Search the GCU Library and find one new health care article that uses quantitative research. Do not use an article from a previous assignment, or that appears in the Topic Materials or textbook.
Complete an article analysis and ethics evaluation of the research using the “Article Analysis and Evaluation of Research Ethics” template. See Chapter 5 of your textbook as needed, for assistance.
https://lc.gcumedia.com/hlt362v/applied-statistics-for-health-care/v1.1/#/chapter/5
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Article Analysis and Evaluation of Research Ethics
Article Citation and Permalink
(APA format)
Article 1
Point
Description
Broad Topic Area/Title
Problem Statement
(What is the problem research is addressing?)
Purpose Statement
(What is the purpose of the study?)
Research Questions
(What questions does the research seek to answer?)
Define Hypothesis
(Or state the correct hypothesis based upon variables used)
Identify Dependent and Independent Variables and Type of Data for the Variables
Population of Interest for Study
Sample
Sampling Method
Identify Data Collection
Identify how data were collected
Summarize Data Collection Approach
Discuss Data Analysis
Include what types of statistical tests were used for the variables.
Summarize Results of Study
Summary of Assumptions and Limitations
Identify the assumptions and limitations from the article.
Report other potential assumptions and limitations of your review not listed by the author.
Ethical Considerations
Evaluate the article and identify potential ethical considerations that may have occurred when sampling, collecting data, analyzing data, or publishing results. Summarize your findings below in 250-500 words. Provide rationale and support for your evaluation.
© 2019. Grand Canyon University. All Rights Reserved.
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P
alliative radiotherapy is an effective modality of
treatment for patients with advanced cancer for a
wide range of distressing symptoms such as painful
bone metastases, bleeding from tumour sites,
dyspnoea caused by central airway obstruction and
neurological compromise caused by spinal cord compression
and brain metastases (Lutz, 2016). However, in reality, palliative
radiotherapy continues to be underused (Lutz et al, 2004) and
is frequently offered at too late a stage in the disease trajectory
to realise the benefits intended (Berger et al, 2014). Lutz and
Chow (2014) deemed research and education in palliative
radiation oncology essential to maintain the connection between
advanced radiation technology and the humanitarian skills
required for palliative care. Ireland’s Health Service Executive
(Hollywood, 2003) recognised that oncology and palliative
care nurses are vital multidisciplinary team members in the
Palliative radiotherapy: what
do nurses know?
Kim Hayden and Michael Connolly
ABSTRACT
Background: palliative radiotherapy can improve quality of life for patients
who are symptomatic of advanced cancers. However, this treatment modality
is underused and is often mistimed, which negates its potential benefit.
Aim: the aim of this study was to assess nursing knowledge of palliative
radiotherapy in the context of caring for patients with a cancer diagnosis.
Methods: a quantitative method of research was employed using a
questionnaire to assess palliative radiotherapy knowledge among a purposive
sample of 162 oncology and palliative care nurses. Findings: the response
rate was 48.14%. More than half of respondents reported their knowledge
of radiotherapy as insufficient for their practice and almost all agreed they
would benefit from more education. Conclusion: nurses require more training
to identify when palliative radiotherapy would be an effective symptom control
option; specific areas of focus for developing future radiotherapy educational
programmes are highlighted.
Key words: Palliative ■ Radiotherapy ■ Palliative care ■ Nurses’ knowledge
■ Symptom control in cancer ■ Bone metastases
Kim Hayden, Clinical Nurse Specialist, Our Lady’s Hospice and
Care Services, Dublin, Ireland, khayden@olh.ie
Michael Connolly, Joint Associate Professor of Clinical Nursing,
University College Dublin School of Nursing, Midwifery and
Health Systems, and Our Lady’s Hospice and Care Services,
Dublin, Ireland
Accepted for publication: September 2019
provision of radiation treatment, and have an integral part to
play in the clinical care of patients who are both receiving
and recovering from radiation. Likewise, Berrang and Samant
(2008) acknowledged that nurses are the health professionals
who care for patients on a day-to-day basis and therefore
require the knowledge and skills to identify those that may
benefit from referral. While nurses are not permitted as yet
to independently refer patients for radiotherapy, as members
of the multidisciplinary team, they can advocate for a patient
who may benefit from palliative radiotherapy and use their
knowledge to contribute to a registered medical practitioner’s
decision to refer them to radiation oncology.
Of all patients who undergo radiotherapy, approximately half
are treated with palliative intent (Hoskin et al, 2013). Although
palliative radiotherapy is most often used to manage symptoms
caused by metastatic disease, it also has a role in the control
of incurable disease which can potentially increase long-term
survival (Aggarwal and Hughes, 2016).
The aim of this study was to assess if nurses who care for
patients with cancer have adequate knowledge of palliative
radiotherapy.
Study objectives were to:
■ Assess the level of understanding among nurses regarding
the clinical indications for palliative radiotherapy
■ Examine any misconceptions they hold relating to the
administration of radiotherapy
■ Ascertain how confident nurses are with their present level
of knowledge of palliative radiotherapy
■ Examine the level of radiation training nurses have received
■ Examine if a lack of knowledge is a barrier to recommending
referral of patients for palliative radiotherapy.
Methods and materials
To obtain an accurate representation of what is understood about
palliative radiotherapy, a purposive sample of nurses who worked
in oncology and palliative care specialist areas was selected.
An invitation to participate in the study was sent to all 162
registered general nurses who were employed in the oncology
and palliative care departments of the selected research sites.
This was the only criteria set in the recruitment of participants.
Considering a 95% confidence level and a 5% margin of error,
the total sample size required was estimated to be 115.
The study was conducted in three clinical sites in Dublin,
Ireland; two were specialist palliative care units and the other an
academic teaching hospital. The specialist units provide palliative
British Journal of Nursing, 2019, Vol 28, No 18 1203
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care through inpatient, day unit and community services. While
no radiotherapy facility is available at either site, there are close
links to radiotherapy services at a nearby radiation oncology
centre. The third research site, a large university training hospital
with over 450 inpatient beds provides oncology, palliative care
and radiation specialist services.
The design of this study was informed by a previous study
that employed a quantitative method of research using an
existing validated questionnaire. The research tool developed
by Berrang and Samant (2008) to assess knowledge of
palliative radiotherapy among community family physicians
and nurses encompassed the key elements that this study
aimed to examine. Permission to adapt the questionnaire for
this study was sought and granted, and it was subsequently
reviewed by a panel of experts.
The five-page questionnaire consisted of 38 items to examine
participants’ experience and knowledge of palliative radiotherapy.
Just under half of all items were set in the format of multiple
choice questions to assess overall knowledge of radiotherapy
and its use in palliative care. Demographic questions to collect
information about the respondents’ experience, training and
specialty were also included. To determine nurses’ self-rated levels
of knowledge and whether they considered their knowledge was
adequate for their needs, they were asked to choose answers from
a four-point Likert scale ranging from ‘very little knowledge’
to ‘extremely knowledgeable’. Actual knowledge of palliative
radiotherapy was assessed through a calculation of correct
responses given to a list of clinical indications using a Likert
scale of answer choices of ‘not effective’, ‘somewhat effective’,
‘very effective’ and ‘don’t know’.
Nurses were asked to rate a list of seven factors, such as age
of the patient or concern about side effects, which influenced
their decision to recommend referral of a patient for palliative
radiotherapy. The questionnaire offered respondents the option
of ticking a ‘yes’, ‘no’ or ‘unsure’ response in a list of 10 possible
conditions to evaluate knowledge of which clinical indications
radiotherapy could be considered useful for. A blank space was
also included where nurses were asked to list indications for
which urgent radiotherapy should be considered. Participants
were asked if they had ever been educated in palliative care
or radiation oncology in their nurse training and if they had
received any training after qualification.
Nurses were assured their participation was entirely voluntary
and their identities would remain anonymous. An information
sheet in each questionnaire pack informed the participant that
completion and return of the questionnaire implied consent.
Nominated gatekeepers at each site were responsible for the
distribution and collection of the questionnaire packs.
Descriptive and inferential statistical analyses of questionnaires
were completed using the Statistical Package for Social Science
(SPSS) Version 21. A Mann-Whitney U test was run to identify
statistically significant differences between oncology and
palliative care nurses in terms of actual knowledge scores.
Results and discussion
A total of 80 questionnaires were returned, which demonstrated
a response rate of 49.38%. Two questionnaires were considered
ineligible because they were returned late so the final sample
size was 78. Table 1 shows participant profiles and self-assessment
of radiotherapy educational needs.
The majority (89.5%; n=70) of respondents were female
with an average of 10 years’ nursing experience within their
clinical specialty. Twenty-four nurses reported they worked
in an oncology setting and a further two were working in
oncology-related areas (haematology and surgical). Fifty-one
nurses described themselves as working within palliative care
areas; 29 on inpatient areas, eight within community palliative
care and 14 who did not specify. Most (89.5%; n=70) of the
nurses surveyed reported that they were often involved in
palliative care management and 94.7% (n=72) of nurses had
experience of patients who had been referred for palliative
radiotherapy.
The study participants were a well-experienced cohort
of nurses and therefore deemed to be representative in the
assessment of what nurses know about palliative radiotherapy.
Assessment of clinical indications
To determine the current level of understanding among nurses
about for which conditions palliative radiotherapy may be
useful, 10 clinical indications were listed and participants were
instructed to tick which answer applied. The list included
situations in which radiotherapy would not be useful, for
example hypercalcaemia and febrile neutropenia. Figure 1 shows
a selection of the conditions in which palliative radiotherapy
would be indicated.
Almost all nurses, 96.2% (n=75) and 76.9% (n=60)
respectively correctly specified that bone metastases and
diffuse brain metastases were clinical conditions for which
palliative radiotherapy may be indicated. However, fewer than
half (39.5%) were aware that palliative radiotherapy could be
a useful modality in the management of ulcerating or painful
skin metastases. Palliative radiotherapy is not a treatment
for the oncologic emergency of febrile neutropenia, but
17.9 % (n=14) of nurses reported they were ‘unsure’ and
2.6% (n=2) incorrectly selected ‘yes’. Almost 17% (n=13)
of nurses incorrectly stated that palliative radiotherapy was
useful in the treatment of hypercalcaemia and more than 20%
(n=16) indicated that they were unsure. Just 61.8% (n=47)
of nurses identified that radiotherapy was effective in the
management of superior vena cava obstruction.
Table 1. Participant profile and self-assessment of
palliative radiotherapy educational needs
Characteristic Response
Median age in years (range) 38 (23–61)
Female (%) 89.5
Involved with care of cancer patients? (% yes) 100
Knowledge of palliative radiotherapy adequate for
needs? (% yes)
45.5
Would you like to learn more about palliative
radiotherapy? (% yes)
84
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Similar results were identified by Fairchild et al (2012), who
demonstrated significant inconsistencies in the knowledge of
the correct indications for radiotherapy in particular with regard
to hypercalcaemia and febrile neutropenia. This would suggest
that indications for palliative radiotherapy should be a specific
area of focus for future education.
Misconceptions of radiotherapy
administration
The questionnaire included general questions pertaining to
treatment times, side effects and conditions necessary for
treatment (Table 2).
Fewer than half of nurses (47.4%; n=37) surveyed accurately
responded that patients did not usually become radioactive
after radiotherapy treatment and 19.2% (n=15) of nurses were
unclear if patients were a danger to those around them. Nurses
were asked to indicate what the minimum life expectancy of a
patient with cancer should be before they should be considered
a candidate for radiotherapy (Figure 2).
The number of nurses who identified the correct answer as
greater than one month was just 17.9% (n=14). More than half
of the nurses surveyed accurately described the usual side effects
of palliative radiotherapy to be none or mild, the remainder
inaccurately choosing the descriptor of moderate or severe.
Nurses were asked to select which factors precluded a patient
from receiving radiotherapy from a list of six. The two correct
factors were ‘actively vomiting’ and ‘delirium’; 64.1% (n=50)
and 71.8% (n=56) respectively of nurses correctly identified
this. However, 15.4% (n=12) of nurses incorrectly indicated
that a patient with a pacemaker in situ was unable to undergo
radiotherapy. Regarding the treatment benefit time for painful
bone metastases, just over half (55.1%) of the nurses surveyed
identified the correct response of 1-3 weeks after treatment.
It is worth noting that Berrang and Samant (2008) cautioned
that treatment may be perceived to have failed if the timing of
treatment benefit was underestimated. Knowledge of palliative
radiotherapy must be accurate and evidence based to manage
the complexities associated with advanced disease and to ensure
that it is delivered both on time and appropriately (Aggarwal
and Hughes, 2016).
Results of the study being reported here highlight several
areas of misconceptions relating to palliative radiotherapy that
may affect its utilisation and potentially have a negative impact
on the patients’ quality of life.
Self-assessment of palliative radiotherapy
knowledge
Just under half (45.5%; n=35) of nurses indicated their knowledge
of radiotherapy was adequate for their needs. When asked to rate
their knowledge of the general aspects of radiotherapy using
a Likert scale, fewer than half of them described themselves as
being ‘moderately knowledgeable’ about the potential benefits
of palliative radiotherapy, 15.85% said they had ‘very little
knowledge’ relating to potential side effects and only 2.6%
(n=2) declared themselves as ‘extremely knowledgeable’ in the
management of side effects. A majority (84%; n=66) of nurses
agreed they would benefit from more education in palliative
Table 2. Side effects of palliative radiotherapy
Survey No
(%)
Yes
(%)
Depends
(%)
Unsure
(%)
Is radiotherapy painful? 60.3 5.1 26.9 7.7
Does palliative radiotherapy
(PR) usually cause nausea or
vomiting?
23.1 9.0 60.3 7.7
Does PR usually cause hair loss? 39.7 3.8 50.0 5.3
Are patients receiving PR usually
significantly immunocompromised
or at high risk of infection?
51.3 24.4 16.7 7.7
Do patients usually become
radioactive after PR?
47.4 17.9 17.9 16.7
Figure 2. What should the minimum estimated life expectancy of a
patient be before considering referral for palliative radiotherapy? (n=78)
90
80
70
60
50
40
30
20
10
0
Greater
than
1 month
Life expectancy
has absolutely
no influence
on referral
Total
Greater
than
3 months
Greater
than
6 months
Greater
than
12 months
Figure 1. Indications for palliative radiotherapy: numbers of participants
correctly answering ‘yes’ (n=78)
80
70
60
50
40
30
20
10
0
Bone
metastases
Haemoptysis Brain
metastases
Ulcerating/painful
skin metastases
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care and almost all (94.8%; n=73) said they would benefit from
more education in radiotherapy and its use in oncology. Olsen
et al (2012), in their examination of the relationships between
family physicians’ knowledge of the indications for radiotherapy,
previous training and referrals to palliative radiotherapy, found
that higher self-rated knowledge was positively associated with
referral rates of palliative radiotherapy.
Radiation education
Participants were first asked to indicate ‘yes’ or ‘no’ if they
had received any formal training in radiation oncology during
their nursing education, to which just 15.6% (n=12) answered
‘yes’. The same question was posed in relation to education
after completing nurse training, to which 25.6% (n=20) of
participants indicated they had received further training in
radiation oncology. Just over half of the nurses surveyed (57.7%;
n=45) had visited a radiotherapy department.
These results were surprisingly low, considering the majority
of nurses surveyed (94.7%) had cared for patients who had
been referred for palliative radiotherapy and on average had
been working within a clinical specialty of either oncology
or palliative care for more than 10 years. It is worth noting
that Aggarwal and Hughes (2016) highlighted the necessity of
providing palliative radiotherapy training to both oncology and
palliative care teams and that continuing education remained
key to the optimal use of palliative radiotherapy.
Barriers to radiotherapy referral
An initial assessment of overall knowledge was calculated to
examine if a lack of knowledge was a barrier to recommending
patients for referral for palliative radiotherapy. This was achieved
by analysing the results of a set of specific questions pertaining
to radiotherapy, with a possible correct score of 30. The lowest
score calculated was 6 and the highest 28. The mean score of
the sample was 18.22 (SD=4.41); 7.7% (n=6) scored 0–10,
64.1% (n=50) scored 11–20 and 28.2% (n=22) scored 21–
30. Participants were asked how much a particular factor
influenced their decision to recommend referral of a patient
for radiotherapy. The Likert scale of tick-box answers available
were ‘not at all’, ‘a little’, ‘somewhat’ or ‘a lot’. Of the total sample
(n=78): six nurses (7.8%) reported that uncertainty about the
benefits of radiotherapy had not influenced their decision to
recommend referral of a patient for radiotherapy at all; 19 nurses
(24.4%) indicated that it had influenced their decision a little;
just over half (n=39) agreed that it had somewhat influenced
their decision; and 16.7% (n=13) that it was a major factor.
Almost half of those surveyed (47.4%; n=37) indicated that
the age of the patient would somewhat influence their decision
to recommend them for referral for radiotherapy, 14.3% (n=11)
a little and 24.7% (n=19) of nurses would be influenced a lot. To
assess the knowledge of the clinical conditions that constitute
an urgent referral for radiotherapy, participants were asked to
list the indications they considered emergent. More than one in
four (26.9%; n=21) correctly identified either of the two main
urgent indications for radiotherapy: spinal cord compression;
and superior vena cava syndrome.
Participants were asked to rate the effectiveness of radiation
treatment from a list of seven possible manifestations of cancer
using a Likert scale of ‘not effective’, ‘somewhat effective’, ‘very
effective’ or ‘don’t know’. Almost all participants (96.1%; n=75)
recognised the effectiveness of radiotherapy to treat painful bone
metastases. In relation to the use of radiation for the treatment
of haematuria or haemoptysis, fewer participants identified its
effectiveness; 16% (n=12) indicated that it was not effective
for haemoptysis and 26.7% (n=20) said they didn’t know. With
regard to haematuria, just over a quarter of participants (26.7%;
n=20) stated that radiotherapy was not an effective treatment,
with a further quarter (24.4%; n=19) stating that they did not
know. For the treatment of an airway obstruction caused by
a tumour, 17.9% (n=13) did not recognise radiotherapy as a
possible modality of care.
Olson et al (2012) demonstrated a correlation between
knowledge of palliative radiotherapy and increased rates of
referral. This is noteworthy, considering the results of the study
reported here show that more than half of all nurses stated
their knowledge of radiotherapy was inadequate for their
needs and almost all agreed they would benefit from more
education on this topic. Continuing education for professional
development would ensure that the nurse, as a member of the
multidisciplinary team caring for patients with cancer, would
recognise the importance of knowledge to facilitate timely
referrals to radiation oncology (Berrang and Samant, 2008).
Knowledge comparison
Because the sample size was relatively small, the non- parametric
Mann-Whitney U test was run to examine statistically significant
differences between oncology and palliative care nurses in terms
of general knowledge scores. A statistical significant difference
(U=386; P<0.01) demonstrated that palliative care nurses had
a higher mean knowledge score (mean=19.12; SD=4.22) than
oncology nurses (mean=16.50; SD=4.57).
This statistical difference in knowledge between the
specialties suggests that the curriculum for oncology training
may require more content on radiation oncology.
Conclusion
It is evident from this study of palliative radiotherapy knowledge
that additional training is required for nurses caring for patients
with advanced cancer. Findings were consistent with those of
Berrang and Samant (2008) concerning inaccuracies in the
ability to correctly identify clinical indications for palliative
radiotherapy, and with the findings of Fairchild et al (2012) and
KEY POINTS
■ Palliative radiotherapy is an effective modality of care that can alleviate
many of the distressing symptoms associated with advanced cancer
■ Palliative radiotherapy is underused and is frequently given too late in the
disease trajectory for it to reach its potential benefit
■ Mistimed radiotherapy can result in unnecessary treatment burden and
decreased quality of life
■ A lack of knowledge is a barrier to patients being referred for radiation
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Olsen et al (2012) with regard to lack of knowledge regarding
the haemostatic properties of radiotherapy. The benefits of
palliative radiotherapy are generally negated for patients with
a prognosis of less than one month and mistimed treatment
could potentially delay the delivery of supportive measures
that focus on end-of-life planning and optimising quality of
life (Jones et al, 2014; Kress et al, 2015).
Fewer than a quarter of nurses were able to recognise the
appropriate minimum life expectancy of a patient before
a referral for radiotherapy should be considered. Lack of
knowledge is recognised as a barrier to radiotherapy use
(Fairchild et al, 2012); in this study, the majority of nurses
reported that uncertainty about the benefits of radiotherapy
and concern about side effects would influence their decision
to refer patients for radiotherapy. Although all of the nurses
surveyed cared for patients with cancer, only slightly more
than half had ever visited a radiotherapy department. Only a
minority of nurses had received training in radiation oncology
during their nurse education and only a quarter had received
any training after registration.
Optimal use of palliative radiotherapy relies on the
knowledge of health professionals involved in the care of
the patient. The findings from this quantitative study have
demonstrated a significant gap in nurses’ knowledge of
palliative radiotherapy and identified specific areas of focus for
developing future radiotherapy educational programmes. To add
to the understanding of nurses’ knowledge regarding palliative
radiotherapy, a qualitative component should be considered for
future research in this area. BJN
Declaration of interest: none
Acknowledgement: the authors wish to thank all the nurses who
participated in this study and Dr Rajiv Samant for his support and
allowing them to adapt his questionnaire
Aggarwal A, Hughes S. Palliative radiotherapy: evolving role and policy
challenges. J Cancer Policy. 2016;10:21–29. https://doi.org/10.1016/j.
jcpo.2016.05.003
Berger B, Ankele H, Bamberg M, Zips D. Patients who die during palliative
radiotherapy. Strahlenther Onkol. 2014;190(2):217–220. https://doi.
org/10.1007/s00066-013-0471-6
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Hollywood D (chair, Expert Working Group on Radiation Oncology
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■ Have you ever been to a radiotherapy department and, if so, how did this improve your knowledge of how to support
patients who are undergoing radiotherapy?
■ Have you cared for patients whose radiotherapy treatments have potentially been mistimed and have died during
radiotherapy treatment, or been unable to complete radiation schedules?
■ How would you consider the role of palliative radiotherapy for patients who are symptomatic of their cancer and how
would you discuss the possibility of a referral to radiation oncology with the medical oncology/palliative care team?
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