50 NURSING RESEARCH

A Survey of Oncology Advanced

Practice Nurses in Ontario: Profile
and Predictors of Job Satisfaction
Denise Bryant-Lukosius, RN, PhD
Assistant Professor, School of Nursing, McMaster University
Clinical Nurse Specialist, Juravinski Cancer Centre
Hamilton, ON

Esther Green, RN, MSc(T)

Chief Nursing Officer, Cancer Care Ontario
Assistant Clinical Professor, School of Nursing, McMaster University
Toronto, ON

Margaret Fitch, RN, PhD

Head of Oncology Nursing and Supportive Care, Toronto Sunnybrook
Regional Cancer Centre
Professor, Faculty of Nursing, University of Toronto
Toronto, ON

Gail Macartney, RN, BScH, MSc(A), ACNP

Advanced Practice Nurse, Malignant Hematology
The Ottawa Hospital
Ottawa, ON

Linda Robb-Blenderman, RN, BScN, MSc

Clinical Practice Leader, Oncology
Cancer Centre for South Eastern Ontario at Kingston General Hospital
Kingston, ON

Sandra McFarlane, RN, BScN, MHSc

Director, Medicine Health Service
Toronto East General Hospital
Clinical Lecturer, School of Nursing, McMaster University
Toronto, ON

Kwadwo Bosompra, PhD

Research Associate, CHSRF/CHIR Chair in Advanced Practice Nursing Program
McMaster University
Hamilton, ON
 A Survey of Oncology Advanced Practice Nurses in Ontario 51

Alba DiCenso, RN, PhD

CHSRF/CIHR Chair in Advanced Practice Nursing
Professor, Nursing & Clinical Epidemiology & Biostatistics
McMaster University
Hamilton, ON

Susan Matthews, RN, PhD

National Executive Director, Disease Management and Chief of Practice for Ontario
VON Canada
Formerly, Chief Nursing Officer, Ontario Ministry of Health and Long-Term Care

Harry Milne, RN, MScN

Manager, Regional Operations, Southwest Regional Cancer Service Alliance
London Health Sciences Centre
London, ON

Abstract
The purpose of this study was to examine role structures and processes and their
impact on job satisfaction for oncology advanced practice nurses (APNs) in Ontario.
APNs caring for adult, paediatric or palliative patients in integrated regional cancer
programs, tertiary care hospitals or community hospitals and agencies were invited to
complete a mailed self-report questionnaire. A total of 73 of 77 APNs participated in
the study. Most APNs (55%) were acute care nurse practitioners employed by regional
cancer programs or tertiary care hospitals. Adult patients with breast or haematological
cancers and those receiving initial treatment or palliative care were the primary focus
of APN roles. APN education needs related to specialization in oncology, leadership
and research were identified. Overall, APNs were minimally satisfied with their roles.
Role confidence (b=.404, p=.001) and the number of overtime hours (b=–.313, p=.008)
were respective positive and negative predictors of APN job satisfaction. Progress in
role development is described, and recommendations for improving role development
and expanding the delivery of oncology APN services are provided.

Introduction
Well-designed oncology advanced practice nursing (APN) roles have demon-
strated significant improvement in patient and health systems outcomes related
to access to care; coordination and continuity of care; satisfaction with care; and
health outcomes and lower costs due to fewer hospitalizations and shorter lengths
of stay (Bredin et al. 1999; Corner et al. 1996; Faithfull et al. 2001; Moore et al.
2002; Ritz et al. 2000). APN care is also associated with fewer deaths in elderly
patients post cancer surgery (McCorkle et al. 2000). However, the successful intro-
duction of APN roles is a complex and challenging process (Bryant-Lukosius et
52 Nursing Leadership Volume 20 Number 2 • 2007

al. 2004). Full role implementation depends on the extent of structures in place to
support APN role development.

The Canadian Strategy for Cancer Control (2002) predicts the incidence of cancer
will increase by 70% over the next 15 years. Several Ontario reports recommend the
expansion of APN roles in the delivery of cancer services to ensure the province’s
capacity for meeting the rising demands for care (Cancer Care Ontario 200la and b,
2004, 2006; Fitch and Mings 1999). The Canadian Nurses Association (CNA 2002)
recognizes two types of APN roles: clinical nurse specialists (CNSs) and nurse
practitioners (NPs). Hospital-based oncology CNS roles have existed for many
years. However, in the last five years, Ontario has witnessed the introduction of an
unprecedented number and new types of APN roles in various cancer settings.

This paper describes the first Canadian study to examine a provincial cohort of
oncology APNs and their roles. The PEPPA Framework, outlining a participa-
tory, evidence-based, patient-focused process for developing, implementing and
evaluating the introduction of APN roles, was the conceptual guide for this study
(Bryant-Lukosius and DiCenso 2004). The framework recommends formative
evaluations examining the structures and processes of new APN roles to monitor
progress in role development and to identify and address barriers to role imple-
mentation. Structures refer to role resources, the physical and organizational
environment and characteristics of APNs and patients (Sidani and Braden 1998).
Graduate education, licensure and certification are other structures that affect role
legitimacy, autonomy and the extent to which role competencies are fully realized
(Brown 1998; Irvine et al. 2000; Woods 1998). Processes refer to the work or char-
acteristics of what the APN does in the role. The ability to achieve desired goals
or outcomes of new APN roles is dependent on core planning and provision of
resources necessary for role implementation.

Study Purpose and Methods

The purpose of this study was to conduct a formative evaluation to identify and
describe role structures and processes and their impact on job satisfaction among
oncology APNs in Ontario. Study results inform recommendations for how APNs,
educators, administrators and policy makers can enhance the continued develop-
ment of these and future oncology APN roles. This paper reports on the following:

1. Structural elements of the APN roles, including characteristics of the APN, APN
education needs and patient characteristics;
2. Role processes or the work of the APN and focus of activities in five role
domains: clinical practice, education, research, organizational leadership and
scholarly/professional development;
3. Predictors of APN job satisfaction.
 A Survey of Oncology Advanced Practice Nurses in Ontario 53

Role structures and processes were examined within the context of the advanced
oncology nurse as defined by the Canadian Association of Nurses in Oncology
(CANO). The oncology APN is a “registered nurse, prepared with a minimum of
a Master’s degree in nursing, who has acquired in-depth knowledge and clinical
experience in oncology” (CANO 2001: 61). Role processes are characterized by
the integration of five domains: direct patient care, education, research, organiza-
tional leadership and scholarly/professional development (CANO 2001). A follow-
up paper will report on administrative support, role barriers and role facilitators
and their impact on APN job satisfaction.

Design
A mailed self-report questionnaire was developed for this descriptive study.

Setting
The study took place in all Ontario integrated regional cancer programs, tertiary
care hospitals, community hospitals and community agencies where oncology
APNs are employed.

Participants
Study participants included all nurses working in a defined APN role that involved
the care of adult, paediatric or palliative patients affected by cancer. APN roles
included CNS, NP and other roles titled as advanced according to their job
description. To ensure adequate familiarity with the APN role, eligibility was
limited to nurses who had been in the position for six months or more.

Sample and participant recruitment

The aim was to survey the entire population of oncology APNs in Ontario. We
estimated there were about 50 oncology APNs in the province. Currently, there is
no provincial system in place to document the number or types of oncology APN
roles or where they exist. A snowball technique was used over a five-month period
to identify eligible APNs. First, the research team generated a list of potential
participants known to them through regional, provincial and national oncology
nursing initiatives. This list was circulated to a provincial network, the Ontario
Oncology APN Community of Practice (COP). COP members, representing
APNs from various practice settings across Ontario, reviewed the list with local
and regional colleagues to identify additional APNs. Other participants were iden-
tified from Ontario members listed on the CANO website and through recruit-
ment efforts at two conferences held by CANO and the Canadian Association
of APNs. The research team and COP reviewed each updated list. The process
concluded on a fifth review when no new participants were identified and all
feasible strategies to identify APNs were exhausted. A total of 80 APNs were iden-
tified, of which 77 were eligible for the study.
54 Nursing Leadership Volume 20 Number 2 • 2007

Methods for data collection

Ethics approval for the study was obtained from McMaster University. Participants
received written information about the study purpose, voluntary participa-
tion, methods used to ensure confidentiality and plans for disseminating results.
Participants were invited to complete a questionnaire consisting of closed and
open-ended questions and the Misener (2001) Nurse Practitioner Job Satisfaction
Scale. This scale is one of few valid and reliable instruments that measure job
satisfaction (Misener 2001). Oncology nursing leaders from five provinces, with
experience in managing APNs, gave feedback on the questionnaire content and
format. A five-member expert panel of oncology APNs evaluated and piloted the
questionnaire. Their feedback about face and content validity, readability, clar-
ity and time to complete the questionnaire was documented on a review form
and used to make revisions. On average, the questionnaire took 45 minutes to
complete. Data collection occurred between October 2005 and January 2006. To
minimize bias associated with poor response rates, several strategies to promote
questionnaire return were employed (Edwards et al. 2001). A signed consent form
was not requested; rather, return of the completed questionnaire signified consent
to participate in the study.

Data Analysis
Descriptive statistics, including frequency counts, percentages and mean scores,
were used to summarize quantitative data about APN and role characteristics.
Paired t-tests were used to examine perceived differences in initial and current
role confidence. APN and role variables were examined in bivariate correlation
analyses, and those significantly associated with job satisfaction were entered in a
multiple regression model to determine whether they were independent predic-
tors of job satisfaction. The variables included age, acute care nurse practitioner
(ACNP) education, years as an oncology nurse, years in a previous APN role,
months in current role, role confidence and overtime hours worked per week.

Results
APN characteristics
A total of 73 out of 77 eligible APNs participated in the study, for a response
rate of 94.8%. The mean age was 45.1 years, and 25% of respondents were over
50 years of age. While they had considerable nursing experience (mean, m=21.5
years), they had not much APN experience prior to their current role (m=2.7
years), and they had been in their current role for a mean of 3.6 years. For almost
half the sample, this was their first APN role. Most were seasoned oncology nurses
with a mean of 12 years in the specialty. However, 20% of APNs had zero to less
than five years of oncology experience. Almost all APNs had a master’s degree, and
55% were graduates of an ACNP program. Another 18% were enrolled in master’s
or doctoral programs. About half the APNs had basic certification in oncology or
 A Survey of Oncology Advanced Practice Nurses in Ontario 55

palliative care, but just 5% had advanced certification. About 35% had completed
an oncology or palliative care certificate program. (See Table 1.)

Table 1. APN characteristics

APN Characteristic Total (N = 73) Statistic SD

Females (%) 73 (100)

Mean age in years 45.13 .93

Ages 51 to 60 years (% of APNs) 18 (25)

Mean years as an RN (min – max) 21.45 (2.5–37) 1.0

Mean years in oncology (min – max) 12.22 (0–26.0) .76

Mean years in current APN role 3.62 2.90

Mean years in previous APN role 2.72 .46

Number in first APN role (%) 36 (49.3)

Completed education programs (%)

• Master’s 68 (93)
• PhD 0 (0)
• Acute care nurse practitioner 40 (54.8)
• Primary healthcare nurse practitioner 5 (6.8)
• Oncology nursing certificate 15 (20)
• Palliative care nursing certificate 11 (15)

Currently enrolled in programs (%)

• Master’s 6 (8.2)
• PhD 3 (4.1)
• Acute care nurse practitioner 4 (5.5)

National nursing certification – Total (%) 36 (49.3)

• Basic oncology 31 (42.4)
• Advanced oncology 4 (5.5)
• Palliative care 1 (1.4)

SD: Standard deviation

APN perceptions of role preparedness, confidence and competence

Using a Likert scale (scores = 0 to 4, with high scores reflecting better levels), APNs
rated their preparedness for and confidence in the role at the time of hiring. While
their education somewhat influenced their preparedness for the role (m=1.96,
SD=0.12), the APNs scored previous nursing experience as a stronger influence on
56 Nursing Leadership Volume 20 Number 2 • 2007

preparedness (m=2.67, SD=.11). The APNs felt confident in their role at the time
of hiring (m=2.27, SD=.71) and currently (m=2.8, SD=.55). There was perceived
improvement between initial and current role confidence (t=–10.55, df=72,
p<.001). At the time of hiring, APNs felt the least confident about their diag-
nostic skills (m=1.63, SD=1.08), technical skills (m=1.32, SD=1.32), knowledge
about medical interventions (m=1.82, SD=.94) and research (m=1.52, SD=1.08).
Current areas where APNs felt less confident included technical skills (m=1.93,
SD=1.35) and research (m=2.08, SD=1.10).

Based on Benner’s (1984) theory of nursing practice development, the APNs rated
their competency (from novice = 1 to expert = 5) in five role domains defined by
CANO (2001). They did not perceive themselves to be functioning at an expert
level of practice, but felt the most competent or proficient in their clinical roles
(m=4.0, SD=.70). For non-clinical activities, they felt competent in education
roles (m=3.7, SD=.80), scholarly/professional development (m=3.4, SD=.84) and
leadership (m=3.3, SD=.87). The APNs saw themselves functioning as advanced
beginners in research (m=2.8, SD=.83).

Educational needs
The APNs identified strategies that would have helped to improve their initial
educational preparation for the role (Table 2). Graduate oncology nursing
courses, internship or fellowship programs, mentorship from a master’s-prepared
oncology nurse and a research practicum were the most frequently reported strat-
egies. Other strategies included access to oncology faculty, physician mentorship
and postgraduate courses or practica. Respondents also identified strategies to
support the continued development of their roles. Over 50% of APNs identified
needs for continuing education courses and programs. Strategies similar to those
for improving initial education were identified, but there was greater emphasis
on education to develop research and leadership skills. Fewer APNs identified the
need for extended clinical practica.

Role characteristics
Table 3 summarizes role characteristics related to employment. Most APNs were
employed full time by integrated cancer programs and tertiary care hospitals,
with a small proportion working in community hospitals or agencies. According
to role title, the majority (42.4%) were in ACNP or NP roles and 22% were in a
CNS role. Over a third of APNs were in roles that did not clearly identify them
as an NP or CNS. These roles were generically titled as APN or other positions
not formally recognized as an APN, such as professional practice leader, project
leader or program coordinator. Just over a quarter of APNs were in palliative
care–specific roles.
 A Survey of Oncology Advanced Practice Nurses in Ontario 57

Patient characteristics
Table 4 describes the types of patients cared for by APNs. The majority of APNs
cared for adults and estimated they saw slightly more female than male patients.
Overall, APNs spent more estimated time with patients receiving care during
the initial treatment and palliative stages and had less involvement with patients
during the pre-diagnosis, diagnosis or post-treatment stages of the cancer contin-
uum. The APNs also reported caring for more patients with locally advanced or
advanced disease and those with haematological and breast cancers.

Table 2. Recommendations for improving initial and ongoing

APN education

Education Strategy N = 73 %

Initial APN Education

• Oncology graduate nursing courses 37 51
• Internship or fellowship program 32 44
• Mentorship from master’s oncology nurse 32 44
• Research practicum 31 43
• Access to faculty with oncology expertise 28 38
• Mentorship from oncology physician 27 37
• Leadership practicum 22 30
• Post-master’s education 16 22
• Longer clinical practicum 14 19

Ongoing APN Education

• Continuing education courses or programs 41 56
• Research practicum 32 44
• Internship or fellowship program 27 37
• Access to faculty with oncology expertise 21 29
• Leadership practicum 21 29
• Mentorship from oncology physician 19 26
• Oncology graduate nursing courses 18 25
• Mentorship from master’s oncology nurse 15 21
• Longer clinical practicum 4 6

N: Number of APNs reporting.

Role implementation (role processes)

Table 5 summarizes how APNs implemented their roles. Clinical practice,
followed by education and leadership activities, accounted for the largest amount
of estimated work time. Research and scholarly/professional development activi-
ties each accounted for less than 10% of work time. The wide range of work
time for each domain indicates a high degree of role variability. For example, the
estimated work time providing direct clinical care ranged from 0 to 100%. Some
APNs (21%) spent less than 50% of their time and others (27%) spent over 80%
58 Nursing Leadership Volume 20 Number 2 • 2007

of their time in this domain. Some APNs did not spend time in each of the five
domains. About three-quarters (78%) of APNs worked overtime on a regular
basis. The amount of overtime was substantial, on average 7.6 hours per week,
with some APNs working up to 20 extra hours per week.

Table 3. APN role characteristics

Role Characteristics N = 73 %

Employer
• Integrated cancer program 32 44.0
• Tertiary care hospital 31 42.4
• Community hospital 6 8.2
• Community agency 4 5.4

Full time 68 93.1

Role title
• ACNP or NP 31 42.4
• CNS 16 22.0
• APN or other 26 35.6

Role focus
• Palliative care 19 26.0

The majority of APNs received patient referrals from hospital and cancer centre
health providers. Just about one-third received referrals from community health
providers or from patients themselves. Patient care was provided via telephone,
inpatient visits, patient appointments with physicians and consultations. About
one-third of APNs had independent clinics with scheduled patient appointments,
and a small number made home visits to patients.

Most APNs perceived they functioned as collaborative rather than independent

practitioners and worked with one or more healthcare teams. Within these teams,
the majority of APNs were the primary provider responsible for coordinating the
care of some or all of the patients. However, one-third of APNs had no respon-
sibilities for coordinating patient care. Pain and symptom management were
the primary focus of APN interventions, with less time providing care related to
patient and family education, counselling or health promotion.

APN job satisfaction

The Misener (2001) NP Job Satisfaction Scale has scores ranging from zero (very
dissatisfied) to six (very satisfied). The APNs were minimally satisfied (score of
 A Survey of Oncology Advanced Practice Nurses in Ontario 59

Table 4. Patient characteristics

Patient Characteristics N Mean % Min–Max SD

Age (estimated % of patients in APN practice)

• Paediatric (birth to 17 years) 71 14.4 0-100 34.2

• Adult (18 years and older) 71 85.5 0-100 34.2

Female (estimated % of patients in APN practice) 70 53.2 10-100 17.3

Estimated % of clinical time spent across the

cancer continuum

• Prevention 71 2.0 0-50 6.9

• Screening 71 1.7 0-50 7.2

• Genetic counselling 71 0.4 0-10 1.6

• Diagnosis 71 8.9 0-55 11.7

• Initial treatment 71 25.8 0-100 26.9

• Post-treatment follow-up 71 14.9 0-100 22.5

• Treatment for recurrence 71 15.4 0-100 16.2

• Palliation 71 32.6 0-100 33.7

Stage of Disease (estimated % of patients in APN

practice)

• Pre-cancer 69 3.2 0-90 13.2

• Early/localized 68 11.8 0-70 16.3

• Locally advanced 68 32.0 0-90 25.5

• Advanced/metastatic 67 53.7 0-100 34.3

Cancer Type (estimated % of patients in APN

practice)

• Haematological 69 30.2 0-100 40.1

• Breast 70 16.3 0-100 27.9

• Gastrointestinal 69 13.6 0-100 20.7

• Lung 69 12.2 0-100 20.3

• Genitourinary 69 5.5 0-85 11.5

• Gynecological 69 5.8 0-100 13.7

N: Number of APNs responding; Min–Max: Respondents’ actual minimum and maximum scores.
60 Nursing Leadership Volume 20 Number 2 • 2007

Table 5. Role implementation (processes)

Role Processess N Statistic Min–Max SD

% of estimated work time in each domain (mean %)

• Direct clinical care 72 62.7 0-100 22.6

• Education 71 13.0 0-60 10.6
• Organizational leadership 71 11.5 0-80 13.6
• Research 72 6.7 0-30 6.8
• Scholarly & professional development 71 6.5 0-20 4.5

Hours of overtime per week (mean) 57 7.6 2.5-20 3.5

Source of APN patient referrals (% of APNs)

• Cancer centre physician 73 49.3

• Hospital healthcare providers 73 46.6
• Cancer centre health team 73 46.6
• Community health providers 73 32.9
• Patient self-referral 73 31.5

Ways in which patient care is provided (% of APNs)

• Telephone advice and support 73 78.1

• In hospital 73 71.2
• See patient during appointment with MD 73 65.8
• Consultation for other providers 73 65.8
• APN clinic 73 34.2
• Home visits 73 12.3

Interaction with health providers (% of APNs)

• Collaborate with 2 or more teams 46 63.0

• Collaborate with 1 team 26 35.6
• Function as an independent practitioner 1 1.4

Care coordination (% of APNs)

• Responsible for all patients 15 20.6

• Responsible for some patients 26 35.6
• Not responsible 24 32.9
• Missing responses 8 11.0

% of APN clinical time focused on nursing

interventions (Mean%)

• Symptom management 71 31.9 0-100 18.3

• Pain management 72 19.6 0-80 17.8
• Patient education 72 15.9 0-50 9.6
• Family education 71 11.4 0-43 8.0
• Psychosocial counselling 72 6.8 0-30 6.7
• Health promotion 72 4.7 0-30 5.9
 A Survey of Oncology Advanced Practice Nurses in Ontario 61

4 to 4.9) with their jobs (m=4.5, SD=.61). Age (r=.099, p=.407), ACNP educa-
tion (r=.110, p=.354), prior APN experience (r=.148, p=.214) and months in
current APN role (r=.097, p=.418) were not significantly associated with job
satisfaction. In contrast, years as an oncology nurse (r=.263, p=.025), hours of
overtime worked per week (r=–.356, p=.007) and current level of overall confi-
dence (r=.378, p=.001) were significantly correlated with job satisfaction. Table 6
summarizes the results of the multiple regression analysis examining these three
variables as independent predictors of job satisfaction. Combined, these variables
accounted for 28% of the variance in job satisfaction (p<.001). Two variables were
predictive of job satisfaction. The number of overtime hours worked each week
(b=–.297, p<.05) was negatively associated and current role confidence (b=.39,
p<.01) was positively associated with job satisfaction. Years as an oncology nurse
(b=.159, p=.17) was not a predictor of job satisfaction.

Table 6. Regression model of predictors of job satisfaction

Variables Entered Standardized Adjusted Degrees of Significance

Coefficients (b) R2 Freedom

Years as an oncology nurse .157a 27.7% (3,53) .000

Number of overtime hours –.313b

Current role confidence .404c

a: p=.176; b: p=.008; c: p=.001.

When asked about their future, 67% of APNs reported they were satisfied with
their current role and had no plans to seek new employment. However, 33% of
APNs were thinking about or actively seeking new employment. Of the 24 APNs
in this latter category, reasons for seeking new employment included insufficient
administrative support (42%), insufficient resources to fulfill role expectations
(36%), personal growth and/or career advancement (33%) and perceptions that
the role demands were negatively affecting their health (25%).

Discussion
Full implementation of a new APN role takes time. Hamric and Taylor
(1989) identified seven stages of role development and found it took three to
five years for novice CNSs to achieve an expert level of practice. In our study,
progress in APN role development seems appropriate given the average
62 Nursing Leadership Volume 20 Number 2 • 2007

length of time in the role (3.62 years) and the large number of respondents
(49.3%) in their first APN role. APNs perceived their confidence improved
with increasing time in the role and felt competent in most domains,
particularly related to clinical practice. Other studies have noted that in the
early stages of role implementation, APNs focus on developing their clinical
role as a strategy for establishing credibility among stakeholders and to gain
systems entry (Brown and Olshansky 1997; Kleinpell-Norwell 1999; Sidani
et al. 2000).

Evidence suggesting that the roles are becoming integrated within the health
system include the varied sources of patient referrals, different ways patients
receive APN care and the high proportion of APNs collaborating with other
health providers. Opportunities to increase patient access to APN care
include expansion of services through home visits, patient self-referrals and
linkages with community providers. Models of care that permit APNs to
transition with the patient across health sectors promote continuity of care
and are associated with improved patient outcomes and lower hospital costs
(Brooten et al. 2002).

Important role development needs were identified related to specializa-

tion in oncology nursing. A key feature of advanced nursing practice is
specialization or expertise in a defined area of clinical practice (ANA 1995;
CNA 2002). CANO (2001) also recognizes graduate education, oncology
experience and advanced certification in oncology nursing as prerequi-
sites for advanced practice. Yet, at the time of hiring, a substantial propor-
tion of APNs lacked previous oncology nursing experience and only a few
APNs were certified at an advanced level. In addition, only a small propor-
tion of APNs had received oncology nursing education through certificate
programs. The need for advanced specialty-based education and supports
is further highlighted by the substantial number of APNs wanting access to
graduate oncology nursing courses, oncology faculty and mentorship from
master’s-prepared oncology nurses and oncologists. The APNs also identi-
fied educational needs related to leadership and research. As in this study,
research is often reported as the most underdeveloped aspect of APN roles
(Bryant-Lukosius et al. 2004). The APNs spent the least amount of time in
research-related activities and felt the least competent in this area.

The large variation in role activities and in APN work time spent in each
role domain is expected and desirable (see Table 5). APN roles are dynamic
and should be tailored and responsive to unique patient and health systems
 A Survey of Oncology Advanced Practice Nurses in Ontario 63

needs in practice settings (Bryant-Lukosius and DiCenso 2004). However,

a concerning feature is that not all APNs contribute work time to each
domain of advanced nursing practice, including clinical practice, educa-
tion, research, organizational leadership and scholarly/professional practice.
Operationalization of each role domain, particularly related to direct patient
care, is required to meet the definition of advanced practice (CANO 2001).
The lack of APN involvement in all role domains suggests that some roles are
not being fully implemented and may not reflect an advanced level of practice.

The reason is unclear, but underutilization of the full scope of APN expertise
is a common role implementation problem (Bryant-Lukosius et al. 2004).
Poor administrative support, lack of priority setting and competing clini-
cal demands are frequent barriers to participation in education, research
and leadership activities. In this study, over 78% of APNs reported working
overtime hours, suggesting that time management, excessive role demands
or both may be barriers to role implementation. Inconsistent and unclear
role titling are also common barriers to role implementation associated with
stakeholder confusion and lack of understanding about APN roles (Bryant-
Lukosius et al. 2004). This confusion may lead to the development of roles
lacking responsibilities in each role domain. Such may be the case in this
study, where some roles had no clinical involvement and over 35% of roles
were generically titled as APN or other role titles not formally recognized as
advanced practice.

Another potential gap in role implementation is the low estimate of time

spent in care coordination, patient/family education, psychosocial counsel-
ling and health promotion. These interventions are considered the value-
added features of advanced practice (Brooten et al. 2002). Furthermore,
patients and families affected by cancer report significant unmet needs
related to fragmentation of care, coping, information and psychosocial
support (Canadian Cancer Society 2003).

Other points of discussion relate to resource planning and the effective use
of APN roles. Considering that almost half of the APNs in this study were
hired into new roles in the previous 3.6 years, there has been some success in
recruitment. However, there is high competition for these roles, with many
unfilled positions across the country. This finding may account for hiring
APNs who lacked desired role requisites, including advanced certification
and previous oncology experience. In addition, 25% of the population was
between the ages of 50 and 60 years and therefore close to possible retirement.
64 Nursing Leadership Volume 20 Number 2 • 2007

Retention was also problematic, with one-third of APNs considering or seek-

ing new employment owing to poor job satisfaction.

Finally, the implementation of these roles is clustered in the initial treatment

and palliative stages of the cancer continuum. There is tremendous opportu-
nity to expand the use of APN roles across the cancer continuum. Expansion
of APN roles should be considered in areas of high provincial priority related
to cancer prevention, early detection and screening; reduction of wait times;
and access to post-treatment surveillance and supportive care (Cancer Care
Ontario 2004). Currently, patients with haematological and breast cancers
are the focus of almost 50% of existing APN roles. Future expansion of APN
roles should consider other high-incidence and high-need populations, such
as those with colorectal, lung and prostate cancer.

Study limitations
It is possible that despite our comprehensive approach to recruitment, we
did not identify all eligible APNs. However, as the number of identified
APNs was much higher than expected, the number of missed APNs is likely
small. Given that 95% of the sample took part in the study, we believe the
results are representative of oncology APNs in Ontario. However, variability
in education, roles and practice settings may limit the generalizability of
results to oncology APNs in other provinces. An incomplete account of role
implementation may also have occurred due to recall bias and retrospective
APN estimates of role activities.

Implications for education and practice

The mandate of all APN roles is to maximize, maintain or restore patient
health through innovation in nursing practice and in the delivery of health
services (CNA 2002; Davies and Hughes 2002; Hamric 2000; McGee and
Castledine 2003). APNs enhance care delivery through flexible, expanded
scopes of clinical practice; research; education; the advancement of evidence-
based nursing practice; and leadership in implementing organizational and
health system change. To achieve this potential for innovation in cancer care,
strategies to enhance the full implementation of all five domains of oncology
advanced nursing practice will be required.

There is a need to increase APNs’ access to graduate courses, continuing

education and mentorship opportunities to further develop their roles,
particularly related to oncology nursing practice, leadership and research.
Given the high anticipated demand for oncology APN roles, the ideal solu-
 A Survey of Oncology Advanced Practice Nurses in Ontario 65

tion would be to establish a graduate program designed specifically to

produce oncology APNs for the province (Mitchell-DiCenso et al. 1996).
Currently, only a small handful of Canadian universities offer limited elec-
tive undergraduate or graduate courses, and none offer a comprehensive
program in oncology nursing. Advanced oncology nursing certification is
important for ensuring that APNs have the minimum level of specialty-
based knowledge and skills required for the role. The lack of a Canadian
examination is a major barrier for obtaining this credential. CANO and the
CNA should establish a national advanced certification process and/or adopt
existing examinations available in other countries.

The development of postgraduate certificate programs in oncology nursing

may also be an effective strategy to meet the continuing role development
needs of APNs. Strengthening collaborative links among academic institu-
tions, oncology nursing faculty and practice settings may also provide APNs
with increased access to specialty and research expertise. A provincial strat-
egy to provide role development resources is now underway by the Oncology
APN Community of Practice, sponsored by Cancer Care Ontario. A key
feature of this strategy is to create an e-based mentorship, preceptorship and
peer support program.

There is a need to implement a systematic provincial approach to nursing

and health human resources planning for cancer care. This approach should
examine how well the current complement and focus of APN roles are
meeting patient, organization and health systems needs and determine
the numbers and types of oncology APN roles required over the next five to
10 years. This plan should also include strategies to educate, recruit and retain
highly qualified APNs with the expertise required to meet role demands.
Targeted strategies to improve APN job satisfaction related to administra-
tive support, practical resources, workload and career advancement are also
required.

Conclusions
The results of this study demonstrate the ad hoc implementation of oncol-
ogy APN roles in Ontario. While progress in role development is being
made, there are substantial opportunities to improve the implementation
of these roles across the cancer continuum. There is agreement among
provincial stakeholders that “new ways of working” are required to achieve
a sustainable system of cancer services providing high-quality, efficient and
patient-centred care (Cancer Care Ontario 2006: 4). Commitment on the
66 Nursing Leadership Volume 20 Number 2 • 2007

part of all stakeholders to supporting the successful development and effec-

tive utilization of oncology APN roles will be required to achieve this goal.

Acknowledgements
This study was supported and funded by the Nursing Secretariat and the Ontario
Ministry of Health and Long-Term Care. Recommendations from this study do
not reflect government positions or policies. At the time of this study, Dr. Bryant-
Lukosius held a Post Doctoral Fellowship Award from the Canadian Health
Services Research Foundation and the Canadian Institute of Health Research. Our
sincere thanks go to oncology APNs in Ontario for their commitment to improv-
ing the health of patients with cancer through advances in nursing practice and
care delivery.

Corresponding Author Info: Denise Bryant-Lukosius, RN, PhD, Assistant Professor

and Senior Researcher for the CHSRF/CHIR Chair in APN, School of Nursing,
McMaster University, Clinical Nurse Specialist, Juravinski Cancer Program, Faculty
of Health Sciences, Room 3N25D, McMaster University, 1200 Main Street West,
Hamilton ON. L8N 3Z5, e-mail: bryantl@mcmaster.ca

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