Competencies of Oncology Nurses in Malaysia

Cancer remains a leading cause of death in the world. The World Health Organization estimates that without intervention 84 million people will die of cancer between 2005 and 2015 (WHO, 2011). Malaysia is a multi-racial country with a population of 28.3 million. The three main races in the country include Malays (63.1%), Chinese (24.6%) and Indians (7.3%) (Department of Statistics, Malaysia, 2010). In line with the global situation, cancer is a major disease in Malaysia. According to the National Cancer Registry (NCR), between 2003-2005, a total of 67,792 new cases were diagnosed in Peninsular Malaysia alone (Zainal Ariffin et al., 2006). As nurses are the important person in health-care institution, the current global nursing shortage has created excessive strain on health care systems throughout the world and it is critical (Oulton, 2006; Buchan & Aiken, 2006). In the context of Malaysia, skilled nurses in midwifery, intensive care, coronary care, trauma and rehabilitation is needed (The Star, 2010). Cancer care nurses are particularly wanting in Malaysia, as the country’s oncology patient ratio stands at 1: 650,000 (Yip et. al., 2006). According to the Health Ministry, the need for specialized nurses is increasing because of the


Introduction
Cancer remains a leading cause of death in the world. The World Health Organization estimates that without intervention 84 million people will die of cancer between 2005and 2015(WHO, 2011. Malaysia is a multi-racial country with a population of 28.3 million. The three main races in the country include Malays (63.1%), Chinese (24.6%) and Indians (7.3%) (Department of Statistics, Malaysia, 2010). In line with the global situation, cancer is a major disease in Malaysia. According to the National Cancer Registry (NCR), between 2003-2005, a total of 67,792 new cases were diagnosed in Peninsular Malaysia alone (Zainal Ariffin et al., 2006).
As nurses are the important person in health-care institution, the current global nursing shortage has created excessive strain on health care systems throughout the world and it is critical (Oulton, 2006;Buchan & Aiken, 2006). In the context of Malaysia, skilled nurses in midwifery, intensive care, coronary care, trauma and rehabilitation is needed (The Star, 2010). Cancer care nurses are particularly wanting in Malaysia, as the country's oncology patient ratio stands at 1: 650,000 (Yip et. al., 2006). According to the Health Ministry, the need for specialized nurses is increasing because of the competences to ensure that they are able to deliver the highest quality nursing care. "Competency is focuses on an individual's actual performance in a particular situation" (McConnell, 2001). According to Sharon et al. (2006) competency refers to the knowledge and performance that we can observe and measure to contribute the improving of health.
Although a considerable number of studies related to profiling oncology nurses' competencies have been conducted in the West (Fallowfield and Jenkins, 1999;Kettunen, 2002;Wilkinson, 2002), similar research is wanting in non-Western contexts, particularly in developing countries like Malaysia. This is a significant gap due to cultural differences related to expectations of care, training and education, professionalism, understanding the needs of patients and other factors that may have an influence on communication between nurses and patients. Thus, in the current study we sought to gain insight on communication competencies of Malaysian cancer care nurses using four focus group discussions. Specifically, we explored the importance of communication to the nurses, how they communicate and what they communicate in their work.
Update and expand the knowledge about global health is needed in oncology nursing setting (Sheldon, 2010). Thus, oncology nurses are the main aspect of patient care and family support survivorship (Ferrel et al., 2003). Therefore, nurses have to know the standard of care for their work and deliver quality service and care to their patients. Oncology nurses are facing with many challenges which is can affect their ability to maintain their competence (Brixer and Mahon, 2010). Thus, it will give poor outcome to the cancer patient care.
Since doctors, especially those in developing country settings, have little time to support patients in times of distress, nurses play a key role in helping patients' deal with the distress caused by disease diagnosis and care (Fukui et al., 2009;United State National Cancer Institute, 2011). For instance, "patients who enjoy effective communication with their nurses tend to be more satisfied with the overall care received, exercise greater adherence to recommended treatment regimens, and seem to make more rapid recoveries with fewer complications" (Irving and Dickson, 2004). A competency in nursing setting is not only a skill and tasks but also includes a nurses' characteristic in order to perform effectively (Dunn et al., 2000).
Communication in nursing is one of the fundamental mechanisms for delivering quality nursing care (Attree, 2001). Wilkinson (1991) cited in Kruijver et al. (2000, communication in nursing is an open two-way, where patients are informed about their disease and treatment and patient can express their emotions. A nurse needs to communicate with her/his patients as well as their families to share information, knowledge, experience and available services. According to Larson and Butterfield (2002), general nursing competencies include four types: (1) knowledge and concepts; (2) assessment and referral; (3) advocacy, ethics and risk communication; and (4) legislation and regulation. Communication is important (Pai, 1999) and one of the nurses' core competency dimensions (Lu, 1998).
Since nurses are part of multidisciplinary team, they provide 24-hours care for patients. As such, patients have the most contact with nurses compare to other care team member (Wilkinson, 2002). Effective communication can influence patient recovery, effective pain control, adherence to treatment regimens and psychological wellbeing (Fallowfield and Jenkins, 1999;Kettunen, 2002). Moreover, effective communication among nurses and patients can make patients feel more relaxed and think more positively during their treatment.
A high level of interpersonal engagement and communication is needed when caring for cancer patients (Stajduhar et al., 2010). Thus, effective communication is increasingly being recognized as a core clinical nursing skill (Gysel, 2004) and importance for building rapport with patients (Legg, 2011).
Communication is a speaker and subject's interaction and also environment that influences the process (Anoosheh et al., 2009). Communication not only exchanges the information, but it also involves transmitting of feelings (Sheppard, 1993). Wilma et al. (1999) stated that nurses recognize the patients' feelings through nonverbal communication such as patient-directed eye gazes, head nodding, smiling, forward leaning and touch.
According to Wouda and Van de Wiel (1996) in Irma et al. (2001), providing clear information about medical issues regarding treatment is an important aspect in nursing context. Davison, Degner and Morgan (1995) further mentioned that cancer patients need information regarding disease, treatment, cancer recurrence (Luker, 1996), treatment and illness (Jenkins, 2001), pain symptoms and relief (Pam et al., 2010) and survival issues (Graydon et al., 1997).

Aim
The aim of the study was to explore communication competency among cancer nurses in Peninsular Malaysia.

Design
A qualitative approach was used to explore the competency of cancer care nurses in communication skills.

Sample/Participants
Four focus group discussions (FGDs) were held with 17 nurses from three public hospitals. All three public hospitals selected had cancer treatment specialties (not all hospitals in Malaysia have the capacity to treat cancer patients). Purposive sampling was employed to select oncology/cancer care nurses who had completed a postbasic course in oncology, or had work experience as a cancer care nurse. All 17 nurses who participated in the focus groups were women. The majority were Malay (82.4%), while the rest were Chinese (11.8%) and Indian (5.9%). The informants' ages ranged between 28-56 years with a mean of age of 37.9 years. The range for years of nursing experience was 5-34 years with a mean of 14.4 years. A majority (76.5%) of the informants had a diploma in nursing and over half were married (70.6%) (

Data collection and analysis
Overall, four researchers participated in the FGDs, and each was facilitated by two researchers at a time. All of the FGDs took approximately 90 minutes and were conducted at the hospitals. The researchers used an interview guide that was primarily developed from a review of the related literature (Krauss et al., 2009). The FGDs were conducted in both Malay and English (either one or the other depending on the researchers conducting them) and the interview in Malay was translated into English for the purpose of analysis. All four discussions were recorded using digital recorders. The data were transcribed verbatim and then double-checked for errors and inconsistencies by the researchers. Data analysis was guided by the constant comparative method (Glaser, 1978;Miles and Huberman, 1994), by coding key responses, grouping the codes into similar concepts and then forming categories or themes.

Ethical considerations
The study underwent ethical approval by the Malaysia National Institute of Health. Informants completed a demographic questionnaire and signed a written consent form to participate in the study. All informants were assured of their anonymity prior to their participation in the study.

Validity and reliability
To enhance trustworthiness of the findings, much of the data were analyzed by the researchers together. First, peer review was used where several researchers conducted the interviews and read through and analyzed the data together. Secondly, we spent considerable time in the field working with the nurses and included an expert nurse on the research team to help us make sense of the data. A volunteer cancer care nurse was also brought onto the research team to further validate the findings arrived at by the researchers. Although we did not employ an interrater reliability approach to analysis, in general overall agreement by the researchers on the codes, categories and resulting themes was high.

Results
The findings are presented according to the three research questions that guided the analysis, which were: (i) Why is communication important to cancer care nurses; (ii) How do nurses communicate; and (iii) What do the nurses communicate when interacting with their patients.

Why communication is important
According to the nurses in our study, communication competencies are important in terms of delivering quality care to cancer patients. How nurses communicate and what they communicate are key components of communication competencies. Communication is important because it is related to acceptability, building trust, establishing close relationships and providing moral support to the patients. As part of the care team, nurses are the most accessible to patients, especially when the patients are warded for treatment. With greater and more frequent contact with their nurse, a patient will communicate more (if they had not done so already) and gradually accept the nurse as part of the team. Nurse 1 shared her experience in such cases: Sometimes they [patients] refuse to talk even when we try to. [But] when the patients are admitted to the ward, they will observe the nurses; how the nurses communicate with them, how the nurses treat them. And then day-by-day, they can [get to] accept the nurses.
Nurse 1's account also shows that building trust to enhance communication is an important aspect of the nurse-patient relationship. Communication thus becomes enhanced only after the patients spend time with the nurses and begin to accept them, assuming that the nurses make an effort to communicate with the patients.
The nurses' communication with their patients as an important foundation for building trust also makes it easier for the nurse to approach the patients and get along with them. This was emphasized by Nurse 2: We try to talk to them and … the important thing is how we talk to the patients. We have to get them to trust us first. When they trust us, then we can easily tackle them.
Nurse 11 added: Communication is very important among nurses and patients. Cancer patients are very sensitive, so we have to talk in a nice way to them. It's not easy to build relationships; we as nurses have to be close to them, understand them and then become a friend [to them].
With open, two-way communication a patient can become closer to their nurses; in some cases, as our informants highlighted, their relationship with their nurses can be closer than those with their own family members [on matters related to cancer] as claimed by Nurse 3: "I think we are closer to the patients compared to the family members. They can say anything to us".
Although the nurses in our FGDs acknowledged the importance of providing moral support to patients, several of them found it to be challenging from a communication perspective. Acknowledging its importance but realizing its challenging nature, Nurse 4 commented: It is important to talk to the patients to give moral support, but it's not easy to do. As an oncology nurse I think it's really a challenge. So I think we are closer to them and [then] when they are in their terminal stage, we can be with them. We are more trustful than their family members. They will call you [the nurses]; they will ask you this and that.

How do they communicate?
From the data, we found that the nurses use a ]. The nurses we interviewed used a variety of non-verbal communication approaches such as smiling, facial expression, touch and maintaining eye contact. By doing so, their aim was to build psychological closeness with the patients. According to Nurse 7, "When I talk with my patients I will make sure I sit close to them…like sitting near to them as if no barrier is between us". The informants felt that sitting or standing near the patients when talking to them helps the patients feel the nurses' concern for them. Non-verbal approaches between nurses and patients were found to be important in making the patients feel comfortable when communicating. Beside the patients, the nurses also talk to and try to convince the family members that the cancer is curable and that having the disease does not necessarily mean that the patient will die, as reported by Nurse 4: "We try to talk to them…that is the important thing is how we talk to the patients and how we talk and convince the family." Under such circumstances, since doctors have limited time with patients, the attending nurses will step in to provide further clarification about the process of cancer treatment, as narrated by Nurse 5: The patients are well-informed by the doctor before they start chemo or radiation. But as [a busy] human being, how long can [the oncologist] stay with the patient, how long you can talk to the patients? So, we as oncology nurses, we usually will talk to them. And we give chemo, we will talk to them and they also will be close to us.
Nurse 7 also emphasized that patients asked a lot of questions regarding chemotherapy treatment: "When we give chemo we talk to them so they will ask a lot of questions about chemo; sometimes they will ask how long they will go through with the chemotherapy." The nurses also reported that the most important type of information requested by patients was anything related to the side effects of chemotherapy treatment. As narrated by Nurse 7 and Nurse 4, respectively, "As an onco nurse we must know about chemo and what the side effects of chemo are that need to be communicated to the patients [Nurse 4]." And, "To me it is important to inform the patients about the side effects of chemo treatment [Nurse 7]." Nurses also communicate about their patients' diet. As narrated by Nurse 13 and Nurse 14, respectively, "Beside the treatment, we also tell the patients about diet, and type of food [Nurse 13]." And, "We talk about diet, food, what type of food they should take after surgery and what the healthy foods are [Nurse 14]."

Discussion
The study findings revealed that communication is important in Malaysian nursing care as it contributes to close relationships and builds trust between nurses, patients and their family members. With effective communication, nurses can provide information on how patients can take care of themselves during and after treatment. When a nurse can communicate well with a patient, he/she can build a close bond with the patient, gain acceptance and be trusted as a reliable care team member. For this bonding to take place, however, communication must be bi-directional, as it is not enough for the nurses solely to be effective in transferring information to their patients. The nurses need to communicate appropriately and give clear information to the patient, however, the nurses in our study emphasized that unless the patients are also communicating with the nurses, the level of effectiveness of the communication will be hindered due to the lack of trust and strength of the relationship between the two. Back et al. (2005) reported that build trust is one of the aspect in communication that most valued by patients. Thus, communication among the nurses in our study is as much about building relationships, and creating safe space for the unique relationship between nurse and patient to grow, and then it is about merely transferring information about cancer and cancer care. Patients' family members also play a central role in the process of patient recovery, and as such the nurses must also be able to communicate clearly and effectively with them. Good communication between the cancer care nurses and patients' family members can support the patient in coping and living with the enormous challenge that the disease creates. Meaningful information provided by the nurses to the patients' families can help the families make sound decisions in regard to the cancer treatment process.
The findings of the study also show that nurses give moral support to cancer patient and their families. The patients feel better with the moral support. It also helps cancer patients and their family in fighting against cancer. The study result is consistent with Holland and Holohan (2003) who stated that nurse-patient communication is important in helping nurses give social and moral support to patients, which has been shown to be highly correlated with total psychological well-being and positive health behaviors. Other than that, the nurses also have to communicate among each other. They can communicate and share the knowledge, experience and some issue DOI:http://dx.doi.org/10.7314/APJCP.2013.14.1.153 Communication Competencies of  related to the cancer treatment (Pam et al., 2010).
The study also revealed the cancer nurses able to communicate with patients, verbally and nonverbally. Usually, nonverbal communication takes place in influencing patient emotion (Jirwe, 2010) and patients are disappointed when the nurses not to pay attention with them (Uitterhoeve et al., 2009). Patients feel happy when the nurses understand their situation. Sometimes, nurses have to touch the patient to make them feel calm. Nurses need to smile and maintain eye contact when meeting patients to help them comfortable. When they talking to patients, they must be careful do not touch on sensitive topic. Some patients do not want anybody to know that they have cancer. Further, communication involves transmitting feelings which is the patients feel recognized by the nurses (Sheppard, 1993). One of the major cancer treatments is chemotherapy. According to the study's informants, some patients do not want to carry out this more demanding treatment (compared to surgery or radiotherapy). Thus, one of the nurse's tasks is to ensure that the patient observes the treatment. To do so, the nurses need to provide information about chemotherapy, what it is, why it is essential for the patient to undergo the treatment, what he or she needs to go through, and how to manage the side effects. Sometimes, patients do not understand the treatment procedure. The lack of comprehension will affect treatment observation. Recommendation on cancer treatments are made by oncologists. But due to the high oncology-patient ratio in Malaysia which is 1:650,000 (Yip et al., 2006), the time available for a patient is limited. Thus, nurses can undertake the role in providing information to cancer patients. The need for the nurses to provide information revealed from the study supports that of Wouda and Van de Wiel (1996). According to them, an important nursing aspect concerns providing clear information about medical issues regarding treatment. Family members are also involved in cancer treatment decision making (Othman and Mazanah, 2010). For the purpose, the nurses also have to provide relevant information about cancer, to the patients' families as reveal in their inquiry.
In conclusion and implications, the nurses communicate with cancer patient to build trust towards established for close relationship. They communicate with the family to give moral support. When cancer patient can communicate well with the nurses, they accept the nurses' recommendation better. Nurses communicate with patients verbally and non-verbally. Nonverbal communication can make the cancer patient feel appreciated during cancer treatment process. Usually, the nurses and cancer patients are communicate about the process of cancer treatment and all the side effect. The nurses also communicate about the treatment and side effects with the patients' family.
They perceived the skill to be essential to provide information to patients and their families, so that the patients can acquire new knowledge and skill about treatment and side effects. With the information gained through effective communication, a patient may also change her/his negative attitude towards a more favorable one that would facilitate treatment and living a quality life.
To achieve the competency of the oncology nurses they need opportunities to acquire and practice the needed skill. Since cancer patient in Malaysia is multicultural and multi-language, the nurses need to be culturally appropriate when communicates with the patient. The patients' family is involving in decision making thus the nurses need to communicate to the family. The nurses need to understand the patients' language and dialect to ensure the effectiveness of communication process. The nurses also have to take consideration in terms of cancer patients' religion when communicating with them. They have to respect and be sensitive with the patient belief. This study strengthens the previous study in Western context, which is communication competency is important in cancer care services. Thus, training in soft skill especially in communication is needed by the oncology/cancer care nurses in order to give good healthcare services to the cancer patient.