Abstract
BACKGROUND:
Breast cancer-related lymphedema (BCRL) is one of the most common complications among women with breast cancer.
OBJECTIVE:
This study was conducted to evaluate the oncology nurses’ knowledge about lymphedema assessment, prevention, and management among women with breast cancer, and identify the relationships between oncology nurses’ academic qualification, years of experience, and level of knowledge.
METHODS:
A cross-sectional descriptive design was used. A sample of 150 participants from three institutions completed the study surveys.
RESULTS:
60% (N = 90) of the participants did not pass the knowledge test. 70% (N = 105) of the participants showed lack of knowledge regarding BCRL assessment and examination. The results showed that the participants had knowledge deficit regarding BCRL anatomy, pathophysiology, assessment and examination, risk factors, prevention interventions and precautions, patient education and consultation, and follow-up appointment. Importantly, 96% (N = 144) of the participants reported that they did not receive any continue education regarding BCRL. The results showed that was no significant relationship between years of experience, and level of knowledge (r = 0.25; n = 150; p < 0.51). A significant relationship was found between the nurses’ knowledge according to their academic qualifications (𝜒2 = 6.21; p < 0.0001).
CONCLUSIONS:
The results indicated that there is a need for a structured educational program to improve oncology nurses knowledge regarding BCRL.
Introduction
Lymphedema is one of the most common complications among women with breast cancer. It is considered as one of the most distressing and devastating complications associated with breast cancer treatment modalities. It is defined as accumulation of fluid in the interstitial tissue, it is commonly happens after surgical intervention or radiotherapy treatment [1–3]. Recently, a follow-up four years study reported that incidence of lymphedema was 13.7%. The incidence is associated with type body mass index and type of treatment. The results indicated that patients treated by lymph node dissection with regional lymph node radiation had higher incidence of lymphedema (31.2%) comparing with patient receiving lymph node dissection without regional lymph node radiation (24.6%), followed by those receiving sentinel lymph node biopsy with regional lymph node radiation (12.2%). Moreover, the results stated that the risk of lymphedema can reach to the peak between 12 and 30 months after surgical intervention [4].
In Jordan, breast cancer is the most common cancer type among Jordanian female. It accounts 36.7% of all cancer types [5]. The incidence of lymphedema among Jordanian female with breast cancer was 21.6% [6]. Considering these percentages, it can be concluded that lymphedema is considered a common health problem that require studying and investigating to prevent it and minimize its’ negative impact [6,7].
Breast cancer-related lymphedema (BCRL) associated with wide range of negative impacts including physical limitation (e.g. decrease limb range of motion), pain, role function impairment, psychological distress, changing mode, decreasing quality of life (QOL) [8]. Additionally, it affects the health care system by increasing the cost of treatment, length of stay, and burden of the health care system [7,9].
Unfortunately, there is no cure for BCRL [10]. However, promoting prevention and early detection through increasing patients’ awareness and knowledge might decrease the incidence of BCRL. Informing patient about risk factors for BCRL including obesity, infection, lymphatic system trauma, and exposure to radiation might increase early detection and prevention [11]. In addition, patients who are unable to perform regular, aerobic, and resistance exercises have an increased risk for BCRL [12].
Ability of nurses to educate the patients about postoperative care following breast surgery might decrease the potential complications. Knowledgeable nurses can enhance patients to engage in their care plan postoperatively. Teaching patients about BCRL definition, assessment, risk factors, preventive steps should be considered top priorities for oncology nurses and considered as part of oncology nurses competencies [13,14].
Importantly, the majority of health care providers particularly doctors and nurses have limited opportunities in educating patients with BCRL. Previous studies indicated that majority of patient undergoing breast surgery did not receive basic information about BCRL [15]. Continue training for the oncology nurses is recommended to increase their knowledge and therefore their ability to educate the patients or families [15]. However, identification of oncology nurses’ baseline knowledge about BCRL assessment, risk factors, prevention, and management is essential for developing a specialized training program. In Jordan, no study assessing oncology nurses’ knowledge about BCRL was conducted, accordingly assessing their knowledge is considered a fundamental step to determine their educational/training needs.
Methods
Aim
This study was conducted to evaluate the Jordanian oncology nurse knowledge about lymphedema assessment, prevention, and management among women with breast cancer.
Study design
A descriptive cross-sectional design was used to determine the Jordanian oncology nurses’ knowledge about lymphedema assessment, prevention, and management among women with breast cancer.
Setting and sample
A sample of 150 participants from surgical wards and outpatient clinics participated in the current study. A convenience sampling technique was used. Power analysis was used to estimate the sample size; a sample of 150 nurses was estimated with an effect size of 0.5, alpha at 0.05, and a power of 0.80 [16]. Sample was collected from three different regional hospitals in Jordan by research assistants. The participants who met the inclusion criteria included those working in surgical wards or outpatient clinics for more than 6 months and who worked with patients with BCRL. The trained and expert research assistants (holding a BSN degree) distributed an invitation letters with information sheet. An overview about the study purpose and methodology was detailed in the information sheet. Once the potential participants agreed to participate; they were instructed to complete the survey and return back within three weeks maximum. If the participant failed to returned it back within three weeks, he/she was considered declined. The research assistant collaborated with a contact person in each clinical site.
The research assistant worked with a contact person in each clinical site. Their role involved receiving, distributing, reminding, and delivering the questionnaires. Then the research assistant collected to completed surveys. The participants returned the survey in sealed envelope without identification details in locked box that located in the unit. A sample of 150 participants participated and returned the questionnaire; 30 participants declined participation and did not return the questionnaires with no explanation. The response rate was 83.3%. Data was collected over three-week period.
Instruments and procedures
The participants completed the demographic form. Data related to the participants’ gender, age, job title, level of academic qualification, experience, hours of education about BCRL pre-graduation and continued education at the hospital regarding BCRL.
Knowledge test
A knowledge test was used to determine the oncology nurses’ knowledge about BCRL. Thirty multiple choice questions were structured by the researcher to determine the oncology nurses’ knowledge about BCRL. The test included various questions related to definition (2 questions), anatomy (2 questions), pathophysiology (4 questions), BCRL assessment and examination (4 questions), risk factors (4 questions), Prevention Interventions and Precautions (8 questions), patient education and consultation (4 questions), and follow-up appointment (2 questions). Previous literature, guideline, and textbook were used to develop the knowledge test. The total potential score of the test was 30 points (one point for each question). The participants’ score was classified; scores less than 15 were considered failed, scores between 15 and 20 were considered acceptable, between 21 and 25 were considered good, and between 26 and 30 was considered excellent. Face and content validity were assessed before implementing the test. The test was checked by experts in the field (three experts, two PhD holders in nursing and had clinical and theoretical experience in oncology nursing, and one breast surgeon) checked the content validity. In addition, pilot testing was undertaken to check the reliability. The knowledge test is available on request.
Pilot testing
A pilot study was conducted to check the reliability of the knowledge test, determine the applicability, and identify the difficulties. A sample of 20 participants completed the test. The time to complete the test was ranged between 40 to 60 minutes. No major changes were made on the developed test. The preliminary analysis showed that the test was reliable with Cronbach’s alpha 0.87. The panel of experts reviewed these results and approved the test.
Statistical analyses
Statistical Package for the Social Science (SPSS version 23.0) was used to analyse the data. Descriptive analyses included mean, standard deviation and frequencies. Pearson’s correlation coefficient was used to identify the relationship between years of experience, and level of knowledge regarding BCRL among oncology nurses. Chi-square test was undertaken to assess oncology nurses’ level of knowledge according to the academic qualifications.
Results
Sociodemographic characteristic of the participants
Of the 150 participants; 87 were female (58.0%) and 63 were male (42.0%). Mean age was 25.8 (SD 4.33) years. The results showed that the majority of participants held a bachelor’s degree in nursing (83.3%). 93.3% (140) of the participants reported a desire to attend a structured educational program about BCRL. Finally, 96.0% (144) of the participants reported that did not receive continue education program regarding BCRL at hospital. Table 1 details these results.
Demographic characteristics of the participants (N = 150)
Demographic characteristics of the participants (N = 150)
The results indicated that majority of the participants had holding bachelor degree of nursing failed in the knowledge test (N = 75, 60%). Table 2 details these results.
Oncology nurse’ level of knowledge (N = 150)
Oncology nurse’ level of knowledge (N = 150)
Furthermore, oncology nurse’ level of knowledge according to the knowledge test’ sub-scales was assessed to gain deeper understanding of the results and identify the strengths and areas for improvement. The results showed large percentage of the participants reported lack of knowledge in BCRL assessment and examination (70.0%), patient education and consultation (56.7%), and follow-up appointment (63.3%). Table 3 details these results.
Results of knowledge test sub-items (N = 150)
Relationships between oncology nurses’ academic qualification, years of experience, and level of knowledge were evaluated in the current study. The results showed that was no significant relationship found between the previous variables (r = 0.25; n = 150; p < 0.51).
Furthermore, a significant difference was found between the nurses’ knowledge according to their academic qualifications (𝜒2 = 6.21; p < 0.000).
Discussion
Limited studies were conducted to determine the oncology nurses’ knowledge about lymphedema assessment, prevention, and management among women with breast cancer, and to identify the relationships between oncology nurses’ academic qualification, years of experience, and level of knowledge. The results of the current study identified the gap in nurses’ knowledge and determined the areas for improvement through conducting a structured educational program.
Importantly, the results showed that large percentage of the participants had unsatisfactory results and failed in the knowledge test (N = 90, 60%) although the passing score was 50%. These results could be related to lack of training and continues education, and in adequate preparation during their undergraduate studying. In the last decade, number of patients diagnosed with breast has been increased. Although the number of cancer patients continue to increase, there has not been a similar increase in continue education and training about cancer care and management with the undergraduate nursing curriculum (6–8 from Jennifer R. Klemp, 2011).
Alarmingly, 70% of the participants showed lack of knowledge regarding BCRL assessment and examination. This is definitely related to lack of exposure during their clinical placement in the undergraduate preparation. The review of undergraduate nursing curriculum showed that BCRL has not been intensively covered during the theoretical or clinical courses, as the topic usually been covered on one theoretical lecture (50 minutes). In addition, the review showed that the primary sources about BCRL for the health professional were postgraduate courses and workshops. In the current study, 96% of the participants reported that they did not revive any continue education regarding BCRL. Clearly, these results were related to inadequate development of nurses’ skills and education. These results supporting the previous study conducted by Langbecker (2008) [17]. Both studies indicated that nurses and other health care providers had lack of knowledge regarding BCRL assessment and examination [17,18].
Oncology nurses as day-by-day care providers are expected to provide an optimal care based on their knowledge and competencies. The quality of care provided to the patients based on the nurses’ knowledge and skills. In the current study, the results indicated that the nurses had limited knowledge regarding BCRL prevention interventions and precautions, risk factors, patient education and consultation, and follow-up appointment. These results expand our knowledge and determined the learning needs for the oncology nurses regarding BCRL. These results are considered the first step in conducting educational and training program, and a frame for nursing curriculum modification. The results were supporting and adding to the previous study conducted by Lester (2014). In that study, health professionals’ knowledge about treatment, diagnostic procedures, advice and confidence in treatment of patients with either upper-limb (ULL) or lower-limb lymphedema (LLL) was assessed. A sample of 63 health professionals participated in the study. The results showed that 30.2% of the participants received adequate training from their institution to provide lymphedema treatment. This led to that less than 50% of nurses reported having knowledge of lymphedema [19].
Surprising results were gained from the current study, as the results showed that was no significant relationship between years of experience and level of knowledge. These findings are inconsistent with the previous results by Klemp (2011). The nurses knowledge about lymphoma was around the average (3.2, SD = 1.2). This was considered low comparing with their knowledge about other topics such as fatigue, anxiety, fear of recurrence, hope, and palliative care. In addition, in her study, strong relationship was found between years of experience and knowledge domains. These surprising results may be related to the lack of continue education regardless years of experience, inadequate training/workshop about BCRL [20].
The results from the current study increase our understanding and knowledge regarding areas for continuous education and training. Knowledge gaps were existed and need to obtain additional education to ensure the quality of care is recommended. Curriculum changes in nursing to include BCRL assessment and management also recommended. Further researches with large sample size are recommended to overcome the limitation of the current study. Additionally, future researchers using qualitative approach is recommended for deeper understanding of nurses learning needs.
Limitations
Further researches with large sample size are recommended to generalize the results. More nurse practitioners holding a master degree in Jordan is recommended to be included in the future research. Additionally, future researchers using qualitative approach is recommended for deeper understanding of nurses learning needs.
Conclusion
BCRL is a common complication that remains under-recognised by the oncology nurses. Oncology nurses are essential and key professionals within the health care team who necessary to be knowledgeable about BCRL including definition, assessment, management, and follow-up. The results determined the areas for continue education and training. Therefore, there is a need to educate and train the nurses how to manage patients with BCRL. Our study strongly suggests and recommends introducing the BCRL assessment and management in the undergraduate nursing curriculum.
Compliance with ethical standards
Ethical compliance
Institutional Review Board approval was obtained.
Conflict of interest
The author declares no conflict of interest.
Acknowledgement
The author would like to thank the participants for their effort and time.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.