This document proposes a research study to evaluate the relationship between post-graduate cancer education for nurses and patient, nurse, and hospital outcomes in cancer settings. The study would compare outcomes at Peter MacCallum Cancer Centre, which heavily subsidizes post-graduate cancer education, to four other metropolitan cancer services with less subsidized education. The study hypothesizes that patient, nurse, and hospital outcomes will be significantly better at Peter Mac. The study aims to quantitatively and qualitatively evaluate various outcome measures through outcome-based and needs-based evaluation methods to determine if relationships exist between education and outcomes.

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Research Evaluation Proposal : What is the relationship between university post-RN (registered nurse)
cancer education and patient, nurse and hospital outcomes in the cancer setting ?
A comparison between nurse, patient and hospital outcomes of Peter MacCallum Cancer Centre
(Peter Mac) and four metropolitan, accredited, cancer services in Victoria.
Summary
The current premise for post-RN or post-graduate cancer education is that expertise, derived
from post-RN or post-registration (nursing) cancer education may improve the quality of cancer care
by means of increased knowledge, skills, confidence and self-awareness (Wyatt, 2007). Specialty
education in cancer for registered nurses may increase their ability to prevent adverse effects early or
initiating therapy that is otherwise not initiated (CNSA (Cancer Nurses Society of Australia), 2002;
Williams, 2010). There is limited evidence linking the benefits of post-graduate education (certificate,
diploma, masters or phD level) in cancer nursing or cancer outcomes, rendering the workload and
expertise of nursing to become oversimplified and undervalued (Crossan, 2005). As nurses are the
front line of patient assessment and care, learned and expert nurses are able to present their cases to
the multidisciplinary team, accelerate decision making and use their expertise to provide the best
patient outcomes (Lankshear & Sheldon, 2005). Despite the strong practice of clinical education in
improving nurse expertise, research in the benefits of clinical education in the Australian context is
scarce. One systematic review of nursing skill mix and patient outcomes provided only estimations of
quality of care outcomes and report that studies in this area are limited due to small effect sizes and
lack of definition of terms (Lankshear & Sheldon, 2005). In a review of sixty-one studies of the
benefits of post registration education, less than 10% of evidence reported were type 1, 2, 3 and 4.
Further, the majority (80%) of evidence are of type 5 or from anectdotal sources. Current literature
therefore provides no insight on the nurse or patient outcomes gained from post-graduate cancer
education.
The benefits of advancing education is not limited to qualified, registered nurses. Evidence
suggests that even university-based nursing education appear to be beneficial to patient care
outcomes. A large study of 168 hospitals involving over 10,000 RNs in the United States showed that a
10% increase in proportion of nurses with higher degrees decreased the risk of mortality and ‘failure
to rescue’ by 5% in surgical patients (Aiken, Charles, Cheung, Sloane, & Silber, 2003). Higher degrees
in this study were defined as a pre-registration bachelor of science in nursing or masters which were
compared with hospital-trained, diploma or associate degree qualified registered nurses. Other
studies suggest that acquisition of higher degrees and age may determine one’s level of knowledge,
adherence to evidence based practice and confidence (Wyatt, 2007). These in turn contributes to
changes in practice that are not specific to studying a post-graduate oncology programme as a
qualified registered nurse.
The higher degree experience may itself assist pre-registered students in acquiring generic
and professional skills in nursing. A UK cohort study compared perceptions of preceptors of the
students who were qualified with a diploma of nursing and the master of nursing and found that the

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master of nursing students, whom had prior undergraduate degrees, were more proficient in decision
making and communication to multidisciplinary team (Park, Wharrad, Barker, & Chapple, 2009). In
the first few months of their first year of nursing, diploma and master of nursing nurse had similar
levels of knowledge, however the master of nursing students demonstrated greater confidence in the
long-term in areas of communication, time management and information seeking. This may be
explained by the academic training of inquiry and greater theoretical knowledge gained (Park,
Wharrad, Barker & Chapple, 2009). Advancing education within the unversity provides both specific
and general skills that benefit the current nursing workforce.
Since university education and post-RN education appear to benefit nurses and patients,
economic analyses may provide a claim for the value for money in cancer education. The Victorian
Cancer plan 2008-2011 was a 150 million dollar investment in four ‘Action Areas’ of which 77 million
were invested into ‘Area 2’, that is : ‘Ensuring rapid translation of research into effective treatments
and clinical care’ (p55, Cancer Australia, 2008). The use of research funding in quantifiying the value
for money of post-graduate cancer nursing courses may in future Cancer Australia initiatives, provide
better allocation of funds to reduce the financial barriers evidenced to prohibit nurses from
participting in further study. Despite the abundance of post-graduate cancer courses in Australia
through simulated searches using Google, Yahoo search engines and individual university websites,
fees for advancing cancer studies remain largely unsubsidised. The State of Victoria, Queensland and
Western Australia are the only states in Australia whereby access to post-graduate cancer education
is unsubsidised (Hot Courses, 2011), except in the case of the Peter MacCallum Cancer Centre (Peter
Mac) in Victoria. In the former group, the out-of-pocket expense for post-graduate education is
approximately AU$14,000. In other the states, the fees are approximately AU$5,500 per part-time
year (usually 4 subjects per year). Peter Mac is the only cancer specialist centre in the country and
southern hemisphere (Peter MacCallum Cancer Institute, 2010b) and provide heavily subsidised post-
graduate cancer nursing programmes for their registered nurses (RNs). At entry level, RNs can study a
certificate level cancer course with an out-of-pocket cost of less than a government subsidised offer
in other states outside Victoria (AU$1,000). The returned commitment is a nursing service of a
negotiable six-day shifts per fortnights or full time for the duration of the course (Peter MacCallum
Cancer Institute, 2010a). If post-graduate cancer education can improve nurse outcomes in the form
of confidence and competence, and patient outcomes in the form of decreased infection rates and
rates of survival, greater access to cancer education for post-RN nurses may be a cost-effective way to
improve cancer outcomes in our population.
Barriers to the Australian nurses accessing post-graduate education may be explained by a
study of the benefits of cancer education for cancer nurses in the United Kingdom (UK). Cancer nurses
in the UK express their respective barriers as high tuition fees, loss of salary, lack of renumeration on
completion of the course, and limited opportunity for promotion (Wyatt, 2007). Even though this
large-cohort study has not yet been replicated in Australia, the premise that post-graduate cancer
education benefits clinical care needs to be established prior to addressing strategies in upskilling

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cancer nurses. Establishing and quantifying benefits of post-graduate cancer education may challenge
assumptions about the nursing profession in which oversimplify and undervalue nursing expertise
(Crossan, 2005). For the same reasons, greater access may be granted for qualified nurses to study
post-graduate cancer programmes if it is supported by economic analyses.
Where access to post-graduate cancer education is greater, it is likely that the concentration
of expertise in a service like Peter Mac is richer when compared to hospitals that require nurses to
pay higher fees for their post-graduate cancer courses. This study proposes to collect new data and
use available data to compare patient outcomes, nurse outcomes and hospital performance
outcomes between Peter Mac and four other cancer services from accredited hospitals with similar
acuity of cancer patients. This study hypothesizes that patient, nurse and hospital outcomes are
significantly better in Peter Mac when compared to the four other metropolitan cancer services. The
null hypothesis is that patient, nurse and hospital outcomes do not significantly differ between the
five services.
Research question, Aims and Evaluation methods
This study will ask : What is the relationship between post-graduate cancer education and patient,
nurse and hospital outcomes in a cancer settings ?
The aim of the research is to evaluate patient outcomes between cancer services using a variety of
quantitative and qualitative data and analyses. Three evaluation methods will be used on outcome
measures on patients, nurses and hospitals and will have the following outcome measures :

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Patient outcomes
Staff outcomes
Hospital outcomes*
Quantitative
methods:
Outcome-
based
evaluation
• Mortality rate*
• Risk-adjusted mortality*
• Adverse rates events
(falls, Infection rates,
failure to thrive, rates of
complications)*
• Length of hospital stay*
• Staff burnout
• Generic skills
assesment
• Cancer care
expenditure
• Costs of post -
graduate by
hospital
• Costs of
hospital-based
education on
cancer care
• Costs of adverse
events
Quantitative
and
Qualitative
methods :
Needs-based
evaluation
• Patient needs survey • Learner needs
survey
-
Quantitative
and
Qualitative
methods:
Satisfaction
questionnaire
• Patient satisfaction
survey
• Learner satisfaction -
Table 1 : Outcome measures of the relationship between post-graduate cancer
education and patient, nurse and hospital outcomes. *Data available from hospital-based
evaluation and sourced from annual or quality reports of the same year of study.
Evaluative Measures
Where hospital data is not available, the evaluation of outcomes will be performed using established
instruments as follows :
Patient outcomes
Demographic data on patients will be collected on age group, length of hospital stay and reason for
admission. The patient satisfaction questionnaire has both quantitative and qualitative measures
using the Likert scale and short answer questions. The latter is used as qualitative data. Patient
satisfaction is measured by an adapted Patient-Reported Outcomes Measurement Information
System (PROMIS
®
) Network which a measurement tool of patient-reported outcomes using state-of-
the-art psychometric tool (Flynn et al., 2011).
Staff outcomes
Demographic data on staff will be collected on age group, qualifications, current study, years of
service in nursing and years of service in cancer nursing. ‘Learner needs’ and ‘learner satisfaction’ of
staff is measured by using a descriptive survey adapted from Wyatt’s (2006) study which assessed five
domains of practice : Foundations in Cancer, Influences on Cancer Care, Treatment modalities and
Palliative care using Likert scale. This tool will incorporate generic skills such as communication,
prioritisation, critical thinking and decision making under the ‘Influences to Cancer Care domain’. The

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‘learner satisfaction’ and ‘learner needs’ will have a qualitative component for participants to provide
feedback. Professional burnout will be assessed using the standarised and validated Maslach Burnout
Inventory. The 22-item Human Services version measures professional burnout emotional exhaustion,
depersonalisation and personal accomplishment (MBI-HSS) (Girgis, Hansee, & Goldstein, 2009).
Design
The study protocol will be reviewed by the research committee at the University of Sydney prior to
commencement of research. Study recruitment will commence at the start of the academic year in
February and end 18 months post. Patients and nursing staff outcomes will be evaluated at four
different time-points in the study starting in February 2012, May 2012, August 2012, November 2012
and February 2013. Data collection time points will be avoided in university holidays such as in
January, July and December to avoid low recruitment. February 2012 data will be used as baseline for
nursing staff who are enrolled in a post-graduate cancer nursing course for the first time. Needs-
based evaluation and satisfaction questionnaires for nurses and patients will only be administered at
two time-points (with higher number of recruitments numbers in each) to spread the workload of
recruitment and data collection.
Selection of Inpatient Cancer services
Four major cancer services in Victoria will be evaluated in a 18-month time period. Only adult
inpatient cancer outcomes will be compared. Peter MacCallum Cancer Centre’s inpatient services will
be compared with other cancer services listed below. These hospitals were chosen because the bed
numbers are cumulatively similar to Peter Mac (95 beds in Peter Mac). There are cumulatively 100
beds from the other organisation who operate their cancer services at a ward or department level.
These inpatient services will only include active treatment of cancer diseases such as haematological
malignancies, viscera, bone and soft tissue cancers and will exclude Palliative care services. Patients
who are made palliated (ceased active treatment and receiving Palliative or end of life care) during
the study will not be excluded at anytime during the 18-month (unless at the event of death) as they
are seen as part of the cancer disease trajectory.
The cancer service that will be compared to and their respective higher education provider of
postgraduate cancer nursing courses are as follows :
Peter Mac – University of Melbourne
Austin Hospital – La trobe University
Royal Melbourne Hospital – Australian Catholic University
Alfred Health – La trobe University

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Data Analysis
The SPSS programme will be used to compute logistic regression models to estimate the effects of
post-graduate cancer education against quantitative nurse and patient outcomes such as medication
error, length of hospital stay, infection rates and other outcome measures. The cost and benefits of
post-graduate education will be calculated as a cost-effectiveness ratio using economic analysis by
comparing the costs of post-graduate cancer education (in the case of Peter Mac) and costs of non-
university based education by each hospital and against hospital outcomes such as the positive or
negative trends of infection rates, length of hospital stay and staff burnout. Descriptive statistics and
signifiance tests will be used to compare patient and nurse outcomes for satisfaction and needs-
based evaluation of nursing care (for patients) and or post-graduate cancer education (for nurses).
Qualitative data will be used to provide anectdotal support results of quantitative outcomes found.
Internal and External validity : Considerations for Evaluation
Financial barriers may not be the only inhibiting factor of studying post graduate cancer programmes
and must be adjusted for. Time pressures, management cultures, marketing and staff motivation are
additional barriers discussed in the systematic review by Wyatt (2006). Post-RN education may be
beneficial in knowledge and skill acquisition but changes in behaviour may be inhibited by lack of
management support and resources (Wyatt, 2007). Improved quality of care therefore cannot be
substantial if only individuals with post-graduate oncology education conform to evidence based
practices learned from their studies. These biases may be reduced in selecting for more homogenous
hospitals with the similar practices and acuity of cancer patients. The Accreditation Standards for
Hospitals is one way in which to select hospitals that are similar in their practices. This is guided by
the Australian Council for Health Services (ACHS) (Australian Council on Healthcare Standards, 2011).
In addition, large tertiary hospitals selected with this accreditation are likely to have similar acuity of
the cancer patients and thus may have similar demands of nursing expertise and workload.
Qualitative analysis of staff satisfaction may yield greater insight to what and how financial and
managerial barriers can be overcome. Limitations of this study may also include exclusion of non-
English speaking cancer patients which consists of a large proportion of patients with cancer in
metropolitan Victoria (Cancer Council, 2010). Some outcome tools are adapted for the purpose of
collecting quantitative rather than qualitative data about generic skills of which previous research had
recommended for quantitative outcome measures (Ferguson, 1994; Park, et al., 2009).
The research team
The study will be part of a Masters of Philosophy programe at the University of Sydney. The primary
research site is at Peter MacCallum Cancer Institute. The research team will comprise of the student
of the Masters of Philosophy at the Peter Mac site who will responsible in liasing with other cancer
services, recruitment and data collection and analyses.

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Ethical considerations
The study’s ethical considerations will be reviewed by the ethics comittees of the University of
Melbourne and Peter MacCallum Research Institute. All participants will be invited to participate in
the study in writing and assured that confidentiality and anonymity would be protected. Informed
consent will be obtained with a covering letter sent with a questionnaire requesting demographic
data of the participant which will include post-graduate qualifications, current education (if ongoing),
years of cancer service and areas of learning needs. The profile questionnaire will not include any
identifiable information such as name or employee number or be tracked by the investigator.
Participants who were patients will be given a similar questionnaire requesting information such as
diagnosis, reason for admission and Likert scale on satisfaction of hospital services and any
information given will not be identifiable to the investigators of this study. Any journal writing or
thesis writing texts will not contain identifiable information regarding any staff or patient in the
research process.
Conclusion : Value for money
The aim of the study is to evaluate the value for money that post-graduate education has on
outcomes in patients, nurses and hospitals in the context of cancer. Improving the expertise of cancer
care by increasing access to post-graduate education may improve the profile of cancer in our
population. It is believed that expertise in cancer nursing help prevent adverse effects, initiate
therapy and improve patient outcomes (CNSA : Cancer Nurses Society of Australia). This study will
predominantly utilise available data such as infection rates, length of hospital stay and complication
rates from ACHS accreditation reports and hospital annual reports (and or quality reports). Even
though qualitative data is pertinent to understanding nurse and patient outcomes, and may address
areas of which quantitative methodology will be limited in, this research will focus on quantitative
data for several reasons. Economic analyses of cost-to-benefit-ratio and cost-effectiveness ratio may
substantiate claims for greater access for nurses in post-graduate cancer education, if value is
demonstrated. In the case that the null hypothesis is accepted, economic analysis will allow
comparison between the costs-to-benefit ratio of non-university based cancer training. Clear findings
on value for money of post-graduate cancer nursing courses will inform policy decision making to
improve the profile of cancer for all Australians.

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Timeline of study
Date Research Thesis writing
2012
January Ethics Submission
Data Collection for Hospital
February Data Collection for nurses
March Introduction Chapter draft I.
April Data Collection for patients
May Data Collection for nurses
June Research Design and
Methodology Chapter draft I.
July Data Analyses
August Data Collection for nurses Writing journal submissions
September Data Collection for patients
October Data Analyses
November Data Collection for nurses
December
2013
January Data Collection for Hospital Writing journal submission
February Data Collection for nurses
March Data Analyses
April Data Analyses and presentation Thesis draft 1
May Thesis draft II
June
July Submission of final Thesis
August

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References
Aiken, L., Charles, S., Cheung, R., Sloane, D., & Silber, J. (2003). Educational levels of hospital nurses
and surgical patient mortality. JAMA, 290(12), 1617-1623.
Australian Council on Healthcare Standards. (2011). ACHS Clinical Indicator Program Information:
ACHS
Cancer Australia. (2008). A National Cancer Data Strategy for Australia. Canberra: Commonwealth of
Australia.
CNSA (Cancer Nurses Society of Australia). (2002). Position Statement on the National Cancer Nursing
Shortage.
Council, C. (2010). Cancer in Victoria 2008. Melbourne: Cancer Epidemiology Centre.
Crossan, F. (2005). Exploring nursing skills mix/ a review. Journal of Nursing Management, 13,
356_362.
Ferguson, A. (1994). Evaluating the purpose and benefits of continuing education in nursing and the
implication for the provision of continuing education for cancer nurses. Journal of Advanced
Nursing 19, 640-646.
Flynn, K., Jeffrey, D., Shelby, A., Fwazy, M., Gosselin, T., Reeve, B., & Weinfurt, K. (2011). Sexual
functioning along the cancer continuum: focus group results from the Patient-Reported
Outcomes Measuremet Information Systems (PROMIS). Psycho-Oncology, 20(4), 378_386.
Hot Courses. (2011). Oncology Nursing Courses Retrieved 23rd April 2011, from
http://www.hotcourses.com.au/australia/home.html
Lankshear, A., & Sheldon, T. (2005). Nurse staffing and Healthcare Outcomes. Advances in Nursing
Science, 28(2), 163-174.
Park, J. R., Wharrad, H., Barker, J., & Chapple, M. (2009). The knowledge and skills of pre-registration
masters' and diploma qualified nurses: A preceptor perspective. Nurse Education in
Practice(11), 41_46.
Peter MacCallum Cancer Institute. (2010a). Certificate of Cancer & Palliative Care. In P. M. C. Institute
(Ed.). East Melbourne.
Peter MacCallum Cancer Institute. (2010b). Peter MacCallum Cancer Centre: Annual Report 2010:
Peter MacCallum Cancer Institute.
Williams, C. (2010). Understanding the essential elements of work-based learning and its relevance to
everyday clinical practice. Journal of Nursing Management, 18, 624-632.
Wyatt, D. E. (2007). The impact of oncology education on practice - A literature review. European
Journal of Oncology Nursing, 11(11), 255-261.