Research Trends of Oncology Nursing in Japan and Around the World

Review Article Jpn J Clin Oncol 2012;42(10)882 886 doi:10.1093/jjco/hys139 Advance Access Publication 31 August 2012 Research Trends of Oncology Nursing in Japan and Around the World Atsuko Uchinuno * University of Hyogo, College of Nursing Art and Science, Oncology Nursing, Akashi, Hyogo, Japan *For reprints and all correspondence: Atsuko Uchinuno, Kitaouji-cho 13-71, Akashi, Hyogo 673-8588, Japan. E-mail: a_uchinuno@cnas.u-hyogo.ac.jp Received March 1, 2012; accepted August 7, 2012 This article reviews recent cancer nursing research in Japan and the USA, and topics relating to international cancer nursing societies. Most of the articles on cancer nursing published in Japan are in the Journal of the Japanese Society of Cancer Nursing. Atotalof46articles have been published over 3 years from 2009, and many of these are qualitative studies aimed at understanding the response of cancer patients to disease along with their symptoms and backgrounds. The International Society of Nurses in Cancer Care (ISNCC) holds a conference biennially, at which cancer nursing research is presented by researchers from around the world. Many pieces of research on the topics of the symptomatic management and health impact of smoking and cancer screening are discussed. Also, at the Congress of the Oncology Nursing Society (ONS), the world s largest cancer nursing society in the USA, a nation advanced in the field of cancer nursing, symptomatic management has already been discussed; however, the topics have been shifting from nausea, vomiting and pain to adverse events induced by novel treatments such as skin alterations, peripheral neuropathy and fatigue. Cancer nursing research is not yet fully mature in terms of the number and range of articles. In nursing research, it is difficult to measure a patient s response to their disease because it includes psychosocial response; the results are difficult to claim as scientific evidence. Therefore, it is still necessary to conduct research with detailed descriptions of clinical phenomena and to develop cancer nursing research, including actual study methodologies. Key words: trends cancer nursing research article review INTRODUCTION Nurses comprise the largest number of health professionals and operate on 24 h schedules. Cancer treatment is expected to improve patients quality of life (QOL) and well-being as well as their treatment outcome through the provision of highly specialized nursing. Nursing is a study comprising both science and art, and its discipline differs from that of medicine. Nursing incorporates many methods developed from sociology, cultural anthropology and behavioral science. Experimental methods are also used; however, outcomes are influenced by many factors including not only physical and biological factors but also relationships with the surrounding people and socioeconomic conditions. Consequently, verificational study is limited. A systematic review of the characteristics of cancer nursing research published over a 10-year period from 1994 to 2003 (1) showed that half of the articles published were from the USA, followed by those from the UK, Sweden, Canada and Australia. The subjects in 52.2% of the research were not patients but medical staff, and most were nurses. Quantitative research accounted for 60.2% of the total; however, much of the research was surveys and their study designs were descriptive. Qualitative research accounted for 31.5%, while mixed-method studies accounted for 8.5%. The study design most frequently used in qualitative research was a phenomenology grounded theory approach, while ethnography was also used. Data were often collected by interview. Comparative/quasi-experimental research to evaluate nursing intervention was also conducted (1). The # The Author 2012. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Jpn J Clin Oncol 2012;42(10) 883 characteristics of nursing research contributed to the difficulty of identifying factors due to the complexity of the clinical phenomena and slow development in measuring the effects of nursing. The reason why nurses themselves were used as subjects was that nurses have a lot of conflict at clinical practice. Recent research has often been conducted on patients who were provided with educational intervention; the effect of such intervention is evaluated using the relief of symptoms as an outcome indicator. Scientific evidence has been accumulating and quasi-experimental or experimental studies have sometimes been published. However, the responses of patients and their families to health problems including diseases are complex, and it is difficult to elucidate the actual meanings of responses of cancer patients and their families using conventional scientific methods. In other words, conventional research methods were designed to quantitatively determine conditions from within a limited range of conditions and find significant differences from a control group; therefore, these methods had limited value in elucidating the phenomena involved in various factors. However, articles of cancer nursing are gradually accumulating, despite difficulties in methodology. Descriptive research is still the most common, however, and its effectiveness has been used in studies. This article reviews the trends of articles presented by the International Society of Nurses in Cancer Care (ISNCC) and research at the cutting edge of cancer nursing in the USA. The conditions of US cancer nursing are reviewed in sessions of the congress of the Oncology Nursing Society (ONS), and in articles published in the Oncology Nursing Forum (ONF) and the journal Cancer Nursing. In addition, the conditions of cancer nursing in Japan are reviewed in sessions of conferences of the Japanese Society of Cancer Nursing (JSCN) and in articles published in JJSCN. ACTIVITIES OF THE INTERNATIONAL SOCIETY OF NURSES IN CANCER CARE (ISNCC) AND TRENDS OF ONCOLOGY NURSING STUDIES The International Society of Nurses in Cancer Care (ISNCC), founded in 1984, is an international federation of national cancer nursing societies, regional cancer nursing societies, oncology institutions, individual cancer nurse practitioners, researchers and educators. ISNCC represents 60 000 cancer nursing professionals (2). A total of 37 oncology nursing societies from all over the world participate in the ISNCC as full members: 4 organizations in Africa, 12 organizations in the Asia Pacific region, 4 societies in Central and South America,15 societies in Europe and the Middle East and 2 in North America. The ISNCC does not publish an academic journal, but holds a biennial conference. Various members participate from all over the world, with Japanese members rapidly increasing in recent years, although the number of presentation tends to be rather small, from 200 to 500. A major theme of the presentation is symptom management. The nursing management of nausea and vomiting, pain, constipation and terminal restlessness, particularly terminal palliative care, was often discussed in the early 2000s. Lectures on biotherapy, targeted therapy and the cytotoxicity of monoclonal antibodies have also been conducted. Various adverse reactions, including radiotherapy-induced dermal injury, chemotherapy-induced oral mucositis and malaise, and insomnia during hormone therapy, have been studied, and cluster analysis of coincidental treatment complications has also been evaluated. At the conference in Atlanta in 2010, cooperation and leadership were discussed among a consortium of cancer centers and professional cancer nursing organizations from various Middle Eastern countries. They also discussed how they facilitated the education of evidence-based clinical practice. This article reviews research presented at the ISNCC conference, since the ISNCC does not itself publish an academic journal. Topics of research presentations have included nursing care of unpleasant symptoms associated with targeted therapies, and the development of a nursing assessment tool for the recognition and management of delirium. There was also a presentation on the development of a cancer fatigue scale by Japanese researchers. Researchers from the UK gave a presentation on patients preferred places of care for palliative care; this research showed that 85% of the patients died in their preferred place of care; however, those patients who did not die in their preferred place of care usually had not documented their preferred place of care (3). Newsletters published by the ISNCC have indicated the health impact of smoking, cancer screening and labor problems related to cancer nursing. Patient s self-care skills (4) and self-esteem (5) are also being focused on currently, while at the same time, nursing approaches involving patients activities such as patient participation in symptom management are also attracting attention (6). TRENDS OF ONCOLOGY NURSING RESEARCH IN THE USA CONGRESS OF THE ONS AND THE JOURNAL ONCOLOGY NURSING FORUM The USA has been the leading research in not only oncology nursing but also many other fields of nursing and has published a huge amount of articles in comparison with other countries. In particular, the ONS promotes research activities as a society. The ONS traces its origin to the first National Cancer Nursing Research Conference, supported by the American Nurses Association and the American Cancer Society (ACS) in 1973. The Oncology Nursing Forum was established in 1974 as a journal of cancer nursing research. The ONS boasts nearly 40 000 members and 231 chapters,

884 Research trends of oncology nursing as well as 27 special interest groups (SIGs) with subspecialties including bone marrow transplants and chemotherapy. These SIGs provide information and education to nurses all over the world (7). The ONS conducted a research priority survey among ONS members in 2008 and confirmed the research topics that were afforded high priority from among 70 topics (8). Symptoms and side effects such as pain and neuropathy, psychosocial and behavioral issues such as QOL, palliative care decision-making and coping, and healthcare systems were ranked high. Late effects of treatment, palliative care and end-of-life issues were also ranked high. Health promotion topics on the other were not ranked so highly. However, in research agendas set in and after 2009 which were summarized by an ONS project team cancer risk reduction in healthy populations was found to be a critical area for research and was indicated as a high priority issue. Topics such as tobacco control, physical activity, health foods or health diets remain ongoing challenges (9). Although research priority items differed in 2000, 2004 and 2008, QOL and pain were consistently ranked high. Important symptoms were neuropathy, mucositis and functional impairment, the ranks of which showed a steady increase. The rising rankings of such symptoms may be the result of the increasing incidence of these side effects due to the newer chemotherapeutic agents and dose-intensive chemotherapies that are being administered to many patients (8). Pain was also highly ranked; this factor cannot be resolved unless palliative care is advanced. QOL remains an important topic and is used as an outcome indicator; therefore, it is expected to be highly ranked in the future. Palliative care decision-making and continuum of care have been key topics since 2008. Access to care and palliative care are rising in terms of research priority. These are the reasons that have driven the amount of health-care expenditures occurring at the end of life and the ascendancy of palliative care into the spotlight of American society. On the other hand, late effects of treatment and stress management are also topics with high priority because of increasing rates of prolonged survival. As describe above, the ONS organized the 2009 13 Oncology Nursing Society Research Agenda Team and published the 2009 13 ONS Research Agenda of oncology nursing with public comment. The agenda consisted of seven fields: (A) Health Promotion, (B) Cancer Symptoms and Side Effects, (C) Late Effects of Cancer Treatment and Long-term Survivorship Issues, (D) End-of-Life Issues, (E) Psychological and Family Issues, (F) Nursing-sensitive Patient Outcomes and (G) Translation Science (9). In particular, there are 12 million cancer survivors, and hence, cancer survivorship is an urgent topic. Cancer survivors have experienced physical symptom more than the general population and also experienced functional impairment defined as the individual s loss of the ability to perform their daily activities (10). Cancer survivor clinics, in which nurses provide medical care, have been set up in US cancer centers, though they are rarely found in Japan. It is expected that a lot of research will be conducted to gain a better understanding of the cancer survivor population. As a result of the growing number of anticancer agents delivered orally and the shift of responsibility from inpatient to outpatient settings, patients are increasingly expected to control their treatment by themselves. Since patients generally stay at home during therapy, the completion of the therapy depends on whether or not the patients themselves adhere to the treatment regimen. A research that evaluated whether or not nursing intervention improved patients QOL using treatment adherence as the outcome indicator is currently attracting attention. Cancer symptoms and side effects have also been indicated as important topics. Several pieces of research were conducted to inquire or investigate the symptomatic experiences of patients in a multidisciplinary manner and as accurately as possible. Symptoms frequently evaluated from the late 2000s to the present have been QOL-related factors including fatigue, sleep-wake disturbances, depression, pain, hot flashes and changes in cognitive function. Furthermore, research recommends the incorporation of nursing intervention, based on the ONS Putting Evidence into Practice (PEP) resources and the National Comprehensive Cancer Network (NCCN) supportive care guidelines (9). THE JOURNAL CANCER NURSING Cancer Nursing is an important journal for understanding the trends of cancer nursing research. It addresses the whole spectrum of problems in care for cancer patients and most highly evaluated in the cancer nursing field, particularly with regard to the point of the impact factor (1). About 70 articles per year are published in the journal, with the number remaining fairly constant over the past 3 years. Major topics from 2009 to the present have included symptom management, QOL (including patients experiences), psychological issues, nursing intervention, family care and survivor care. Research on symptom management predominantly concerned the evaluation of pain in the 1990s; however, symptoms such as malaise and sleep disturbance are on the increase. A lot of the research on symptom management is descriptive studies elucidating the symptomatic experience of patients. Tool development has been used to evaluate symptoms and studies on care issues during treatment, at the end of life and during the cancer survival period have also been conducted. Symptoms evaluated for research vary by topic, depending on the development of chemotherapy regimens and new agents providing symptomatic relief. However, the full range of unpleasant symptoms that patients suffer cannot be comprehensively evaluated. Research on the QOL of cancer patients is published in similar amounts to that on symptom management. The QOL of cancer survivors is currently attracting attention among researchers, while the QOL of patients living with cancer is also being studied. It is also being evaluated to what extent

Jpn J Clin Oncol 2012;42(10) 885 QOL is influenced by the mental problems and physical depression of patients living with the risk of cancer. Patients with breast cancer have relatively long survival times and are likely to cooperate with such research. Patients with prostate cancer and undergoing hematopoietic stem cell transplants are also frequently studied. In clinical practice, it is easily supposed that there are many significant problems including intractable carcinoma, symptoms affecting QOL and health problem of patients; however, the number of articles does not always indicate such problems. A systematic review of cancer nursing research over the 10 years from 1994 to 2003 indicated that the focus of cancer nursing research did not correspond to the actual incidence of cancer. It is speculated that articles published in the field of cancer show studies that are conducted in accordance with not only the importance of the health problems themselves and the priority of the research but also the feasibility of the research. Articles on psychological issues are based on studies adopting various mental responses to diseases as their concept, such as uncertainty, worry and stress. Studies that elucidate coping patterns for cancer as a life-threatening event have also been conducted. Research on the family issue has been submitted from Taiwan and China. Such research focuses on the experience and health needs of the family as a care giver and the health needs associated with the family. Research on nursing intervention is conducted against a theoretical background, including psychoeducational support interventions, cognitive intervention, therapeutic music video intervention as a complementary nursing therapy, intervention providing comfort through the use of warm-water footbaths and activities such as peer support programs. Furthermore, telephone intervention and home-based aerobic programs, which are interventions available without access to a hospital, are also being studied. Most studies of cancer prevention and screening were conducted to elucidate patient adherence to treatment for breast cancer, cervical cancer and prostate cancer. Studies on children have been published in the Journal of Pediatric Oncology Nursing, established in 1984; thus, submission of such articles has not been found to increase in the journal Cancer Nursing. Molassiotis et al. showed that the quality of research was not highly evaluated in either qualitative or quantitative research (1). Furthermore, few nursing research projects have been conducted in either lung, colorectal or prostate cancer, which is developing in many patients. CONGRESS OF THE JAPANESE SOCIETY OF CANCER NURSING AND THE JOURNAL OF THE JAPANESE SOCIETY OF CANCER NURSING The Japanese Society of Cancer Nursing (JSCN) was founded in 1987, in order to develop and improve the research, education and practice of cancer nursing. The JSCN was approved as council member by the Science Council of Japan in 1996 and has some 4636 regular members (as of 31 December 2011). Activities aimed at nursing specialists include education (conferences, training sessions and workshops), journal publication and international activities. The JSCN organizes the Special Interest Group (SIG)Committee,whichconsistsof13groupsinwhich members interested in specific themes exchange information and improve their specialties. The JSCN Congress has been held annually (11). The 26th JSCN Congress was held in February 2012. Sessions have been increasing since 2010, reaching some 500 presentations in 2012 (Table 1). At congresses held over the 10-year period 1987 96, a total of 406 presentations were conducted. Mental care, home care, QOL, terminal care, support for families, truth telling and pain control were discussed in 74% of the presentations, while topics of side effect control conversely were discussed in very few (12). About 90% of the sessions were case reports and descriptive analyses (13). Over the subsequent 10-year period (1997 2006), 1612 presentation were given, most of them relating to mental care. Nursing care during chemotherapy ranked second, followed by outpatient nursing, nursing care with surgery and care for breast cancer patients, which comprised reports on nursing associated with treatment. Cancer therapy is administered to Table 1. Number of abstracts in each category at the Japanese Society of Cancer Nursing Conference (2010 12) The 24th (2010) The 25th (2011) The 26th (2012) Cancer rehabilitation nursing 0 13 12 Pediatric cancer 2 2 6 Cancer in elderly patients 6 6 Gene nursing 0 2 0 Team approach 10 23 13 Nursing at home and in the community 13 20 20 Palliative care 39 45 42 Outpatient nursing 45 44 63 Nursing associated with diagnosis 63 102 102 and therapy Nurse education 45 51 71 Patient support (supportive care) 25 52 34 Family care 19 35 31 End-of-life care 8 22 22 Mental care/spiritual care 13 11 13 Patient education 18 15 12 Prevention/screening ethics and 14 22 32 informed consent, clinical trials Others 46 35 38 Total 366 500 511

886 Research trends of oncology nursing outpatients, not inpatients, and consequently, topics of chemotherapy and outpatient nursing have seen a particularly strong increase (14). At the 26th Congress in 2012, the latest conference, as shownintable1, 102 out of 511 presentations were on nursing associated with diagnostic treatment, thus forming the largest category. Topics of cancer nursing have shifted from symptomatic relief and mental support in end-of-life stage physical management associated with cancer treatment over the past 10 years. Since patients surviving due to new therapy have increased in number, research on patient support including survivor care has increased correspondingly. The Journal of the Japanese Society of Cancer Nursing publishes 16 18 articles annually. The articles submitted in the journal have presented topics including chemotherapy nursing, terminal care (including home care), family care, patients experiences and nursing support, decision-making, palliative care of lymph edema and pain. The empowerment model, stress-coping and self-care theory, and the QOL model have been used as conceptual frameworks for research. In terms of study design, more than 60% of studies investigated categories and factors based on interviews and participant-observation data, using the grounded theory approach, ethnography and the phenomenology approach for data analysis (14). Adverse events and infusion reactions associated with medical treatment have been presented as topics of clinical practice in educational sessions; however, there have been no studies elucidating good nursing practice for such conditions. FUTURE VISION OF CANCER NURSING RESEARCH The amount of cancer nursing research presented at conferences is increasing in both Japan and other countries. However, the number of articles published in journals has not seen a similar increase. Nursing research generally uses the complex responses of subjects to health problems including psychosocial response as a research theme, and therefore requires multiple study methods. Qualitative methodologies such as the phenomenological approach, the ethnographical approach and the method of symbolic analysis have been developed in nursing studies. It would be expected that cooperative researchers from multiple fields participate in nursing research. To conduct a research project, it is necessary to train more nursing researchers. The number of nursing science doctoral courses and master courses are increasing in Japan (71 doctoral courses and 147 master courses in 2012). It is expected that the number of nursing researchers will increase. In order to generate appropriate research questions, good relationships between clinical nurses and nursing researchers are vital. Cooperation between research institutes, colleges and clinical field such as hospitals is also an important requirement for research. Conflict of interest statement None declared. References 1. Molassiotis A, Gibson F, Kelly D, et al. A systematic review of worldwide cancer nursing research 1994 to 2003. Cancer Nurs 2006;29:431 40. 2. http://www.isncc.org/about/ (February 2012). 3. International Society of Nurses in Cancer Care. International cancer 2010;22. 4. International Society of Nurses in Cancer Care. International cancer 2007;19:4 5. 5. International Society of Nurses in Cancer Care. International cancer 2009;21:4. 6. International Society of Nurses in Cancer Care. International cancer 2009;21:4 5. 7. http://www.ons.org/about (February 2012). 8. Doorenbos ZA, Berger MA, Brohard-Holbert C, et al. 2008 ONS Research Priorities Survey. Oncol Nurs Forum 2008;35:E100 7. 9. The 2009 2013 Oncology Nursing Society Research Agenda Team. The 2009 2013 Research Agenda for Oncology Nursing. Oncol Nurs Forum 2009;36:E274 82. 10. Brearley SG, Stamataki Z, Addington-Hall J, et al. The physical and practical problems experienced by cancer survivors: a rapid review and synthesis of the literature. Eur J Oncol Nurs 2011;15:204 12. 11. http://jscn.umin.jp/index.html (February 2012). 12. Kojima M. Japanese Society of Cancer Nursing: its history and perspective. J Jpn Soc Cancer Nurs 1997;11:1 8 (in Japanese). 13. Kiba S, Iino K, Ishigaki Y, et al. Trend of nursing research in Japanese Society of Cancer Nursing in a past decade. J Jpn Soc Cancer Nurs 1998;12:41 9 (in Japanese). 14. Kojima M. Japanese Society of Cancer Nursing: history of 20 years and progress of cancer nursing. JJpnSocCancerNurs2006;20:5 11 (in Japanese). 15. Makabe R. Research trends and issues in cancer nursing: published research papers in two nursing journals for the past five years (1998 2002). J Jpn Soc Cancer Nurs 2003;17:13 9 (in Japanese).