments and symptoms. services. These networks were developed with peer students And it just gave me that more in depth knowledge that in clinical roles throughout NI, and through meeting other I wouldn’t have had, and hadn’t necessarily already practitioners while on clinical placements. got in my job. And then obviously the more I know, the ‘…it allows you to meet people and to create those more information I can give to my patient.’ (07). links and to actually know the other CNSs in other areas.’ (07). As the participant’s knowledge developed, their com- petence was enhanced leading to their sense of confidence Greater Decision‑making Ability Participants reported their growing in providing patient care. Nurses reported they ability to critically think in practice was enhanced which were more confident in communicating with multidiscipli- led to a greater capacity to make evidence-based complex nary team members and their sense of self-efficacy grew in decisions related to patient care. advocating for patients. ‘You are critically thinking about things all the time. ‘…If maybe medical staff have wanted to do some- You are applying your knowledge base from what you thing and I don’t really think it’s the best thing for the learned…I think the critical thinking before you do patient, I would certainly have the confidence … not things, and thinking, why am I doing this? (11). to challenge them in a bad way, but just to say, would you think…we might be able to do it this way? Or the rationale for maybe doing it this way.’ (05). Theme Two: Impact on Clinical Practice Enhanced Awareness of the Holistic Impact of Cancer The Increased Professional Credibility Theme two focused on the nurse’s ability to assess and provide holistic care was enhanced as a result of the education programme. Content impact of the education programme on clinical practice. Par- ticipants shared the qualification increased their professional on the holistic impact of a cancer diagnosis and person-cen- tred care was provided by services users in the education credibility within the multi-disciplinary team as it provided evidence that they had the knowledge and skills required to programme, and supplemented by academics and clinically based healthcare professionals, which enhanced the nurse’s occupy an Advanced Practice Nurse role. ability to more accurately empathise with patients and appre- ciate the holistic and individual impact of a cancer diagnosis. ‘It’s …like a rite of passage…It’s like, I’ve done it. ‘…that really helped give you insight into understand- I’ve done specialist practice. I feel worthy to be here ing their [patient] journey and I think then you are now…’ (09). able to care for them better as a result.’ (05). ‘I feel confident and able to call myself a Clinical Nurse Specialist and know that, yes, that is what I am, ‘If you can holistically assess your patient, and I think the modules certainly help you to think more holisti- and I have done everything that I need to do, to achieve that, and to be called that..’ (07). cally, and if you are looking at your patient from more of a holistic perspective, I think the patient care is defi- This enhanced sense of professional credibility increased nitely enhanced’ (11). their professional and personal confidence as they had dem- Greater Understanding of Patient Services Available Par- onstrated resilience to overcome the academic and time chal- ticipants shared they were more informed of the range of lenges to complete the education programme. statutory and non-statutory services available which was ‘[There is] value added for the organisation itself as shared with patients and their carers, enhancing the quality being a nurse with a specialist practice qualification, of care provided. These insights were also provided through but also the value that it had on me as a person, is the clinical placement component. me being able to grow and develop as a person, and 1 3 Journal of Cancer Education improve my confidence and my competence and being state that specialist practice nurses should exercise higher able to be a safe and effective practitioner.’ (08). levels of discretion, judgement and decision-making [7]. These ‘higher levels’ required for safe and effective patient care, involve critiquing skills and corroborate their impor- Discussion tance in education programmes. This study demonstrates the transferability value of critiquing skills beyond the edu- Two themes emerged from the data associated with the cational environment, into the clinical setting in improving impact of the post-registration nurse education programme, patient outcomes. These specific insights crystallise how which related to the impact on patient care and clinical learning from education programmes seamlessly translates practice. Theme one demonstrated that nurses reported into improvements in patient care and clinical practice and there were improvements in patient outcomes as a result should be of interest to educators developing and delivering of the education programme for registered nurses working education programmes to healthcare professionals in cancer in cancer services related to five key areas, highlighting services. The second theme related to the impact of the edu- the mechanisms of how the education programme was of cation programme on clinical practice with nurses reporting value in improving patient care. Education programmes in a greater sense of validation in the role they occupied, often HEIs are revalidated approximately every 5 years, provid- Advanced Practice Nurse roles. This was borne out with ing an opportunity to review and update content to ensure reports of improved competence in their clinical role and it aligns to current evidence-based practice, research and enhanced confidence in advocating for patients. This is in policy. One relevant example in this education programme keeping with results from a research study which reported is the European Oncology Nursing Society (EONS) Educa- a cancer education course improved nurses’ confidence in tion Framework which also outlines that specialist cancer caring for patients, highlighting the far-reaching benefits of nursing programmes provide added value in terms of patient education, beyond knowledge development [20]. The impact outcomes [19]. The revalidation process involves represen- of education programmes on registered nurses in cancer tation from patients, carers, students, educationalists, ser- services is currently an understudied area in comparison to vice providers and researchers. If the revalidation process is numerous studies published on the impact of education on robust and rigorous, with effective teaching methodologies undergraduate nursing students. employed, then findings related to theme one are not unex- pected with regards a development in the student’s knowl- Limitations and Strengths edge, enhanced awareness of the holistic impact of cancer, and a greater understanding of patient services available, as One of the limitations of this study related to data collection these relate specifically to the module and programme learn- being undertaken in two HSCTs in the context of NI so there ing outcomes for this education programme. These findings should be caution in the transferability of these findings. To align to results from a quasi-experimental research study support transferability, demographic data has been provided. which reported an increase in registered nurses knowledge The strength of this study was the in-depth exploration of the and perceived skills in the psychosocial care of individuals components of educational programmes which specifically with cancer, following engagement in a cancer education impact patient care and clinical practice in cancer services. programme [20]. However, in returning our attention to the These insights will support educationalists to develop aims, findings in this research, what was interesting were reports learning outcomes, and module content to best support stu- that patient care was enhanced by the development of clini- dents who are healthcare professionals, to improve patient cal networks with other nurses on the education programme, outcomes. and through contacts initiated in clinical placements. These To conclude, SET’s are routinely completed throughout, new insights identify how education programmes meet and at the completion of modules and education programmes additional outcomes not included in programme and mod- at HEI’s, which should be used to not only evaluate teach- ule aims and learning outcomes, which in this study, were ing, but improve teaching [12]. For education programmes attributed to improving patient outcomes. Furthermore, this with students as healthcare professionals, the ultimate aim study reported that nurse’s ability to think critically in the of these education programmes are often to improve patient clinical setting was developed as a result of the education outcomes. Despite this, this data is not routinely captured in programme, which enhanced their decision-making ability HEI SETs. This seems an important omission. If this data related to improving patient care. The association between is gathered, it will shape the content and delivery of edu- critical thinking and improved decision-making in clinical cational programmes to ensure they are fit for purpose. The practice has been established [21]. Criticality is often associ- rationale for this research was to capture this data retrospec- ated as an academic writing skill; however, it is also a funda- tively, however, this approach would not be feasible to glob- mental component of the advanced nurse’s role as the NMC ally implement in HEI’s due to the time required to secure 1 3 Journal of Cancer Education 5. Kerr H, Donovan M, McSorley O (2021) Evaluation of the role ethical and research governance approvals. Consequently, of the clinical Nurse Specialist in cancer care: an integrative lit- we recommend that educationalists review question items in erature review. Eur J Cancer Care 30(3):1–13 module and programme SET to ensure there is a focus on the 6. Jeyarajah S, Adams KJ, Higgins L et al (2009) Prospective evaluation of impact of education programmes on patient care and clinical a colorectal cancer nurse follow-up clinic. Colorectal Dis 13:31–38 7. Nursing and Midwifery Council (2001) Standards for specialist practice, rather than the narrower focus on the educational education and practice. NMC, London experience. Whilst the data collected is often through a ques- 8. Hamric AB, Tracy MG (2019) A definition of advanced practice tionnaire and limited to one point in time, it will still capture nursing. In: Tracy MF, O’Grady ET (eds) Hamric and Hanson’s useful insights into the present and anticipated outcomes advanced practice nursing: an integrative approach, 6th edn. Else- vier, Missouri, pp 202–251 in applying learning to practice, focusing on the impact on 9. Department of Health (2018) Career framework for specialist patient care and clinical practice. This data could be supple- nursing roles. Belfast: DoH mented with discussions with students to capture the appli- 10. Hoel A, Dahl TI (2019) Why bother? Student motivation to participate in cation of learning to practice. The debate on how to capture student evaluations of teaching. Assess Eval High Educ 44(3):361–378 11. Gordon H, Stevenson E, Bookhart A et al (2018) Grade incentive the impact of education on patient care in cancer care, should to boost course evaluation International. J Nurs Educ 18(1):1–5 consider how to routinely capture this data, as this must be a 12. Golding C, Adam L (2016) Evaluate to improve: useful approaches more accurate measurement of learning. to student evaluation. Assess Eval High Educ 41(1):1–14 13. Wiley C (2010) Standarised module evaluation surveys in UK Acknowledgements Thank you to the study participants for their time higher education: establishing students’ perspective. Available as they were frontline nursing staff providing care over the Covid19 at: https:// s3. eu- centr al-1. amazo naws. com/ eu- st01. ext. exlib risgr pandemic. oup. com/ 44SUR_ INST/ s t or a g e/ alma/ EB/ CF/ 90/ 4C/ 20/ 99/ 1B/ 04/ 11/ 48/ 76/ 98/ 47/ 85/ 8D/ 8A/ Wiley% 2C% 20Chr istop her% 20% 282019% 29.% 20Sta ndard ised% 20mod ule% 20eva luati on% 20sur Author Contribution All authors contributed to the study conception ve y s% 20in% 20UK% 20hig her% 20edu cation% 20-% 20Es t ablis and design. Data analysis were performed by Helen Kerr, Oonagh hing% 20s tu dents% E2% 80% 99% 20per spect ives. pdf? r espo nse- McSorley and Monica Donovan. The first draft of the manuscript was conte nt- type= appli cation% 2Fpdf &X- Amz- Algor ithm= AWS4- written by Helen Kerr and all authors commented on versions of the HMAC- SHA25 6&X- Amz- Date= 20220 511T0 85138 Z&X- Amz- manuscript. All authors approved the final manuscript. Signe dHead ers= hos t&X- Amz- Expir es= 119&X- Amz- Cr ede ntial=AKIAJ N6NPM N GJALPPW AQ%2F202 20511% 2F eu-centr Funding Burdett Trust for Nursing. al-1% 2Fs3% 2F aws4_ r eq ue s t&X - Amz- Signa tur e= 0a6f3 ab736 dfb2954927 eeeb4 45235 d29e3 def38 6d10c aec7c da9f7 3888b b866 Declarations Accessed: 9 May 2022 14. Illing J, Corbett S, Kehoe A et al (2018) How does the education and training of health and social care staff transfer to practice Ethics Approval Ethical approval was secured at the university (code: and benefit patients? A realist approach. Final report. Available HKerr.SREC_May19_V). Research governance approval was secured at: https:// eprin ts. ncl. ac. uk/ file_ store/ produ ction/ 250597/ 0918B at the two HSCTs (code: 269931). E55-648C- 439F -8706- 49932 29060 59. pdf . Accessed 7 Aug 2022 15. Neubauer BE, Witkop CT, Varplo L (2019) How phenomenology can Conflict of Interest The authors declare no competing interests. help us learn from the experiences of others. Perspect Med Ed 8:90–97 16. Rodriguez A, Smith J (2018) Phenomenology as a healthcare Open Access This article is licensed under a Creative Commons Attri- research method. Evid Based Nurs 21(4):96–98 bution 4.0 International License, which permits use, sharing, adapta- 17. Braun V, Clarke V (2006) Using thematic analysis in psychology. tion, distribution and reproduction in any medium or format, as long Qual Res Psychol 3:77–101 as you give appropriate credit to the original author(s) and the source, 18. Beauchamp TL, Childress JF (2001) Principles of Biomedical provide a link to the Creative Commons licence, and indicate if changes Ethics, 6th edn. Oxford University Press, London were made. The images or other third party material in this article are 19. European Oncology Nursing Society (2018) The European Oncol- included in the article's Creative Commons licence, unless indicated ogy Nursing Society Cancer Nursing Education Framework. otherwise in a credit line to the material. If material is not included in Available at: https://z2y .621. m yftpupload. com/ wp- conte nt/ uploa the article's Creative Commons licence and your intended use is not ds/ 2020/ 05/ EONSC ancer Nursi ngFra mewor k2018-1. pdf? time= permitted by statutory regulation or exceeds the permitted use, you will 16021 63080. Accessed 7 Aug 2022 need to obtain permission directly from the copyright holder. To view a 20. Steginga SK, Dunn J, Dewar AM et al (2005) Impact of an inten- copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . sive nursing education course on nurses’ knowledge, confidence, attitudes and perceived skills in the care of patients with cancer. Oncol Nurs Forum 32(2):375–381 21. Heidari M, Ebrahimi P (2016) Examining the relationship between References critical thinking skills and decision-making ability of emergency medicine students Indian. J Crit Care Med 20(10):581–586 1. International Council of Nurses (2020) Guidelines on advanced practice nursing. Switzerland: ICN Publisher's Note Springer Nature remains neutral with regard to 2. Dowling M, Beauchesne M, Farrell F et al (2012) Advanced prac- jurisdictional claims in published maps and institutional affiliations. tice nursing: a concept analysis. Int J Nurs Pract 19:131–140 3. Sheer B, Wong FKY (2008) The development of advanced nursing practice globally. J Nurs Scholarsh 40(3):204–211 4. Heale R, Buckley C (2015) An international perspective of advanced practice nursing regulation. Int Nurs Rev 62:421–429 1 3

Journal

Journal of Cancer EducationSpringer Journals

Published: Aug 8, 2022

Keywords: Nursing; Cancer education; Post-registration education; Impact on patient care

References