*Article* **Nurses and Physicians' Perceptions Regarding the Role of Oncology Clinical Nurse Specialists in an Exploratory Qualitative Study**

**Keren Dopelt 1,2,\* ,† , Noam Asna 3,†, Mazal Amoyal <sup>4</sup> and Osnat Bashkin <sup>1</sup>**


**Abstract:** The purpose of the study was to examine the attitudes of nursing and medical teams about the role of oncology clinical nurse specialists in the healthcare system in Israel, where, unlike many countries in the world, such a role has not yet been developed or professionally defined. We conducted 24 interviews with physicians and nurses between August and October 2021. The interviews were transcribed and analyzed using a thematic analysis method. The Consolidated Criteria for Reporting Qualitative Research checklist was used to report the study. Five main themes emerged from the interviews: (1) contribution to the healthcare system, (2) contribution to the patient, (3) drawing professional boundaries, (4) additional responsibilities and authority for oncology clinical nurse specialists, and (5) the field's readiness for a new position of oncology clinical nurse specialists. The findings provide evidence about the need to develop the role of clinical nurse specialists in the oncology field due to its potential benefits for nurses, physicians, patients, family members, and the healthcare system. At the same time, an in-depth exploration of the boundaries of the role and its implementation, in full cooperation with the oncologists and relevant professional unions, is needed to prevent unnecessary conflicts in the oncology field. Professional development training programs in nursing must create a platform for open dialogue between key stakeholders, nurses, and physicians, in order to help all involved parties, place the benefits to the patients above any personal or status considerations.

**Keywords:** oncology; nursing; clinical nurse specialists; cancer patients; expanding nurses' authority; professionalization; policy; education

#### **1. Introduction**

Israel has approximately 200,000 cancer patients, with some 29,000 new cases annually [1]. The oncology field involves complex clinical treatments and deals with complicated psychosocial issues associated with patients and their family members [2]. In recent decades, countries throughout the world have developed medical support positions, such as clinical nurse specialists, as a strategy to meet the healthcare system's challenges. Studies show that clinical nurse specialists can provide the necessary medical care in situations meeting the position's definitional framework and, in a manner, offering the optimal response to patients' needs [3–5]. In the United States, there are about 300,000 clinical nurse specialists, and in the United Kingdom, about 3300, whereas in Israel, there are only 358 clinical nurse specialists working in the fields of supportive care (102), geriatrics (80), diabetes (32), surgery (30), premature infants (28), pain (8), rehabilitation (4), and policy and administration (74) [6].

**Citation:** Dopelt, K.; Asna, N.; Amoyal, M.; Bashkin, O. Nurses and Physicians' Perceptions Regarding the Role of Oncology Clinical Nurse Specialists in an Exploratory Qualitative Study. *Healthcare* **2023**, *11*, 1831. https://doi.org/10.3390/ healthcare11131831

Academic Editors: Margaret Fitch and Joaquim Carreras

Received: 3 May 2023 Revised: 5 June 2023 Accepted: 21 June 2023 Published: 22 June 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

There are barriers and disagreements regarding the definition, authority, and recognition of this role in Israel's healthcare system, which make it difficult to expand it to other clinical areas [7]. Oncology nursing is a challenging and evolving profession that requires regular updating about both the medical aspects of the disease and the mental and social factors related to its diagnosis and treatment [8]. The oncology clinical nurse specialist can improve patients' health outcomes and quality of life indicators [9] and thereby increase patients' satisfaction with the treatment and involvement in disease management [10,11]. Moreover, integrating clinical nurse specialists leads to decreased rates of hospitalization, mortality, and complications [12].

A recent study in Israel examined the experiences of 39 clinical nurse specialists in supportive care. The nurses reported dissatisfaction with the work environment and with how their role was recognized and implemented by hospital physicians and managers. In addition, the limited authority they were granted did not correspond to the description of the role [13]. These findings are consistent with the results of a previous study conducted in Canada, which found barriers to the implementation and assimilation of clinical nurse specialists, including the lack of a model to guide the implementation of the role, lack of an agreed-upon description of the role and responsibilities; and lack of ongoing support and mentorship [14].

Despite the positive evidence of the inherent benefits of oncology clinical nurse specialists, there is disagreement about the role's definition and necessity. A study that examined the perceptions of this role in the field of oncology found that definitions of the position were unclear. While physicians and managers perceived the role of an oncology clinical nurse specialist as "helping" medical practitioners in managing their workloads, the oncology clinical nurse specialists themselves perceived their role as promoting holistic, patient-centered care and proactively meeting the unique oncology patients' needs [11]. Conflicts concerning the boundaries of the role, lack of resources and organizational and systemic support, and physicians' fear that clinical nurse specialists will replace them limit the potential of the role and reduce its essential contribution to quality care in oncology [11].

The growing number of cancer patients and their multiple needs, the shortage of oncologists, and the rapid changes in the clinical, organizational, and technological environment in the field of oncology highlight the need to update the clinical and managerial skills of oncology nurses. The literature shows that oncology clinical nurse specialists offer many advantages. However, in contrast to many countries around the world (the United States, Canada, the United Kingdom, Japan, Brazil, and others), in Israel, the position of an oncology clinical nurse specialist has not yet been established. Implementation of this role in the healthcare system in Israel depends to a large extent on a characterization of the position, understanding its benefits for the healthcare system and the patients, and an in-depth understanding of the barriers to its implementation that must be taken into account already at the planning stage. The purpose of the present study is to examine the potential contribution of oncology clinical nurse specialists as seen through the eyes of medical and nursing professionals.

#### **2. Methods**

We conducted an exploratory qualitative study using semi-structured interviews. The study was approved by the Ashkelon Academic College Ethics Committee (Approval No. 20-2020). The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to report the study.

#### *2.1. Population and Procedure*

Semi-structured in-depth interviews were conducted between August and October 2021, after informed consent was obtained from twenty-four healthcare professionals from various medical centers in all geographical parts of Israel, using purposeful sampling. Purposeful sampling is a non-random sampling technique that uses specific criteria or purposes to select a sample [15]. The aim is to collect in-depth information from the right

respondents. The inclusion criteria: oncology doctors or nurses, doctors or nurses in the position of decision-makers, or clinical nurse specialists. We continued the interviews until theoretical saturation was reached. To recruit interviewees, we contacted people working in the field of oncology and invited them to take part in the study. We asked each participant to provide the name of a colleague who would be willing to participate in the research. Among the twenty-four interviewees, six were physicians and eighteen nurses. Seven interviewees were males, and seventeen were females. All interviews were conducted over the telephone due to COVID-19 social distancing restrictions and were audiotaped and transcribed verbatim in Hebrew. It was emphasized to the interviewees that their details would remain confidential, no findings would be published under their name, and they did not have to answer all the questions, or they could stop the interview. The interviewer was a Clinical Psychology graduate student, trained in qualitative research methods and supervised by KD and OB. There was no relationship between the interviewer and the participants. The interviews lasted between 30 and 50 min.

#### *2.2. Study Tool*

The in-depth interview guide was developed in collaboration with oncology staff members and drew on our literature reviews. The interview guide was validated using the content validation method by two oncology nurses and two physicians to ensure that the questions were relevant to the study goals. The guide was pilot tested with one oncology nurse to ensure a smooth interview flow and verify comprehension of the questions. Information collected during the interviews included perceptions toward the role of nurses in cancer care and the need to develop oncology clinical nurse specialists training (Appendix A).

#### *2.3. Data Analysis*

The interviews were transcribed accurately by a professional and analyzed using a thematic analysis method based on grounded theory [16] in the ATLAS.ti v.8 software (Berlin, Germany). The Grounded Theory method uses both an inductive and a deductive approach to theory development. Our analysis included incorporating deductive themes arising from the research topics and based on a literature review of quality in cancer care and cancer survivors' needs, together with inductive themes that emerged from the data [17]. The interpretive analysis was done close to the interviews in several stages: (1) the interviews were read at least once by KD and OB to gain in-depth knowledge of the data. (2) KD and OB identified ideas, categories, and themes related to the study's objectives. (3) central themes were redefined to include encoded quotes and examples based on re-reading the transcripts. Relevant passages were marked and allocated to one of the content themes. The themes and quotes were examined iteratively by all authors and documented in English at the final stage. The description of the findings was accompanied by citations from the interviewees and thus provided continuous evidence for matching the interpretation and the interviewees' unique voices.

#### **3. Results**

*3.1. Participants' Characteristics*

Participants' characteristics and codification are available in Table 1.




*Healthcare* **2023**, *11*, x 4 of 14

**Table 1.** Characteristics of the interviewees (P = Physician, N = Nurse).

Association (IMA)

**Table 1.** *Cont*. P3 Female Hospital Oncologist P4 Male Hospital and Community Oncologist, Head of the Oncology department

**Code Gender Role** 

#### *3.2. Main Themes 3.2. Main themes*

Five main themes emerged from the interviews: (1) contribution to the healthcare system, (2) contribution to the patient, (3) drawing professional boundaries, (4) additional responsibilities and authority for oncology clinical nurse specialists, (5) the field's readiness for a new position of oncology clinical nurse specialists. A conceptual map of the main categories is presented in Figure 1. Five main themes emerged from the interviews: (1) contribution to the healthcare system, (2) contribution to the patient, (3) drawing professional boundaries, (4) additional responsibilities and authority for oncology clinical nurse specialists, (5) the field's readiness for a new position of oncology clinical nurse specialists. A conceptual map of the main categories is presented in Figure 1.


**Figure 1. Figure 1.** A conceptual map of the main categories. A conceptual map of the main categories.

The themes, with quotes that illustrate each, are presented in Tables 2–6.


**Table 2.** Theme 1—Contribution to the healthcare system.

emergency room is a very difficult experience for the patient. It exposes them to infections, and they wait for many hours. If someone in the community will go to the patient and take care of things that a nurse can do at the patient's home, it will be great for everyone." (N3)

"No one sees the patient as a whole, all the various aspects related to dealing with his medical condition. And I think that nursing, specifically, is a field that really keeps an overall view of the patient." (N5)

"Many patients in the community fall through the cracks, they are neither here nor there. There are oncology patients in advanced stages, but not yet in hospice or terminal. They need follow-up. A clinical nurse specialist in oncology can provide the solution." (N3)

"The nurse frees me from the secondary things. This does not free me from seeing the patient, from providing treatment and instructions. But it improves service to the patient." (P5)


**Table 4.** Theme 3—Drawing professional boundaries.

#### **Quotes**

"The difference between a nurse in an oncology ward and a clinical nurse specialist is their authority and in-depth learning. [They can do] things that an ordinary nurse doesn't have the authority to do: prescribe medications, give referrals for tests, make decisions regarding treatment. At the same time, they have excellent psychosocial skills. [They know] how to communicate with families and people in complicated situations, [to deal] with ethical dilemmas, to support a person at the end of life, and to manage a decision-making process in cooperation with the patient and the family." (N8)

"The added value is that she can provide a sense of balance to patients. She will outline the treatment. Today, she receives instructions from a physician. But if she has the whole range of knowledge about the treatments, the indications, she will have room to take independent action. If we have a clinical nurse specialist in oncology, she will need, for example, to have the ability to respond and make a medical decision about starting a new medication." (P1)

**Table 6.** Theme 5—Conflicts of oncology clinical nurse specialists' professional status.


Nurses and physicians described multiple benefits of oncology clinical nurse specialists to the healthcare system:


However, some physicians argue that the solution to the workforce problem is to add physicians and not to transfer responsibilities to nurses.

#### **Theme 2—Contribution to the patient.**

In terms of contribution to the patient, interviewees mentioned a response that is holistic and available and reduces bureaucracy and waiting time. It is particularly important to integrate the role of clinical nurse specialists into community healthcare settings and to improve services and support for convalescents. The nurse will maintain continuity in the transition between the hospital and the community. This can reduce the need for hospitalization to receive further treatment and alleviate the burden on physicians so that most treatment for convalescents will occur in community settings.

#### **Theme 3—Drawing professional boundaries.**

Clinical nurse specialists in various fields expressed concern about the Ministry of Health's unwillingness to grant real responsibility to clinical nurse specialists. They also described dilemmas regarding nurses' willingness to take on the responsibility of managing treatments or administering medications.

According to the physicians' perception:


#### **Theme 4—Additional responsibilities and authority for oncology clinical nurse specialists.**

Nurses suggested expanding the responsibilities of oncology clinical nurse specialists to include:


Physicians suggested that the position of OCNS should include the following:


#### **Theme 5—Conflicts of oncology clinical nurse specialists' professional status.**

Oncology nurses raised concerns about how physicians would accept oncology clinical nurse specialists. Clinical nurse specialists in other fields mentioned the gaps between the job definition compared to their actual responsibilities and the current situation in the field. The main gap pertained to prescriptions for medications given by nurse specialists, which the Pharmacists Ordinance does not recognize. So, despite their professional knowledge and experience in giving prescriptions, their authority is not recognized in practice. Another issue is that the nurses' responsibilities are not being implemented, making it difficult to grant them more extensive responsibilities. Clinical nurse specialists described the challenges in the implementation process and gaining recognition of their role by the physicians. All nurses mentioned the importance of recognition of this role by physicians.

Physicians referred to the importance of implementing and defining the role in order to promote cooperation in the workplace so that more physicians will recognize clinical specialists as having the knowledge and authority to give advice and as people who can offer teaching and training.

#### **4. Discussion**

The current study aimed to examine the perceptions of nursing and medical teams about the role of oncology clinical nurse specialists. The findings reveal a complex picture regarding the OCNS role and the need for expanding nurses' authority. The delegation of authority from physicians to nurses represents one of the most important elements in the professionalization process of nursing [18] and expanding nurses' authority is a significant contributor to professional autonomy [19]. Various studies describe positive attitudes of physicians and nurses toward expanding nurses' authority in several areas based on their belief that this will improve the quality of care [20–22].

The oncology nurses, some of the clinical nurse specialists, the nurses from the Ministry of Health nursing management, and the oncology physicians were unanimous about the need for oncology clinical nurse specialists' role and about the ability of the nurses to serve as case managers. Nurses related that they see the development of an oncology clinical nurse specialist as an opportunity for professional development, especially in community healthcare settings. From an oncologist's perspective, oncology clinical nurse specialists provide a reliable, professional workforce that can relieve their burden and improve the quality of service to the patient.

Our findings are consistent with other studies conducted around the world indicating the importance of the oncology clinical nurse specialists in several aspects: improving cancer diagnosis and treatment services [23]; preventing the need for hospitalization and emergency services [23,24]; reducing hospitalizations [25]; issuing faster and more accurate therapeutic prescriptions; providing a reliable, accessible, and available source of information [26]; and providing psychosocial support for patients and their family members [27,28].

According to interviewees, the oncology clinical nurse specialist role can offer the added value of comprehensive treatment because currently, no single healthcare professional performs the function of providing overall management of the treatment. Similarly, Griffiths [29] reported that oncology clinical nurse specialists view the treatment of cancer patients from a holistic perspective. Brooten [30] finds an economic rationale for expanding the authority of oncology clinical nurse specialists because they provide high-quality care while potentially reducing healthcare's high costs, given that they earn significantly lower wages than physicians.

In the United Kingdom, clinical nurse specialists provide care once performed by physicians (prescribing medications, making diagnoses), thereby reducing the burden on physicians [31], shortening waiting times for receiving oncology services, and making treatment accessible to patients who live in peripheral areas [32]. Since 2010, the Australian government has been operating rural oncology clinics managed by oncology clinical nurse specialists to bridge gaps in access to oncology services between big cities and remote areas [9,33]. Therefore, a training and implementation model for clinical nurse specialists in oncology will empower nurses, benefit patients, reduce healthcare costs, and relieve the burden on oncology physicians, especially in peripheral areas suffering from a lack of physicians.

Despite all the inherent advantages and potential of the oncology clinical nurse specialists, some of the clinical specialist nurses and physicians from professional organizations thought that such a position is not necessary, and that even if extra assistance is needed, it can be provided by physician assistants (for example, paramedics who will undergo appropriate training) and not necessarily by a clinical nurse specialist nurse. Reasons given for this approach included: possible erosion of physicians' status; physicians not recognizing the role and broad responsibilities of clinical nurse specialists; objections to compromising and accepting fewer professional personnel rather than increasing the number of physicians; and ambiguity regarding the role and the need for a clear and precise definition its responsibilities. Oncology nurses also raised concerns about a lack of recognition of the role on the part of the doctors. The scientific literature frequently mentions topics such as tension with other professionals, intruding on the responsibilities of other professionals in a way that harms teamwork, and ambiguity of the role of clinical specialists working in a multidisciplinary team [34]. Other studies have found that the main challenges in implementing this role are a poor understanding of it among decision-makers, lack of clarity about the role, lack of support from management, and misunderstanding of it among the medical staff [35–37]. Additionally, previous studies have documented condemnations of the role and criticisms of inappropriate and wasteful use of nursing personnel [27]. All these reasons mentioned in the interviews in the current study and in previous studies indicate that interviewees and researchers in the field agree that it is necessary to define clear responsibilities for the clinical nurse specialists and the maximum limits of the role's authority [27,38].

Given the global shortage of medical and nursing staff, the World Health Organization (WHO) stated in the Munich Declaration [39] that healthcare systems must develop new roles for nurses working in hospitals and in the community. The interviewees in the current study said they think that the new role is crucial for community healthcare. Many cancer patients are treated in community healthcare settings, and cancer survivors need treatment and follow-up care in the community. Continuity between treatment in hospitals and community healthcare clinics has a considerable effect on oncology patients. Studies show that such continuity is linked to high patient satisfaction, improved quality of life and mental health indicators [40,41], improved responsiveness to treatment, and better therapist-patient communication [42]. In contrast, lack of treatment continuity was found to be related to increases in the use of unnecessary medical services [43], hospitalizations, and visits to emergency medical facilities [42].

Cancer requires complex treatment, the use of different sections of the healthcare system, and multiple caregivers. Patients and their families frequently report a lack of information concerning treatments, professionals, ways to communicate with healthcare providers, and above all, how to navigate the healthcare system [44]. Oncology clinical nurse specialists can fill this vacuum and play a key role in facilitating cancer patients' encounters with the system. Support for this role was found both in research in the field of oncology and in studies that examined managing chronic care by nurses [45–48].

#### *Study Limitations*

The sample is limited but is considered reasonable for exploratory studies using qualitative research methodology [49]. We made efforts to include a wide range of stakeholders related to the research topic from various settings and regions in Israel in order to obtain responses from a broad and diverse swath of the healthcare system in Israel. Moreover, the interviews were transcribed from Hebrew, the native language of Israel. This may have increased the chances for variations in the interpretation of our data. We made all efforts to ensure methodological rigor and validity of the translations from Hebrew to English by using a standardized codebook, meeting frequently, sharing and comparing our results, and performing a pilot analysis. Throughout the study, we conducted an internal quality audit during our meetings, adapted from Tong et al. [50], to determine whether the data were collected, analyzed, and reported consistently according to the study protocol.

#### **5. Conclusions**

Multidisciplinary, coordinated, and holistic treatment may respond to the psychosocial and clinical issues facing the oncology field. The findings of this study provide evidence about the need to develop a new role of oncology clinical nurse specialists in Israel due to its potential benefits for nurses, physicians, patients, family members, and the healthcare system as a whole. At the same time, the conclusions drawn from the study reveal a complex challenge. An in-depth exploration of the boundaries of the role and its implementation, in full cooperation with the oncologists and relevant professional unions, is needed to prevent unnecessary conflicts in the oncology field. Professional development training programs in the nursing field must create a platform for dialogue between management and key stakeholders of nursing and medical departments in order to help all involved parties place the benefits to the patients first, and above any personal or status considerations. The role of oncology clinical nurse specialists can potentially impact the quality of care, prevent hospitalizations, alleviate the pressure and burden on physicians, and reduce costs for the healthcare system. In addition, we recommend extending the responsibilities of oncology nurses to those that exist in various countries around the world (e.g., Germany, Australia, the United States, etc.) and formally designating them as treatment managers. Additionally, we recommend that more nurses be available in the community to provide support, companionship, and follow-up to cancer survivors. Based on these findings, we recommend further research examining cancer patients' attitudes toward this suggested new role in oncology nursing in Israel.

**Author Contributions:** Conceptualization: K.D., O.B., N.A. and M.A.; Methods design: K.D. and O.B.; Managing data curation: K.D. and O.B.; Analysis and interpretation: K.D., O.B. and N.A.; Writing—original draft: K.D. and N.A.; Review and editing final draft: O.B., K.D., N.A. and M.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was supported by the National Institute for Health Services Research and Health Policy, Israel (Grant number 2020/120).

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Ashkelon Academic College (Approval # 20-2020).

**Informed Consent Statement:** Written informed consent was obtained from all participants in the study. No personal information of participants is published in the article.

**Data Availability Statement:** The data that support the findings of this study are available from the corresponding author.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **Appendix A Interview Guide**


#### **References**


**Disclaimer/Publisher's Note:** The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

**Ching-Hui Cheng <sup>1</sup> , Shu-Yuan Liang 2,\*, Ling Lin <sup>1</sup> , Tzu-Ting Chang <sup>3</sup> , Tsae-Jyy Wang <sup>2</sup> and Ying Lin <sup>2</sup>**

<sup>1</sup> Department of Nursing, Cheng Hsin General Hospital, Taipei 112, Taiwan


**\*** Correspondence: shuyuan@ntunhs.edu.tw

**Abstract:** In Taiwan, oral cancer is the fourth most common cause of cancer death in men. The complications and side effects of oral cancer treatment pose a considerable challenge to family caregivers. The purpose of this study was to analyze the self-efficacy of the primary family caregivers of patients with oral cancer at home. A cross-sectional descriptive research design and convenience recruiting were adopted to facilitate sampling, and 107 patients with oral cancer and their primary family caregivers were recruited. The Caregiver Caregiving Self-Efficacy Scale-Oral Cancer was selected as the main instrument to be used. The primary family caregivers' mean overall self-efficacy score was 6.87 (SD = 1.65). Among all the dimensions, managing patient-related nutritional issues demonstrated the highest mean score (mean = 7.56, SD = 1.83), followed by exploring and making decisions about patient care (mean = 7.05, SD = 1.92), acquiring resources (mean = 6.89, SD = 1.80), and managing sudden and uncertain patient conditions (mean = 6.17, SD = 2.09). Our results may assist professional medical personnel to focus their educational strategies and caregiver self-efficacy enhancement strategies on the dimensions that scored relatively low.

**Keywords:** caregiving self-efficacy; family caregiver; oral cancer

**Citation:** Cheng, C.-H.; Liang, S.-Y.; Lin, L.; Chang, T.-T.; Wang, T.-J.; Lin, Y. Caregiving Self-Efficacy of the Caregivers of Family Members with Oral Cancer—A Descriptive Study. *Healthcare* **2023**, *11*, 762. https:// doi.org/10.3390/healthcare11050762

Academic Editor: Margaret Fitch

Received: 30 December 2022 Revised: 2 March 2023 Accepted: 3 March 2023 Published: 5 March 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

#### **1. Introduction**

In 2018, oral cancer incidence and death were the highest among men in Taiwan, and oral cancer was the fourth most common cause of cancer-induced death in men [1]. When patients with oral cancer undergo treatment and experience its side effects [2–4], patients themselves, their families, and medical caregivers encounter great challenges in caregiving.

Stage classification of oral cancer includes four stages according to the size of the primary tumor (T), involvement of locoregional lymph nodes (N), and distant metastases (M) [5–8]. Stage I is determined by T1–2 and N0–1, stage II by T1–2 and N2 or T3 and N0–2, and stage III by T4 or N3. Stage IV is for patients with metastatic disease [7]. This classification can aid in treatment planning, the estimation of recurrence risk, and the assessment of patient survival [5]. The overall 5-year survival rate for patients in a cohort study at Memorial Sloan Kettering Cancer Center was 63% [9]. In a multicenter retrospective analysis, an advanced T stage was significantly correlated with poor overall survival and disease-specific survival of patients [10]. Lymph node involvement is the most important prognostic factor in oral cancer. The survival rate is reduced by 50% when compared with those with similar primary tumors without neck lymph node involvement [11,12]. The impact of oral cancer at different stages on patients' physical symptoms and impairments was supported, especially the impact of advanced oral cancer [13].

Oral cancer treatment may involve the combined use of surgery, chemotherapy, and radiotherapy, among which surgery is the most essential [14]. However, surgical treatment may change patients' facial appearance and cause oral disabilities, such as impaired communication and eating functions [2]. In addition, patients with oral cancer encounter

the side effects of chemotherapy or radiotherapy. Therefore, care for oral cancer is more challenging than that for other cancers [15].

In Taiwan, family members play a crucial role in the home care of patients with oral cancer, as exemplified by the trends during outpatient treatment. For instance, these family members handle patients' nutritional problems, make care decisions, manage diseaserelated emergencies, and seek relevant resources [16]. However, the difficulties they encounter during home care [16] may discourage these family members from putting effort into patient care, particularly when they lack belief in their own capability, worsening the subsequent care results.

Self-efficacy refers to an individual's capability belief or perceived capability to perform specific health care behavior [17]. During health care processes, self-efficacy is an essential ability that helps individuals overcome difficulties and strive for better health [18]. Self-efficacy is a key factor that affects health care behavior [19] because self-efficacy positively affects individuals' behavioral motivation and persistence when they encounter care difficulties [18].

In the research literature, investigations that examined the difference in gender regarding self-efficacy produced inconsistent findings. Several researchers described self-efficacy as one factor that accounts for gender differences [20,21]. While some researchers suggested that men reported greater self-efficacy than women [20], others suggested that females reported greater efficacy than men [21]. In contrast, no gender differences regarding self-efficacy ratings were noted in some studies [22–24].

Bandura [25] also suggested that age may be a factor that contributes to personal efficacy due to the biological processes of aging resulting in declining ability. Research on the effects of age on self-efficacy has produced mixed results [20,22–24]. Several studies indicated no relationship between self-efficacy ratings and age [20,22,24].

Educational and socio-economic levels may also be personal factors that are associated with self-efficacy since they lead to better access to resources. A researcher has suggested self-efficacy expectations as one factor that accounts for educational differences in responses to outcome measures [22]. However, several studies showed no relationship between selfefficacy and educational levels [23,24]. Most studies on the effects of economic levels on self-efficacy showed no significant difference [23,24].

Understanding the self-efficacy of family caregivers can assist medical teams to understand their capability belief in taking care of patients with oral cancer at home, identify relevant influential factors, and provide countermeasures to enhance their capability belief in patient care. This may improve the home care quality for patients with oral cancer. Therefore, the purpose of this study was to assess the self-efficacy of the primary family caregivers of patients with oral cancer at home.

#### **2. Methods**

#### *2.1. Study Design*

The current study adopted a cross-sectional descriptive research design and convenience recruiting to facilitate the sampling and discussion on the self-efficacy of the primary family caregivers of patients with oral cancer at home.

#### *2.2. Sample and Procedure*

In total, 107 primary family caregivers of outpatients were recruited for a structured questionnaire survey. The participants were enrolled from the radiology outpatient department of a teaching hospital in northern Taiwan from May 2016 to May 2018. Only patients who (1) were aged ≥20 years; (2) were diagnosed as having oral cancer; and (3) received oral cancer-related surgery, chemotherapy, or radiotherapy were included. Moreover, the family caregivers of these patients were required to be (1) aged ≥20 years, (2) recognized as the primary family caregivers by the patients, and (3) living with the patients.

After this study passed the ethical review and the family caregivers signed the informed consent form, a research assistant distributed our questionnaires to the family

caregivers. The assistant checked whether the retrieved questionnaires were completely filled out immediately after the caregivers submitted them. The participants who missed items were asked to fill them out. Regarding patient medical characteristics, they were all collected from medical records by the research assistant.

#### *2.3. Ethical Considerations*

This study was approved by the institutional review board of a teaching hospital in northern Taiwan (VGHIRB No.: 2014-04-001AC). The research assistant verbally explained the research objective, data protection principles, and research procedures to obtain the participants' consent and asked them to sign the informed consent form. Codes were used in the questionnaire in place of personal information to protect participant privacy. For participants who were unwilling to proceed with the survey or were not physically suitable for further investigations, the research assistant acknowledged their withdrawal intention and stopped collecting their data.

#### **3. Measures**

#### *3.1. Sociodemographic Variables*

The current study collected the sociodemographic variables of the family caregivers and patients' medical characteristics. The collected sociodemographic variables were sex, age, marital status, education level, religious affiliation, employment status, and household income. The collected medical characteristics were the time of sickness, stage of cancer, current treatment status, and treatment side effects. Information related to the family caregivers, such as the family caregivers' relationships with the patients, manner of care, and care time, were also collected.

#### *3.2. Caregiver Caregiving Self-Efficacy Scale-Oral Cancer*

The current study applied the Caregiver Caregiving Self-Efficacy Scale-Oral Cancer (CSES-OC) [26] to estimate the self-efficacy of the family caregivers. The scale consisted of 18 items. According to factor analysis, the scale could be divided into four subscales: acquiring resources (AR; six items), managing sudden and uncertain patient conditions (MS; five items), managing patient-related nutritional issues (MN; four items), and exploring and making decisions on patient care (MD; three items). Some examples of the items for AR are "I am confident that I am able to acquire financial support", "I am confident that I am able to seek consultation on the provision of sick family member care", and "I am confident that I am able to acquire respite from caregiving". Examples for MS are "I am confident that I am able to manage the sudden onset of conditions in the sick family member", "I am confident that I am able to handle uncertainty about cancer progression", and "I am confident that I am able to handle the sick family member's uncertainty about death". Examples for MN are "I am confident that I am able to prepare a suitable diet" and "I am confident that I am able to improve the sick family member's willingness to eat". Examples of the items for MD are "I am confident that I am able to explore the most suitable care for the sick family member" and " I am confident that I am able to make decisions on sick family member care". The Cronbach's alpha of each subscale ranged between 0.78 and 0.91, and that of the overall scale was 0.95. The test–retest reliability with a 2-week interval was *r* = 0.83 (*p* < 0.001), and its criterion-related validity with the General Self-Efficacy Scale was *r* = 0.59 (*p* < 0.001). Regarding the scale used, an 11-point Likert-type scale ranging from 0 (not at all confident) to 10 (completely confident) points was adopted, where the higher the total score, the higher the self-efficacy [26].

#### *3.3. Statistical Analysis*

The current study used SPSS for Windows (version 22.0; SPSS, Chicago, IL, USA) for the data processing. Descriptive statistics, such as means, SDs, frequencies, and percentages, were obtained to examine the family caregivers' sociodemographic variables, patients' medical characteristics, caregiver–patient relationships, manner of care, care times, and

caregiving self-efficacies. The differences in the variables in caregiving self-efficacy (e.g., family caregivers' sociodemographic variables, patients' medical characteristics, caregiver– patient relationships, and manner of care) were estimated using the independent sample *t*test and analysis of variance (ANOVA). In addition, a Pearson product–moment correlation test was performed to verify the correlation between caregiver age, care time, patient time of sickness, and caregiving self-efficacy.

#### **4. Results**

#### *4.1. Sociodemographic Variables of the Primary Family Caregivers and the Manner of Care*

The current study recruited 107 primary family caregivers as participants, with a mean age of 51 years (SD = 10.8 years, range = 20–70 years). Among the participants, 91.6% were female, 72.9% were the patients' spouses, 56.1% had an education level of senior high school and above, 87.9% were married, 26.2% were continuing their job, 47.7% had an annual household income of <TWD 500,000, 86.9% had a religious affiliation, and 26.2% had a chronic disease (Table 1). Moreover, 41.1% provided care with the assistance of other caregivers, 40.2% provided care without rest, 83.20% had no experience in patient care, and the mean care time was 36.4 months (SD = 40.3 months, range = 1–171 months; Table 1).

**Table 1.** Sociodemographic variables of the primary family caregivers and the differences in overall caregiving self-efficacy between or among groups (*n* = 107).



**Table 1.** *Cont.*

#### *4.2. Patients' Medical Characteristics*

Among the 107 patients with oral cancer, the mean time of sickness was 42.5 months (SD = 44.4 months, range = 1–171 months). Of all the patients, 36.4% had stage IV oral cancer, 78.5% had completed their treatment, and 36.4% were still experiencing the side effects of the treatment (Table 2).

#### *4.3. Caregiving Self-Efficacy of the Primary Family Caregivers*

The CSES-OC was used to measure the self-efficacy of the primary family caregivers. The overall and subscale (i.e., AR, MS, MN, and MD) scores were considered. The mean overall self-efficacy score was 6.87 (SD = 1.65). Moreover, of all the subscales, MN demonstrated the highest mean score of 7.56 (SD = 1.83), followed by MD (7.05, SD = 1.92), AR (6.89, SD = 1.80), and MS (6.17, SD = 2.09) (Table 3).

**Table 2.** Patients' medical characteristics and the differences in overall caregiving self-efficacy between or among groups (*n* = 107).


**Table 3.** Caregiving self-efficacy in primary family caregivers (*n* = 107).


*4.4. Differences in the Sociodemographic Variables of the Primary Family Caregivers and Manner of Care in Caregiving Self-Efficacy*

No significant correlations were discovered between the overall self-efficacy score and age (*r* = 0.06, *p* > 0.05) and between the overall self-efficacy score and care time (*r* = 0.08, *p* > 0.05). Moreover, no significant differences were noted for the other sociodemographic variables and manner of care in caregiving self-efficacy (Table 1).

#### *4.5. Differences in Medical Characteristics in Caregiving Self-Efficacy*

No significant correlations were discovered between the time of sickness and the overall self-efficacy score (*r* = 0.11, *p* > 0.05). Moreover, the differences among patients' other medical characteristics in the overall self-efficacy were nonsignificant (Table 2).

#### **5. Discussion**

In this study, the researchers analyzed the caregiving self-efficacy of the primary family caregivers of patients with oral cancer. Results of the current study may aid professional caregivers in understanding the capability belief of primary family caregivers in facing challenges during the care process and the most challenging tasks they are likely to encounter.

According to the self-efficacy classification proposed by Kobau and DiIorio [27], a self-efficacy score of 4–7 (range: 0–10) denotes a moderate level of self-efficacy. Here, the mean caregiving self-efficacy score was 6.87, indicating that the caregivers in this study had moderate self-efficacy. However, because the scoring methods used for measuring self-efficacy have varied between previous relevant studies [28–30], the researchers could not compare the results of the current study with those of other studies directly. The mean self-efficacy score of the current study was close to that of Liang, Yates, Edwards, and Tsay [22], where the opioid-taking self-efficacy of patients with cancer was estimated, and it was slightly lower than that of Kobau and DiIorio [27], where the self-efficacy of patients with epilepsy was assessed. The possible reason for this was that the care difficulty differed between diseases, which may have affected the participants' perceived level of capability.

Here, the caregiving self-efficacy in the MN dimension scored the highest, with a mean score of 7.56. Handling the nutritional issues of patients might not be the most challenging task for caregivers. Increasing their willingness to eat and preparing suitable food for them [26] were found to be essential behavior tasks to promote their physiological recovery.

The self-efficacy in the MD dimension scored the second highest, with a mean score of 7.05. In this dimension, the behavior tasks relevant to caregiving self-efficacy included managing the side effects due to cancer treatment and making treatment-related decisions [26]. These types of behavior tasks aim at providing home-based medical assistance.

Moreover, the AR dimension scored the third highest, with a mean score of 6.89. Here, the caregiving self-efficacy-related behavior tasks encompass managing emotional issues, receiving care counseling, and being able to rest during the care process [26]. Emotional management was related to tasks such as dealing with the emotions of patients who were facing oral cancer treatment and prognosis, as well as the emotions of caregivers themselves [16,26]. According to the current results, this was the second most challenging set of behavioral tasks. It was a self-assistance behavior task related to the maintenance of the physical and mental health of the caregivers themselves.

Finally, the MS dimension scored the lowest, with a mean score of 6.17. For caregivers, handling the safety and death issues of patients was the most challenging task. The caregiving self-efficacy-related behavior tasks include handling sudden situations, managing the uncertainty in the disease process, and managing poor prognosis [26]. These most difficult care tasks indicate the care priorities for patients and their family caregivers for health care professionals.

Family caregivers' capability belief (i.e., self-efficacy) is a key factor that affects subsequent care behavior and care results [31,32]. Professional medical personnel can increase family caregivers' capability belief according to the four sources of efficacy beliefs in the self-efficacy theory: family caregivers' performance accomplishment, vicarious experience, professional caregivers' verbal persuasion, and consideration of family caregivers' physical and emotional arousal [17,32]. Furthermore, professional medical personnel could integrate relevant educational strategies, including diary logs [33], videos, and brochures [32], to improve family caregivers' capability beliefs in taking care of patients with oral cancer.

In this study, the researchers adopted a cross-sectional descriptive research design. Therefore, the current study could not obtain the changes in family caregiving self-efficacy with respect to the patient's condition or required care time. The present study involved all patients in the disease period. The timing of patient enrollment was not controlled. Some patients were still undergoing their course of treatment, some patients had finished their treatment. Different times or stages of treatment may affect the challenge of the care of family and, therefore, may affect their ability cognition. In addition, the sample size was small for all sociodemographic and medical variable groups. It is unlikely that statistical differences could be detected in this population. On the other hand, the current research used convenience sampling, which may have caused sampling deviation. Families with large care loads may have been eliminated naturally. The samples were collected from a teaching hospital in northern Taiwan alone, which might affect the inference of the current results.

#### **6. Conclusions**

Our current results indicated that family caregiving self-efficacy scores in the CSES-OC MS and AR items were the lowest and the second lowest, respectively. The current study recommends that professional medical teams focus their educational strategies and caregiver self-efficacy enhancement strategies on the dimensions that scored relatively low (i.e., handling patients' safety and death issues and managing physical and mental health problems through self-assistance). For example, issues in these dimensions include managing the emotional distress of a sick family member and the caregiver themself, handling uncertainty about the sick family member's cancer progression and death, and managing the sudden onset of conditions in the sick family member. Through family caregivers' performance accomplishment, vicarious experience, professional caregivers' verbal persuasion, consideration of caregivers' physical and emotional arousal, and using educational media, the self-efficacy of family caregivers regarding taking care of a patient with cancer may be increased. The current results are from an exploratory study. The cut-off point of the self-efficacy score in this study refers to the research results of other patient groups. The current study suggests that more studies are needed.

**Author Contributions:** Conceptualization and methodology: C.-H.C. and S.-Y.L.; investigation: T.- T.C., L.L. and Y.L.; data curation: T.-T.C.; formal analysis and data curation: C.-H.C., S.-Y.L. and T.-J.W.; writing—original draft preparation: S.-Y.L., writing—review and editing: T.-J.W.; funding acquisition: C.-H.C., S.-Y.L. and L.L.; supervision and project administration: C.-H.C. and S.-Y.L. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the Cheng Hsin General Hospital, grant number CHGH111- (IU)08 and the APC was funded by CHGH111- (IU)08.

**Institutional Review Board Statement:** The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Taipei Veterans General Hospital (protocol code 2014-04-001 AC and date of approval: 5 May 2014).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data presented in this study are available from the corresponding author upon reasonable request.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


**Disclaimer/Publisher's Note:** The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

## *Systematic Review* **The Role of Nurse on the Treatment Decision Support for Older People with Cancer: A Systematic Review**

**Hiroko Komatsu 1,\* and Yasuhiro Komatsu <sup>2</sup>**


**Abstract: Background**: The number of older adults with cancer is increasing worldwide. The role of nurses in supporting patients' decision-making is expanding, as this process is fraught with complexity and uncertainty due to comorbidities, frailty, cognitive decline, etc., in older adults with cancer. The aim of this review was to examine the contemporary roles of oncology nurses in the treatment decision-making process in older adults with cancer. **Methods**: A systematic review of PubMed, CINAHL, and PsycINFO databases was conducted in accordance with PRISMA guidelines. **Results**: Of the 3029 articles screened, 56 full texts were assessed for eligibility, and 13 were included in the review. We identified three themes regarding nurses' roles in the decisionmaking process for older adults with cancer: accurate geriatric assessments, provision of available information, and advocacy. Nurses conduct geriatric assessments to identify geriatric syndromes, provide appropriate information, elicit patient preferences, and communicate efficiently with patients and caregivers, promoting physicians. Time constraints were cited as a barrier to fulfilling nurses' roles. **Conclusions**: The role of nurses is to elicit patients' broader health and social care needs to facilitate patient-centered decision-making, respecting their preferences and values. Further research focusing on the role of nurses that considers diverse cancer types and healthcare systems is needed.

**Keywords:** older adults; cancer; decision-making; nurse

#### **1. Introduction**

Population aging has substantially contributed to an increasing number of new cancer cases worldwide [1]. The global cancer burden is expected to be 28.4 million cases in 2040, a 47% rise from 2020 [2]. The number of new cancer cases among older adults (aged 65 years and older) is expected to double by 2035 (14 million) [1]. Age is a risk factor for cancer due to the duration of carcinogenesis, the vulnerability of aging tissues to environmental carcinogens, and other bodily changes that favor the development and the growth of cancer [3].

Healthcare providers (HCPs) involved in the treatment of older adults with cancer face many challenges. Older adults with cancer often have age-related frailty [4,5], comorbidities [6,7], and polypharmacy [8,9], which complicate the cancer diagnosis and create uncertainty in decisions about treatment goals and outcomes [7]. In addition, the involvement of caregivers and other key persons in decision-making affects the decision structure and process [10,11]. Thus, clinical practice guidelines for older patients with cancer provide recommendations for the appropriate implementation of validated and standardized clinical assessment tools and decision-making models for this vulnerable and prevalent demographic group [12]. However, over 50% of older patients with advanced cancer experience severe toxicity during the first 3 months of chemotherapy [13]. In managing cancer drug-related adverse effects and the quality of life, assessment of

**Citation:** Komatsu, H.; Komatsu, Y. The Role of Nurse on the Treatment Decision Support for Older People with Cancer: A Systematic Review. *Healthcare* **2023**, *11*, 546. https:// doi.org/10.3390/healthcare11040546

Academic Editor: Edward John Pavlik

Received: 12 January 2023 Revised: 7 February 2023 Accepted: 10 February 2023 Published: 12 February 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

the values and preferences of older adults with cancer is critical to informed treatment decision-making [14].

In recent years, there has been growing evidence that geriatric assessments (GAs) can be used to assess and manage the vulnerability of older adults with cancer [7,14], and can aid in shared decision-making (SDM) regarding treatment and interventions among patients, caregivers, and oncologists [12]. Nurses are at the frontline in the care of patients with cancer, particularly in this new era of SDM [15]. Advanced nurse practitioners play a pivotal role in determining and facilitating the preferences of patients with cancer [16]. The nursing role during cancer SDM can be complicated and requires flexibility [17]. Although the importance of nurses' roles has been discussed, a synthesis of the roles of nurses in the treatment decision-making process of older adults with cancer and their effects is lacking. Therefore, this systematic review examined the contemporary roles of oncology nurses throughout the cancer treatment decision-making process of older adults with cancer.

#### **2. Methods**

#### *2.1. Search Question*

What roles do oncology nurses play in the treatment decision-making process of older adults with cancer?

#### *2.2. Search Strategy*

This review was based on a systematic, comprehensive search of three databases, including CINAHL, PubMed (via MEDLINE), and PsycINFO, and was conducted in accordance with PRISMA guidelines [18]. Manual searches of reference lists and gray literature were also performed to identify relevant articles. Searches were limited to articles published in English, database inception to September 2022. To address the research question, a broad range of key search terms based on the MeSH (Medical Subject Headings) topics of "decision making", "older adults", "cancer", and "nurse" were used. For other MESH terms, and a combination of free-text searches refer to Supplementary Files S1 and S2.

#### *2.3. Eligibility Criteria*

The literature searches aimed to identify qualitative, quantitative, and mixed-method studies that provided a description of the roles of the nurse throughout the treatment decision-making process for older adults with cancer. Studies were limited to those that focused on adults ≥ 60 years of age. Additionally, reviews, letters, case studies, editorials, and conference abstracts were excluded.

#### *2.4. Quality Appraisal*

Two reviewers (H.K. and Y.K.) discussed and selected the articles to be included in this review. Studies were selected using a two-step process. Articles were first screened by title and abstract to determine their relevance to the search question. The PRISMA search strategy [18] was used to filter articles and remove duplicates. Full-text articles were then retrieved and independently reviewed to determine whether the inclusion criteria were met. Two researchers (H.K. and Y.K.) independently evaluated the studies that met the inclusion criteria for methodological quality using the Mixed Methods Appraisal Tool (MMAT), V.2018 [19].

#### *2.5. Thematic Analysis*

We provided a narrative summary by conducting a qualitative synthesis to identify key themes based on thematic analysis [20]. First, free line-by-line coding of findings from included studies was conducted into related field. Next, thematic analysis was undertaken to construct themes related to the research questions across studies.

#### **3. Results** manual searches. Of these, 534 duplicates were removed; studies that were unclear on the

**3. Results**

A total of 3029 articles were identified through database searches supplemented by manual searches. Of these, 534 duplicates were removed; studies that were unclear on the involvement of nurses in decision support or did not focus on decision support in patients with cancer, such as those focused on cancer screening, cancer healthcare system, and treatment decisions among physicians, were excluded. Studies that focused on pediatric oncology patients were also excluded because they did not meet inclusion criteria. The remaining articles underwent full-text review and 13 were deemed suitable for inclusion (Figure 1). involvement of nurses in decision support or did not focus on decision support in patients with cancer, such as those focused on cancer screening, cancer healthcare system, and treatment decisions among physicians, were excluded. Studies that focused on pediatric oncology patients were also excluded because they did not meet inclusion criteria. The remaining articles underwent full-text review and 13 were deemed suitable for inclusion (Figure 1).

included studies was conducted into related field. Next, thematic analysis was undertaken

A total of 3029 articles were identified through database searches supplemented by

*Healthcare* **2023**, *11*, x 3 of 16

to construct themes related to the research questions across studies.

**Figure 1.** PRISMA flow diagram. **Figure 1.** PRISMA flow diagram.

#### *3.1. Study Characteristics*

*3.1. Study Characteristics* Table 1 presents the main characteristics of the 13 studies included in this review. Seven studies were conducted in European countries [21–27], and six in the USA or Canada [28–33]. Two studies used a quantitative cross-sectional design [22,24], one used a retrospective cohort design [26], one used a quasi-experimental design (pre-post study design) [32], one used a mixed-method design [28], six used a qualitative design [21,23,25,27,30,31], and two were case studies [29,33]. Only one study examined the effect of a nurse-led GA on treatment modifications and outcomes [26]. One pre-post study examined the effect of a Communication Skills Training module on the HCP's SDM approach to meetings with older adults with cancer and their family [32]. Two case studies described the usefulness of nursing practices in the treatment decision-making of older adults with cancer [29,33]. One quantitative cross-sectional study examined the perception of HCPs (including nurses) on treatment decisions of older adults with cancer [24]. One cross-sectional questionnaire survey investigated older women's preferences for receiving information about breast cancer treatment options [22]. Qualitative studies focused on perceptions in older adults with cancer and their partners' decision-making [30], Table 1 presents the main characteristics of the 13 studies included in this review. Seven studies were conducted in European countries [21–27], and six in the USA or Canada [28–33]. Two studies used a quantitative cross-sectional design [22,24], one used a retrospective cohort design [26], one used a quasi-experimental design (pre-post study design) [32], one used a mixed-method design [28], six used a qualitative design [21,23,25,27,30,31], and two were case studies [29,33]. Only one study examined the effect of a nurse-led GA on treatment modifications and outcomes [26]. One pre-post study examined the effect of a Communication Skills Training module on the HCP's SDM approach to meetings with older adults with cancer and their family [32]. Two case studies described the usefulness of nursing practices in the treatment decision-making of older adults with cancer [29,33]. One quantitative cross-sectional study examined the perception of HCPs (including nurses) on treatment decisions of older adults with cancer [24]. One cross-sectional questionnaire survey investigated older women's preferences for receiving information about breast cancer treatment options [22]. Qualitative studies focused on perceptions in older adults with cancer and their partners' decision-making [30], and the perceptions of older adults with cancer [31], HCPs [21,27], and older adults with cancer, their families, and HCPs [23,25].

and the perceptions of older adults with cancer [31], HCPs [21,27], and older adults with

cancer, their families, and HCPs [23,25].



comorbidities, psychosocial and supportive care needs, and patient preferences.





**Score, %**

*Healthcare* **2023**, *11*, 546

28

cancer) and who had made a treatment decision in the preceding six months. A Cancer Centre, University Health Network or Health Sciences Centre, Toronto, Ontario, Canada,

undergoing chemotherapy and/or radiation therapy.

education on treatment options.





*Healthcare* **2023**, *11*, 546



#### *3.2. Quality Assessment*

Among the 13 included studies, two were case studies and did not undergo quality assessment; the remaining 11 primary studies underwent methodological quality assessment using the MMAT [19]. These studies met 100% of the quality criteria, with the exception of one study that met 75% of the quality criteria, and had high quality scores (Table 1, Supplementary File S3).

#### *3.3. Themes of Included Studies*

The data were categorized into three themes regarding the nurse's role in the treatment decision-making process of older adults with cancer: (a) accurate GAs, (b) provision of available information, and (c) advocacy.

#### *3.4. Accurate GAs*

The oncology nurse plays an important role in assessing the factors to be considered in the cancer treatment decision-making process by properly implementing GAs in older adults with cancer. Festen et al. conducted a retrospective analysis of the outcomes of nurse-led GAs and patient preference assessment; they found that nurse-led GAs may lead to the tailoring of treatment decisions to the patient's frailty status and preferences, and improve outcomes [26]. There was no significant difference in one-year mortality between the unchanged and modified group (29.7% versus 26.1%, *p* = 0.7). There were, however, significantly fewer days spent in hospital (median 5 vs. 8.5 days *p* = 0.02) and fewer grade II or higher postoperative complications (13.3% versus 35.5% *p* = 0.005) in the modified group. Additionally, two case studies reported on the usefulness of advanced practice nurses. Specifically, Shahrokni et al. reported on comprehensive geriatric evaluations and effective GA-based interventions performed at the Geriatrics Service department in the Memorial Sloan Kettering Cancer Center [29]. At this center, geriatric nurse practitioners performed GAs to identify geriatric syndromes, derive patient references, and efficiently communicate with patients, caregivers, oncologists, and primary care physicians [29]. Similarly, Strohschein et al. conducted a case study of an 89-year-old man with head and neck cancer [33]. The authors concluded that oncology nurses could identify and address age-related concerns, facilitate communication, and contribute to personalized care by integrating GA tools into their practice.

In these three studies, nurses were responsible for comprehensive GAs in collaboration with a multidisciplinary team for cancer treatment [26,29,33]. Nurses conducted adequate comprehensive GAs by selecting standardized assessment tools for each domain, based on the geriatric domain framework. GAs performed by nurses led to timely interventions, proactive follow-ups, support of patient goals and values, and coordination of care. However, as GAs aim to tailor care to individual patients and improve outcomes [26], extra time must be spent on patient assessments during the decision-making process [26,33]. Thus, time is sometimes a limiting factor in the implementation of GAs.

In older people, oncology nurses can facilitate treatment planning and recovery by conducting an accurate GA. A key issue related to this is the acquisition of competencies for effectively and efficiently assessing patients in the presence of time constraints.

#### *3.5. Provision of Available Information*

Nurses play a role in the timely provision and sharing of information in the treatment decision-making process, based on a relationship of trust with the patient. A qualitative study reported that nurses attempted to compensate physicians' shortcomings by providing patients with additional information and opportunities for discussion, and sought to form trusting relationships to enable a continuity of care and facilitate access to support during treatment [21]. As older adults are sometimes reluctant to share personal information, nurses should focus on building trusting relationships with elderly patients [21]. Furthermore, pertinent patient information is not always available at the time of treatment decisions. Therefore, nurses need to continuously collect quality, available, and timely

information about older adult patients, assessing what is happening in their daily lives, to enable informed treatment decisions [21].

The importance of nurses' provision of information was also indicated in studies on the perceptions of older adults with cancer. In a survey by Burton et al. of older adults with breast cancer who needed information for treatment decision-making, nearly 40% indicated that a face-to-face discussion with a nurse was their preferred source of information [22]. Furthermore, most women stated that a breast care nurse (45/55, 82%) was the ideal person with whom they would discuss their treatment decisions [22]. These results suggest the importance of the role of nurses in providing information and ensuring that women receive their preferred level and amount of information, as well as their involvement in treatment decision-making using decision support tools.

On the other hand, in a qualitative study on perceptions regarding treatment decisions in older adults with cancer, the majority of patients were satisfied with the communication with their oncologists, and none of the patients mentioned nurses as having input or providing support in their treatment decision-making process [31]. Therefore, nurses must be actively involved in decision-making processes so that their role is recognized by patients. For example, nurses may coach patients on how to seek evidence-based discussions regarding treatment options and provide supplementary education on treatment options.

McWilliams et al. conducted a qualitative study on treatment decision-making in older adults with cancer and dementia and their families, as well as HCPs, including specialized nurses [23]. One important theme was the effective communication of clinically relevant information, and the authors provided the following recommendations: taking more time with the patient, exchanging information, and understanding the options for cancer treatment. HCPs may need to speak slowly and repeat information several times to help patients and their families navigate treatment decision-making, and avoid vague descriptions of side effects, complex information, and a lack of timely information [23]. Shahrokni et.al points out that effective and efficient communication between oncologists and primary physicians or geriatricians, and nurses, especially among older people and their families, needs to be promoted to drive decision-making among older people [29].

Training in communication skills is required to promote the communication of clinically relevant information. Shen et al. evaluated a Communication Skills Training module for HCPs by applying a SDM approach to meetings with older adults with cancer and their family [32]. The results indicated a significant effect of training on overall skill; HCPs' self-efficacy in utilizing communication skills related to shared geriatric decision-making significantly increased from pre- to post-training. Communicating in a way that promotes true SDM is even more important when facing critical treatment decisions in older adults with cancer who may experience cognitive decline [32].

Studies on the perceptions of HCPs show that nurses who are trusted by patients play a role in treatment planning through the timely provision of information. Survey studies of the perceptions of older people with cancer highlighted the importance of nurses providing information, while other studies showed that there was little recognition of the input or support provided by nurses during treatment planning. Therefore, nurses need to be actively involved in the decision-making process to make patients aware of their role and to strengthen and train their communication skills.

#### *3.6. Advocacy*

Oncology nurses play an important role in advocating respect for individual values and preferences of older adults with cancer in their treatment decisions. Bridges et al. surveyed clinicians, including nurses, on the characteristics of cancer treatment decisionmaking in older patients with cancer and found that nurses play an important role in advocating for the patient's autonomy and the right to make informed decisions [21]. Oncology nurses involved in multidisciplinary teams focus on complex patient-centered information, such as comorbidities, psychosocial and supportive care needs, and patient preferences, indicating the importance of nurses' input in calling attention to broader

issues at the meeting [21]. However, there is a difficulty in nurses providing consistent contributions to multidisciplinary team meetings [21].

On the other hand, Tariman et al. [28] reported on the preferences of older adult patients newly diagnosed with symptomatic myeloma for participation in the decisionmaking process and found that most patients wanted to share treatment decision-making with their physicians or make decisions themselves. Therefore, physicians and nurse practitioners must practice full disclosure of treatment options to their patients so that they can make truly informed decisions [28]. Further, the authors discussed the importance of the following roles of oncology nurses for respecting and helping individual patients with their preferences: (a) making sure patients receive disease and treatment-related information, (b) encouraging patients to express their decisional role preference to the physician, (c) developing a culture of mutual respect and value of the patient's desire for autonomy in treatment decision-making, (d) acknowledging that the patient has a right to make treatment choices, and (e) providing psychological support to the patient during decision-making, from the time of diagnosis to the end-of-life. Because the level of preference for participation is highly variable across patients, and may have personal meaning for each patient, physicians and oncology nurses must also elicit the patient's preferences, explore what participation truly means for him or her, and facilitate the patient's decision-making process [28].

The utility of decision aids (DAs) in eliciting patient preferences and providing proactive support has been evaluated. In a study of HCPs by de Angst et al. [24], 60% of nurses used DAs to elicit individual patient preferences, suggesting that DAs can be beneficial in supporting SDM. However, oncology nurses were more in favor of DAs than oncologists. In a study of older adults with advanced prostate cancer and their decision partners by Jones et al. [30], participants viewed DAs as helpful in treatment decision-making. DAs allowed issues that they were not aware of to be highlighted, thereby helping them to consider the issues in depth and discuss them with HCPs [30]. Enabling patients and decision partners to discuss issues more thoroughly and providing the time to do so improved their understanding and confidence in their decisions [30]. Additionally, DAs facilitate closer patient–HCP relationships, allowing for more patient-centered and productive conversations [30].

Older adults with cancer often have adult children or spouses involved in treatment decisions [25,27]. Therefore, nurses need to consider the impact of family involvement and family relationships on decision-making processes when supporting the patient's decision-making. Griffiths et al. indicated the necessity of an assessment that considers multiple factors and ensures psychological well-being in order to help patients apply their individualized abilities in the decision-making process [25]. Dijkman et al. explored how surgeons and nurses perceive the involvement of adult children of older patients with cancer in treatment decision-making [27]. The results indicated that nurses use the following six strategies to support positive family involvement in treatment decision-making: focus on the patient, acknowledge different perspectives, involve adult children, get to know the family system, check that the patient and family members understand the information, and stimulate communication and deliberation with adult children [27]. However, involving families in treatment decision-making also triggers specific complexities and challenges in treatment decision conversations that call for the development and implementation of practical patient- and family-centered strategies [27].

Studies on the perceptions of HCPs demonstrate the need for both nurses and physicians to fully disclose all treatment options to enable patients to make informed decisions. In particular, the preferred level of participation varies greatly from patient to patient and may have personal implications for each patient, and attention should be paid to the influence of family involvement and family relationships on decision making. Nurses need to develop communication skills to support patients' decision making, by eliciting patients' information needs and preferred level of participation.

#### **4. Discussion**

This review is unique in that it focused on the role of nurses in the treatment decisions of older adults with cancer. Previous work reported on physicians' perceptions of the decision-making process in patients with cancer [34–36] or the role of nurses [37]. One of the novel features of this review is the inclusion of data on the effect of GAs by nurses. By conducting GAs, nurses identified geriatric syndromes, elicited patient preferences, and promoted efficient communication with the patients, caregivers, and physicians. The current literature suggest that tailoring treatment decisions to a patient's frailty status and preferences leads to improvements in patient outcomes.

However, time constraints regarding the implementation of GAs were mentioned [26]. Therefore, for nurses to fulfill their expected role in a multidisciplinary team, they need to acquire competency in efficiently and effectively conducting GAs. The ability of oncology nurses to implement geriatric screening and assessment depends on additional training [33,38], as well as having the time, space, and institutional support to conduct such assessments [39,40]. Outlaw et al. provided an overview of the field of geriatric oncology and highlighted recent breakthroughs in the use of GAs in cancer care [41]. GAs are now recommended for all older adults with a new cancer diagnosis, according to recommendations from the American Society of Clinical Oncology [42], National Comprehensive Cancer Network [43], and International Society of Geriatric Oncology [44]. Further work is needed to better understand and overcome the barriers to the broad implementation and utilization of GAs [41].

Although the level of evidence was low, two case studies [29,33] provided clues regarding the development of GA training programs for nurses that are efficient and effective, as well as personalized implementation of GAs in older adults. Festen et al. showed that incorporating nurse-led GAs in decision-making may improve patient outcomes; however, future studies should use prospective cohorts in diverse cancer populations. Randomized controlled trials are needed to accumulate evidence on the effects of nurse-led GAs in decision-making [26].

Older patients with cancer are often overwhelmed by the complexity and sheer volume of information about cancer diagnosis and treatment, which hinders their access to the information they need [31,45]. The present review clarified that nurses play an important role in identifying the information needs of older patients by assessing each patient's level of understanding and helping them to understand the information. Many older patients with cancer trust their physicians and are satisfied with their provision of information; however, they also experience poor communication during the treatment decision-making process and beyond [31]. For instance, oncologists' use of medical jargon, the downplaying of treatment side effects, a lack of sensitivity, and a lack of time spent with patients are some of the issues voiced by patients in this regard [31]. Declining numeracy, lower literacy, and increasing age are associated with the desire to conserve time and energy, which may explain the strong preference for face-to-face conversations using lay language. This preference is of concern, as it may lead to inaccurate risk perceptions. Nurses need to use the teach-back method to confirm the patient's understanding of the information they receive from physicians [46], provide psychological support [37], elicit and identify individual patient-specific information needs, and facilitate accurate risk perception.

On the other hand, the present review shows that older patients with cancer sometimes do not view nurses as professionals from whom they receive important treatment-related information. Oncology nurses are key players in cancer treatment decision-making; however, they face challenges, including barriers in practice, education, institutional policies, and administration [47]. Nurses need to develop communication skills that can guide patients' information needs by employing a preemptive and proactive approach that reduces these barriers and raises nurses' roles as key persons in the care of older patients with cancer. To support the treatment and care decisions for older adults with complex health problems, physicians and nurses must have the communication skills to appropriately respond to complex patient needs through multidisciplinary-team meetings and additional information exchange as well as outside of the conference [21]. Furthermore, we believe that health care providers (HCPs) involved in the multidisciplinary-team need to share treatment and care plans using the Collaborative Care Model to facilitate smooth communication [29].

The practice of SDM is recommended as a standard approach in the decision-making process by policymakers and clinical practice guidelines [48,49]. Implementing a communication training program promotes patient engagement and SDM. The cancer treatment decision-making processes that immediately follow diagnosis occur in a team and can be characterized as medically dominated and narrowly focused on cancer pathology [21]. The importance of knowing about patients' wider health and social care needs is acknowledged by clinicians; however, they experience difficulty in ensuring that this information is available in time to inform cancer treatment decisions [21]. Thus, nurses must undertake a type of compensatory work to enable patients to engage in treatment decision-making processes and make patient-entered decisions [21]. Further, attention should shift towards exploring decision-making process modifications and providing structural support to ensure that patients with cancer with complex needs receive adequate and timely assessments and access to clinical experts with the capacity to support them in arriving at the best treatment decision [21].

DAs enable patients to fit into the treatment decision process and elicit their values and preferences, leading to proactive support by nurses [24]. A systematic review of the effectiveness of DAs for older adults showed that they improve older adults' knowledge, increase their risk perception, decrease decisional conflict, and seem to enhance participation in SDM [50]. However, few of the studies included in the present review conducted subgroup analysis in adults with low health literacy or numeracy, low-educated adults, frail patients, or other vulnerable subgroups [50]. When applying DAs to older patients with cancer, nurses need to consider several factors, including multi-morbidities, cognitive impairment, and low health literacy. In addition, more evidence concerning the effects of DAs on decision-making in older patients with cancer is needed.

Older patients with cancer often involve adult children or spouses in treatment decision-making. Family can stimulate deliberation and move the conversation beyond a mere medical perspective by considering relevant aspects of a patient's life; however, patients may withhold information in the presence of their children, or specific complexities and challenges in treatment decision conversations may be triggered [27]. Thus, nurses should develop practical strategies for triadic conversations related to treatment decision-making based on the core elements of a family system approach and family health conversations [27].

#### **5. Limitations**

One limitation of the present study is that the evidence reviewed was from a small number of studies, highlighting the need for further research that considers populations with diverse cancer types, characteristics of older adults, and diverse healthcare systems. In addition, the role of nurses may differ depending on their expertise, such as general, oncology, geriatric, and advanced practical nurses. Therefore, it is necessary to promote research that considers these subspecialties. Thematic analysis was conducted in a small number of included studies, making it difficult to extract subthemes. The present review was conducted by repeated exchanges of opinions between two researchers with different specialties (i.e., nurse and physician), from review planning to the literature searches, evaluation, and analysis. Since various professionals are involved in decision-making regarding the treatment of older people, future reviews by a multi-disciplinary expert team with collaboration among various specialties are desirable.

#### **6. Conclusions**

Cancer treatment decision-making in older patients remains a complex issue. A significant finding from the current literature is that the roles of nurses in the decisionmaking process of older patients with cancer involve performing an accurate GA, providing

available information, and advocating respect for individual values and preferences. The role of nurses is to elicit patients' wider health and social care needs in complex decisionmaking processes, respecting individual references and values. However, it may be difficult for older adults and their families to perceive the complementary role of nurses in treatment decision-making, and opportunities for nurses to interact with patients may be missed due to time constraints. Further investigations focusing on the role of nurses that consider diverse cancer types, characteristics of older people, and healthcare systems are needed.

**Supplementary Materials:** The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/healthcare11040546/s1, Supplementary File S1. Key words; Supplementary File S2. Searches; Supplementary File S3. Scores.

**Author Contributions:** Study design and concept: H.K. and Y.K.; writing the study protocol: H.K. and Y.K.; data acquisition: H.K. and Y.K.; data analysis and interpretation: H.K. and Y.K.; manuscript drafting: H.K. and Y.K.; critical revisions of the manuscript for important intellectual content: H.K. and Y.K. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the Japan Society for the Promotion of Science KAKENHI (Grant No.: 19H03867).

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** The datasets used or analyzed during the current study available from the corresponding author on reasonable request.

**Acknowledgments:** This review was performed in collaboration with Ayako Tagawa and Rie Shirakura, librarians.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


**Disclaimer/Publisher's Note:** The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
