EONS NEwsletter Fall 2008

Theme:

Education

eons newsletter

Fall 2008

Editor in Chief: Jan Foubert, RN, MSc Communications team: Carol Krcmar, RN, MN Emile Maassen, RN, CRN Cath Miller, MA, RGN Dip Hsm The aim of the EONS newsletter is to provide a written resource for European nurses working in a cancer setting. The content of the articles are intended to contribute to the growing body of knowledge concerning cancer care.

All correspondence should be addressedto the Editor-in-Chief eons@ secretariat@skynet.nl EONS Secretariat: Rudi Briké Avenue E Mounier 83/4B-1200 Brussels, Belgium Tel: + 32 (2) 779 9923 Fax: + 32 (2) 779 9937 E-mail: eons.secretariat@skynet.be Website: www.cancereurope.org/EONS.html EONS acknowledges Amgen, AstraZeneca, Merck, Mundipharma, Novartis, Roche, Sanofi Aventis and Topotarget for their continued support of the Society as Sustaining Members.

Print run: 6500 copies Electronic version accessible to 24000 EONS members Printed by: Drukkerij Trioprint Nijmegen Bv The Netherlands Disclaimer The views expressed herein are those of the authors and do not necessarily reflect the views of the European Oncology Nursing Society. The agency/ company represented in advertisements is solely responsible for the accuracy of information presented in that advertisement.

The European Oncology NursingAssociation (EONS) does not accept responsibility for the accuracy of any translated materials contained within this edition of the EONS Newsletter.

Comments about the Italian version of the EONS Newsletter should be addressedto the Associazione Italiana Infermieri diOncologia (AIIO) by emailing info.aiio@ libero.it

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Letter from the Editor

Dear Colleagues, On the 2nd of June 2008, EONS organised the Modernising Cancer Nursing Education event in Brussels. The aim of this training day was to provide an opportunity for cancer nurse educators to received updated information on cancer-related developments within the EU, information on issues related to the Bologna agreement and an opportunity to share experiences on how these developments impact on the provision of future nurse education.

In total, 35 participants from nine countries attended this event. Participants were pleased with the information provided during the conference and they felt that the presentations were well balanced and supported with adequate evidence. At future conferences, participants would like more practical information on the Bologna Agreement and more time to discuss the practicalities of implementing a core curriculum in different countries. Because most speakers came from the UK, participants suggested a more “European flavour” to future presentations. Further, they recommended more time for discussion in small groups, fewer speakers, more focus on cancer, and a consensus session on the key issues in cancer education.

In this newsletter you will find articles from the speakers at this event. The articles cover different aspects of education including development of education, mentoring and personal development, learning outcomes and competencies, skills development, and e-learning.

Education is one of the core business elements of EONS. The TITAN and TARGET courses and the EONS accreditation program are three of the most successful educational programs developed

by EONS to date. More on EONS e-learning opportunities can be found by exploring the www. eonsconnect.com website.

There has been a lot written about education; why it is important, what it does or doesn’t do, who should provide education and who should benefit from it. I found some interesting quotes related to education which I’d like to share with you: • The central task of education is to implant a will and facility for learning; it should produce not learned but learning people. The truly human society is a learning society, where grandparents, parents, and children are students together. Eric Hoffer • No one has yet realized the wealth of sympathy, the kindness and generosity hidden in the soul of a child. The effort of every true education should be to unlock that treasure. Emma Goldman • The only purpose of education is to teach a student how to live his life by developing his mind and equipping him to deal with reality. The training he needs is theoretical, i.e., conceptual.

He has to be taught to think, to understand,

to integrate, to prove. He has to be taught the essentials of the knowledge discovered in the past and he has to be equipped to acquire further knowledge by his own effort. Ayn Rand • The aim of education should be to teach us rather how to think, than what to think, rather to improve our minds, so as to enable us to think for ourselves, than to load the memory with the thoughts of other men. Bill Beattie • The one real object of education is to leave a man in the condition of continually asking questions.

Bishop Creighton These quotations demonstrate the diversity of beliefs about the purpose of education. How would you complete the statement, “The purpose of education is...”? If you ask five of your fellow nurses to complete that sentence, it is likely that you’ll have five different statements. Some will place the focus on knowledge, some on the teacher, and others on the student. Yet peoples’ beliefs in the purpose of education lie at the heart of their teaching behaviours.

Perhaps it is time for the focus of education to shift from what’s “out there” - meaning curriculum, assessments, classroom arrangement, books, computers - to the fundamental assumptions about and definitions of education held by educators and policymakers.

We at EONS believe that education is important.

Hence, I hope that this issue of the EONS Newsletter will provide you with information which will generate new ideas, new challenges, provide you with renewed energy and motivation and . . .

Jan Foubert, Editor in Chief

Countries represented at the Modernising Cancer Nursing Education event in Brussels Country Number of participants Belgium 11 Finland 1 Germany 3 Iceland 1 Italy 1 Portugal 2 Spain 1 Turkey 1 UK 14 Total 35

Our colleagues from...

Estonia

Anu Saag, President of the Estonian Oncology Nursing Society; Siiri Telling, Vice-president of the Estonian Oncology Nursing Society History The Estonian Oncology Nursing Society is the successor of the nursing section of the Estonian Cancer Society (founded in 1992) and became a free-standing organization in 1996.

Last year we celebrated the 15th anniversary of our society.

Goals The goal of the Oncology Nursing Society is to ensure consistent development of oncology nursing and thereby enhance the quality of nursing care offered to the patient and his family.

To achieve this goal the Society: • Plans and conducts training courses and seminars for health care professionals who deal with cancer patients; • Develops cooperation and exchange of information between members; • Develops the web page of the society; • Motivates nurses to actively take part in the activities of the society; • Introduces the work of oncology nurses and training possibilities to novice nurses; • Promotes participation of nurses in international conferences on oncology; • Co-operates with various professional nursing organizations and similar organizations in other countries.

Organizational Structure The central board consists of five members and the expanded board consists of seven members. The board governs the activities of the Society and nurses working in all different fields of oncology are represented on the board.

We currently have 130 oncology nurses from the oncology departments in Tartu and Tallinn and nurses from other specialities who are members of our society. By becoming members, these nurses have signaled that they would like to further develop their knowledge in the treatment and nursing care of cancer patients.

Membership Benefits One of the benefits of membership is access to our web site which provides members with timely and continual delivery of information.

Our web site, www.eons.ee, was created in May 2007. With the introduction of the web site, we also introduced a new logo. The symbols yin and yang were chosen as a part of the logo.

Activities The organization of our annual spring conference is a major activity of the Society. This event is attended by most of our members and is open to nurses working in other fields.

One part of every spring conference is the general meeting during which the board summarizes the activities of the previous year and introduces plans for the upcoming year.

Following the launch of the web site, we issued the schedule of training programs which were to take place during 2007/2008.

Following is a list of these programs: • The 2nd Autumn Seminar of Oncology Nurses; • A 2-day course for surgical oncology nurses; • A teaching programme on adverse effects of chemotherapy, protective isolation, and improper hand hygiene for oncology department personnel; • A training course on bleeding disorders (the fourth course on this topic); • Training courses on psychology and non-Hodgkin’s lymphoma; • A 3-day course on chemotherapy, accredited by EONS; • The 10th annual spring conference.

Because members of the Estonia ONS work in different oncology settings (hematology-oncology, bone marrow transplantation, surgical oncology, and radiation therapy and home care) we plan our educational courses with the diverse needs of these nurses in mind.

Collaboration with other Societies We actively cooperate with various organizations involved in general nursing as well as oncology nursing. These include the Estonian Nurses Union, the Estonian Cancer Society and, at the European level, EBMT. Our relationship with EBMT has been close over the years and they have provided us with practical and theoretical advice.

Relationship with the European Oncology Nursing Society In association with EONS, the Estonian ONS has organized several educational courses for oncology nurses. We have been a member of EONS since 1994. Some of the events we have collaborated on with EONS include: • Training courses on oncology nursing which began as early as 1994; • Palliative care training with physicians in association with ESMO, EONS and ONS; • Educational courses on chemotherapy which were accredited by EONS. The 4th Baltic Oncology Congress took place in Tartu in 2006 which included a programme for nurses. Steve O’Connor from EONS attended the congress as a guest. The feedback on the nursing program was very good, especially from Lithuanian and Latvian colleagues. Steve also stated that he obtained a good overview on the activities of oncology nursing in the Baltic States through his attendance.

In association with EONS we have conducted 2 TITAN-training courses and one TARGET-training course. Jan Foubert from EONS attended one of the TITAN courses and his presence was inspiring to the participants.

Future Directions In the future we would like to give more importance to the following topics: • Developing and conducting nursing research and implementing results into practice; • Providing professional training for oncology nurses and further developing the specialty of cancer nursing; • Providing translation of scientific literature and guidelines which have been developed by EONS.

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From learning outcomes to competencies

What are they and do they reflect practice?

Professor Annie Topping, Director - Centre for Health & Social Care Research, University of Huddersfield, Huddersfield, UK Introduction Learning outcomes have come to represent the building blocks of curriculum in contemporary higher education in many western countries. Learning outcomes, and other outcomes based approaches such as competency frameworks, have wide ranging implications for the design of curriculum, learning, teaching and assessment strategies, quality assurance including comparability and harmonisation of qualifications across institutions and national borders. Debate about competence, competency and competencies has been rumbling in the health professions for decades. Some commentators suggest it has regained centre stage in response to criticisms from employers, regulators and the public. Indeed in the UK competency frameworks are commonly used in health care and applied to evidence organisational as well as individual performance.

One of the more recent criticisms of health professional education, and in particular of nursing, is that too much importance has been placed on the acquisition of knowledge and theory to the neglect of performance. This has particularly significance when set against a health care industry undergoing enormous change. The penetration of independent providers of health care into social medicine systems such as the UK National Health System; the impact, and often confounding, influences of evidence based medicine, technology and performance management on care delivery; and an increasing mobile global health care workforce places ever greater necessity on a common understanding, if not currency, of qualifications. Similar economic and technological drivers have impacted on education providers and in part the learning outcomes process can be seen as an attempt to exert control on curriculum design and delivery in order to assure the nature and quality of the product from higher education institutions. This inevitably exerts a number of tensions both at a philosophical level and managing the quality control and surveillance required to ensure concordance. Learning outcomes and competency frameworks are therefore now viewed as the building blocks of transparent systems and processes, not just for individual educational institutions providing modules and programmes, or health care providers but they are also fundamental at national and international levels (Adam 2004, Cowan et al 2005, EONS 2005).

Learning Outcomes Learning outcomes have their theoretical origins in behaviourism.

This set of theories places emphasis on the identification and measurement of learning and education as a process with observable and measurable outcomes. In order to establish what has been learnt, the boundaries of learning need to be clearly charted. Learning outcomes, which are written statements that summarise what the learner will be able to understand, know, and, or demonstrate following a period of learning, become significant. As long ago as 1956, Bloom developed a taxonomy, a language of education, that offers a common glossary and offers consistency for how learning can be expressed. This classification of terms enables discrimination between the different levels or complexity of learning (see Box 1).

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Box 1: Bloom’s Taxonomy • Knowledge: Recall relevant information • Comprehension: Explain salient information • Application: Solve closed-ended problems • Analysis: Solve open-ended problems • Synthesis: Create unique solutions to problems • Evaluation: Make critical judgments based on

sound knowledge For example using this taxonomy a learning outcome emphasising knowledge undertaken early in a student’s programme might be expressed as: “At the end of the module the student will be able to describe the normal cell cycle”. The factual nature of the learning required then helps direct the type of assessment that would best judge that learning had occurred. In this case, knowledge could readily be assessed by an unseen examination using multiple choice type questions. Whereas a more complex outcome involving evaluation might be expressed as: “At the end of the module the student would be able to critically appraise clinical problems that emerge in response to cancer treatments and independently devise a plan of care based on evidence based rationale”, and be assessed by an objective structured clinical examination (OSCE). Successful completion of this outcome requires knowledge and understanding but also critical appraisal and decision-making skills. Hence, this complexity needs to reflected in the assessment strategy chosen. In both examples the learning outcomes express the learning and also implicitly guide the module or programme author to devise a suitable assessment strategy to test student achievement of learning.

Fundamental to the use of learning outcomes is that they place the concern of education on to the learner and what they can achieve. This shift of emphasis from input (what teachers teach) to output (what students know and can do) makes learning an active transparent process and education student-centred. Learning outcomes therefore serve as both a guide and a device to enable shared understanding for students and their teachers about what can be expected. They can also be used to inform potential students and employers what they can expect as outcomes of graduates of a course or programme of study.

Learning is not just about acquiring the knowledge or skills of a discipline like cancer nursing it is also about gaining, or extending generic skills such as time management, use of information technology (IT) and multidisciplinary team working. These generic or transferable skills can also be expressed through learning outcomes.

They are seen by students and employers as particularly significant as they have the potential to facilitate workforce flexibility in a working environment that constantly changes. For instance the acquisition of IT skills are vital for the current and future generation of health professionals as the introduction electronic patient records systems become embedded in care delivery. The integration of IT in learning and teaching strategies employed by expecting students to use

electronic databases for literature retrieval, access virtual learning environments for links to additional learning material, and use mobile devices, all contribute to the acquisition of transferable skills for care delivery. Moreover, this enables students on graduation to function more effectively when faced with change like new information systems or technology in the workplace.

Over the last twenty years the use of learning outcomes, as part of an overall outcomes based approach used in education, has become common in the USA, UK, Ireland, Australia, New Zealand and South Africa. The Bologna process has created considerable interest and indeed movement towards adoption of a learning outcomes based processes for programme design in Europe. This whole system approach makes integration of academic and vocational education and training easier. It also aids the development and introduction of accreditation of prior learning, credit transfer and accumulation and lifelong learning frameworks. At an institutional level learning outcomes can be expressed at programme and, or module level and can be used to frame individual units of study such as a lecture or directed learning activity. Learning outcomes also allow comparison across programmes and have the potential to act as an enabler for transparent European harmonisation (Cowan et al 2005, Mallaber and Turner 2006). In parallel competency frameworks have been developed to differentiate between different grades and expectations of staff and better conceptualisation of current and future workforce requirements. Examples of cancer nursing competency frameworks are available via the world wide web (eg. Weatherall 2004, The National Cancer Nursing Education Project [EdCAN] 2008) or for specific competencies (see Consensus Panel on Genetic/Genomic Nursing Competencies 2006; Skills for Health 2008) Competency and competencies For a profession such as nursing the main aim of any programme of preparation for initial or specialist practice is that the learner acquires the necessary skills, knowledge and attitudes to practice; in effect that are competent. Establishing a definition of what is meant by competency or indeed judging that an individual has met the benchmark of competence is a challenge at best and one fraught with controversy (Watson et al 2002). Gonzci (1994) suggests that there are a number of ways of viewing of competency. One approach is to focus solely on the behaviour demonstrated by the individual, a second is to consider the general characteristics demonstrated by an individual that constitute effective performance; and the third is by determining the components that constitute the requirements for the role (competencies) that collectively will constitute competence. All these approaches have their weaknesses. The problem with merely focusing on behaviour is that underpinning knowledge is assumed, yet remains invisible, or by default viewed as unnecessary and possibly undervalued. An attention on general attributes may result in a practitioner failing to have acquired the specific requirements of the role. Whereas reducing the art and science of nursing merely to its component parts may not when reconstituted meet the expectations of public (Calman 2006), employers, statutory and professional regulation (Mallaber and Turner 2006) or indeed the individual. An even greater challenge is the complexity inherent in the measurement (assessment) of competence (Watson et al 2002, Topping et al 2002). Despite these weaknesses competency frameworks have been adopted in the health care sector as a means of assessing capability, judging performance and even used as basis for determining level of remuneration such as the scheme Agenda for Change and Knowledge and Skills Framework adopted in the UK (DH 2004; DH 2007).

Do learning outcomes and competencies reflect practice?

The aim of systems that adopt learning outcomes and/or competencies is that they provide assurances about what a graduating student or employee will know and be able to do. In effect create confidence that practitioners that are produced are fit for purpose and practice and meet the requirements of the academic award. To achieve that aim learning outcomes and competencies adopt the language of objectivity. This gives the impression that judging achievement through the use of such frameworks can be scientific in its precision (Hussy and Smith 2002). Whereas many forms of assessment are anything but precise particularly when demonstration of achievement of a learning outcome or competency in the health sciences requires a complex interplay between the students knowledge, skills and attitudes, the assessors ability to make the judgment, the test or task adequately extracts the evidence and the context is stable to ensure it does not influence the assessment. In effect the reliability and validity, sensitivity and specificity have to be assured. This is made even more complex in practice settings where control of the learning environment is difficult particularly in terms of ensuring consistency. Practice is essentially messy and indeterminate (Schon 1983). There is considerable and growing evidence that a range of factors influence practice assessment not least the failure of assessors to fail students (Duffy 2003) and the small tyrannies such as the personal characteristics of the learner that can influence outcomes. That said the levels of reported errors, adverse incidents and failure to report systematic failings in competency of health care practitioners in health care (European Commission 2005; Pietro et al 2000) creates a real impetus to establish robust approaches for the preparation and continued professional development of current and future generations of practitioners. Hence the enthusiasm for frameworks Education and training for health care professionals may prepare them for the role but it remains only an element of the necessary preparation for expertise. It is now widely acknowledged that education alone will not result in expertise and that novice practitioners require a period of consolidation to realise their skills and knowledge. Exposure and emersion in practice, acts as a catalyst for the transformation and embedding of learning, and after a period of time the development of expertise (Benner 1984, Benner et al 1996, Topping et al 2002). A feature of practice emersion is that the learner gains familiarity with the unique features, and cultural nuances, of the particular specialism. However a particular concern

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for educators is that availability of suitable quality clinical learning placements are becoming less available and funding for clinical educators to support students in practise is often limited if available at all. Clinical skills laboratories have emerged as an alternative as they provide a stable learning context to reproduce clinical practice and assist in skill development. .

Repeated execution of a procedure in order to develop and maintain competency is a feature of industries such as aviation where error minimisation is paramount (Armitage and Knapman 2003). Indeed case volume is often used as a criteria for judging the suitability of a clinical learning environment in health professional education.

Utilising approaches that seek to replicate the real world of healthcare are also increasingly used to accelerate familiarity with situations or typical cases through the use of simulated learning. The evidence is mounting concerning the benefits of simulation especially the impact on the confidence of novice practitioners in practice (Moule et al 2008). Confidence without knowledge or skill would be a concern but the elegance of simulation is that many of the features of practise can be introduced but the focus remains on the learning not just getting the task done. That said simulation can never replace the benefits of experiential learning in practise.

This aim of this paper was to explore whether frameworks that adopt learning outcomes or competencies make a difference in practice.

The benefits of articulating what a practitioner should know and be able to do seem clear even if the complexity of robust evaluation in the messy real world of health care is elusive. A separate but linked question is whether the use of instruments, or tools, to assess specific elements of learning or performance have benefit? Further, when all outcomes (or assessments) are aggregated the result constitutes competency of the individual clinician. In response…. assuring the reliability and validity of assessment in outcome based education so patients, employers, regulatory bodies and the individual practitioner can be confident of competence remains a challenge but hopefully one that is not insurmountable in the future.

References Adam S (2004) A consideration of the nature, role, application and implications for European education of employing ’learning outcomes’ at the local, national and international levels Scottish Executive ISBN 0 7559 1058 3 (available for download from: http://www.scotland. gov.uk/Publications/2004/09/19908/42711 accessed 25/05/08) Armitage G & Knapman H. (2003) Adverse events in drug administration: a literature review. Journal of Nursing Management 11 130-140 Benner P (1984) From Novice to Expert Menlo Park. CA: AddisonWesley Benner P, Tanner C A, Chesla C A (1996) Expertise in nursing practice New York. NY Springer Publishing Company Bloom B S (1956) Taxonomy of Educational Objectives: The Classification of Educational Goals: Handbook 1: Cognitive Domain New York: Longman Calman L (2006) Patients’ views of nurses’ competence Nurse Education Today 26 8 719-725 Consensus Panel on Genetic/Genomic Nursing Competencies (2006). Essential Nursing Competencies and Curricula Guidelines for Genetics and Genomics. Silver Spring, MD: American Nurses Association.

Download from http://www.genome.gov/Pages/Careers/ HealthProfessionalEducation/geneticscompetency.pdf (accessed 24.08.08)

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Cowan D T , Norman I J , Coopamah VP (2005) A Project to establish a skills competency matrix for EU nurses British Journal of Nursing 14 (11) 613-617, Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process (October 2004) available for downloadhttp:// www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4090843 (accessed 24.08.08) Department of Heath (2007) Agenda for Change (Resource Pack) download from http://www.dh.gov.uk/en/ Managingyourorganisation/Humanresourcesandtraining/ Modernisingpay/Agendaforchange/DH_4112440 (accessed 24.08.08) Duffy K (2003) Failing students: a qualitative study of the factors that influence the decisions regarding assessment of students competence in practice London Nurse Midwifery Council (Download: http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=1330 ) (accessed 24.08.08) European Commission (2005) Luxembourg Declaration on Patient Safety (see download http://ec.europa.eu/health/ph_overview/ Documents/ev_20050405_rd01_en.pdf (accessed 24.08.08) European Oncology Nursing Society (2005) EONS Post-basic Curriculum in Cancer Nursing 2005 (3rd Edition) Brussels EONS download from: http://www.cancerworld.org/CancerWorld/ getStaticModFile.aspx?id=902 [accessed 24.08.08] Gonzci A (1994) Competency based assessment in the professions in Australia Assessment in Education 1 27-44 Hussey T and Smith P (2002) The trouble with learning outcomes Active Learning in Higher Education 3 (3) 220-233 Mallaber C & Turner P (2006) Competency versus hours: An examination of a current dilemma in nurse education Nurse Education Today 26 2 110-114 Moule P, Wilford A, Sales R, Lockyer L (2008) Student experiences and mentor views of the use of simulation for learning Nurse Education Today 28 (7) 790-797 National Cancer Nursing Education Project [EdCAN] (2008) National Education Framework – Cancer Nursing: A national professional development framework for cancer nursing Cancer Australia Canberra (Download from http://www.edcan.org/pdf/ EdCanFramework1-6.pdf (accessed 24.08.08) Pietro, D A Shyavitz, LJ Smith R A and Auerbach S (2000) Detecting and reporting medical errors: why the dilemma? British Medical Journal ;320;794-796 doi:10.1136/bmj.320.7237.794 Schon D (1983) The Reflective Practitioner: How professionals think in action New York: NY Basic Books Skills for Health (2008) Chemotherapy Framework http://tools. skillsforhealth.org.uk/competence/searchResults?keywords=Chem otherapy&framework%5B%5D=21&level%5B%5D=1&level%5B%5D=2& level%5B%5D=3&level%5B%5D=4&adv_search.x=36&adv_search.y=7 (accessed 24.08.08) Topping A, Porock D, Watson R & Stimpson A (2002) Evaluation of the effectiveness of educational prepration for cancer nursing and palliative care. Report to ENB/Department of Health. London Watson R, Stimpson A, Porock D and Topping A (2002) Clinical competence assessment in nursing: a systematic review of the literature Journal of Advanced Nursing 39 5 421-431 Weatherall A (2004) National Care Competency http://www.city. ac.uk/sonm/dps/pre-reg-curriculum/references_usefuldocs/ KSF%20Cancer%20Competencies.pdf (accessed 24.08.08)

Dungeons and dragons

Exploring the EU policy context of cancer nursing

Sara Faithfull, EONS president Over the summer I have been working with an Erasmus student from Germany who has been visiting the UK & Belgium as part of a 3 month educational exchange to EONS as an Erasmus graduate apprentice from Saarland University. It has been an enlightening experience as we have both explored the “dungeons and dragons” of EU policy. I have marvelled at the bravery of my colleague of leaving family and friends, going overseas and living in another culture. Although a novel experience and one that widens horizons and challenges beliefs it is still scary. Differences in culture and health roles are much more than just in what people are called or what nurses are able to undertake in terms of nursing practice. It makes one examine what we also believe about Europe and multidisciplinary working. Learning the living language (i.e. the slang or colloquial talk) eating new foods and understanding different health systems is part of learning from that experience. Despite all these wider experiences our Erasmus/ EONS project is to map the policy context of cancer specialist nursing and identify how far national member states have met or undertaken change as response to these EU directives. It has been so far a journey of discovery.

Our first step has been exploring the dungeons of EU policy. Let me explain going back to EU cancer policy basics.

The Commission of the European Communities (CEC) Europe against cancer (EAC) programme identified the need for effective education and training in its first action in 1987. This was reaffirmed in the second action plan 1990-94. The commission recognised the vital role of the different health professionals both in prevention and early diagnosis of cancer and encouraged undergraduate and postgraduate training on screening methods, counselling appropriate methods of treatment, rehabilitation and terminal care (EU 1997). The third action plan 1996-2000 consolidated this and encouraged new training initiatives such as the inclusion of psychosocial care. However it should be remembered that at that time that nursing was and still is largely a non graduate profession in many countries and that these recommendations reflect exchanges within centres of excellence and development of training networks. These networks have largely not been accessed by nurses.

Later policy reflects discussion papers in relation to areas of need such as cancer care in the Baltic member states or specific tumour groups such as cervical screening. They also reflect a predominantly preventative strategy. Layered on top of this EU level are the World Health and global propositions providing a complex maze of guidance and policy. Furthermore, local and national initiatives need to be considered at the level of cancer plans and cancer health service provision. No wonder few of us understand the EU policy context for cancer provision let alone in support of cancer nursing!

The dungeons of the game are that much of EU policy is in the form of recommendations i.e. providing guidance to member states rather than binding. Policy is like a maze in that there are several forms of advice from white and green papers providing discussion

to that of directives becoming legally binding at a national level.

Deciphering these levels is important in realising the power of such statements in making or directing change and then finding if any part relates to the provision of specialist cancer nursing. This is like exploring the dungeon without a light! Visiting EU policy experts and talking with those developing new EU cross border policy has been insightful. However, I can tell you so far we have found that cancer nursing is mainly invisible at a policy context.

The focus on prevention and cure leaves little discussion about health care packages, communication skills, symptom management or supportive care. Nursing is neither defined nor appraised as part of prevention or treatment provision. We now come to our dragons “multidisciplinary care”. What this means in EU speak is the breadth of medical provision from surgeons to oncologists and not encompassing nurses or health care providers. Even the recent Slovenian document, challenging the future burden of cancer care (2008) had chapters written by clinicians, patients and psychologists but not a nurse amongst them when considering the provision of future care. Where are the nurses and why can’t they be seen?

Partly I think this relates to the valuing (or lack of value) of specialist cancer nurses in many countries within Europe, but also the paucity of firm outcome evidence that specialist cancer nursing provides benefits for patients. Where such evidence exists for example in breast care then nurses are visible within policy guidance. However nurses are largely seen as a supporting roles rather than professionals in their own right. You may feel offended by this take on why nursing is invisible but how many of us have lobbied politicians for nursing issues, written in to policy statements or involved ourselves at national policy level. To get out of the so called dungeon we need to respond to policy statements, develop our evidence that specialist cancer nursing maters and provide the leadership to make nursing count. Start by responding to the UICC world cancer declaration 2008 (www.uicc.org) and make this a call for action.

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Lifelong Learning

Mentoring and Personal Development Planning in Health Care

Alison Rhodes, Director of Studies – Learning and Teaching Framework, Faculty of Health and Medical Sciences, Division of Health and Social Care, University of Surrey, Guildford, Surrey I was delighted to be asked to make a presentation at the EONS educational event earlier this year, on topics that are my passion – mentorship and development.

My motivation in these areas began some 20 years ago whilst working as an Intensive Care Unit Sister, where pre-registration and post registration students were placed to gain clinical experience.

Through this time, I found myself experimenting with creative ways to not only develop the student’s knowledge and understanding but to also support them to not be fearful of such a high technological environment. It seemed so natural to facilitate development through mentorship, and in fact, my mentorship role was and still is an exciting challenge and one that continues today. My enthusiasm for these concepts led to my research in development and personal development planning (PDP), where I became interested in the concept of the Learning Organisation and the provision of support within the workplace for learning and development.

My learning journey has culminated in my role as Director of Studies for the Learning and Teaching framework, which caters for the preparation of mentors, practice teachers and qualified teachers at both undergraduate and postgraduate levels. In developing the framework, a curriculum was designed based on the Nursing and Midwifery Council’s (NMC) Standards (2006) which highlighted areas of responsibility and accountability through four stages (figure 1), relating to supporting learning and assessment in practice.

Figure 1 – Stages identified within the standards (NMC 2006, Standards to Support Learning and Assessment in Practice [updated 2008]) STAGE 1 STAGE 2 STAGE 3 STAGE 4

ASSOCIATE MENTOR MENTOR PRACTICE TEACHER QUALIFIED TEACHER (NMC 2006)

The framework was developed as an escalator (figure 2) with mentorship at undergraduate level, leading to the practice teacher and the qualified teacher at postgraduate level.

Figure 2

The underpinning philosophy (figure 3) of this framework was build around the concept of development. A new philosophical curriculum model was designed (six-dimensional multi-faceted module of development [Rhodes 2006]) integrating theory and practice in a progressive way encouraging independence, motivation and critical thinking.

Figure 3 - Philosphy

As highlighted on figure 3, the student is considered to be central to this philosophical approach, giving an opportunity to explore past experiences, knowledge and aspirations.

The majority of students enter the framework at stage 2 - the mentorship module, where they are required to complete a PDP in the form of a Learning and Development Plan. This plan takes the student through a number of activities primarily to explore their skills in mentoring but to also explore the complexities of mentorship through the integration of the concepts of teaching, learning and assessment in practice, leading to a practitioner who can assist others on their journey of learning.

The mentorship module has proved to be a very successful module - its strength lies in the positive relationship between students, practice colleagues and teachers, with very strong links to clinical practice, enhancing a journey of lifelong learning.

References and further reading: Gopee N. (2008) Mentoring and Supervision in Healthcare. Sage Publications, London.

Nursing and Midwifery Council (2008) Standards to support learning and assessment in practice (2nd edn.) [online] Nursing and Midwifery Council, London. Available from: http://www.nmc-uk.org/ aFrameDisplay.aspx?DocumentID=4368 Quinn F. & Hughes S. (2007) Quinn’s Principles and practice of nurse education (5th edn.) Nelson Thornes, Cheltenham.

Rhodes A.K. (2006) Learning and Teaching for Professional Practice Curriculum Document University of Surrey West S., Clark T. & Jasper M. (2007) Enabling Learning in Nursing and Midwifery Practice: a guide for mentors. John Wiley & Sons, Chichester.

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New Education Standards for Nurses in Turkey

Implementation of Chemotherapy Nursing Certificate Program

Sultan Kav, Fatma Gundogdu, Nurgün Platin, Figen Bay Kara, Meral Bakar, Kadriye Sanci, Kıymet Akgedik, Oncology Nursing Association of Turkey, Board Members Background and Aim Nurses caring for patients receiving chemotherapy require specialized knowledge and skills in order to ensure the safety of both the patient and the nurse. In Turkey, while some of the universities and oncology institutes organize local courses, which range from 2- to3-days and are intended as in-service education, there is no agreed educational standard for nurses working in chemotherapy settings. Many Turkish nurses lack the necessary information to care for patients receiving chemotherapy and have not received education regarding safe handling or administration of chemotherapy agents (Burgaz et al, 1999; Karadag et al, 2004; Turk et al, 2004; Kosgeroglu et al, 2006).

In light of this situation, the Oncology Nursing Association of Turkey developed a chemotherapy certificate program for nurses.

The program has received approval by the Ministry of Health.

Contents of the Program The course is of 37 hours in length and consists of 27 hours of theoretical and 10 hours of practical training. The duration of the course is five working days. The EONS Core Curriculum for a Post-Registration Course in Cancer Nursing, the Oncology Nursing Society’s (ONS) Cancer Chemotherapy Guidelines and Recommendations for Practice and, the needs of nurses were taken into consideration developing the educational program.

Theoretical and practical content of the Chemotherapy Nursing Certificate Program Theoretical content - Carcinogenesis, epidemiology and etiology - Diagnostic procedures and treatment methods - Legal and ethical aspects - Basic principles of chemotherapy - Safety precautions in chemotherapy - Assessment and monitoring of the patient - Patient and family education Practical content Visiting a day-treatment unit with supervision provided by a designated mentor. Each participant administers at least five different groups of chemotherapy agents.

Certificate Participants who successfully meet the expected achievement are issued the “Oncology Nurses Association Chemotherapy Certificate”. The certificate is valid for three years and must be renewed.

Eligibility The registration requirement for the course is at least 6 months of experience in chemotherapy administration.

Educators /Trainers The theoretical content of the course is delivered by clinical and academic nurses experienced in the field of oncology, pharmacologists and medical oncologists. During the practical part or the hands-on parts of the program, participants are supervised by experienced clinical nurses.

Evaluation of the Participants The participants are evaluated on the basis of their hands-on practice (100 % performance is expected) and the result of the written theoretical test (at least 80 % performance is expected).

Pre-test / post-test evaluation is used to monitor individual and group achievement.

Implementation of the Program From September 2005 to February 2008, total of ten courses were organized in Ankara and 306 nurses (from all over the country) were issued a chemotherapy certificate. According to the pre-test and post-test scores, the nurses showed a great improvement in their understanding of administering chemotherapy and monitoring side effects.

Figure 1: Pre-test and Post-test Results (Means)

Conclusion and Plans for the Future Overall, participants rated the courses “highly beneficiary” and stated that they became “more confident” with the care of the chemotherapy patient. Recently “The training of the trainers” program was organized for the potential educators of the program.

A study on the assessment of the effectiveness of the program on the care of the nurses is being planned.

References Burgaz S, Karahalil B, Bayrak P, et al. Urinary cyclophosphamide excretion and micronuclei frequencies in peripheral lymphocytes and in exfoliated buccal epithelial cells of nurses handling antineoplastics. Mutat Res 1999; 439: 97-104.

Karadag A, Unlu H, Yavuzarslan F, Gundogdu F, Kav S, Terzioglu F, Taskin L. Profile of nurses working in oncology departments in Turkey. Turk J Cancer 2004, 34: 24-34.

Turk M, Davas A, Ciceklioglu M, Sacaklioglu F, Mercan T. Knowledge, attitude and safe behaviour of nurses handling cytotoxic anticancer drugs in Ege University Hospital. Asian Pac J Cancer Prev 2004; 5:164-8.

Kosgeroglu N, Ayranci U, Ozerdogan N, Demirustu C. Turkish nurses’ information about, and administration of, chemotherapeutic drugs. J Clinl Nurs 2006; 15: 1179–1187.

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Patient Diary Project receives 2008 EPE Award

An interview

EONS newsteam The recipients of the EPE award 2008 are Mrs. Catherine Oakley and Mrs. Jo Johnson for their project ‘Patient Oral Chemotherapy Diary’. The diary was developed to provide a robust generic method of supporting cancer patients and their carers, to manage oral chemotherapy treatment.

The Excellence in Patient Education (EPE) Award was launched in 2005 with the aim of honouring individual nurses or organisations that have consistently excelled at enlightening cancer patients about their disease and its treatments. EONS believes that this Award will encourage creative and cutting-edge approaches to the development of patient education materials.

In an interview with Jan Foubert, the winners of the 2008 EPE Award provide insight into the background, development, and future of their patient education project.

care and to ask questions designed to assess a patient’s ability to manage their oral chemotherapy.

Q: At a time when so many patient diaries are provided in all kinds of written form including on the internet and on CD, what led you to consider producing this kind of format for your patients?

A: There are many diaries currently in circulation but they are predominantly orientated to one brand or method of administration of oral chemotherapy. We reviewed a large number of diaries during the initial stages of designing our diary, and were not able to identify a generic diary which was grounded in research or completely patient-driven. These elements were both considered essential in facilitating an outcome which could be used across tumour types and be considered as evidence based.

We have considered all modes of delivery. However, a significant proportion of the patient population receiving oral chemotherapy still do not have regular access to a computer or feel confident using one.

Some of the patients who were interviewed as part of the research communicated that although they had been given both the electronic and paper versions of previous diaries, they favoured the paper version. This was due to the fact that they were more confident managing this format and that they could carry it with them at all times. We would be very keen to develop this diary via a hand held computer device. A further step could be provision of a computerised diary to enable pharmacy staff to complete dose scheduling of medications electronically and print this information for patients.

We feel that there are several major key issues and concerns for patients prescribed oral chemotherapy. Firstly, there is often an unstructured approach to oral chemotherapy services with a lack of assessment, education, monitoring and support. Patients and carers seem to feel the responsibility of managing their treatment alone which can be and overwhelming (Oakley, Plant and Bloomfield, 2006).

Patients are not usually able to assess when to interrupt treatment and nurses don’t generally provide proactive monitoring and support services. Anecdotal accounts suggest that patients prescribed oral chemotherapy often don’t phone the hospital when toxicities occur.

Postulated reasons for this include patients are not knowing able to recognize severe symptoms and patients deny that side effects will occur (Oakley, Plant and Bloomfield, 2006) and patients do not want to interrupt treatment which they urgently want to take to treat the cancer (Chau et al, 2004).

Q: Is this diary user friendly? How has it been evaluated and used by both patients and nurses? What are the major key issues and concerns surrounding the care of patients undergoing oral chemotherapy?

A: This is a newly developed diary which has recently been implemented. It was developed in consultation with patients who told us what they would like to have included. The diary provides an education focus as it provides key information related to self care in terms of managing treatment administration and action to be taken to minimise toxicities. The diary is being used in one health service trust within the South West London Cancer Network with a view to extend use to other constituent trusts. At the host trust the individual patient scheduling regimen is added to the diary by the pharmacy. The diary and chemotherapy tablets are dispensed to the chemotherapy nurse. Patients then have a separate appointment with the nurse who provides education including use of the diary.

Only when the nurse is confident that the patient can manage the treatment is this handed over. The session also includes a check list which prompts the nurse to educate the patient, assess supportive

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The diary has been evaluated with patients through research carried out by Jo Johnson. This study demonstrated that patients found the diary to be a useful aid to managing their treatment. The scheduling part of the diary provided a useful prompt to remind patients when to take their tablets. Patients also like to tick doses off when taken to help prevent incorrect scheduling (Oakley, Plant and Bloomfield, 2006). Participants particularly appreciated the “traffic light system” which alerts them to which symptoms should be reported promptly.

It is out intention to role out the diary across two cancer networks for six months. At this time we will carry out separate focus groups with patients and staff who are familiar with using the diary.

Q: In the application you refer to a study (Johnson 2008) which is awaiting publication, can you explain more?

The study quoted is part of a Master’s degree which was completed in April 2008. This study is now being formally written up for publication (Autumn 2008). The results of this study will also be used in conjunction with the results of the study by Oakley (2005), to allow publication of an in depth overview of the entire research. An article providing a summary of the programme and a pictorial overview of the diary has just been published in Cancer Nursing Practice (Oakley, Johnson and Deeprose 2008).

Q: For which kind of patients is this diary intended?

A: The intention is to use the diary for patients receiving anti-cancer oral chemotherapy treatment and the diary has been designed to accommodate all current oral chemotherapy regimes. Following evaluation of the diary within colorectal cancer and haematological malignancies, we have made adaptions to include both weekly and 28 day cycles. As most haematology regimens run over 28 days, patients within the study struggled to use the weekly equivalent.

Patients who have reviewed the diary following this amendment report that the instructions on the first page provide a clear explanation of how to use the two different cycles.

Q: How many copies of the diary have been distributed so far?

A: 100 diaries were printed (2nd version) and used as part of the research process. This diary is now the 4th version, with changes

made in response to patient feed back from the study and evaluation from health care professionals. We are currently in the process of rolling out the diary across the South West London Cancer Network (SWLCN). In the interim, we have secured a print run for 300 copies of the latest version, which will be used within St George’s Hospital, to continue the excellent model of care introduced to support the use of the diary.

Q: What attempts have you made to evaluate use of the diary?

This diary has been evaluated at every stage of its development. The initial versions were evaluated by primary, secondary and territory care providers within the SWLCN. It was also evaluated by patients, both within the context of the Diary Development Group and the SWLCN Patient Partnership. The final versions have been evaluated formally and informally within the units caring for these patients. We wanted to find out the practicalities of using this diary and also valued the varied feedback from healthcare professionals. All feedback has been examined, interpreted and used to shape the final version of the diary.

Q: How have you changed the diary to reflect the comments made by patients?

A: The patients’ responses and comments to the diary have driven this programme from the outset. We were able to work with a number of patients who had recently undergone a course of oral chemotherapy, thus enabling us to gain a good insight into the problems encountered.

Q: Have any particular groups or minorities had problems using the materials?

A: The initial research study had to exclude patients who did not have English as their first language for funding reasons. This was a feasibility study and was not attached to any external funding. It is not possible to predict at this stage whether any particular groups or minorities would have problems using the diary and further research is required to explore this.

Q: What about minority groups? Have you thought about translating it into other languages?

A: We would like to evaluate the diary further before it is translated into other languages. These would reflect the ethnicity of our local population.

Q: Did you have support to produce the diary?

A: Up to this point the diary has progressed and been produced through good will! Our graphic designer is a family member and has worked on the design and creation of each version of the diary free of charge. The initial batch of printing was carried out free of charge through an independent company who wished to support the programme. The majority of the work for this programme has been done in our own time.

us to fully evaluate the model of care chosen to support the diary which we hope can be adopted by other providers to improve the management of oral chemotherapy patients.

Q: How will you use the prize money from the EPE award?

A: We are going to use the prize money to fund education. This will allow us to extend our existing skills and knowledge and to be able to take this work forward effectively.

Q: What was the most valuable thing you learned from undertaking the project?

A: The most valuable lesson we learned was the importance of patient involvement. One of the most poignant moments of the programme occurred during a meeting of the Diary Development Group. Following long discussions and healthy debate over the possible contents of the diary, one patient spoke up and asked ‘Is this diary going to be designed to meet your needs (the healthcare professionals) or ours?’ This patient completely refocused the group and his words stayed with us throughout the diary’s development Grounding the development of the diary within the research process has also been invaluable. It has provided us with a clear beginning and end point, thus allowing structured evaluation.

Q: What advice would you give to others who might be thinking about doing something similar?

A: It is important to form a project group from the outset which includes both patients and representatives from all providers. A clear, structured project plan is essential and should include realistic time lines and deadlines for completion. This maintains the momentum and allows simple monitoring of all progress. Four versions of the diary were produced in total. All of these versions have been commented on by the Diary Development Group, as well as being sent out for wider consultation throughout the SWLCN. Q: Are there any other members of the production team that you would like to thank?

Yes, we would like to thank the Diary Development Group, in particular the patients and staff who gave time to the project and supported us through this long and at times stressful process. We are also very grateful to the continued support from Mark Deeprose, our graphic designer. Without him we would not have been able to transfer our vision and ideas into print. We also are indebted to King’s College, London. We both completed our MSc studies there and received a significant amount of additional support with the diary from Dr. Emma Ream, our shared supervisor and role model. And last but not least, we extend thanks to our families for putting up with us!

Q: This is a rather involved project. How long did it take to produce the diary?

A: Three years.

Q: Did you receive funding to conduct the project?

A: The research study was not associated with any funding. We managed the overall programme with minimal funds. Refreshments for meetings and reimbursement for patient travel costs were provided by the South West London Cancer Network.

Q: Do you have plans to develop the project further?

We would like to formally evaluate the introduction of the 4th version into practice to enable us to roll it out more widely. This will allow

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Cancer Updates

Results Policy and Programmes

Report provided by Jan Foubert, Executive Director EONS CONCORD Study shows Large Differences in Cancer Survival Worldwide The CONCORD study ‘Cancer survival in five continents: a worldwide population-based study’ by Prof. Michel Coleman et al and the CONCORD Working Group was published online in Lancet Oncology on 17 July 2008. It is claimed that it is the first worldwide study designed to quantify international differences in populationbased relative survival by age, sex, country and region for patients diagnosed during 1990-94 with breast, colon, rectum or prostate cancer. The study provides data on 1.9 million adult cancer patients (aged between 15 and 99) from 101 cancer registries in 31 countries on 5 continents.

Key points from the study include: 5-year survival for breast, colorectal and prostate cancers was generally higher in North America, Australia, Japan, and northern, western and southern Europe, and lower in Algeria, Brazil, and eastern Europe.

For colorectal cancer, 5-year survival for patients ranged from around 60% in North America, Japan, Australia and France and down to 40% in Algeria, Brazil, Czech Republic, Estonia, Poland, Slovenia and Wales. Pooled 5-year survival for Europe ranged from 45% for women and 48% for men. Almost 11% of patients with colorectal cancer die within the first month after diagnosis.

For breast cancer, 5- year survival for patients ranged from 80% or more in North America, Sweden, Japan and Australia to less than 60% in Brazil and Slovakia, and below 40% in Algeria. Pooled 5-year survival in Europe was 73%. About 2.3% of patients with breast cancer die within the first month after diagnosis.

Survival from cancers of the breast, colorectal and prostate varied with the type of health insurance in a population based study. Survival was highest with patients who had insurance (private or otherwise) and lowest with no insurance.

Most of the wide variations in survival are likely to be due to differences in access to diagnostic and treatment services.

For further reference, please consult http://www.thelancet.com/ journals/eop Current Trends on Cancer Incidence, Mortality and Survival in Europe The European Journal of Cancer (EJC) published a special edition on ‘Cancer control in Europe, state of the art in 2008’ on 2 July 2008. The issue features ten articles on the cancer burden and on recent trends in cancer survival. In an overall analysis of the papers, co-editors Prof. Jan Willem Coebergh (The Netherlands) and Dr. Tit Albreht (Slovenia) conclude that cancer prevention and management in Europe is moving in the right direction. Differences between countries in policies for mass screening, access to healthcare and treatment, however, are reflected in varying cancer rates. The main conclusions of the articles include the following: • In the more prosperous countries of Northern and Western Europe, cancer incidence shows a downward trend, with the exception of obesity-related cancers (such as colorectal cancer), and for tobacco-related cancers in women; • Due to better access to specialised diagnostics, earlier detection and better treatment, EU-wide survival rates for most cancers have improved; • The highest incidence rates of breast, prostate, testicular cancer and melanomas were observed in Northern and Western Europe, while lung, stomach and cervical cancer were more common in Southern and Central Europe.

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• Cancer prevention efforts must be improved, in particular with regard to female smoking and the emerging obesity epidemic.

Prof. Coebergh and Dr. Albreht expect the special issue to provide relevant input to the drawing up of the European Commission’s forthcoming Action Plan on cancer. For further information, also see the press release from the European CanCer Organisation (ECCO) and on the website http://www.ecco-org.eu:80/News/News/ In-the-news and on http://www.sciencedirect.com/science/ journal/09598049.

EUROPA DONNA to launch Breast Health Day in Europe on 15 October 2008 The European Breast Cancer Coalition (EUROPA DONNA) will launch a Breast Health Day in Europe on 15 October 2008. A press conference featuring expert speakers will take place in Milan in the late afternoon.

The aim of this initiative is to start a public education campaign to ensure that women and girls across Europe have correct information on the early detection and prevention of breast cancer. The ultimate goal is to reduce incidence rates as a result of immediate action on breast cancer. To increase public awareness, EUROPA DONNA is preparing a short public service TV announcement, which will be aired in 41 countries in October. Representatives of the 41 member countries of EUROPA DONNA, including all 27 EU countries, will be present at the launch. The new “Short Guide to Breast Health” which covers lifestyle factors influencing breast cancer, as well as the “Short Guide to the European guidelines for quality assurance in breast cancer screening and diagnosis” (see www.cancerworld.org), will be discussed at the event.

EU Health Ministers adopt Council Conclusions on Cancer The EU Health Ministers adopted Council Conclusions on reducing the burden of cancer at the Employment, Social Policy, Health and Consumer Affairs Council (EPSCO).

While highlighting the cancer burden and the expected increase in cancer incidence in an ageing population, the Conclusions call for a patient-centered, comprehensive and interdisciplinary approach to cancer control. They further point at the existing inequalities within and between Member States with regard to cancer incidence and survival rates. As a key element, the Conclusions stress the importance of cancer registries and cancer control strategies, as

well as the need for greater cooperation between care services at different stages of the cancer cycle.

Underlining prevention as the most effective long-term strategy to reduce the burden of cancer, the Conclusions reiterate the importance of healthy lifestyles and the reduction of occupational and environmental carcinogens.

The document also welcomes the involvement of civil society, in particular patient groups, in shaping cancer policies and developing services to better address patient needs.

Among other actions, the Conclusions invite Member States to: - Develop and implement cancer strategies or plans; - Continue the implementation of cancer screening programmes in line with the Council’s Cancer Screening Recommendation (2003); - Provide the best possible evidence-based treatment for cancer patients within the framework of national health priorities and financial resources; - Ensure population-based cancer registration as an important tool for the development and monitoring of policies to prevent and treat cancer; - Take advantage of existing financial mechanisms to improve cancer prevention and control and also exchange best practices in these two fields.

The Conclusions further invite the European Commission to: • Present an EU Action Plan on Cancer addressing cancer control from prevention to palliative care; • Facilitate the exchange of best practice and encourage cooperation in the evaluation, monitoring and assessment of health actions; • Support Member States in the implementation of the Council’s Cancer Screening Recommendation; • Support the networking of cancer registries; • Extend the knowledge of cancer, e.g. with regard to risk factors, early detection and treatment.

Finally, Health Ministers encourage representatives of civil society to actively participate in raising awareness of cancer risk factors and of screening and prevention programmes. The Member States and the Commission should also promote the empowerment of civil society; these should contribute to the development and implementation of cancer strategies or plans.

At the Health Council meeting Slovenian Health Minister Zofija Mazej Kukovič outlined the main elements of the Conclusions, emphasising the growing cancer burden despite progress made in prevention and treatment to date. EU Health Commissioner Androulla Vassiliou reiterated that the Commission will put forward an EU Action Plan on Cancer in 2009, which will be accompanied by an impact assessment of the human, social and economic costs of cancer. She also said that much remains to be done to implement the Council’s Screening Recommendation from 2003.

In the national speeches, national and/or regional cancer strategies and plans emerged as the most common topic of interest. For instance, Portugal called for cooperation between the Member States in developing national cancer strategies while Spain stressed that regions must have an input in European cancer strategies. The Health Ministers also outlined national screening and prevention policies, with an emphasis on lifestyle-related initiatives. Finally, they highlighted the importance of cooperation on research and exchange of best practices.

Endorsed by the Health Ministers of all Member States, the Council Conclusions on cancer reflect broad political support of further action to reduce the cancer burden and the existing cancer inequalities across Europe. Together with recent European Parliament initiatives on cancer, such as the Resolution on combating cancer in the enlarged EU, the Council Conclusions pave the way for a comprehensive EU Action Plan on cancer to be introduced by the Commission in 2009.

PREVENT

Prediction, Recognition, Evaluation and eradication of normal tissue effects of radiotherapy

11-12th January 2009 Brussels, Belgium This ESTRO conference, in collaboration with EONS, explores the science and clinical knowledge of radiotherapy side effects. This two day conference brings together scientists, clinicians and nurses to focus on the important issues of radiation toxicity and explores the impact and future management for patients. The plenary speakers will present the latest radiotherapy research and discuss the clinical and scientific issues facing clinicians in the management of patients undergoing radiotherapy including acute and late effects. This conference is aimed at health practitioners working in the field of radiotherapy or caring for patients who receive or have received radiotherapy.

Parallel clinical sessions will explore: • Impact of toxicity on patients • Measurement of toxicities • Managing toxicities Speakers include both nurses and clinicians researching this field and providing the evidence base for radiotherapy management and discussion of where our gaps in knowledge exist.

For further information of the scientific programme and registration: http://www.estro.be/estro/index.cfm or contact the ESTRO office on 0032 2 775 93 40.

Mains sessions explore radiation induced cancers, radiation biology and mechanisms of normal tissue damage

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EONS, Eusoma, ESSO Training Programme

Report from the participants

Jan Foubert, EONS representative on this Training Programme.

Regular readers of the EONS Newsletter may recall an article published in the Winter 2007 issue which announced the recipients of a traineeship supported by Eusoma, EONS, and ESSO. The aim of this educational initiative is to train specialist health care professionals to better deal with patients with breast cancer.

Following a very successful call for applications for the traineeships, five EONS members were chosen to participate in a one-month visitation to a European breast care center. As you will read below, both recipients made the most of the opportunity to learn more about nursing care of the patient with breast cancer and to extend their network of European colleagues.

Lara Kaligaric from Slovenia was selected to attend a clinical training programme in the Senology Department, Fondazione Salvatore Maugeri, Pavia, Italy, here follows her impressions of the traineeship: Although the approach to care was multidisciplinary on this breast unit, most of my traineeship was concentrated on interaction with the nursing staff. I had the opportunity to observe different procedures while working on the unit as well as observing procedures in the operating room. I found the experience of assisting in the operating room particularly interesting as I had never before done this type of nursing.

Experiencing the interaction and collaboration between oncologists and plastic surgeons was new for me as plastic surgeons are not part of the oncology team at my ‘home’ institution. I also gained new knowledge by participating in multidisciplinary sessions where patient cases and treatment options were discussed.

Although I am sure that I have developed new competencies through my experience, the one-month duration of my traineeship was too short for these newly acquired skills to really show themselves. I have learned some new aspects of cancer care that I will certainly be able to use in one form or another when I return to my place of work.

These are: • The importance of developing a relationship with the patient prior to surgery; • Different patients have different needs: some want to know everything about their illness while others just want to have surgery and get on with their lives; • Sometimes the best nursing care is to just be quiet and listen to the patient.

The training was a good experience however what I observed was not so very different from the situation on my ‘home unit’. Before undertaking the training I was very motivated to initiate change and still am! On the unit where I work we care for patients with all types of cancers so it will be somewhat difficult to implement all of what I experienced. I would like to eventually work in an outpatient setting with women who have different stages of breast cancer undergoing different types of treatment.

Marjia Adamovic from Serbia did her traineeship at the Cancer Institute-Antoni van Leeuwenhoek in Amsterdam My one-month traineeship in a specialized, high-standard institution like The Netherlands Cancer Institute-Antoni van Leeuwenhoek (NKI-AVL) in Amsterdam was a great experience for me that widened my knowledge. I had an opportunity to visit the operating rooms, the internal medicine department, the outpatient clinic for chemotherapy,

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the radiology department and the department for creative therapy.

My attendance at the interdisciplinary meetings was especially rewarding. Contact with patients really increased my understanding of the role of cancer nurses.

Working in the medication preparation room, which was specially designed to protect nurses and pharmacists from contact with hazardous agents, taught me a lot about the proper handling of chemotherapy agents. That is something we do not have at the Institute for Oncology and Radiology of Serbia.

In everyday work with kind and helpful colleagues, I gained insight into new protocols to treat breast cancer and other malignancies.

I also saw a new generation digital mammography in practice and stereotactic biopsy used as a diagnostic procedure.

What I found most intriguing was the organization of the institute which is centered around the patient and many procedures, for example MRI, are performed within one day. I also was surprised that breast reconstruction is paid by the social insurance fund. The accommodations for patients are spacious and brightly decorated and there are meditation rooms for both Christians and Muslims.

Patients and their families can easily access information which is available in leaflets, books, internet and open phone lines.

Workshops and creative therapy play a big role in the psychological aspect of patient care. I met an elderly lady who was receiving chemotherapy and happily chatting about a necklace she was making in creative therapy. Concerts are held every month for patients.

All these experiences left a big impression on me and I hope that one day we will have the facilities and resources that I saw at the Cancer Institute-Antoni van Leeuwenhoek at my institute. Although we cannot offer patients the same treatment as offered in Amsterdam, we give our best, we use what we have, and we try to make everything easier for them.

Elizabeth Vella from Malta went to Burney Breast Unit in Whiston Hospital in Prescott Merseyside.

My one-month traineeship was positive and an excellent learning experience. Although I had had an opportunity to attend the course ‘Care of the Patient with Breast Cancer’ at the Royal Marsden Hospital in London, actually experiencing first-hand how things are done and being present as part of the team on the Burney Unit was a much more enriching experience.

Burney Breast Unit is situated within Whiston Hospital and covers a population of 360,000. The breast service is staffed by a team of dedicated clinicians and specialist nurses. The team detects and treats over 200 new cases of cancer each year. I had the opportunity to attend a variety of services offered by the clinic, such as rapid access, non-urgent, follow-up and clinical trials clinics. I also participated during surgical procedures, in the chemotherapy unit, at oncology consultations, and during reconstructive/plastic surgeon consultations.

Mr. R Audisio under whose patronage I was entrusted, kindly invited me to attend clinic sessions. Although my main interest was to observe, share and work with the specialist breast care nurses, watching surgical procedures which have not yet been introduced in Malta, was interesting.

Being in various clinics once or twice a week for a month’s time gave me the opportunity to follow patients through the first part of their ‘cancer journey’. The breast care nurse is present when the patient is diagnosed, when she is being prepared for surgery when histology results are discussed and again when the oncologist explains treatment options. The breast care nurse is a constant companion through the cancer journey, providing support, counselling and information for both patient and family.

My learning experience was enhanced by the time I spent shadowing the breast cancer nurses. I learned a lot from their gentle but comprehensive and diligent approach toward patients. We are still in contact and I feel this is one of the most important outcomes of the traineeship: meeting with professionals who work in the same area and learning from each other’s experiences in order to provide a better service for our patients.

Attending the oncology clinics was one of the highlights of the traineeship. The oncologist explains in a comprehensive and detailed manner the treatment options and their side effects. Patients are then given written information and are asked to ‘think about it’ and to come back the following week with a list of questions. This enables patients to make informed treatment decisions. Unfortunately our oncology clinics are not so well equipped. We have only two

oncologists in Malta who see all the patients diagnosed with any cancer in the whole of the island. Ideally we should have a specialist breast oncologist as a member of the multidisciplinary team.

I’ve had discussions with my colleagues in Malta regarding some changes in our service. We are considering to each have an individual patient load and to maintain better nursing records. It has been difficult for us to provide this specialist care since we have no support or clerical staff on our team and we spend much of our time preparing for clinics and meetings.

Vesna Kodzopeljic from Serbia attended the University Clinic in Aachen, Germany. Her visit to this breast centre has been extremely useful and helped her to justify previous knowledge and skills. She noticed that all activities at the clinic are standardized. She had the opportunity to take part in obtaining lab specimens, changing dressings, working with the surgical team, assisting during biopsy procedures and observing other medical and surgical procedures.

This training has great influenced Vesna and will stimulate here to make some changes in her daily practice.

The first thing that Vesna is going to apply to her work environment is the multidisciplinary approach toward patient care including the collaboration of a psycho-oncologist which she believes will improve the care provided to patients and their families.

10th World Congress of Psycho-Oncology

International Psycho-oncology Society (IPOS)

Report by Sara Faithfull, EONS president The theme of this conference was: “Advancing culturally diverse approaches in psycho-oncology and palliative care. Psychologists, clinicians and nurses were represented at this conference that presented overviews and recent research in the field of psychology.

Symposiums covered how suffering and pain are related examining the relationship between symptoms and psychological distress. Marta Schroder and Debra Koatz (1L-2 2008) in a study of Spanish cancer patients needs found that few of the 25 reviewed hospitals provided psychological or emotional care services. They also found that patients who had unmet psychological patients need later developed distress. They concluded that a greater appreciation of psychological need early in the treatment trajectory could lead to better care.

Screening for distress was a common theme in that we are all aware of the association between anxiety and distress.

The EONS symposium (16) explored crossing boundaries: E technology and patient care. The idea of this symposium was to look at work in progress on communication support provided through

technology to enhance patient‘s care experiences. Paz FernandezOrtega from Spain opened the session with some of the future care issues in assessing patients remotely and the need for new models of care. Roma Maguire from Stirling Scotland described existing research work on the ASyMS study on remote monitoring and its successful use in patients receiving chemotherapy. Sara Faithfull from England presented work on the role of the workforce and attitudes in implementing telehealth systems and Nynke de Jong from the Netherlands described pain symptom management technology system that are being utilised and evaluated in clinical practice to reduce cancer patient distress. The symposium was a great success with discussion of the role of technology in providing remote supportive care.

It was a common theme in many of the papers that there continues to be a need for greater education and training in communication skills and guidelines for assessment and management of psychological problems as a result of cancer.

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Diversional activity deficit

Recreation and activities in the oncology setting

Patrizia D’Amico, Roberto Quarisa, Servizio di Oncologia Medica, Ospedale di Ivrea (TO), Italia, translation of the original version of Sarah Liptrott, European Oncology Institute, Milano “Diversional activity deficit” is one of the nursing diagnoses identified from the NANDA in 2005 (00097, II, 2005).

The work of ‘recreation’ has progressed now for 10 years in the department of oncology at Ivrea Hospital, near Torino, and is a concrete response to this diagnosis. It consists of a general series of interventions, between the areas of creative activity and occupational therapy, to be performed when the onset of inadequate activity of the patient is identified or anticipated.

We work in a medical oncology department, composed of an inpatient unit with twelve beds, a day hospital, an outpatient service and a service welcome centre (CAS). Our ‘users’ are adults, usually over 50 years of age.

Participating can take attention away from the symptom – it can be reduced or disappear temporarily. Also immobility is not an obstacle, some small pieces of work can be carried out in bed, surpassing physical handicap. Sometimes the participation stimulates leaving the bed area and taking individuals to a communal area.

Environment Carrying out this activity allows us to go and to act in an environment that constantly changes because it is staged and modified according to the different seasons and for the different events that characterize our lives. The time outside of the ward becomes lived also inside with preparations created by the patients and personnel. The seasons – holidays like Christmas, Epiphany and carnival, so important in our town for the oranges-battle! – are remembered in our ward: the snow that comes down from above, the flags of the carnival, grapes and autumnal leaves… recreate symbolic objects that evoke the “time” of daily life.

In alternative to these moments, each person researches topics around which to create the objects of the projects: Threedimensional animals made with card, rubbish bags, glue, coloured card, plastic bottles; coloured stained-glass windows made with card and tissue paper; Larger objects; showcases for the postcards and for the photographs; large cardboard silhouettes.

Usually they use cheap materials, recovered, recycled (above all packing materials), easily available. However we have available for every activity scissors, glue, staplers, string, adhesive tape, wire, thumb tacks, fishing line, coloured cards, tempera, paint, felt-tip pen, tissue paper, crepe paper.

In our hospital as in the majority of hospital departments in Italy, the absence of pleasant and diversional activites and the cold and clinical environment, emphasize and sometimes increase the perception of the symptoms and the sense of isolation that oncological illness can cause. Also if the range of service ‘users are diverse in relation to age and social status’ , the problem can be amplified. Depressed states and apathy are often present in these types of patients.

The choice of the topic to be developed is by chance – a proposal from whoever has an idea: users, family, personnel… will find idea or activity they like, begin work and leave it on the table in the department and very slowly it is built upon. We aim to realize every proposal, looking not to be repetitive, and for this reason, at the end of the period, the arrangement is dismantled completely and eliminated, recycling only the material still useable. In this way we do not run the risk of same projects every year, stimulating the construction of new ideas.

Throughout these activities, we aim to face the onset of these inconvenient situations. Our recreational interventions aim essentially to make participants profit from light creative activity to fill the long empty spaces of hospitalization.

Often the project is not of high quality and during its realisation small inconveniences occur or the aesthetic result is not that desired. , For us it is not important, the thing that we aim for is participation in the accomplishment…all that is realized, is meaningful for the individual.

The activity is proposed to every individual, dedicating the time deemed convenient; it is personalized allowing creativity, manual ability, artistic skill and potential, even if this means discovering an ability that they did not think they had. Also where there are high levels of fatigue, they can participate, showing therefore that even the presence of the symptoms leaves some margin for activity.

Timing • The long moments of inactivity that characterize a hospitalization bring into focus the changes in life that cancer causes, redefining long term objectives and often favouring a state of depression.

These recreational interventions aim to allow individuals who wish to participate in different activities, to avoid the situation of depression.

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This happens not only with the creation of projects, but also with different interventions that involve the user in social games, the accomplishment of a puzzle, reading of a book chosen from the many available in the library. There are then moments of fun in which to assist like onlookers listening to some songs, musical groups or watching entertainment shows.

Atmosphere The structural interventions are aimed to be more welcoming to the environment, the work of collaboration between personnel and users for the accomplishment of the projects, participation as simple onlookers to the events: are all elements that contribute to change the “atmosphere”. The climate is defined as an integration between physical environment and social aspects, relations and emotions that characterize an organization.

Our intention is to create a family atmosphere, warm and attentive to the human dimension in providing a positive quality care environment.. Sometimes during the recreational activity, nurses, patients and carers find themselves around a table together, which breaks down the professional/institutional structure and allows a more human dimension providing exchange and ‘chatting’ to know more personal aspects, taste, episodes of life not usually recalled in normal hospital interactions.

It is these “chats”, exchanged in friendship, that often help to establish answers to inexplicable reactions, reveal family dynamics, unexpressed fears, elements that become a valid help for our activity, and that allow better individualised care.

The participation in recreational activity otherwise allows different users to know, or to be familiar with them, to go out from their rooms and to share with the others….

This recreation often takes place also with the family, for them this represents a diversion that allows temporary removal of the attention of worries bound to the illness of the person for whom they care.

The project started in 1997, driven by the corporate training center and aimed at students participation. The initial stages included some nurses and the activity was aimed at group-work and playing rediscovery . The project was then managed totally by nurses in the general medicine department and successively in oncology, and from the start it has been self-financed. The time dedicated is almost entirely within normal working hours, due to diversional activity being developed concomitantly with the activity in the department.

Within the Italian Oncology Nurses Association (AIIO), a study group named Grano (oncology recreation group) established in 2004 collected information about the Italian reality of the development of existing light, artistic, and recreational activities.

One of the first objectives of the group was to map within Italy the consistency of the diversional activity in non-paediatric oncology departments. This enquiry has emphasized the scarce attention to this problem and the scarce interest, maybe correlated to a lack of knowledge in this subject that this aspect of humanisation and related activity are covered in the nursing profession.

The AIIO National Congresses of and other educational courses have been organized with the objective of conveying theory and techniques of recreational interventions to make nurses aware of these less ‘scientific’ aspects of care, but that are equally important for our activity. After these episodes of training/education, the reality has begun to dawn on their services. To increase further the circulation of the awareness of the diversional techniques, they have been put onto the AIIO website – a space that collects the blog of some services. Besides documenting activity carried out, the blog constitutes a cue for those who want to begin to enliven the actual working reality. The site AIIO is found at: htpp://www.aiio.it

The carrying out of recreational activity has been valid help to improve the work of the team, all the activities are carried out thanks to the support of the health care professionals.

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E-learning in cancer education

Exploring the potential

Graham G. Dark. Centre for Cancer Education, Newcastle University, Westgate Road, Newcastle upon Tyne, NE4 6BE Everyone learns all the time, using a variety of means, but the initial hype of promise from e-learning was met by resistance and a perception of inferiority. What everyone missed was that ‘e-‘is only the method of delivery and that the impact of the education was dependent on the quality of the learning within the content and not how is was delivered to the user. These early predictors of e-learning saw the replacement of all classroom teaching and that e-learning was all about the technology. The initial offerings excited everybody with the level of instructional design and interactivity and this increased the availability of learning opportunities.

Many organisations quickly jumped on the bandwagon and purchased or developed their first generation of e-learning technologies, but unfortunately the evaluation of these initial approaches did not support the over-hyped expectations and a downturn in popularity followed. The initial hype of e-learning focused on the technology and has now been replaced by a refocus on the educational pedagogy, producing learning materials that are engaging learners in activities that reward their efforts.

Web-based learning is here to stay and a number of important lessons have been learned over the last 10 years. The content must be useful to the learners and technological glitz cannot replace content. The development time and cost of quality resources was frequently underestimated, usually by an order of magnitude. So e-learning allows the interaction of users, tutors and content using technology, so e-learning really is about the technology. Everyone gets seduced by the technology and yet successful e-learning is always about the learning and not the technology. The investment in e-learning should therefore be: 5% in student factors, including student training, 10% in the technology, 15% in staff factors, including mentoring and staff training, and 70% in content creation. Projects that have technology as the main expenditure often do not deliver on-time nor on budget.

Key points: • Don’t believe the hype – look for evidence of what works • ‘e-‘ is only the method of delivery • focus on excellence in the education, not the technology • invest in your staff In 20 years, education will be different as we move from a justin-case approach, like learning algebra at school, to a just-in-time solution, delivering learning immediately after users identify their need. There is a constant demand for access to reliable knowledge and learning, and users are willing to pay if the service is useful to them. The technology is well advanced but the problem remains access to quality content. In the future, the doubling time for knowledge will be so short that users will be overwhelmed with both

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good and bad content and therefore the skills of navigating and locating the right information at the right time will be key. Trusted providers of high quality knowledge and learning will prevail in this global market.

Learning technology has introduced just-in-time and just-enough approaches which deliver relevant training, on-demand, to the individual learner in their workplace environment. The usefulness of training is therefore improving, as is the return on investment for corporate purchasers of training. The modern workplace for healthcare professionals has changed and e-learning allows the whole workforce to participate in learning that accommodates their work patterns and allows them to study at a time and place that is determined by the learner and not by the teaching.

The problems of traditional teaching can be found in e-learning too. The largest challenge is to maintain curriculum congruence, where the intended learning outcomes are matched by the learning activities and addressed by the assessment by choice of method and depth of questioning. This clearly requires that the method of learning and assessment are appropriate for the module outcomes, but more importantly, that they are appropriate for electronic delivery. A practical skill can be observed from a video, but not easily assessed using a web cam. Adults learn best when the content is relevant and purpose to everyday issues, when the learner is actively involved and the objectives are clear and unambiguous, with students demanding more feedback that is timely and constructive. These requirements are made both e-learning and traditional teaching and therefore innovative approaches are required to ensure that such requirements are delivered. The difficulty with the online student is that they can have a shorter concentration time and often expect a response much quicker that their face-to-face counterparts. This can increase the burden to the online tutors to respond quickly to student enquiries.

Nevertheless, by improving the materials in response to student queries, the support requirements can be diminished. It is more a process of understanding the students and learning from them, which in turn allows the delivery team to use their time and resources more effectively.

The modern approach to working in teams can, and should, be extended to learning in teams, and multidisciplinary education can be a powerful tool for deep learning. E-learning provides a means of communication within a learning environment that removes the geographical and temporal boundaries that can impede group learning activities. Utilising this approach requires a commitment to high quality materials, simplicity of technology and teaching staff with appropriate skills. Although e-learning utilises technology as an effecter of the teaching, it is important to remember that in e-learning ‘e-‘ is only the method of delivery, and that it still requires quality learning content.

Continuing Professional Development

Assessing clinical skills through objective assessment and portfolios

Eileen Furlong, Lecturer UCD School of Nursing, Midwifery & Health Systems, Belfield Dubin 4 The assessment of clinical skills performance poses a challenge for nurse educators. Two methods of assessing clinical competence are the Objective Structured Clinical Examination (OSCE) and the use of Portfolios. This paper aims to highlights key literature on the above methods of assessment and discuss some practical examples of how competence can assist in the integration of theory with practice.

The OSCE emerged as an assessment strategy for medical education in Scotland during the 1970’s. It is an assessment approach to students’ clinical skills that is objective rather than subjective (1). This assessment is used widely in medical education and has now emerged in many other disciplines, including nursing. The clinical competence is divided into various components such as history taking, or the interpretation of clinical data (such as nursing diagnoses) with each component being assessed at a different station (2). Students rotate through a number of stations, spending a pre-specified equal amount of time at each station (1).

There are two principle types of stations: (a) procedure or observer and (b) question or marker stations. Generally the procedure / observer station involves task performance, usually presented in a short written scenario (1,2). This is followed by a request for the required action using a pre-determined check-list of criteria, with the performance being checked by an observer (1,2). The advantage of this checklist should be increased reliability and objectivity (1).

The observer stations are particularly suited to clinical skills of an interpersonal and / or psychomotor nature and also to intervene performance (2,3). However, many variations exist and some stations may be longer and involve multiple choice questions or longer written formats (3). The use of a modified OSCE used by oncology nurses has been evaluated (4). This evaluation was a non-experimental postonly evaluation of oncology nursing students’ perception of an OSCE. Students were asked to complete the evaluation form indicating the extent to which they agree / disagree, with statements relating to their degree of preparation for the OSCE exam, their views on the efficacy and relevance of the exam in testing clinical skills and the level of anxiety or stress experienced as a result of the OSCE. The findings indicated that 90 % of the students (n=185) viewed the OSCE as stressful despite their high level of preparation and affirmative views on the relevance of the skills tested. Using the OSCE in conjunction with a number of assessment methods may attempt to maximise the transfer of knowledge to clinical practice (4).

Objective Structured Clinical Examination (OSCE) • Emerged as an assessment strategy for medical education in Scotland during teh 1970’s

(Harden & Gleeson 1979)

• Adopting by nursing • Approach that is objective rather than subjective • Clinical skills are tested rather than pure theoretical knowlegde • Clinical skills laboratories and simulation of practice became important in nursing faculties/universities in past decade

• A product consistent with adult learning • Organised collection of written evidence • Record of continuing competence • Personal and professional development • Reflect upon achievements • Assessment of skills and knowledge • Critical analysis of contents

A portfolio used by nurses and midwives is generally understood to be an organised collection of documents chronicling an individual’s career. These accumulated documents may be drawn upon when applying for jobs or courses in order to demonstrate learning.

Portfolio contents can help individual nurses and midwives to identify their own strengths and areas requiring development, plan how they can enhance their knowledge and skills in order to improve clinical practice, maximise their opportunities to undertake appropriate continuing professional development and develop strategies for achieving their individual career goals (5) The development of a portfolio supports independent and lifelong learning. It is suggested that portfolio strategy puts students at the centre of the learning process (6) and encourages nurse to critically analyse care.

A major requirement of the nursing profession is to safeguard the public in providing a valid and reliable means of admitting to practice only those who meet the minimum requirements and who are deemed competent (7). As nurses in practice, management and education we must strive to ensure that competence is achieved.

References: 1. Harden R.M, Gleeson F.A: Assessment of medical competence using an objective structured clinical examination (OSCE) ASME Medical Education Booklet 8, 3-10, 1979.

2. Ross M, Carroll G, Knight J, Chamberlain M, Fothergill-Bourbonnais F, Linton J: Using the OSCE to measure clinical skills performance in nursing, Journal of Advanced Nursing 13 (1): 45-56, 1988 3. Newble D: Techniques for measuring clinical competence: objective structured clinical examination, Medical Education 38, 199-203, 2004.

4. Furlong E, Fox P, Lavin M, Collins R: Oncology nursing students’ views of a modified OSCE, European Journal of Oncology Nursing 9, 351-359, 2005.

5. National Council for the Professional Development of Nursing and Midwifery Guidelines for Portfolio Development for Nurses and Midwives, 2006. www.ncnm.ie/publications 6. Corcoran J, Nicholson C: Learning portfolios – evidence of learning: an examination of students’ perspectives. British Association of Critical Care Nurses, Nursing in Critical Care. 9 (5) 230-237 2004.

7. Bradshaw A, Merriman C: Nursing competence 10 years on: fit for practice and purpose yet ? Journal of Clinical Nursing 1263-1269, 2008.

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TITAN 2008 update

Courses on track!

Rudi Briké, TITAN coordinator Since the beginning of 2008, 7 TITAN courses have been successfully organized in several countries, using the 2008 updated course material.

colleagues and the multi- disciplinary team helping to increase awareness of prevention, detection and management of these toxicities and to improve patient care.

The KOK (Germany) organized 2 courses in February and May 2008, with a total of 31 participants. Both courses received very positive feedback from the participants and overall, the TITAN course was judged to be valuable and useful. One of the participants pointed out that “ …There should be more nurses doing this training programme as this is a very good educational project!”. Other participants particularly appreciated the good quality of the teachers and the use of inter active sessions. Further courses are planned in October 2008.

The UK also held a TITAN course in Leeds in June 2008, with 13 participants, providing a good example of the way to organize and manage a local meeting for nurses. This course was managed internally at the Leeds Teaching Hospitals NHS Trust using the hospitals own venue and speakers. . Mrs. Kirsten Midgley (clinical educator) chaired and delivered most of the sessions, with the remaining sessions led by the haematology specialist nurse and members of the patient education group. “This course was very useful and I gained new knowledge, allowing me to transfer this in clinical practice” noted one of the participants.

TITAN courses are not just taking place in Europe but have now gone ‘International’. The first TITAN course to take place in the Middle East occurred in February 2008 at the Tawam hospital in Abu Dhabi with 40 nurses participating. The TITAN course was very well received by the audience, thanks to the fact that no one less than Mr. Jan Foubert chaired and presented the course. Amgen Middle East are busily planning further TITAN courses for nurses in the Middle East in 2008.

Further TITAN courses are planned to take place in Austria (AHOP), Belgium (SIOP), Czech Republic, Greece and Italy (AIAO).

Lecturing during the IANO course in May 2008 The IANO (Ireland) organized their TITAN course in May 2008 with 25 participants from both community and hospital based nurses caring for cancer patients. On evaluation, participants found the day very useful and relevant to everyday clinical practice, as one of the participants stated: “This course is hugely beneficial to practice on general non specialized wards.” Another participant pointed out “…all oncology/haematology nurses, no matter how experienced, should do this course. This is a very useful training day, relevant to everyday practice and increasing the benefit for patients as a result”.

Indeed, as part of the programme, participants will now develop a dissemination project over the next six months and this may take different forms, such as developing staff/patient education leaflets or workshops. The overall aim is to share information with nursing

Participants who have participated in a TITAN course should undertake a project with the aim of disseminating their enhanced knowledge to their colleagues or patients experiencing haematological toxicities, within 6 months of completion of a course.

We would like to inform the TITAN course organizers that there will be once again a TITAN Dissemination project Award organized in 2008. The request for nominations has been send to TITAN course organizers by e mail and is available on the TITAN section of the EONS website at http://www.cancerworld.org/eons If you would be interested in receiving more information about TITAN or would like to organize or participate in a course, please contact Mr. Rudi Briké at eons.secretariat@skynet.be With special thanks to Mrs. Jacqueline Baumann, Amgen (Europe) GmbH for her kind assistance.

This programme is supported by an unrestricted educational grant from Amgen (Europe) GmbH

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See you at the joint

ECCO 15 and 34 TH ESMO Multidisciplinary Congress BERLIN, 20-24 SEPTEMBER 2009

www.ecco-org.eu

European Society for Medical Oncology

Introducing Vectibix®: the first 100% human anti-EGFR monoclonal antibody for mCRC* patients with nonmutated (wild type) KRAS1

The power of individualised therapy…

NOW IN YOUR HANDS

*mCRC: metastatic colorectal cancer Reference: 1.Vectibix® Summary of Product Characteristics 2007.

VECTIBIX® (panitumumab) ABBREVIATED PRESCRIBING INFORMATION Please refer to the Summary of Product Characteristics before prescribing Vectibix® (panitumumab).

PHARMACEUTICAL FORM: Vectibix® 20 mg/ml concentrate for solution for infusion. Each vial contains 100 mg of panitumumab in 5 ml. Excipients: sodium chloride, sodium acetate trihydrate, acetic acid (glacial [for pH adjustment]), water for injection.

INDICATION: Monotherapy for the treatment of patients with EGFR-expressing, metastatic colorectal carcinoma (mCRC) with nonmutated (wild type) KRAS after failure of fluoropyrimidine-, oxaliplatin-, and irinotecancontaining chemotherapy regimens.

DOSAGE AND ADMINISTRATION: The recommended dose of Vectibix® is 6 mg/kg of bodyweight given once every two weeks. The recommended infusion time is approximately 60 minutes. Doses higher than 1000 mg should be infused over approximately 90 minutes.

CONTRAINDICATIONS: Hypersensitivity to the active substance or to any of the excipients, interstitial pneumonitis or pulmonary fibrosis. © 2007 Amgen. All rights reserved. PMO-AMG-620-2007

SPECIAL WARNINGS AND PRECAUTIONS: Dermatologic reactions: Dermatologic reactions are experienced with nearly all patients (approximately 90%) treated with Vectibix®; the majority are mild to moderate in nature. If a patient develops dermatologic reactions that are grade 3 (NCI-CTC/CTCAE) or higher or considered intolerable, temporarily withhold Vectibix® until the reactions have improved to b grade 2. Once improved to b grade 2, reinstate administration at 50% of the original dose. If reactions do not recur, escalate the dose by 25% increments until the recommended dose is reached. If reactions do not resolve (to b grade 2) or if reactions recur or become intolerable at 50% of the original dose, the use of Vectibix® should be permanently discontinued.

Pulmonary complications: If pneumonitis or lung infiltrates are diagnosed, Vectibix® should be discontinued and the patient should be treated appropriately. Hypomagnesaemia: Patients should be periodically monitored for hypomagnesaemia and accompanying hypocalcaemia every 2 weeks during Vectibix® treatment, and for 8 weeks after the completion of treatment.

INTERACTIONS: Concomitant use of Vectibix® and IFL or bevacizumab and chemotherapy combinations is not recommended. Increased deaths were observed when panitumumab was administered in combination with bevacizumab and chemotherapy combinations. Patients receiving Vectibix® in combination with IFL regimen, leucovorin and irinotecan experienced severe diarrhoea; therefore administration of Vectibix® in combination with IFL should be avoided.

PREGNANCY AND LACTATION: There are no adequate data from the use of Vectibix® in pregnant women. In women of childbearing potential, appropriate contraceptive measures must be used during treatment and for 6 months following the last dose. It is recommended that women do not breast-feed during treatment with Vectibix® and for 3 months after the last dose.

UNDESIRABLE EFFECTS: Very common (r 1/10): Rash, erythaema, skin exfoliation, pruritus, dry skin, skin fissures, paronychia, diarrhoea, fatigue, nausea, vomiting, dyspnoea, cough. Common (r 1/100 to < 1/10): Infusion reactions (pyrexia, chills), hypomagnesaemia, hypocalcaemia, hypokalaemia, dehydration, headache, conjunctivitis, growth of

eyelashes, increased lacrimation, ocular hyperaemia, dry eye, eye pruritus, stomatitis, mucosal inflammation, onycholysis, hypertrichosis, alopecia, nasal dryness, dry mouth.

PHARMACEUTICAL PARTICULARS: Store in a refrigerator (2°C – 8°C). Do not freeze. Store in the original carton in order to protect from light. Chemical and physical in-use stability has been demonstrated for 24 hours at 25°C. Vectibix® should be diluted in 0.9% sodium chloride injection using aseptic conditions.

LEGAL CLASSIFICATION: Medicinal product subject to medical prescription.

MARKETING AUTHORISATION HOLDER: Amgen Europe B.V., Minervum 7061, NL-4817 ZK Breda, The Netherlands. Further information is available from Amgen (Europe) GmbH, Dammstrasse 23, PO Box 1557, Zug, Switzerland, CH-6301. Additional information may be obtained from your local Amgen office.

Marketing Authorisation Number 100 mg vial: EU/1/07/423/001

Immune Thrombocytopenic Purpura

New Treatment Options

By Dion Smyth, Birmingham City University, Birmingham, UK Introduction Immune (idiopathic) thrombocytopenic purpura (ITP) is a rare autoimmune disorder characterized by low numbers of circulating platelets. Patients with ITP often have platelet counts of less than 50 x 109/L and, although otherwise well, they may feel fatigued and have an increased tendency for bleeding, easy bruising, or extravasation of blood from capillaries into skin and mucous membranes (Figure 1). In severe cases, patients with very low platelet counts may have spontaneous intracranial or internal bleeding (1). ITP affects patients of all ages and ethnic groups, and there are approximately 39 new cases of ITP per million people per year in the UK (2).

Platelets are non-nucleated disk-shaped cells produced in the bone marrow by megakaryocytes. Several growth factors are involved with the regulation of platelet production, most importantly thrombopoietin (TPO). Endogenous TPO regulates platelet levels through its binding activity with receptors found both on platelets and on progenitors of platelets (such as megakaryocytes and haematopoietic stem cells).Until recently ITP was considered as a disease of increased platelet destruction mediated by antibodies; however as the understanding of the pathophysiology of ITP has increased, sub-optimal platelet production (Figure 2) has emerged as an additional mechanism of ITP (3, 4).

Symptoms and diagnoses of TIP

Platelet count and symptoms Often asymptomatic • > 50 x 109/L • 30-50 x 109/L Easy bruising Petechiae and purpura • 20 x 109/L Severe cutaneous bleeding, epistaxis, • <10 x 109/L

gingival bleeding,

haematuria and mennorrhagia Risk of spontaneous intracranial haemorrhage • < 5 x 109/L

or bleeding at other internal sites Diagnosis ITP is a diagnosis of exclusion and other causes of thrombocytopenia (e.g., pseudothrombocytopenia (i.e. an artifactual clumping of platelets in vitro due to the effects of EDTA in the vacutainer tube and without clinical significance) or familial thrombocytopenia (i.e. thrombocytopenia occurring in families due to a possible genetic link) have to be ruled out. ITP can also develop secondarily in patients with other diseases, such as systemic lupus erythematosus, B-cell neoplasms or immune thyroid disorders, or in bone marrow transplant patients (1). Nurses could also assess for and possibly advise against the use of alternative medicines, in particular herbal medicines that may affect platelet counts (5, 6).

When diagnosing ITP, it is important to: • document the patients’ medical history to identify any social influences on health such as excessive alcohol consumption.

It might also help identify the use of medications causing thrombocytopenia, such as certain antibiotics, anticonvulsant medications, diuretics, or analgesia such as aspirin or NSAIDs. A recent medical history of viral or respiratory infection, blood transfusion or blood disorders may allude to other potential secondary causes of ITP. • perform a physical examination to assess the type, severity, and extent of bleeding events and establish the duration of symptoms.

• investigate the patient’s family history. This may indicate a hereditary basis for the low platelet count.

• perform a blood count and peripheral blood smear. Low platelet levels are the only abnormality found in the blood count of patients with ITP. A bone marrow biopsy may be indicated in older patients, in patients where other haematological disorders are suspected (1) or in patients who are considered for splenectomy (7).

The symptoms of ITP and their severity depend on the platelet count, with severity increasing as the platelet count decreases.

Nurses should familiarise themselves with the signs and symptoms of bleeding, such as petechiae and purpura, so that more effective physical examination of skin and mucosal surfaces can be achieved.

Advanced nurse practitioners may also undertake examination of the fundi or retina to establish evidence of bleeding.

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Nursing issues associated with ITP Whether patients who present with only petechia or purpura should be treated is controversial and medical practice varies in this respect between hospitals and countries.

Treatment is considered appropriate for: • patients who have platelet counts of <20-30 x109/L or patients with counts of <50x109/L with significant mucosal bleeding or risk of bleeding

• patients planning to undergo medical or dental procedures likely to provoke or bring about blood loss, such as the extraction of a tooth • patients with lifestyles associated with an increased risk of bleeding, such as those participating in hazardous or dangerous activities such as full-on contact sports.

Current treatments for patients with ITP Currently, four treatment options that focus on reducing platelet destruction are commonly used: corticosteroids, anti-D immunoglobulin, intravenous immunoglobulins (IVIGs), and splenectomy. Corticosteroids, typically prednisone, are considered the first line of therapy and are effective in 50-75% of patients.

(8) Unfortunately, the long-term use of corticosteroids can be associated with various side effects, including hypertension, diabetes, osteoporosis, glaucoma, and in extreme cases, Cushing’s syndrome as well as an increased risk of infection associated with steroidinduced immunosuppression.

Anti-D immunoglobulin is equally effective, but only in 70-75% of Rhesus+ patients in the non-splenectomised setting (4). IVIGs are recommended for patients unresponsive to corticosteroids, or those with severe bleeding (7). Possible side effects associated with immunoglobulins include fever, chills, headache, nausea, dyspnea, and chest pain. In rare cases, patients may develop acute kidney failure, aseptic meningitis, or haemolytic anaemia following the administration of immunoglobulins.

Splenectomy is an option for patients with severe ITP refractory to corticosteroids but the trend now is for more conservative medical management of patients. Patients can have a lifelong increased risk of infection following splenectomy, and 40-50% of splenectomised patients later relapse (1).

Rituximab is not currently approved for the treatment of ITP but has demonstrated efficacy. (9,10). Approximately 45-65% of patients have a response to rituximab (11) but treatment can be complicated due to unpredictable patterns of response. Some patients have an early increase in platelet counts (after the first or second infusion) which peak between weeks 6 and 10; others may have a late response where increases in platelet count are first achieved 6 to 8 weeks after treatment initiation and reached a peak count quickly.(12,13) New treatment options for patients with ITP New therapies developed to address sub-optimal platelet production include growth factors that stimulate platelet production (4). The first recombinant TPO—manufactured by adding the relevant DNA into the existing genome of bacteria so that proteins are created that stimulate the production of platelets—was similar to endogenous TPO produced naturally in the body. The recombinant TPOs proved to be immunogenic and the body’s immune system identified the recombinant TPO as ‘foreign’ leading to the production of autoantibodies and the destruction of endogenous TPO. The second recombinant TPO receptor agonist, romiplostim and the small molecule TPO receptor agonist, eltrombopag, currently in late phase clinical development have no structural similarity to endogenous TPO and do not stimulate an autoimmune response.

Romiplostim Romiplostim is a thrombopoeisis-stimulating Fc-peptide fusion protein (peptibody) which binds to the TPO receptor on the surface of platelet-producing megakaryocytes (Figure 3). The binding of romiplostim activates cell signalling pathways which lead to activation

of platelet production (4). Romiplostim is administered as a onceweekly, subcutaneous injection and the dose of romiplostim is individualised for each patient and their specific platelet level. The efficacy and safety of romiplostim (1μg/kg weekly) was investigated in two 24-week, parallel, placebo-controlled, double-blinded, phase III trials, one in splenectomised patients (romiplostim N= 42; placebo N = 21) and the other in non splenectomised patients (romiplostim N=41; placebo N= 21) (14). Patients could receive concurrent ITP therapy with corticosteroids, azathioprine, and danazol. The primary endpoint of both studies was durable platelet response defined as a weekly platelet count of ≥ 50 x 109/L during at least 6 of the last 8 weeks of treatment, in the absence of rescue medication at any time during the study. Transient response was defined as 4 or more weekly platelet responses without a durable response from week 2-25. Platelet responses that occurred within 8 weeks of rescue treatment were not included in any measures of platelet outcome.

Altogether 83% of the romiplostim-treated patients achieved an overall platelet response (either durable or transient) compared with 7% of patients receiving placebo (p<0.0001; Cochran-MantelHaenszel test controlled for splenectomy and baseline concurrent ITP therapy). A total of 49% of romiplostim-treated patients had a durable platelet response compared with 2% of the patients receiving placebo. Target platelet count (≥ 50 x 109/L) was achieved by 50% of both splenectomised and non-splenectomised patients receiving romiplostim within 2-3 weeks and was sustained during the duration of treatment (Figure 4). Of the patients receiving concurrent ITP treatments, 87% of the romiplostim-treated patients (20/23 patients) were able to reduce (by over 25%) or discontinue their co-medication compared with 38% of placebo-treated patients (6/16 patients).

Romiplostim was well-tolerated and adverse events were generally mild. Headache was the most commonly reported adverse event in both the romiplostim and placebo treatment groups. Romiplostimtreated patients had an increase in dizziness, insomnia, myalgia, and pain in the extremities and abdomen, the clinical significance of which could not be assessed due to the small study size. No neutralising antibodies against romiplostim or thrombopoietin were detected in any of the patients in the phase III trials.

Thromboembolism occurred in two romiplostim-treated patients and one placebo-treated patient, all of whom had predisposing factors to thromboembolism. Increased bone marrow reticulin was observed in one patient receiving romiplostim (who had increased reticulin at baseline) and resolved following discontinuation of treatment.

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similar or worse compared with patients with diabetes or arthritis (19). Patients report that the bruising and bleeding resulting from ITP has a substantial negative effect on their quality of life, and fatigue (possibly due to the anaemia caused by bleeding) hinders their ability to perform their routine daily activities. (20). When presented with a patient with ITP, the nurse therefore has to help the patient adapt to the physical and psychosocial demands of the disease. The changes to body image associated with corticosteroid treatment, the implications of a potential splenectomy, rehabilitation, roles and responsibilities, and the risk of sepsis are examples of some of the fears and concerns that nurses should be assessing and addressing when informing patients about, and explaining, different treatment options to patients with ITP. Keeping up to date with the developing and future therapeutic options enables the nurse to educate and reassure the patient, thereby potentially alleviating fears of treatment failure or that eventual splenectomy is unavoidable.

The long-term efficacy and safety of romiplostim are now being confirmed in an ongoing, open-label, extension study (15). The European Medicines Evaluation Agency is currently reviewing the Marketing Authorisation Application for romiplostim. Romiplostim was recently approved for the treatment of adults with chronic ITP in the US and Australia.

Eltrombopag Eltrombopag is a small molecule TPO receptor agonist that is administered orally once-daily. It activates the TPO receptor by binding to the transmembrane region. Although eltrombopag binds to the receptor differently than endogenous TPO or romiplostim, the final pathways seem to be identical (4). The results from a 6-week treatment-period, placebo-controlled phase II trial where the primary end point was a platelet count of â&#x2030;Ľ50 x 109/L on day 43 of treatment showed that 28%, 70%, and 81% of patients receiving, respectively, 30 mg, 50 mg or 75 mg of eltrombopag daily achieved this endpoint (versus 11% in the placebo group). (16) Mild to moderate headache was the most commonly reported adverse event followed by aspartate aminotransferase elevation, constipation, fatigue, and rash. Cataracts have been noted in both preclinical and clinical studies of eltrombopag, and elevated alanine transaminase in conjunction with raised bilirubin levels have been observed in some patients treated with eltrombopag (17). Phase III studies of eltrombopag are currently ongoing and the published data are awaited soon.

Discussion With the development of the TPO receptor agonists, the treatment options for patients with ITP have been widened. Current treatments can have many side effects and the treatment of ITP may result in increased morbidity from adverse effects and opportunistic infections, which often surpass the problems actually caused by ITP (18). The phase III trials investigating romiplostim and the phase II trials on eltrombopag show that TPO receptor agonists appear to be well-tolerated and effective in patients with ITP (14, 16). As the TPO receptor agonists are not immunosuppressive agents, the problems associated with immunosuppressive treatment can be avoided and the overall health of the patient better maintained.

Both the symptoms of ITP and its treatment affect the quality of life of the patient; indeed the impact on quality of life is perceived as

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When considering the management of the patient, two important issues during the treatment of ITP arise: firstly, the need for treatment concordance and secondly, regular platelet count monitoring. A onceweekly subcutaneous therapy such as romiplostim may facilitate concordance; it also combines treatment with frequent platelet count monitoring and reinforces regular contact with medical staff which may be reassuring for the patient. This approach facilitates individually tailored and controlled dosing schedules and minimises the risk of thrombosis that might occur if platelet counts increase (e.g. due to irregular drug intake).

In adults, ITP is a chronic disease often associated with a remitting â&#x20AC;&#x201C; relapsing course. Many patients do not require treatment and the decision to introduce therapeutic interventions will be based upon the laboratory findings, clinical circumstances, and individual patient risk factors. The development of the upcoming TPO receptor agonists provides patients with a new perspective to living with this chronic medical condition.

Acknowledgements This article was supported by Amgen Europe GmbH, Zug, Switzerland.

Author for Correspondence: 033 Bevan House, Birmingham City University, Edgbaston , Birmingham, B15 3TN, UK E-mail: dion. smyth@bcu.ac.uk

References 1. Cines DB, McMillan R: Management of adult idiopathic thrombocytopenic purpura. Annu Rev Med 56:425-42, 2005.

2. Kaye J, Schoonen M, Fryzek J: ITP incidence and mortality in UK general practice research database. Haematologica 92 (Suppl.1):280 (Abstract 0751), 2007.

3. Bussel J: Treatment of immune thrombocytopenic purpura in adults. Semin Hematol 43 (3 Suppl 5):S3-10; discussion S18-9, 2006.

4. Stasi R, Evangelista ML, Amadori S: Novel thrombopoietic agents: A review of their use in idiopathic thrombocytopenic purpura.

Drugs 68 (7):901-12, 2008.

5. Arnold J, Ouwehand WH, Smith GA, Cohen H. A young woman with petechiae.

Lancet 352:618, 1998.

6. Azuno Y, Yaga K, Sasayama T, Kimoto K. Thrombocytopenia induced by Jui, a traditional Chinese herbal medicine [Letter]. Lancet 354:304-5, 1999.

7. George J, et al.: Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology [see comments]. Blood 88 (1):3-40, 1996.

8. Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med 346: 995-1008, 2002 9. Provan D, et al.: Activity and safety profile of low-dose rituximab for the treatment of autoimmune cytopenias in adults.

Haematologica 92 (12):1695-8, 2007.

10. Godeau B, et al.: Rituximab efficacy and safety in adult splenectomy candidates with chronic immune thrombocytopenic purpura - results of a prospective multicenter phase 2 study.

Blood:Epub ahead of print, 2008.

11. Arnold DM, Dentali F, Crowther MA, et al. Systematic Review: Efficacy and Safety of Rituximab for Adults with Idiopathic Thrombocytopenic Purpura. Ann Intern Med. 2007;146(1):25-33.

12. Stasi R, Pagano A, Stipa E, et al. Rituximab chimeric anti-CD20 monoclonal a ntibody treatment for adults with chronic idiopathic thrombocytopenic purpura. Blood. 2001;98(4):952957. Clinical trial.

13. Stasi R, Stipa E, Forte V, et al. Variable patterns of response to rituximab treatment in adults with chronic idiopathic thrombocytopenic purpura. Blood. 2002;99(10):3872-3873.

14. Kuter DJ, et al.: Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet 371 (9610):395-403, 2008.

15. Newland C, et al.: Evaluating the long-term efficacy of romiplostim (AMG 531) in patients with chronic immune thrombocytopenic purpura (ITP) during an open-label extension study. Haematologica 93 (Suppl.1):377 (Abstract 0945), 2008.

16. Bussel JB, et al.: Eltrombopag for the treatment of chronic idiopathic thrombocytopenic purpura. N Engl J Med 357 (22):2237-47, 2007.

17. FDA Oncologic Drug Advisory Committee Briefing Document.

Promacta (Eltrombopag Tablets) http://www.fda.gov/ohrms/ dockets/AC/08/briefing/2008-4366b1-02-GSK.pdf. Accessed July 21st 2008 18. Portielje JEA, et al.: Morbidity and mortality in adults with idiopathic thrombocytopenic purpura. Blood 97 (9):2549-2554, 2001.

19. McMillan R, et al.: Self-reported health-related quality of life in adults with chronic immune thrombocytopenic purpura. Am J Hematol 83 (2):150-4, 2008.

20. Mathias SD, et al.: Impact of chronic Immune Thrombocytopenic Purpura (ITP) on health-related quality of life: a conceptual model starting with the patient perspective. Health Qual Life Outcomes Feb 8;6:13, 2008

Update accreditation • Diploma of Advanced Studies Berner Fachhochschule in Onkologiepflege, Lindenhof Schule, Bern Switzerland, educational programme of study. For more information: www.lindenhof-schule.ch • Chemotherapy course for oncology nurses, Estonian Oncology Nursing society, 14,15,16 April 2008, educational event • ESO “11 Internationales seminar: Onkologische pflege Fortgeschrittene Praxis”., September 2008, educational event. For more information: www.oncoconferences.ch

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Personalised Cancer Therapy

What is KRAS and What Does it Mean for Patients With Metastatic Colorectal Cancer?

Liesbeth Lemmens, BSc, MSc, Coordinator Clinical Trials, Digestive Oncology Department of Gastroenterology, University Hospitals Leuven, Belgium Introduction Recent advances in understanding the molecular basis of cancer have revolutionised medical oncology. Scientists have identified functionally important proteins that are involved in regulating the growth, survival, and metastatic properties of tumour cells. These proteins have served as targets for the rational design and discovery of novel treatments, referred to as “targeted therapies” (1, 2).

Although many of these novel targeted agents have been shown to improve outcomes in clinical trials, it is clear that not all patients benefit from the therapies. The current research challenge, therefore, is to identify indicators that can predict response to treatment (3).

“Biomarker” is defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention (4).” Whereas prognostic biomarkers indicate clinical outcomes independent of treatment, predictive biomarkers determine the response of a tumour to a specific therapy. Consequently, predictive biomarkers are used to identify the treatment option that will result in the best patient outcomes. By also identifying patients who are not likely to benefit from therapy, predictive biomarkers will prevent exposure to and toxicity from ineffective treatments while preventing treatment delays with other potentially effective regimens and reducing healthcare costs.

This article explains how personalised medicine may become a reality for patients who have colorectal cancer (CRC) by allowing healthcare providers to select appropriate treatments for patients on the basis of their specific genetic profile. Scientists have recently identified a differential response to antibodies that target the epidermal growth factor receptor (EGFR) based on the presence or absence of a mutation of a specific gene called Kirsten RAS or KRAS. KRAS is a part of the rat sarcoma oncogene virus (ras) family, which encodes the KRAS protein (5, 6). The biology of EGFR and KRAS, the effect of the KRAS mutation, and the studies that have led to the identification of KRAS as a clinically relevant biomarker will be discussed.

Figure 1: Relationship between EGFR pathway and KRAS in colorectal cancer

EGFR as a Therapeutic Target in Colorectal Cancer The EGFR pathway plays a critical role in tumour growth and progression (7, 8). The EGFR-mediated signalling activates multiple pathways that result in cell proliferation and survival (Figure 1). The abnormal activation of EGFR is implicated in many types of cancers, including 75% to 90% of CRC, and seems to reflect a more aggressive pathology and clinical behaviour, such as more tumour angiogenesis, proliferation, metastasis, and survival (9-11). As a result, EGFR has been identified as a logical target in cancer treatment, and therapies have been developed to inhibit this signalling pathway.

The activity of EGFR can be inhibited by either small molecule inhibitors or by monoclonal antibodies. Small molecule inhibitors, such as erlotinib (Tarceva®), selectively inhibit the enzyme (tyrosine kinase) activity of EGFR inside the cell; thus, they are referred to as tyrosine kinase inhibitors or TKIs (12). No TKI has been approved for use in CRC to date. Monoclonal antibodies, such as cetuximab (Erbitux®) and panitumumab (Vectibix®), target EGFR outside the cell by blocking ligand binding and subsequent activation of EGFR signalling (8). In randomised clinical trials, both of these anti-EGFR antibodies have been shown to improve patient outcomes and provide alternate treatment options for patients with metastatic CRC (mCRC) (13-19).

Despite promising results in clinical trials, not all patients respond to cetuximab and panitumumab; in clinical trials, monotherapy with these agents yielded response rates of approximately 10% and disease stabilisation rates of approximately 30% (13-15, 20). These results led to a search for a biomarker that would help identify patients who were likely to respond to anti-EGFR therapy.

Biomarkers for Anti-EGFR Therapy EGFR overexpression as a biomarker Preclinical data had suggested that sensitivity to anti-EGFR agents was linked to levels of expression of EGFR, and patients participating in the initial clinical trials were required to have detectable EGFR protein expression as determined by immunohistochemistry (IHC) testing. However, objective responses were seen in patients regardless of EGFR expression status, and the use of EGFR IHC as a predictive marker of response has been questioned despite the product labels’ requirement for testing (21-23).

Several studies are also evaluating whether the presence of a large number of copies of the EGFR gene in the tumour cells (compared to 2 copies in normal cells) are predictive of response; to date these studies have yielded conflicting results (22, 24-27). Thus, levels of EGFR protein or gene in tumour cells are not considered predictive for response based on currently available measurement methods.

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Skin toxicity as a biomarker EGFR inhibitors are associated with the development of many adverse effects, such as hypersensitivity reactions, gastrointestinal disorders, metabolic disorders (hypomagnesaemia and secondary hypocalcemia), and dermatologic toxicity (28). Several studies have shown that adverse skin reactions consistently correlate with response to cetuximab and panitumumab (29). In fact the occurrence of a more severe rash upon treatment with cetuximab or panitumumab predicted a longer progression-free survival (PFS), as well as overall survival (13-15, 30).

Skin rash, however, is not considered a reliable biomarker because of the lack of toxicity criteria designed to measure the effect of EGFR inhibitors. Other factors, such as the optimal timing for measuring skin toxicity, also need to be determined (31). In addition, some responders to anti-EGFR treatments do not display a rash, and some patients with a severe rash do not respond to treatment (9, 13, 15).

Therefore, an emerging issue in the appropriate use of EGFR-targeted therapy in patients with CRC is to identify an effective method for selecting patients who will most likely benefit from these agents.

KRAS: The Quest for Biomarkers of Response KRAS is an important protein that plays a crucial role in regulating cell division. KRAS receives signals from several receptors, including EGFR, and upon activation regulates other proteins located further down in the complex signalling cascade, which in turn eventually stimulate cell proliferation and survival (Figure 1). Signalling through these cascades is normally tightly regulated. A loss of control of the KRAS pathway can lead to hyperactive signalling in tumour cells and result in tumour angiogenesis, proliferation, metastasis, and survival (5, 6, 32).

Mutations of the KRAS gene are among the most common genetic alterations in solid tumours (5). It was estimated that 35% to 45% of patients who have CRC have a mutated form of the KRAS gene, with the remaining patients having a nonmutated or wild-type gene (20, 33, 34). These mutations result in a constitutively activated KRAS protein. In other words, the mutation leaves the KRAS protein always turned â&#x20AC;&#x153;on,â&#x20AC;? in order that signalling within the cancer cell continues even in the absence of extracellular stimuli (5, 6, 32). As a result, antitumour effects mediated by anti-EGFR antibodies are bypassed by the mutated KRAS protein (Figure 2). In contrast, in tumours with wild-type KRAS, the signalling pathway is turned on only in response to ligands, such as epidermal growth factor. This allows for effective blockade of the KRAS signalling pathway by antibodies that target EGFR (5, 6, 32).

Early evidence from uncontrolled studies has suggested a correlation between KRAS gene mutations and a poorer prognosis (35, 36), leading researchers to ask if KRAS is an appropriate biomarker for patient selection for anti-EGFR therapy in CRC and other EGFRassociated cancers.

First Step Towards Tailored mCRC Therapy Recently, several studies have indicated that KRAS gene mutation status determines whether patients are likely to respond to EGFRtargeted therapies, such as panitumumab and cetuximab, for mCRC. In 2007, the European Medicines Agency (EMEA) ruled that data were sufficiently convincing to mandate KRAS testing as part of the conditional marketing approval for panitumumab in mCRC. This decision was based on a prespecified biomarker subset analysis of the phase 3 trial that showed the superiority of panitumumab over

Figure 2: Mechanism by which mutant KRAS overcomes inhibition by ant-EGFR antibodies newsletter fall

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best supportive care (BSC) in patients with refractory mCRC (20).

This analysis was conducted to determine whether the effect of panitumumab monotherapy on PFS differed between patients with tumours having a mutant KRAS and those with tumours having a wild-type KRAS. When panitumumab was compared to BSC alone, a statistically significant improvement in PFS was observed in patients whose tumours harboured wild-type KRAS; median PFS was 12.3 weeks for panitumumab and 7.3 weeks for BSC (P < .0001). In contrast, panitumumab treatment conferred no additional benefit compared with BSC alone (median PFS = 7.4 vs 7.3 weeks) in patients carrying the mutant KRAS gene (Table 1) (20). Consistent with these findings, the response rate to panitumumab was 17% in the wild-type KRAS group, while no patients in the KRAS mutation group responded to therapy.

Table 1: Randomised Trials of Anti-EGFR Agents Based on Mutational Status

Study Treatment

Patients, No.

Median PFS (HR) Mutant KRAS

Wild-type KRAS

Amado BSC vs 427 7.3 vs 7.3 vs

panitumumab 7.4 wk 12.3 wk

(third-line) (HR = 0.99) (HR = 0.45;

P < .0001) Van Cutsem (CRYSTAL)

FOLFIRI vs 540 FOLFIRI + cetuximab (first-line)

8.1 vs 8.7 vs 7.6 mo 9.9 mo (HR = 1.07; (HR = 0.68; P = .75) P = .017)

Bokemeyer (OPUS)

FOLFOX vs 233 FOLFOX + cetuximab (first-line)

8.6 vs 7.2 vs 5.5 mo 7.7 mo (HR = 1.83; (HR = 0.57; P = .02) P = .02)

Tejpar (EVEREST)

Irinotecan + cetuximab (irinotecanrefractory patients)

148

83 d

173 d

BSC, best supportive care; FOLFIRI, irinotecan, 5-fluorouracil, leucovorin ; FOLFOX, 5-fluorouracil, leucovorin, oxaliplatin.; HR, hazard ratio.

The same result has been found with cetuximab and is the basis for the recent recommendation by the EMEA to restrict the use of cetuximab to patients with EGFR-expressing, KRAS wild-type mCRC. The most recent data on this subject come from the retrospective analyses of 3 randomised trials of cetuximab in combination with chemotherapy, the CRYSTAL trial (33), the OPUS trial (34), and the EVEREST trial (37) (see Table 1).

In the randomised phase 3 CRYSTAL trial, the addition of cetuximab to folinic acid, 5-fluorouracil, and irinotecan (FOLFIRI) in the overall unselected patient population resulted in a small PFS benefit for cetuximab(8.9 vs 8.0 months, P = .0479) (17). As shown in Table 1, patients with wild-type KRAS had a median PFS of 9.9 months when treated with chemotherapy plus cetuximab compared with 8.7 months when treated with chemotherapy alone (P = .017). Patients with the mutated gene had a median PFS of 7.6 months in the cetuximab arm compared with 8.1 months in the chemotherapy-only arm (P = .75) (33).

Similar results were observed in the OPUS trial, which evaluated the benefit of adding cetuximab to folinic acid, 5-fluorouracil, and oxaliplatin (FOLFOX) chemotherapy (see Table 1). In this retrospective analysis, patients with wild-type KRAS had median PFS of 7.7 months when treated with chemotherapy plus cetuximab compared with 7.2 months when treated with chemotherapy alone (P = .02), thus confirming the benefit of cetuximab in this population. Patients with the

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mutated gene had a median PFS of 5.5 months in the cetuximab arm compared with 8.6 months in the chemotherapy-only arm (P = .02), showing that the addition of cetuximab to FOLFOX had a detrimental effect on outcomes in patients who had tumours with KRAS mutations compared with those who had received FOLFOX alone (34).

The EVEREST trial evaluated the benefit of cetuximab in combination with irinotecan after the failure of irinotecan-based treatment. In this study, the PFS estimate in patients with a mutant KRAS was 83 days compared to 173 days for patients with the nonmutated KRAS (37).

Taken together, these trials provide compelling evidence of the predictive nature of KRAS in EGFR-targeted therapy. The KRAS mutation is a biomarker for nonresponse to panitumumab and to cetuximab, both as monotherapy and in combination with chemotherapy. It should be noted that a similar correlation with KRAS mutant status has also been observed in patients treated with small-molecule TKIs in nonâ&#x20AC;&#x201C;small cell lung cancer (38-40), as well as pancreatic cancer (41).

Implications for Nursing Practice It is imperative that oncology nurses understand the clinical relevance of these data to treatment decisions for patients with CRC. Like human epidermal growth factor receptor 2 (HER2) status for breast cancer, KRAS status is the first indicator allowing personalised treatment of CRC. KRAS testing is likely to become a critical component in patient selection for anti-EGFR therapy.

All patients being considered for panitumumab or cetuximab therapy, as well as all patients with newly diagnosed advanced CRC, should have their tumour biopsies tested for EGFR mutation status. Tumour samples should therefore be obtained at the time of surgery, regardless of whether the surgery is for diagnostic or therapeutic purposes. Available data indicate that both the primary and metastatic colorectal tumours exhibit the same KRAS mutation status because the mutation of the KRAS gene occurs early in the development of the disease (42). This is important because many patients may present at the clinic with metastatic disease that was diagnosed following surgical resection of their primary site or may only have testing results available from the metastatic site. Oncology nurses may play a key role in ensuring that testing for the KRAS mutation is requested at the time of surgery and completed prior to the initiation of treatment.

Nurses may also play a key role in educating patients about the clinical relevance of the mutant KRAS. It is extremely important to convey to patients who have a KRAS mutation that current chemotherapy regimens remain active and effective against their disease. The use of the KRAS mutation as a marker for nonresponse allows clinicians to avoid treatment delays with other potentially effective regimens. In addition, clinicians now have a tool to avoid prescribing costly therapies with known toxicities to those patients who may derive little or no benefit; and as a result, both the patient and the healthcare system benefit.

Conclusion As new agents are being introduced into clinical practice, more options are available to oncology healthcare professionals and to the patients they treat. Targeted therapies, and in particular EGFR-directed therapies, are a key component of treatment for patients with CRC, and the optimal use of these agents is essential. As we enter the era of personalised medicine, the discovery that the mutation in the KRAS gene is a biomarker for nonresponse to the anti-EGFR agents panitumumab and cetuximab promises to be practice-changing.

Acknowledgements The author thanks Mary Jensen Camp, Pharm D, BCOP, and Supriya Srinivasan, PhD, for writing and editorial support. Amgen (Europe) GmbH sponsored an external agency for writing support.

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21. Chung KY et al: Cetuximab shows activity in colorectal cancer patients with tumors that do not express the epidermal growth factor receptor by immunohistochemistry, J Clin Oncol 23:18031810, 2005.

22. Lenz HJ et al: Multicenter phase II and translational study of cetuximab in metastatic colorectal carcinoma refractory to irinotecan, oxaliplatin, and fluoropyrimidines, J Clin Oncol 24:49144921, 2006.

23. Hecht J et al: Panitumumab (pmab) efficacy in patients (pts) with metastatic colorectal cancer (mCRC) with low or undetectable levels of epidermal growth factor receptor (EGFr): final efficacy and

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29. Agero AL et al: Dermatologic side effects associated with the epidermal growth factor receptor inhibitors, J Am Acad Dermatol 55:657-670, 2006.

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34. Bokemeyer C et al: KRAS status and efficacy in the first-line treatment of patients with metastatic colorectal cancer treated with FOLFIRI with or without cetuximab: the OPUS experience, J Clin Oncol 26(15S):178s, 2008. Abstract 4000.

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37. Tejpar S et al: Relationship of efficacy with KRAS status (wild type versus mutant) in patients with irinotecan-refractory metastatic colorectal cancer (mCRC), treated with irinotecan (q2w) and escalating doses of cetuximab (q1w): The EVEREST experience (preliminary data), J Clin Oncol 26(15S):178S, 2008. Abstract 4001.

38. Pao W et al: KRAS mutations and primary resistance of lung adenocarcinomas to gefitinib or erlotinib, PLoS Medicine 2:e17, 2005.

39. Tsao M, et al: An analysis of the prognostic and predictive importance of K-ras mutation status in the National Cancer Institute of Canada Clinical Trials Group BR.21 study of erlotinib versus placebo in the treatment of non-small cell lung cancer, J Clin Oncol 24(18S):365s, 2006. Abstract 7005.

40. Massarelli E, et al: KRAS mutation is an important predictor of resistance to therapy with epidermal growth factor receptor tyrosine kinase inhibitors in non-small-cell lung cancer, Clin Cancer Res 13:2890-2896, 2007.

41. Moore MJ et al: The relationship of K-ras mutations and EGFR gene copy number to outcome in patients treated with erlotinib on National Cancer Institute of Canada Clinical Trials Group trial study PA.3, J Clin Oncol 25(18S):202s, 2007. Abstract 4521.

42. Loupakis F et al: Evaluation of PTEN expression in colorectal cancer metastases and in primary tumors as predictors of activity of cetuximab plus irinotecan treatment, J Clin Oncol 26 (15S):178s, 2008. Abstract 4003. newsletter fall

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MASTERCLASS

3RD ESO-EONS MASTERCLASS IN

ONCOLOGY NURSING 21-26 March 2009 Sintra, Portugal

Chair: J. Foubert, BE - N. Kerney, UK The new-formatted Masterclass in Oncology Nursing programme is designed for advanced oncology nurses as a multi-professional joint event. Five intensive days of full immersion in modern oncology will create a collective spirit of teaching and learning to improving clinical skills and patient care.

In organ-oriented Clinical sessions focusing on breast cancer, gynecological cancer, prostate cancer, colorectal cancer and lung cancer, an international faculty of experts will deliver clear knowledge of todayâ&#x20AC;&#x2122;s practice and address cutting-edge therapeutic strategies.

Spotlight sessions will facilitate compact update on hematological cancers, development in immunotherapy, adolescent patients, cancer and pregnancy and long-term survivorship.

Nursing sessions are specific nursing-oriented sessions on communication, supportive care, symptom clusters, care of the older patient, guidelines, side effect management and symptom management.

Practical training will be offered in the frame of group mentor sessions on advanced clinical practice.

ATTENDANCE TO THE MASTERCLASS IS BY APPLICATION ONLY AND SUCCESSFUL APPLICANTS ARE GRANTED FREE REGISTRATION AND ACCOMMODATION

APPLICATION DEADLINE: 18 DECEMBER 2008 For more information contact: European Oncology Nursing Society, EONS Secretariat Att. Rudi Brike E. Mounierlaan 83 1200 Brussels, Belgium Tel: +32 27799923 - Fax: +32 27799937 Email: eons.secretariat@skynet.be Website: www.cancerworld.org/eons or www.eso.net

Supportive Care in Cancer Conference

Of the International MASCC/ISOO Symposium

Report by Sara Faithfull, EONS president This conference in the steamy heat of Houston explored the new advances in symptom management and supportive care. Fatigue assessment and management was very much on the agenda with reviews of cytokine and immunological research that may impact on fatigue as well as studies that identifies the efficacy of exercise. Fiona Cramp (05-041) presented the results of a systematic review and meta analysis of fatigue interventions , found that through metaanalysis of 13 studies it was possible to conclude that exercise was beneficial for individuals but that more work is required on intensity training and timing of exercise interventions. An interesting area of debate was the needs of cancer survivors and the impact of nutrition and lifestyle behaviour on future health and well being.

evaluation of growth, dental health and gastrointestinal symptoms were affected by the impact of bone marrow transplantation and graft versus host disease. The EONS presentation identified the advance of nursing and symptom science in Europe. This paper explored the role of nurses in symptom research and the assessment and non pharmacological management. Nurses at all levels are now expected to assess cancer patient symptoms, address symptom management during all stages of cancer therapy and make judicious decisions about patient follow-up care. From a broader perspective poor symptom management not only impacts, on the patient and carers, but also on economics with greater use of health services.

Long term side effects of chemotherapy and radiotherapy were identified in many tumour groups. Dimitrovska Aneta (10-102) found in lymphoma patients a high incidence of late effects from cardiac problems to renal impairment. The high late toxicity identified in many of the studies highlights the need for further detection and research for intervention additional supportive care following cancer treatment. This was also a theme in paediatric cancer where

Recent research identifies that symptoms are still a major problem for cancer patients and that symptoms such as pain, fatigue and breathlessness are not well managed. There is still much work to address unmet needs and to facilitate improvements in patientâ&#x20AC;&#x2122;s quality of life. This conference provided symptom research from bench to bedside with a focus on the evidence base for symptom interventions.

Impact Factor is comingâ&#x20AC;Ś

Make your article count!

A few tips on how to cite.

Please remember to use the full name of the journal - European Journal of Oncology Nursing or Eur J Oncol Nursing - to cite articles published in EJON. You must also include the year of publication, the volume number and the pages of the article that you wish to cite.

Here is an example of how to cite an article: Miller M., Maguire R., Kearney N. (2007). Patterns of fatigue during a course of chemotherapy: Results from a multi-centre study. European Journal of Oncology

Nursing, 11 (2), 126-132

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Developing European Oncology Nurse Education

Sara Faithfull, President EONS, Professor of Cancer Nursing Practice, Faculty of Health and Medical Sciences, Surrey University, Guildford, UK Introduction Education is clearly an important tool in the development of specialist nursing within Europe. Awareness of cancer and its treatment and the impact it has on individuals and families helps in reducing negative perceptions and fatalistic attitudes. Education not only improves care, but can enhance patient outcomes. However care is becoming more complex with the ever changing and increasing complexity of cancer treatment delivery, which is demanding wider skills and critical thinking within health care professionals. Individuals with cancer are being cared for in community and ambulatory settings, as well as in the traditional cancer centres, and this has created the need for widening cancer knowledge to nurses working in generalist specialities such as community and public health. EU directives provided political pressure to ensure the effectiveness and efficacy of cancer care raising the profile by identifying the need to improve knowledge of oncology within the EU member states.

The commission identified the vital role of the different professions in the provision of cancer therapy; rehabilitation and terminal care (EU 1997). The Europe against Cancer programme encouraged new initiatives such as training programmes. This legitimatised the need to improve the knowledge and skills of health professionals in cancer as well as in cancer prevention, counselling and the support of training networks. Eleven years on and it is time to reflect on how education has developed and where we should be going for the future in modernising cancer nursing education. This paper explores the challenges ahead in how we develop our future cancer nursing workforce.

Change in cancer provision; is it challenging educators?

Over the last 10 years cancer care has been changing. Developments include reforms of health care systems, changes in treatment and the development of consumer focused provision. From all the recent projections and figures we know that with the increasing ageing population that cancer burden within Europe will rise over the next 10 years. We also know that those individuals who have cancer are more likely to be surviving their diagnosis and requiring prolonged monitoring and greater rehabilitation needs (Berino 2007).

Responding to these scientific and technological innovations is difficult as often health services reform follows major change with little planning or educational provision. The reality is that throughput of patients is high within cancer centres, bed stays are short and hospital treatment is increasingly acute. The increased use of ambulatory care and oral medication has shifted care from hospitals to the home where the provision of specialist nursing is often limited (Faithfull 2006). Providing such supportive care requires translation across disciplines and care settings with multi-agency approaches to care (Boal et al. 2000, Webb 1991). These changes coupled with ever increasing demands in health care require a constantly developing and flexible nursing workforce. Much of the specialist cancer provision is acute cancer centre based, however clearly much of the care is now being provided in community and general health care settings. The need to up skill community and public health practitioners is a priority for future political agendas but it is unclear as to what skills they require and how to identify those who have training needs? Those nurses working in the community are often

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neglected. Wood and colleagues (Wood et al. 2000) in focus groups with non specialist staff found six key areas of training that they felt they required 1) an overview of cancer, 2) treatments and side effects, 3) communication skills, 4) physical and practical issues, 5) care organisations, referral routes and staff roles and 6) finally death and dying issues. Similar areas of need were found in community sector staff in Kellyâ&#x20AC;&#x2122;s (2006) training needs analysis study. These studies indicate a workforce who would benefit from continuing professional education in cancer care. This is an area that needs to be developed and it is hard to envisage how future home based chemotherapy and rehabilitation will progress without considering such community staff training needs.

Is it possible to identify the impact for patients and nurses of cancer education?

Evidence is limited as to whether current educational provision is fit for purpose in meeting the new technological and acute patient agenda for providing 21st century cancer care. There are few evaluation studies of continuing professional cancer nursing education. Ferguson (1994) in a review of the literature to examine the purpose and benefits of continuing professional education for cancer nurses reported that studies to measure practice benefits were inconclusive. Subsequent cancer education studies indicate similar findings in relation to practice change (Langton 1999, Wyatt 2007a). Although not oncology based, studies of bachelor nurse programmes have found, that graduate nurses perform significantly better at decision making than their non academic colleagues (Girot 2000). Evidence for the effectiveness of education and training for communication skills in oncology has been well established (Wilkinson et al. 2002) however the sustainability of their use in practice has still to be ascertained. Practice outcomes are difficult in oncology as such studies require comparators and are scarce, much of the evidence is based on limited UK or USA educational provision. It is imperative that in the era of evidence based care, educators demonstrate their contribution to clinical outcomes. One of the problems for such research is that it is easier to evaluate the processes of education than the outcomes (Jordan 2000).

It is not surprising that process evaluations of nurses practice perceptions has been the most common way of evaluating the impact of continuing professional education. Studies of the nurses themselves indicate that continuing professional education improves confidence, communication skills and decreases anxiety (Copp et al. 2007) it also has a perceived impact on practice (Wyatt (2007b, Pelletier et al 2004, Steginga et al 2005). A study of a UK health provider found that nurses’ perceptions of training needs are often different from that of health managers and that curriculum content was often generic and not adapted to reflect cultural characteristics of the local health population and health economy (Kelly et al 2006).

The wide variation in continuing educational provision has been seen in specific courses such as in chemotherapy administration and training with some nurses receiving minimal education in the underpinnings of knowledge required for safe chemotherapy practice (Verity R et al 2008).

Clearly saying is not the same as doing?

Developing both process and outcome evaluation of continuing professional education is required within Europe with a need to look at specific cancer nursing skill sets and comparator groups.

Proving the “value added” nature of education is essential if we are to develop specialist cancer nursing. As well as research in this area we need to identify the costs and consequences of up skilling the workforce for health service managers and policy makers. There is a need to recognise such specialist skills as part of employment providing financial incentives and job satisfaction. In many countries there is no recognition of specialist nursing roles and there is little financial incentive or support for the development of specialist cancer skills (Foubert & Faithfull 2006). Barriers to education and training are not only financial they can be time related and reflect accessibility (Wyatt 2007a). However effective continuing professional development has been linked with enhanced morale, increased motivation and staff retention so also provides benefits for managers (Smith & Topping 2001). Unpacking the complexity of these outcomes is essential if specialist cancer nursing is to be valued.

Conclusion Recognising that the developments within education have been quite dramatic in the last few years more is being required of educators.

Furthermore increasing financial constraints in education has meant that nurses are finding it difficult to get release and fund further continuing professional development within many EU clinical settings. There is also an increasing need for short more work-based programmes to enhance accessibility. The development of the EONS post basic cancer nursing curriculum has made an impact on learning resources providing a gold standard for educational provision within Europe but requires evaluation of the outcomes that result as part of this education. Future development of new specialist curricula and advancing levels of practice through consensus and expert panels identify these curricular as recognised professional education for

specialist cancer nurses. We need more evidence as to the value of specialist education in outcomes that policy makers and health economists understand. Providing a trained and skilled workforce will have benefits not only for nurses themselves but in patient care. Those in nurse education face many challenges not only in the processes of how cancer education is provided and to whom, but also in redefining the skills needed by the cancer workforce to clearly impact on the practice outcomes.

References: Berino F et al. (2007) Survival for 8 major cancers: results of the Eurocare4 study. Lancet Oncology 8(9) 773-783 Boal E, Hodgson D, Banks-Howe J, & Husband G (2000) A cultural change in cancer education and training European Journal of Oncology Nursing 9,30-35 Copp G, Caldwell K, Atwal A, Brett-Richards M, Coleman K (2007) Preparation for cancer care: perceptions of newly qualified health care professionals European Journal of Oncology Nursing 11 159-167 European Commission (1997) Public Health in Europe employment and social affairs, EC Luxembourg Faithfull S (2006) E. Milly L. Haagedoorn Lecture EACE 2006.

Developing oncology nurse education and training across Europe. J Cancer Educ. Winter; 21(4):212-5.

Foubert J, Faithfull S (2006) Education in Europe: are cancer nurses ready for the future? J BUON. 2006 Jul-Sep;11(3):281-4.

Ferguson A (1994) Evaluating the purpose and benefits of continuing education in nursing and the implications for the provision of continuing education for cancer nurses Journal of Advanced Nursing 19, 640-646 Girot EA (2000) Graduate nurses: critical thinkers or better decision makers? Journal of Advanced Nursing 31(2) 288-297 Jordan S (2000) Educational input and patient outcomes: exploring the gap Journal of Advanced Nursing 31 (2) 461-471 Kelly D, Gould D, White I, Burridge EJ (2006) Modernising cancer and palliative care education in the UK: insights from one cancer network European Journal of Oncology Nursing 10 187-197 Langton H, Blunden G, Hek G (1999) Cancer nursing education: literature review and documentary analysis: English National Board for Nursing, Midwifery and Health Visiting, London Pelletier D, Donohue J, Duffield C (2004) Australian nurses’ perceptions of the impact of their postgraduate studies on their patient care activities. Nurse Education Today 23 434-442 Smith J & Topping A (2001) Unpacking the ‘value added’ impact of continuing professional education: a multi-method case study approach Nurse Education Today 21 341-349 Steginga SK, Dunn J, Dewar AM, McCarthy A, Yates P, Beadle G. (2005) Impact of an intensive nursing education course on nurses’ knowledge, confidence, attitudes, and perceived skills in the care of patients with cancer. Oncol Nurs Forum. Mar 5;32(2):375-81.

Webb P, (1991) Educational initiatives for cancer nursing in Europe. J Cancer Educ. 6(1):9-14.

Wilkinson S, Gambles M, Roberts A (2002) The essence of cancer care: the impact of training on nurses’ ability to communicate effectively Journal of Advanced Nursing 40(6) 731-738 Wood C & Ward J (2000) A general overview of the cancer education needs of non-specialist staff. European journal of Cancer Care 9 191-196 Wyatt DE. (2007a) The impact of oncology education on practice--a literature review.

Eur J Oncol Nurs. 2007 Jul; 11(3):255-61.

Wyatt D (2007b) How do participants of a post registration oncology nursing course perceive that the course influences their practice? a descriptive study European Journal of Oncology Nursing 11, 168-178 Verity R, Wiseman T, Ream E, Teasdale E, Richardson A (2008) Exploring the work of nurses who administer chemotherapy European Journal of Oncology Nursing doi:10.1016/j.ejon.2008.02.001

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“Declare Yourself!”

Oncology Nursing Society 33rd Annual Congress

Anita Margulies, EONS Board Member Philadelphia presented itself in the finest of Spring weather for the 33rd annual ONS congress. The central location at the Philadelphia Convention Center was only a short walk from all the historic sites in the City of Brotherly Love and brought many of the participants closer to the roots of American democracy.

One day of pre-congress sessions were offered with obligatory preregistration. Over the four official congress days, participants were able to choose sessions that were of interest, of importance for work, and of importance for the future of oncology nursing. Many sessions were offered twice to allow for better attendance. Depending on the session, one could also choose to attend a session depending on their level of knowledge of the subject: basic or advanced.

Special sessions on the first day welcomed and supported these participants to help them cope with the large dimension of the congress. Despite the enormity, the atmosphere was relaxed, open, friendly, and stimulating.

A large number of industry-supported satellite symposia were offered with a large array of topics dealing with new therapies, supportive treatment options, and symptom management options. Participants had to register in advance for many of these symposia. The exhibition hall hosted approximately 200 companies, organizations, societies, hospitals, and patient interest groups.

Official Congress Opening Ceremony The local Philadelphia chapter greeted the attendees at the opening ceremony with red, silver and blue garlands of stars. A musical entry of the Executive Board and international visitors was led by a group of Philadelphia Mummers a very well-known, traditional group of stringband musicians. The mood was festive, to say the least.

The keynote address at the opening ceremony entitled Plan, Brief, Execute, Debrief = Win presented by P. Houlahan, activated the audience for the kick-off or better said take off of the congress.

Mr. Houlahan is a U.S. marine corps FA/18 Hornet instructor and pilot. The execution of a flight mission was paralled with teamwork in the oncology nursing setting. The audience was visibly and audibly revved up by Mr. Houlahan and his colleague, a female fighter pilot, to take a different approach to solving problems and achieving goals using what he demonstrated as a “flawless execution model”.

With approximately 6000 participants, one would imagine a rambasamba event. The planning and the execution of the convention were excellent and the convention center accommodated all without the feeling of being crushed in the crowd. Participants could contact other members, have spontaneous discussions with session neighbors and network for future collaboration. The distance between rooms was easy to manage.

The congress program objectives were stated as: - Describe innovations in cancer care; - Identify ways to integrate and disseminate information about evidence-based cancer care; - Summarize issues and trends in cancer care that will transform your commitment to the field of oncology; - Participate in an environment of peer networking and collaboration; - Summarize new information related to major cancer diagnoses.

These objectives were, in my opinion, met to a greater extent.

Congress newcomers, and this was almost half the participants, had an excellent opportunity to get oriented to such a large congress.

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Visiting the Sessions The convention was divided into eight topic tracks, these being: - Types of Cancer and Treatment - Leadership - Survivorship - Practical Aspects for Clinical Practice - Safe Practice - Administration - Research in Practice - Nursing Care/Self-Growth The current health policy problems of the U.S. were addressed in several sessions. Comparing these to the European setting, one saw and heard many similarities in health care disparities, staffing problems, and political complacency. In spite of these well-known negatives, there were more positives to derive from the lectures.

The session, How does your garden grow? presented various career options that might be open for the oncology nurse. Three main tracks were utilized; administrative roles, educator roles, clinical roles each being broken down into individual possibilities within each track. The job market offers a lot more than meets the eye, e.g. nurse lawyers, informatics, independent practice to mention a few. The presenters

gave some useful hints as to the educational preparation for some of the less known areas. All participants received a packet of forgetme-not seeds which were labelled “encouraging growth”.

Early Toxicities/ Delayed education: Providing Safety and Quality in the Management of Oral Therapies was a session devoted to the problems with the increasing number of oral cancer drugs in the U.S. and in Europe. Deficits in nurses’ knowledge of pharmacology and poor communication patterns both with patients and physicians appear to be ubiquitous. Using keypads it was shown that the work settings of 63% of the attendees do not have specific tools to teach patients about oral agents. Roberta Strohl presented some strategies to rectify the problems.

Also on Saturday, another excellent lecture about adherence to oral tumor therapies was presented. Of particular interest was the presentation from Karin Schulte, (Dana Farber Cancer Institute). She showed the results of her study on the assessment of current nursing practice associated with oral chemotherapy adherence. Keeping the message short, one could ask: If we were involved earlier, would the adherence be better? This is a problem that seems to be universal.

On similar lines, several lectures focused on molecular targets, whether in applied research (bench) to clinical application (bedside).

The profiling of molecular characteristics has allowed single genes, growth factor receptors, and other molecular targets to be recognised not only for treatment purposes but for prevention and for early detection as well. With the targeted therapies, new side effects have taken on an important part in daily nursing activities. As in the EONS educational program, TARGET, one lecture also dealt with dermatological toxicities and the nurse’s role in providing care during treatment.

Carol Estwing Ferrans, PhD, RN, FAAN, Professor and Associate Dean for Research from the University of Illinois at Chicago, presented the Distinguished Research Special Session lecture, Research Exposing the Deadly Difference. Ms. Ferrans demonstrated with her research findings that through nursing research change can be made in healthcare policies, legislation and increased funding to alleviate some health care disparities. Dr. Ferrans studied the prevalence of racial disparities in women with breast cancer and the higher mortality incidence due to these disparities. The results were incredible and dramatic and left one wondering how these disparities could even arise. It truly left one with an “Oh, no – not possible” feeling when looking at the facts and figures. One outcome of the study was positive: An inaugural meeting of the Consortium of Metropolitan Chicago Institutions dedicated themselves to work together to improve quality of care. We might have a look at disparities in health care on the European level – the sooner the better.

Saturday morning started with the traditional Mara Morgensen Flaherty Memorial Lectureship. Terry A. Badger, PhD, RN, FAAN presented an excellent lecture entitled Depression Assessment and Psychosocial Interventions for Cancer Survivors and Partners. The lecture started with the re-definition of the social network: change in the traditional household and who is important. Her take-home message was: If you are important to the person you are a partner whether or not related by blood or marriage.

Briefly, the content of her lecture dealt with the facts that depression is an important issue in cancer survivorship and it significantly influences cancer recovery, quality of life and possibly, long-term survival. Further, partners of cancer survivors often suffer the same or higher levels of emotional distress as the patient. She described several barriers which hinder the assessment process. Finally, she stated that all nurses can provide assessment, patient education and information, referrals and therapeutic social support.

One of the last sessions on Sunday morning, was “Clinical Hot Topics”. This presentation featured several of cancer treatment modalities, the place of pharmacovigilance and pharmacogenomics in cancer treatment, special nursing considerations for emerging side effects of these drugs, and how cancer genetics may influence treatment decisions in the future.

Other Highlights Meeting with the executive board of ONS as well as various ONS project leaders was a highlight of the conference for me. Topics relating to possible EONS/ONS collaboration were discussed and mapped out. Further talks with Paula Rieger Trahan (ONS CEO), Len Mafrica (International Affairs), Brenda Nevidjon (President) and Georgia Decker (Past president) will explore the possibilities of the collaboration of EONS with ONS. We agreed that we could imagine joining forces on developing guidelines and leadership programs adapting the content accordingly to European circumstances.

There was time in the evening to see a bit of Philadelphia, visit the parks, enjoy a baseball game with the “Phillies” (they won) and get the feel of life outside of oncology nursing.

To say the least, after five days of conference one left with a wealth of information and with a feeling of confirmation that one is doing the right thing. I also had the feeling that we have a great task ahead of us in light of the changing health care systems around Europe and the world and it will be a challenge to provide competent, safe, and equal cancer nursing care for all. I came away realizing that European nursing does not differ greatly from that in the U.S. but because of the structure of Europe we definitely have greater gaps in the standardization of cancer care.

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Skills Development

Different approaches to leaning

Jan Foubert, Lecturer, Erasmushogeschool, Department of Healthcare, Brussels Introduction A skill is the learnt capacity or talent to carry out pre-determined results often with the minimum outlay of time, energy, or both.

Skills can often be divided into domain-general and domain-specific skills. For example, in the domain of work, some general skills would include time management, teamwork and leadership and self motivation whereas domain-specific skills would be useful only for a certain job.

The following skills, self-confidence, ability to uncover hidden opportunities, decision-making abilities, networking skills, relevant experience and knowledge of changes in the labour market relate well to some characteristics of our imagined 21st century learners.

Currently, learners may gain such skills and experiences more from their informal social activity through travel, internet and mobile-phone communication, than through formal learning within institutions of higher education.

Skill development Higher education may have to respond to the opportunistic, flexible, pro-active approaches to learning which modern social activities and life-styles represent (Bloxham 2004). It may need to do much more to: • identify the individual styles and experiences which learners bring to the learning process and the learning strategies which are at their disposal; • design and develop responses to these styles and strategies such as new materials, new delivery, new environments; • develop and respond to new concepts of competency and jobrelatedness; • combine imagination and specificity in refinement of formative and summative assessment; • handle the huge tensions between such complex flexibility and the safeguarding of standards.

As educator’s we cannot force students but we can help students to develop skills and strategies for more effective learning. We can help them to be reflective about how they approach learning, to be self-directed, and to be able to sustain motivation (Pintrich, 2004). Traditionally, it was assumed that students acquired these skills as they mastered subject content. Research into how students learn in higher education suggests learning is very contextualised; students need to see how skills relate to a subject which enables them to transfer and connect the new skills to the material being studied (Pintrich, 2004; Schunk & Ertmer, 2000). This results in better learning and better understanding (Biggs, 1999). There is not one best method to stimulate skill development but the student approach to learning and the self regulated learning can be used as an example.

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Recommendations to enhance skill development include: • Include learning skills within the students’ regular learning environment and integrate with the subject content; • Provide support for interventions that increase the use of specific cognitive and self regulatory strategies; • Define a deep and surface approach (O’Connor, 2006).

Conclusion As educators we can intervene at several levels of the learning environment to help students develop their learning skills and improve the support they receive while learning. We should incorporate skills development in educational courses and provide opportunities to practice learning skills in context. Although we are the teachers, we should remember that there is not one ‘right way’ to do anything.

References Biggs, J. B. (1994). Student learning research and theory: Where do we currently stand?

In G. Gibbs (Ed.), Improving student learning: Theory and practice (pp.

1-19). Oxford: Centre for Staff Development.

Bloxham, S. (2004). Embedding skills and employability in higher education: an institutional curriculum framework approach. Retrieved 6 February 2006 from the Higher Education Academy web site: http://www.heacademy.co.uk.

Connor, H., Pearson, R., Court, G. and Jagger, N. (1996). University Challenge: Student Choices in the 21st Century. Brighton: The Institute for Employment Studies.

O’Connor, T. W. (2006). Developing effective learners in higher education: A case study of different approaches to teaching learning skills in context and integrated with academic content. Unpublished doctoral thesis, University of East London, London, England.

Pintrich, P. R. (2004). A conceptual framework for assessing motivation and self-regulated learning in college students. Educational Psychology Review, 16 (4), 385-407.

Schunk, D. H. & Ertmer, P. A. (2000). Self-regulation and academic learning: Self-efficacy enhancing interventions. In M. Boekaerts, P. R. Pintrich & M. Zeidner (Eds.), Handbook of self-regulation (pp. 631649). San Diego, CA: Academic Press.

“Sol Omnibus Lucet”

-The Sun Shines on Everyone-

The Faculty of Health Sciences of Semmelweis University Hungary, Budapest

Prof. Judit Mészáros Ph.D. Dean, Csaba Avramucz RN, MSN, assistant lecturer Semmeweis University Faculty of Health Sciences Our motto “The sun shines on everyone” is meant to characterize the foundation of both our personal and professional approach to the work we do. This ancient phrase represents the ethical paradigm that there are no fundamental differences between people regarding truly important things that are common to all of humanity.

Hungary, as a member of the European Union, belongs to the unified European Higher Education Area, which in principal follows the British and American multi- cycle (bachelor, master and doctorate) training system. The qualifications are comparable and recognized across Europe. In this system it is much easier for students, lectures and researchers to travel and build international relations, moreover, as citizens of the European Union they can continue their studies and plan their future as employees or entrepreneurs in each member state. These opportunities open up a wider field also for nonEuropean citizens studying in Hungary, since the possibilities of internal mobility inside the unified Europe are based on the training channels and close relationships between countries, in the labour market and among institutions.

Semmelweis University is Hungary’s largest higher education institution training physicians and health care professionals. Presently there are more than 8000 students studying at this over 200- year old university. The Faculty of Health Sciences of Semmelweis University provides training at an international level in the field of health sciences and awards internationally competitive diplomas.

There is an ever increasing choice in training health professionals with about 200 lectures and part- time teachers of distinction working within the Faculty.

The Faculty offers study rooms, lecture halls, computer rooms, specialist laboratories, a public library, all equipped with state-of the art technology, as well as a great variety of active student life and a motivating environment to prospective students. There are also job opportunities for students within the University during term- time and the summer vacation. The main advantage attracting international students is that while the level of training is outstanding, tuition fees and the cost of living are considerably lower than at any other university in Central and Western Europe.

The range of job opportunities covers a large area in Hungary and naturally in all countries in the European Union. Besides the general opportunities of employment- primary care, out- patient clinic network, in- patient care- graduates can get jobs in range of areas that have emerged recently in the field of health care (e.g. visitor of surgeries, pharmacies and hospitals, transplantation coordinator, and nurse and organizer in various health care servicing enterprises within the private sector). The physician, pharmacist, dentist, nurse and midwife diplomas issued by Semmelweis University are universally accepted in the member states of the European Union.

There is a shortage of trained nurses in Europe and the United States of America, so it is fairly easy for our graduates to obtain work permission there.

The structure of the BSc programmes in the multi- cycle training system in terms of specialization Nursing and patient care programme • Nurse specialist programme (full time and correspondence course) • Dietician specialist programme (full time and evening course) • Physiotherapist specialist programme (full time and evening course) • Paramedic specialist programme (evening course) • Midwife specialist programme (full time and correspondence course) Health care and prevention programme • General public health inspector specialist programme (full time and correspondence course) • Health visitor specialist programme (full time course) Medical laboratory and diagnostic imaging programme • Diagnostic imaging analyst specialist programme (evening course) • Optometrist specialist programme evening course) The structure of the MSc programmes in the multi- cycle training system in terms of specialization • Nursing and patient care master’s programme • General public health master’s programme • General public health officer specialist programme • Health care manager master’s programme Our postgraduate training programmes • Substance abuse counselor, health care manager, school nurse, clinical engineer, cardiology technician, wellness manager, acute care nurse.

The Transatlantic Nursing Curriculum Project (TCN) A unique international project has been started to educate nurses at Semmelweis University, Faculty of Health Sciences. Against the framework of being the largest transatlantic curriculum project between the European Union and the United States, for the first time a dual-degree can be given with Hungarian contribution in the field of health science. The common consortium between Semmelweis University, Faculty of Health Sciences (Hungary), Nazareth College of Rochester (USA) and Laura University of Applied Sciences (Finland) offers a possibility for nurses to accomplish some courses at the Nazareth College of Rochester in the United States with scholarship support from the European Union. The university offers the American BSc nurse degree and the purchase of work registration. The cooperation agreement was signed on 23 June 2008 at the Faculty of Health Science, Budapest.

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In this unique program the American, Finnish and Hungarian institutes share a common concern for developing a new health training programme which can exceed the BSc system considering its transatlantic objectives.

The support of the Atlantis Program, which is the base of the cooperation, has already been won by 107 transatlantic consortiums.

However, it is the first cooperation regarding nursing education which is aimed at the development and purchase of a training graduate accepted on both continents (Europe and North-America).

All students with such scholarship can receive a degree at both Semmelweis University and Nazareth College through the mutual admission of the studies between their institutes. In addition, they can get the possibility to make a NCLEX test (American nursing registration test). In the course of the students’ foreign studies, they could acquire vocational-, cultural- and lingual - communicational knowledge, experiences and competences which could influence their whole vocational career and they can get new job opportunities both in Europe and in America. Through their foreign studies they will have the possibility to do their thesis and to continue their work using the opportunities of the receiving institution.

This September, 16 students are going to start the training, 8 American students and 8 European (4 Hungarian and 4 Finnish).

Ones students can participate in the programme after an application process and they will study in Finland, America and Hungary in the following four years. The education is free and the students obtain a scholarship.

Lectures and seminars are held in English, which may mean great advantage in case of finding a job either in Hungary or abroad.

International relations The Faculty takes pride in its extensive international relations in Europe, Asia and America. In Europe under the scheme of the ERASMUS Exchange Programme every year 15-20 students and lectures have the opportunity to enhance their professional skills and knowledge abroad.

Students spend 3 month in their fourth year at the Finnish, Swedish, Norwegian, Dutch, Belgian, Greek, Spanish and Turkish partner institutes, where they participate in professional training. In addition, there are shorter, 1-3 weeks long further training course available for them within the framework of the ERASMUS programme and through the coordination of the COHEHRE organisation for European higher education in health. The international scholarship can be obtained via application. Every year there are scholarship students who spend a whole month in the United States and who are also selected with the help of application. The Nazareth College of Rochester, New York State annually organises a four – week long intensive English language, professional and recreational programme for our students in July. All the registered students of our faculty can submit their application for this training, in which almost 100 students and lectures have participated in the last three years.

The Faculty of Health Sciences has partnerships with several renowned universities also from the Asian region ( Anhui University of TCM, Beijing Medical University, Shanghai Jiao Tong University, Shenyang Chinese Medical University), which provides further opportunities for students and lecturer exchange.

Should you need any information about our educational programmes (including the training of oncology nursing); please don’t hesitate to contact us. Ideas or suggestions for eventual future international collaboration are most welcome too. To contact us, please use: meszarosj@se-etk.hu OR csabaavramucz@yahoo.com. For further information log on to: http://www.seetk.hu OR www.tcn-atlantis.org

A Summary of the Bologna Process

In summer 1999 the European ministers of education met in Bologna where they agreed to establish a “European Higher Education Area”.

This involved the introduction of the Bachelor’s and Master’s degrees (a 3-tier educational system) by 2010. The degrees would be valid throughout Europe and meet international norms. The Bologna Process aims to strengthen the competitiveness of European colleges and universities and support the mobility between educational institutions and courses of study.

As a result of the Bologna process, European colleges and universities are not only optimizing their former academic structures, but also the content of their academic programmes. The reform of higher education has resulted in new opportunities to address age-old problems and actively pursue academic policies. Uniform admission criteria, practical application, a clear orientation of competence and streamlined degree programmes can reduce the average length of study and increase the number of graduates. Innovative and interdisciplinary, courses of study have given universities a competitive edge both nationally and internationally.

The Bologna Process and the European Qualification Framework are without a doubt having an impact on Directive 36 which is the

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Directive on Mutual Recognition of Professional Qualifications of Nurses. The objectives of the Bologna Process are: • Adoption of a system of easily accessible and comparable degrees (Bachelor’s Master’s and PhD degrees) • Establishment of a European credit transfer system • Promotion of mobility • Promotion of European co-operation in quality assurance • Promotion of the European dimension in higher education • Life long learning • Greater involvement of students • Attractiveness and competitiveness of the European Higher Education Area In follow up to the original meeting, working groups on mobility, employability, qualifications, lifelong learning, social dimensions, and the position on the European Higher Education Area in a global context have been recently established. Of particular interest is the agreement that the 46 Bologna signatory countries will develop national qualification frameworks, to be referenced against the Bologna 3-tier structure, by 2010.

More information on the Bologna Process is easily available in many languages on the internet.

Addressing the Training Needs of the Cancer Workforce

Insights from one Cancer Network in London

Dr. Daniel Kelly, Reader in Cancer & Palliative Care, School of Health & Social Science, Middlesex University, London Education and training are considered central to the delivery of the UK Government’s modernisation agenda for the National Health Service with more than £3 billion now being invested in such activities each year. Strategic Health Authorities in England are expected to ensure that education (including cancer education) is relevant to the needs of local health economies. For example the Strategic Health Authority for the capital – known as NHS London - manages the performance of 31 primary care trusts, 35 acute trusts, 9 mental health trusts and the London Ambulance Service.

Continuing Professional Development (CPD) and lifelong learning strategies are intended to be closely aligned to service modernisation and the needs of patients themselves. In a rapidly changing health service, a key requirement is that value for money and research evidence is taken into account when commissioning education for the workforce. The National Cancer Plan (2000) also emphasised the need for ‘Investment to tackle key gaps in the cancer workforce and make better use of existing staff’ (p.11).

This presentation concerns a study carried out in an innerLondon Cancer Network in 2004-05. The aim was to explore what opportunities existed for professionals involved in the delivery if cancer care in specialist and general settings- as well as those involved in delivering care in the home.

were provided. The curricula of programmes did not reflect the ethnic or social profile of the local health economy and much of the CPD available had been continually provided for a number of years with little evidence of innovation.

Methods Using a range of survey and interview methods, 94 professionals were asked about their training needs in relation to their professional role, current education and training opportunities and future education priorities. An analysis of cancer-related content from the nursing and medical school curricula of three local universities was also carried out. Findings from the National Cancer Patient Survey for the same Cancer network were used to provide insight into needs of patients. Ethical approval was obtained from the local Research Ethics Committee.

Conclusions The training needs of the workforce in this Cancer Network were not reflected fully within available CPD courses and the needs of some members were being poorly addressed. In order to ensure that education meets the changing needs of the cancer workforce there is a need for more responsive commissioning as well as more creative provision by the university sector in the UK.

Key findings Findings from the study suggest a dominance of uni-professional, specialist cancer nursing focus with gaps for key members of the workforce (e.g. health care assistants, community nurses, allied health professionals and senior nurses). There was a lack of interprofessional education within the university sector although this was more common in the practice sector when education events

References Department of Health (2000) National Cancer Plan. Her Majesty’s Stationery Office, London.

Kelly D, Gould D, White I, Berridge EJ (2006). Modernising cancer and palliative care education: insights from one cancer network.

European Journal of Oncology Nursing, 10: 187-197.

Gould D, Kelly D, White I, Glen S (2004). The impact of the commissioning process on the delivery of continuing professional development for cancer palliative care. Nurse Education Today. 24: 443-443.

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23-25 April 2009

SARAJEVO, BOSNIA AND HERZEGOVINA Chair Co-Chairs

Host Chair

T. Cufer, (SI) H. Basic, (BA) (ESO) G. Maistruk, (UA) (EUROPA DONNA) J. Foubert, (BE) (EONS) S. Beslija, (BA) (Sarajevo)

Scope Further to the successes of the first Interconference Breast Cancer Meeting 2007, IBCM returns to bring the very latest in breast cancer research, treatment, care to the Balkan area, Central and Eastern Europe.

Within a truly multidisciplinary and multi professional setting, participants can expect a comprehensive review of cutting edge discovery from breast cancer biology and the clinic, the latest trends and developments in nursing care as well as updates on topical issues from the patient advocacy perspective.

To discover the many programme highlights of interest to the European oncology nursing community including the joint Europa Donna and EONS session on What do we need to know about counseling and prevention? and the Educational Session on Nursing intervention in breast cancer and so much more, EONS invites you to download your copy of the Advance Programme and register today at: www.ecco-org.eu (select ‘congresses and conferences’ > ‘IBCM-2’).

Dates to Bookmark Abstract submission open: 01 November 2008 Early rate registration deadline: 12 January 2009

Secretariat For further information and general enquiries please contact the IBCM Secretariat directly: ECCO – the European CanCer Organisation Avenue E. Mounier 83 B-1200 Brussels Belgium Tel: +32 2 7750201 Fax: +32 2 7750245 Email: IBCM2009@ecco-org.eu

Venue Parlamentarna Skupstina Bosne I Hercegovine (National Assembly Sarajevo) Trg BiH,1 71000 Sarajevo Bosnia & Herzegovina