Introduction

Over the past several decades, improvements in the early detection of cancer and effective therapies have led to increased numbers of cancer survivors. Currently, there are 13 million cancer survivors in the USA. This number is expected to rise to 20 million by 2026 [1, 2]. During the transition from active treatment to post-treatment care, cancer survivors may be left lacking the knowledge, resources, or skills necessary to manage their disease and treatment’s long-term effects. Hence, it is vital for patients who become cancer survivors to receive high-quality survivorship care.

Nurses have played a vital role in educating and assessing cancer patients and assisting in the continuity of care needed to cope with the late and long-term consequences of the medical conditions. The Institute of Medicine has highlighted the diverse roles that nurses could play in delivering high-quality cancer care, including assessing, educating, and coordinating care for patients through the care continuum. However, in the midst of a looming nursing staff and faculty shortage, there are fewer nurses who receive training and education in specialties, such as oncology [3,4,5,6]. In a survey of 2000 oncology nurses, nurse executives, and oncologists, the respondents reported that the shortage of experienced nurses led to decreased cancer care quality [5]. Studies have also shown that staff education contributed to significant improvements in all domains of survivorship care. However, barriers such as lack of time, funding, and inadequate knowledge were identified as hurdles to provide quality survivorship care [4, 7]. Furthermore, most nurses reported knowing the patient’s physical well-being during active treatments, such as healthy lifestyles, chemotherapy, radiation, surgery, and symptom management. However, nurses were reported to be less knowledgeable on patient issues related to social and psychological well-being, such as employment, quality of life, genetic risks, and financial issues [8].

To ensure the nursing workforce is equipped with knowledge about cancer care, for patients not just during active treatments but also during post-treatment, infusing the notion of managing cancer as a chronic condition in nursing education is essential. In addition to continuing education, it is also recommended that educational institutions include portions of cancer survivorship in both undergraduate and graduate nursing programs. A comprehensive cancer curriculum is recommended to have the whole cancer trajectory and issues related to follow-up and survivorship care because well-educated nurses will further improve the quality of cancer nursing care [7, 8]. The concept of a survivorship care plan (SCP) has been recommended as a supportive framework to highlight the recommended contents of the cancer survivorship education curriculum [9,10,11,12]. Blending or introducing cancer care and survivorship concepts early in the nursing program curriculum could help foster student nurses’ readiness and interests to practice in this specialty. While the concept of cancer survivorship is imperative, there is limited research to evaluate the knowledge and attitude of nursing students toward cancer survivorship. This paper describes the knowledge and attitude of cancer survivorship among nursing students from a pilot evidence-based educational project, of which the concept and framework of the survivorship care were incorporated.

Method

A pilot evidence-based educational project was developed and administered to a group of undergraduate and graduate nursing students to evaluate cancer survivorship care’s knowledge and attitudes.

Proposed Educational Activities

The proposed educational activities for nursing students included (1) a brief lecture, (2) a discussion with a case study, (3) pre- and post-test, and (4) a reflective journal. This project’s expectation was to produce nurses who recognize an ever-increasing population of cancer survivors who are in desperate need of champions to educate and advocate for their vast array of needs. The principles of this educational project included that cancer survivorship is a lifelong journey for cancer patients; it can change a cancer patient’s life goals in various aspects of life, including interpersonal relationships, work-life balance, family building, life stage development, or control of symptoms and achieving the quality of life. Patients’ life goals can be disrupted and need to be readjusted in the cancer survivorship journey. Nursing planning and goal setting align with the needs of adjusting life goals in cancer survivorship [13,14,15]. It is essential to understand cancer survivorship’s nature and concept and how to work effectively with cancer patients to improve the quality of life.

The lecture presentation introduced the current state of cancer survivorship in the USA, key areas of focus to address barriers to implementation, examples of and resources for survivorship care plans, and nurses’ role in survivorship care. The brief lecture proceeded for approximately 30–45 minutes. In addition, a 15-minute discussion was conducted to explore students’ perception of cancer, cancer patient, and oncology units. A follow-up case study of cancer patient was provided to student participants during a 30-minute session for immediate reinforcement and connection between the clinical scenario and didactic content.

The evaluation of the educational program included the use of a pre- and post-test survey. A pre-test consisting of 11 questions about students’ knowledge of cancer care was given prior to the lecture presentation. As the participants were likely to have some knowledge about the distinctive roles of nurses in cancer care and cancer care in general, the pre-test served as a baseline knowledge of nursing students about cancer care, specifically survivorship care. Following the educational segment, a post-test consisting of 7 questions that were distinctive from the pre-test was given. Pre- and post-test surveys were administered to participants as anonymous surveys. Supplemental to the pre- and post-test was the reflective journal. The use of reflective journal in nursing helps create an understanding of situations in current and past events. The process of reflective writing enhances students’ clinical reasoning skills and self-awareness in clinical situations [16]. The purpose of using the reflective journal in this project was to encourage students to document personal reflections on current challenges and issues encountered with cancer survivorship care. This activity was voluntary. Students were encouraged to develop a reflective journal to document the reflection and observation of cancer survivorship during their clinical practicum if they had the rotations in cancer survivorship care.

Participants

The pilot educational plan was administered to nursing students in one undergraduate course and one graduate course during the academic year of 2017–2018 at a school of nursing in the Northern California region. The course instructors were consulted, and their approvals were obtained to coordinate the class time to provide the proposed educational activities to these students. All student participants were given information about the goal of this project. In addition, information on voluntary participation and confidentiality of pre- and post-tests was given. The institutional review board approved the data analysis of pre- and post-test feedback obtained from this project.

Data Analysis

The pre- and post-test data were summarized through a content analysis process where themes and categories were generated inductively. Content analysis is a method to analyze the presence, meanings, and common relationships of concepts and themes [17]. Content analysis was considered to be manifest analysis, where the data represented what the participants say. This way, misinterpretations were hoped to be reduced. Lastly, to increase the validity of data analysis, two investigators analyzed the results from the pre- and post-tests and obtained the consensus of the themes.

Findings

Between August 2017 and March 2018, a total of 55 nursing students were entered into this educational project. The undergraduate nursing students (n = 38) received this educational activity in one of their first nursing pre-licensure courses. Graduate students (n = 17) received this educational activity in one of their final program courses. As alluded to earlier, these students came from a combination of ethnic/racial, age, and educational background. More than or at least 50% of the nursing students have had experience with the adult patient population. At least about 60% of both undergraduate and graduate nursing students also had experience in working at a pediatric and/or adult oncology unit.

Of the total of 55 participants, 55 (100%) completed the pre-test, while 53 (96%) completed the post-test. Given that this educational project was carried out among the first-semester nursing major undergraduate students, some students had yet to start their formal training on how to use the nursing process and nursing care plans, which are clinical reasoning tools commonly used in nursing education. Hence, it was expected that less than half (45%) of the participants would identify themselves as not yet comfortable with nursing discipline–specific reasoning tools. However, 55% of undergraduate nursing students expressed that they were “somewhat comfortable” in developing nursing care plans compared with 59% of graduate students suggesting they were “comfortable.” In addition, 63% of undergraduate students have not used any electronic healthcare systems. Graduate students, as expected based on the level of education, had all (100%) used at least one of the electronic healthcare systems (Table 1).

Table 1 Comparison of answers to pre-test questions between undergraduate and graduate nursing students
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Only 11% of undergraduates and 18% of graduate students reported awareness of survivorship care plans. In addition, only 3% of undergraduate and 12% of graduate nursing students could accurately answer what is the range of cancer survival rates. Based on the responses to these two questions, the gap in students’ knowledge about cancer survivorship was evident, whereas most of the student participants showed a better understanding in the acute stage of cancer care. At least 68% of the participants were knowledgeable about the types of treatment for patients with cancer, which includes medications, chemotherapy, radiation, surgery, and palliative care. All student participants understood that patients with cancer can experience multiple side effects from their treatments. Lastly, 100% of the participants reported that nurses had a major influence on their patient’s quality of life and that educational materials were necessary for educating cancer patients and families regarding their cancer care (Table 1).

The open-ended questions and interviews from the post-test assessments revealed several common themes (Table 2). Following the education section of this project, all (100%) of the undergraduate and graduate nursing students believed survivorship care plans to be helpful for patients and at least 97% conceded in the adoption of a multidisciplinary team in the development of these survivorship care plans. Moreover, 95% of undergraduate students and 75% of graduate students expected institutional support for the development and implementation of survivorship care plans. The common themes included recognizing the complexity and multidimensionality of cancer, ensuring patient’s safety and quality of life, continuous education of cancer survivorship among institution leaders and medical staffs, transferability versus specialization of cancer survivorship care plan, and barriers and facilitators for implementation. In the theme of “recognizing the complexity and multidimensionality of cancer,” student participants generally recognized that cancer is a complex and prevalent condition, where multidisciplinary patient-centered care is important to the quality of life. In the theme of “ensuring patient’s safety and quality of life,” students reported that it is the duty of nurses to ensure patient’ safety and quality of life, and nurses understand the multidimensional aspects of caring for cancer patients. Nurses can play key roles in coordinating empathic care and advocacy for cancer patients. In the theme of “continuous education of cancer survivorship among institution leaders and medical staffs,” participants described educating providers to empower cancer survivors to participate in their care and manage fears or reoccurring issues. The use of educational tools in staff education can help in the adoption of SCP, such as electronic versions and patient education to share the SCP with other providers. In the theme of “transferability versus specialization of cancer survivorship care plan,” there are conflicting points of views shared by the participants. Some participants considered that SCP is specific only to oncology units, not applicable to other settings, such as the emergency department. Some students considered that education should only be included in oncology or nurses who specialize as they never come into contact with cancer patients, whereas the need to include survivorship care in nursing education was supported by some participants as well. In the theme of “barriers and facilitators for implementation,” the possible barriers and facilitators to implementing SCP identified by student participants included willingness to participate, lack of staff support, lack of information, and institutional support and awareness. The most common barriers anticipated by the undergraduate students in the utilization of survivorship care plans were time and funding, while graduate students identified time and physician support as the greatest barriers to use. Moreover, 95% of undergraduate students and 75% of graduate students expected institutional support for the development and implementation of survivorship care plans. Furthermore, participants were asked to recommend strategies related to the role of nurses to address the barriers of time, funding, institutional support, and physician support. The responses included continuing education for providers, institution leaders (i.e., directors, managers), nursing staff, and patients; increase in research to expand evidence-based practice; achieving standardization of survivorship care plans (i.e., use the same survivorship templates); and the acquisition of community support as top priorities that determine the successful implementation of survivorship care plans (Table 2).

Table 2 Content analysis of post-test surveys
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The reflective journal helped students connect their clinical observations with abstract complex concepts related to cancer survivorship. As shown in the example voluntary reflective journal (Table 3), a graduate student described the change of attitude and understanding toward cancer survivorship after the clinical interaction with cancer patients and clinicians.

Table 3 Example of a reflective journal
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Discussion

According to the results of this study, nursing students agreed that nurses play a critical role in patient education and care coordination for cancer patients. However, only a small portion of both undergraduate and graduate students were aware of the concept of cancer survivorship, long-term trajectory of the illness, and accurate cancer survival rate, whereas most students had a better awareness of the multidisciplinary effort and system infrastructure which are required to implement cancer survivorship care planning. However, the results showed a mixture of misperception about their future roles in cancer survivorship care planning when they start in their own clinical practices. The gap in students’ understanding could be due to the fact that most courses offered in nursing curricula focus on basic science, treatments, and interventions occurring in the acute care phase or episodic cares. Although the post-treatment supportive care and palliative care related to cancer has been increasingly incorporated in nursing curricula, the concepts of care coordination and transition between treatment phase and survivorship can be still foreign to nursing students, especially to undergraduate students.

Notably, a couple of the graduate students did not perceive a role for them in cancer care for the reason that he or she was not an oncology nurse. Nursing students, regardless of the level of education, still hold inaccurate impressions regarding cancer care. This inaccurate belief that cancer patients and survivors only receive care from oncology nurses is another reason to include the concepts related to cancer survivorship in nursing curriculum. Cancer patients may also receive generalized clinical care; for instance, a leukemia survivor may be admitted to the emergency department for shortness of breath related to a recent bone marrow transplant. The notion of departmentalizing cancer care based on institutional structure and medical specialty was rooted in students’ perceptions. Lastly, participants were invited to share their views in regard to the incorporation of survivorship care in nursing program curricula. All undergraduate nursing students and 67% of graduate nursing students supported the inclusion of survivorship care in their nursing education. This discrepancy in the degree of enthusiasm and support for survivorship care plans between undergraduate and graduate students is, perhaps, partly related to the fact that graduate students were, at the point of their career development, certain about their particular clinical emphasis. In contrast, undergraduates were yet to familiarize themselves with the different specialties surrounding nursing care and thus are more receptive to change.

The content of cancer nursing care has been recommended as one of the key content areas to be taught in nursing curricula [18,19,20,21]. A quality education and training in cancer care can provide foundations to healthcare professionals acquiring the knowledge, skill, and attitude to manage actual or potential human responses in cancer care continuum [20]. Most of the recommended cancer nursing curricula were proposed for post-entry nursing specialization and certification in oncology, which include multiple modules from basic science and treatment of cancer to evidence-based application in cancer care to cancer as a chronic illness [18,19,20]. While a comprehensive curriculum can help providers to develop mastery of oncology care, it can be a challenge to integrate the whole program in the pre-licensure or undergraduate programs when contents of other specialties (e.g., cardiovascular, pediatrics) are also needed in the undergraduate nursing curriculum. It has been found that a short (3.5 days) collaborative program co-produced by instructors, practitioners, patients, and caregivers, on the long-term impact of cancer, can enhance good overall knowledge of the impact and consequences of a cancer diagnosis, more positive attitudes toward cancer treatment and cancer care, and greater confidence in their ability to support cancer patients at all stages of the cancer journey from pre-diagnosis to survivorship among undergraduate nursing students [21]. Our study results also showed that participants’ appreciation and understanding of cancer survivorship can be enhanced after a short program of which a combination of different learning activities (lecture, discussion, and reflection) was implemented. As shown in this pilot project, short and interactive learning activities can enhance learner’s knowledge, skill, and attitudes while complex concepts are introduced [22]. Additionally, reflective writing is a helpful tool in medical and nursing education [23]. As used in this study, incorporating reflective journaling in concurrent clinical rotations can be an effective tool to engage undergraduate and graduate students to identify the gaps between the conceptual understanding and clinical observation of cancer survivorship, explore career interest in oncology care, and encourage developing self-awareness in personal’s strengths and limitations.

Conclusion

The introduction of concept of cancer survivorship care will help educated and competent nurses who are valuable in ensuring a positive quality of life for survivors. In addition to understanding the pathophysiology of cancer and whole cancer trajectory, handling issues related to follow-up and survivorship care, such as communication training, is necessary to be initiated early in the nursing curriculum for both undergraduate and graduate students. Quality communication is an integral part of cancer care. Nurses encounter complications in conversations that include “bad news, spiritual or religious concerns, and palliative care issues with patients and families from different cultures” [24]. Yet nurses report communication barriers to patient-centered care. It was reported that oncology nurses have limited opportunities to receive communication training. Lack of consistency in communication from healthcare staff and lack of adequate knowledge are found to be the challenges for oncology nurses to understand and sort out information to patients and families. Additionally, the relationship between nurse and physician determined the communication flow about the patient’s plan of care can pose additional challenge [24]. As summarized from our study findings, these key concepts and training could be introduced early in the nursing education in both undergraduate and graduate programs to support nursing new graduates and enhance their readiness in providing cancer care. Future research can explore the effectiveness of different learning modalities in deliver cancer care content for both undergraduate and graduate students in nursing. As the number of cancer survivors is increasing and there is a looming shortage of oncology workforce, it is vital to introduce the topic of cancer care and engage students who are interested in cancer care early on in the pipeline of workforce development [25].