An evaluation of the quality of a
chemotherapy administration service
established by nurses in an oncology
day care centre
LeeYik Mun, RN, BN,
BBA, PGPDip, MRCNA,
Oncology Nurse Specialist,
Department of Clinical
Oncology, Prince of Wales
Hospital, Hong Kong
Chan Man Ping, RN,
BHS, PGDip, Sta¡ Nurse,
Department of Clinical
Oncology, Prince of Wales
Hospital, Hong Kong
Wong Ka Fai, RN, BN,
Sta¡ Nurse, Department of
Clinical Oncology, Prince of
Wales Hospital, Hong Kong
Molassiotis Alexander,
RN, PhD, Senior Lecturer
in Cancer & Palliative Care,
School of Nursing, Faculty
of Medicine & Health
Sciences, University of
Nottingham, UK
Tsoi Yi Ki, RN, Sta¡
Nurse, Department of
Clinical Oncology, Prince of
Wales Hospital, Hong Kong
Chan Suk Jing, RN,
BAppSc, MSc,
Department Operations
Manager, Department of
Clinical Oncology,
Prince of Wales Hospital,
Hong Kong
Correspondence and
o¡print requests to:
LeeYik Mun, E-mail:
ymlee61@hotmail.com
European Journal of Oncology Nursing 5 (4), 244 ^253 # 2001 Harcourt Publishers Ltd
doi:10.1054/ejon.2001.0150, available online at http://www.idealibrary.com on
LeeYik Mun,Chan Man Ping,Wong Ka Fai, Molassiotis Alexander,
Tsoi Yi Ki,Chan Suk Jing
Traditionally, chemotherapy administration has been a medical role in Hong Kong. In 1998,
two chemotherapy nurses took over part of this role within a major oncology day care
centre after completing a course in chemotherapy administration and patient care.The aim
of this study was to measure and evaluate the quality of care by using a self-developed audit
form and the Worthing Chemotherapy Satisfaction Questionnaire (WSCQ). All records of
patients who had had IV cannulas inserted by nurses over a period of one year were audited
for the accuracy of the IV cannulation (n = 2217). Also, patient satisfaction was assessed in
50 patients.The results showed that the accuracy of IV cannulation was kept constantly
above 80% from the eighth month of auditing onwards. It was also found that patients
preferred the use of a butterfly needle for the administration of chemotherapy.The study
revealed that the level of information received regarding treatment (r = 0.36, P = 0.011) and
satisfaction of practical advice on caring for side effects (r = 0.35, P = 0.012) were
determinants of patients’overall satisfaction. Furthermore, anxiety when patients
received chemotherapy could also be associated with overall satisfaction (r = 0.27),
although the P value was of borderline significance only (P = 0.58). In conclusion, the study
reflected a high level of quality of care in relation to this element of nurse-led practice.
r 2001 Harcourt Publishers Ltd.
Keywords: chemotherapy administration, nurse-led, patient satisfaction
Qualitts-Bewertung eines vom Pflegepersonal in einer onkologischenTagessttte eingerichteten Dienstes zur Verabreichung
von Chemotherapie
In Hongkong fiel die Verabreichung von Chemotherapie herk˛mmlicher Weise in den medizinischen
Zust"ndigkeitsbereich. Nachdem sie eine Fortbildung in der Verabreichung von Chemotherapie und der
Patienten-Fˇrsorge absolviert hatten, ˇbernahmen im Jahre 1998 zwei Chemotherapie-Pfleger teilweise diese
Rolle in einer gro
en onkologischenTagesst"tte. Das Ziel dieser Utersuchung war, die Qualit"t der Pflege zu
messen und auszuwerten, wofˇr ein eigenes Untersuchungsformular sowie der Fragebogen WSCQ (Worthing
Chemotheraphy Satisfaction Questionnarie) verwendet wurden. S"mtliche Krankenunterlagen von Patienten,
bei denen vom Pflegepersonal im Laufe eines Jahres IV-Kanˇlen eingefˇhrt worden waren, wurden auf die
Genauigkeit der Einfˇhrung hin ˇberprˇnt (N=2217). Darˇber hinaus wurde der Zufriedenheits grad von 50
Patienten bewertet. Die Ergebnisse zeigten, dass sich die Genauigkeit der Einfˇhrung von IV-Kanˇlen vom achten
Monat nach Beginn dieser Utersuchung an konstant ˇber 80% hielt. Es stellte sich auch heraus, dass Patienten zur
Verabreichung der Chemotherapie eine Butterfly-Nadel bevorzugten. Die Studie zeigte, dass der Umfang an
Information ˇber die Behandlung (r=0.36, P=0.011) und der Zufriedenheitsgrad bezˇglich praktischer Beratung
ˇber den Umgang mit Nebenwirkungen (r=0.035, P=0.012) entscheidende Faktoren bei der allgemeinen
Zufriendenheit der Patienten waren. Darˇber hinaus konnte die Angst der Patienten bei der Verabreichung
der Chemotherapie auch als abh"nging von der allgemeinen Zufriedenheit gesehen werden (r= 0.27).
Dabei war jedoch der P-Wert nur von geringfˇgiger Bedeutung (P=0.58). Als Schlussfolgerung zeigte die
Studie einen hohen Qualit"tsgrad der Pflege in bezug auf diesen Aspekt der vom Pflegepersonal angefˇhrten
Praxis.
 Evaluation of a chemotherapy administrating service 245

Evaluacio¤n de la calidad de un servicio de administracio¤n de quimioterapia creado por enfermeros de un centro diurno de
atencio¤n oncolo¤gica
Tradicionalmente, la administracio¤n de quimioterapia ha sido una functio¤n me¤dica en Hong kong. En 1998, dos
enfermeros de quimioterapia se encargardon de una parte de esta functio¤n en un importante centro diurno de
atencio¤n oncolo¤gica tras seguir un curso de administracio¤n de quimioterapia y atencio¤n de pacientes.El objetivo de
este estudio era medir y evaluar la calidad de la atencio¤n utilizando un formulario de auditor|¤ a autodesarrollado y
el Cuestionari Worthing de Satisfaccio¤n respecto de la Quimioterapia (WSCQ).Todos los registros de pacientes a
quienes los enfermeros habian colocado ca¤nulas IVdurante un per|¤ odo de un anPo fueron auditados en cuanto a
exactitud de la colocacio¤n de ca¤nulas IV (n=2217). La satisfaccio¤n de los pacientes se evaluo¤ asimismo en 50
pacientes. Los resultados indicaron que la exactitud de la colocacio¤n de ca¤nulas IV se mantuvo constantemente
por encima del 80% a partir del octavo mes de la auditoria.Tambie¤n se descubrio¤ que los pacientes prefer|¤ an el uso
de una aguja mariposa para la administracio¤nde quimioterpia. El estudio revelo¤ que el nivel de informacio¤n recibia
con relacio¤n al tratmiento (r=0.36, P=0.011) y la satisfaccio¤n del asesoramiento pra¤ctico en cuanto a la atencio¤n de
efectos secundarios (r=0.035, P=0.012) eran aspectos determinantes de la satisfaccio¤n general de los pacientes.
Adema¤s, la ansiedad cuando los pacientes recib|¤ an quimioterapia tambie¤n pod|¤ a asociarse con la satisfaccio¤n
general (r= 0.27), si bien el valor P era tan so¤lo de impotancia lim|¤ trofe (P=0.58). En conclusio¤n, el estudio¤ reflejo¤
un alto nivel de calidad de atencio¤n con relacio¤n a este elemento de la pra¤ctica dirigida por enfermerus.

INTRODUCTION for future services and it is a way for patients to

Traditionally, intravenous bolus administration
of chemotherapy is administered by doctors in
all hospitals under the Hospital Authority in
Hong Kong. However, nurse-administered che-
motherapy bolus injections have been general
practice in many western health care settings for
many years. In order to evaluate a newly-
established nurse-led chemotherapy service, the
success of nurses’ cannulation skills and patients
satisfaction with the service were examined.
Patient participation is a form of consumer
opinion and may also be considered as a
therapeutic nursing activity, which improves the
quality of care by offering an active recipient
role. Contemporary nursing practice is often
guided by the principles of patient participation
and collaborative practice (Kirk, 1998),
which in turn may lead to better provision
of care and higher levels of patient satisfaction
with care (Harvey et al. 1999). Patient satisfac-
tion is a measure of care and reflection of the
respondent, and it is individualized and perso-
nalized.
LITERATURE REVIEW
Patient satisfaction
Usually, the passive patient is regarded as a good
patient. However, the Patient Charter states that,
‘as a patient, you have the right to receive
medical advice and treatment which fully meet
the currently accepted standards of care and
quality’ (Hospital Authority, 1994). The health
service now has to listen to patients and to heed
public opinion. Patient satisfaction has become
an important indicator of the effectiveness of the
quality of health care. It also opens alternatives
have a voice in the health care process.
Oliver (1981) defined satisfaction as, ‘a sum-
mary psychological state resulting when the
emotion surrounding disconfirmed expectations
is coupled with the consumer’s feeling about the
consumption experience’ (p 27). In other words,
patient satisfaction is related to patients’
expectations of their role within the health care
system (Williams, 1994), and their perception of
their rights and obligations. One of the satis-
faction models identified by Fitzpatrick
(1984), proposed that the major concern of
patients is not only to express their dis/satisfac-
tion but to gain some resolution to their health
problem. Furthermore, patients’ expectations are
highly predictive of their satisfaction with a
service (Hsieh & Kagle, 1991). Also, the theory
behind ‘expectations’ may assist in understand-
ing patient satisfaction, as it is influenced by
personal and social variables (Thompson &
Sunol 1995).
Patient satisfaction is a prerequisite to high
quality of care and clinical outcomes and it gives
information to healthcare providers on how to
meet patient values and expectations in the
process of care (Williams 1994). In contemporary
nursing the interest in both cost-containment
and evidence-based practice has led to questions
as to whether the profession has a role in
outcome measurement. Therefore, an evaluation
of the quality of services is an integral part of the
nursing movement to demonstrate worthiness in
terms of effective and efficient care (Thomas &
Bond 1996).
Literature reviewed by Sitzia and Wood
(1998a) on patient satisfaction with chemother-
apy outpatient services identified as critical
components: accessibility to care and the treat-
ment environment; interpersonal aspects of care;
technical aspects of care, and patient education
and information.

European Journal of Oncology Nursing 5 (4), 244 ^253

246 European Journal of Oncology Nursing
Demographic factors
Patient characteristics including age, gender,
and previous experience of hospital services,
can influence the satisfaction response (Cleary
& McNeil 1988). Various studies (Pascoe, 1983;
Blanchard et al. 1990) have revealed that
satisfaction is positively related to age. The
elderly are more satisfied with health care than
the younger generation. However, Sitzia and
Wood (1998b) reported that age was not
associated with patient satisfaction with quality
of services.
A meta-analysis conducted by Hall and
Dornan (1990) concluded that patient gender
did not have much influence on satisfaction.
However, a British study (Williams & Calnan
1991) reported that female patients were more
likely to express their complaints on rigid time
schedules and lack of privacy than their male
counterparts. Men were less satisfied with inter-
personal care than women, but not with other
aspects of care (Sitzia & Wood 1998b).
Waiting time
Clinic waiting times can significantly influence
institutional image and reputation in the com-
munity (Rondeau 1998). Various studies have
shown that waiting time is associated with
satisfaction (Astedt-Kurki & Haggman Laitla
1992; Rondeau, 1998; Smith & Sanderson 1992).
Thomas et al. 1997 reported that 27% of patients
in an outpatient oncology clinic described the
waiting time as extremely long. Coates et al.
(1983) reported the most common 73 problems
associated with chemotherapy. The ‘length of
time treatment takes’ was ranked as the fifth
most common problem. However, Sitzia and
Wood (1998b) reported in their study that about
43% of patients could have their treatment
administered within 15 minutes after arrival
and the waiting time of 44% patients was around
15–30 minutes. The optimization of patient
waiting times lead to higher levels of patient
satisfaction and it is surprising that the health
care professionals pay little attention to this.
Informational support
Patients attending hospitals in Hong Kong are
advised by a Special Report by the Hospital
Authority (1994) that,
‘‘You have the right to information about what
health care services are available . . . You have the
right to be given a clear description of your
medical condition, with diagnosis, prognosis, and
of the treatment proposed including common risks
and appropriate alternatives. . . You have the right
to know the names of any medication to be
European Journal of Oncology Nursing 5 (4), 244 ^253
prescribed and its normal action and potential
side-effects given your condition’’.
This statement has particular interest, as it
highlights the importance of providing clear
and adequate information to patients about their
illness and treatment. However, information
provision may at times not be perceived as
adequate by patients. Some studies have indi-
cated that patients who are satisfied with the
information provided to them are less anxious
(Steptoe et al. 1991; Fallowfield et al. 1986).
Kincey et al. (1975), pointed out that adequate
informational support to patients could enhance
patient satisfaction and compliance with
therapeutic regimes. It appears that failure to
provide information contributes to dissatisfac-
tion. Fallowfield et al. (1987) and Suominen et al.
(1994) revealed in their studies that breast cancer
patients felt that they had not received adequate
information from the hospital regarding their
treatment. Studies show that quite a number of
oncology patients are dissatisfied with the
amount of information provided to them regard-
ing their care and treatment (Wiggers et al. 1990;
Wilkinson 1992). Nevertheless, in a study of
patient satisfaction with chemotherapy nursing
care, satisfaction with informational support was
high (Sitzia & Wood 1998b). Sitzia and Wood
(1998a) also reviewed the literature on patient
satisfaction with chemotherapy nursing care and
found that provision of patient information was
one of the two major concerns of patients.
Interpersonal care
One of the models of satisfaction elicited by
Fitzpatrick (1984) mentioned that many patients
were able to reflect their satisfaction by judging
the non-technical aspects of care. Therefore,
communication and affective behaviours are a
focus for patients to express their satisfaction.
Sitzia and Wood (1997) suggested that patient
judgement about the manner of health care
professionals was an essential determinant of
their satisfaction level. When compared between
interpersonal and technical competence, Wiggers
et al. (1990) reported that communication was
rated by patients more important than other
elements of care in terms of satisfaction.
Communication and affective behaviours are
significant components of interpersonal care in
oncology nursing care (Moorey 1988). Fernsler
(1986) reported that there was a deficit in
interpersonal care between cancer patients and
the nursing profession. Significant problems were
avoidance of communication, inadequate infor-
mational support provided to patients and poor
appreciation of the patient needs. Greater
satisfaction with communication could enhance
factual knowledge regarding the causes and
treatment of cancer (Steptoe et al. 1991). Krause
 Evaluation of a chemotherapy administrating service 247
(1993) recognized that empathy and reassurance
from health care professionals were significant
determinants of the relationship between the
patient and the health carer and how well
patients coped with the disease process.
Technical care
Preparation of cytotoxic treatment includes
venous access, which is one of the five aspects
of the oncology nurses’ role as described by
Tanghe et al. (1994). A pioneer in intravenous
therapy was Ada Lawrence who practiced as an
intravenous (IV) nurse therapist in Massachu-
setts General Hospital in the 1940s and who also
introduced the concept of the IV nursing team in
the USA. In the UK, individual nurses began to
practice IV therapy in 1970 (Dougherty 1996).
Sitzia and Wood (1997) discuss that research
studies have failed to emphasize the importance
of technical care because patients assume that
health care professionals have a basic level of
competence. In the study by Sitzia and Wood
(1998b) on patient satisfaction with chemother-
apy administration, nurses’ technical skills in
administering chemotherapy achieved the high-
est mean score among all the technical care
items. Mendez (1987) found that the accuracy of
IV cannulation by non-IV team nurses was about
50%, as compared to 83% in IV team nurses. A
good standard of IV cannulation contributes to
less traumatic venepuncture and minimizes
complications.
The aim of the current study was to evaluate
quality of care in terms of nurses’ IV cannulation
success and patient satisfaction in a newly set up
nurse-led chemotherapy administration service
in an oncology day care centre. Objectives of the
study included.
 To measure the efficacy and change over time
of the nurses’ intravenous (IV) cannulation
success.
 To evaluate patient satisfaction with nurse-
administered chemotherapy
 To identify weaknesses and strengths of the
chemotherapy administration service
 To identify factors influencing overall patient
satisfaction.
STUDY DESIGN
This was a descriptive study measuring the
quality of a nurse-led service in relation to
chemotherapy administration. The study was
conducted in an oncology day care centre of a
University Hospital in Hong Kong. The che-
motherapy unit is one of the activity areas in the
outpatient department, where patients receive
chemotherapy treatment after consultation with
the doctor. Approximately 60–80 patients receive
chemotherapy treatment each day. The nursing
staff of the unit include an oncology nurse
specialist, four registered nurses and four en-
rolled nurses. The most commonly treated cancer
in the unit is colon cancer (30% of the patients),
followed by breast cancer (23%), lung cancer
(14%), liver cancer (13%), head and neck cancer
(5%), gynaecological cancers (3%), with other
cancers accounting for 12%. Besides chemother-
apy administration, some minor diagnostic and
therapeutic procedures are carried out, such as
bone marrow biopsy, chest and abdominal
aspiration. The study included an audit and a
patient satisfaction survey.
The audit was carried out to assess the
accuracy of performing IV cannulation in
patients being administered chemotherapy by
chemotherapy nurses and also patient preference
for a butterfly needle or angiocath. The patient
satisfaction survey was carried out to evaluate
patient satisfaction with chemotherapy adminis-
tered by nurses after approval from the Research
& Ethics Committee of the Medical Faculty,
Chinese University of Hong Kong. Only colo-
rectal cancer patients were used in the study, as
these were the only patients nurses were
permitted to administer chemotherapy at this
initial stage of service development.
Sampling procedures
All patients who had their IV cannulation
carried out by nurses between August 1998–July
1999 (n=2217) were audited for accuracy of
cannulation and their preferences for either a
butterfly needle or angiocath. In addition, a
convenience sample of 53 subjects that had been
receiving nurse-administered chemotherapy was
recruited on the last day of the sixth cycle of their
treatment to evaluate their satisfaction with the
service.
Instrument
Audit documentation forms were developed to
record the number of attempts for IV cannula-
tion for each patient by chemotherapy nurses as
well as patient preference IV cannula. For
patient satisfaction, the Worthing Chemotherapy
Satisfaction Questionaire (WCSQ), developed by
Sitzia and Wood (1999), was adopted for use in
the current study, after translation into the
Chinese language. Subscales deal with accessi-
bility to care and the treatment environment;
interpersonal aspects of care; technical aspects of
care, and patient education and information. A
score for overall satisfaction can also be
obtained. The reliability of the questionnaire was
reported to be satisfactory as its Cronbach’s a
internal consistency was higher than 0.71 in all
components except the component about hospi-
European Journal of Oncology Nursing 5 (4), 244 ^253
248 European Journal of Oncology Nursing
tal accessibility (a=0.35) (Sitzia and Wood
1999). Validity was established through content
and construct validity (Sitzia and Wood 1999).
In each component of the satisfaction scale there
was space for patients’ comments. The ques-
tionnaire uses a combination of visual analogue
scales (one section) and Likert-type scales to
elicit responses in relation to the variables of
interest.
Data analysis
Mean and standard deviations were used for
descriptive purposes. T-tests for independent
groups were performed to assess if there were
any significant differences between gender in
overall satisfaction and anxiety level. ANOVA
was used to compare waiting time with patient
satisfaction and anxiety level. Furthermore,
Pearson correlations were employed to examine
the association between the perceived satisfac-
tion and anxiety level with different aspects of
care and demographic data including nursing
care, information support, length of waiting
time, level of privacy and age.
RESULTS
Audit
Chemotherapy nurses nursed 2627 patients with
2217 IV cannulations and 4993 IV injections
during the audit period. The average number of
patients attending the chemotherapy administra-
tion clinic were 218 per month, with an average
of 184 IV cannulations managed by nurses per
month and 416 IV injections administered by
nurses per month.
Accuracy of IV cannulation
The audit measured the accuracy of IV cannula-
tion performed by two chemotherapy nurses
starting from the first month of service for twelve
months. As proposed by departmental che-
motherapy administration guidelines, each che-
motherapy nurse was only to attempt to insert
the IV cannula twice for each patient. Any
patient who had two unsuccessful IV cannula-
tion attempts by the first chemotherapy nurse
should be handed over to the second chemother-
apy nurse. The first chemotherapy nurse was
defined as the nurse who first interviews the
patient and performs the IV cannulation. The
percentage of successful first attempts of IV
cannulation by first nurses varied between 64%
and 89% (mean=78.5, SD=7.69) (Fig. 1). There
were nine patients who were referred to medical
officers for IV cannulation after four unsuccess-
European Journal of Oncology Nursing 5 (4), 244 ^253
Fig. 1 Percentage of successful first attempts on IV cannula-
tion by the first nurse.
ful attempts by the two chemotherapy nurses in
the first four months of auditing. After the first
four months there were no patients referred to
the medical officers for IV cannulation. Among
the nine cannulations carried out by medical
officers, five were carried out at high risk sites
(three in the antecubital fossa and two in the
inner wrist) which chemotherapy nurses are not
normally permitted to access under the depart-
mental chemotherapy administration guidelines.
Preference of IV cannulation
The new service offered patients the choice of
either a butterfly needle or an angiocath infusion
set. For patients who opted for butterfly needle,
they had a venepuncture each day of chemother-
apy. The angiocath infusion set could be kept in
situ with heparin lock as long as the vein was
viable for the chemotherapy cycle. Patients were
free to make the choice according to their will,
needs, comfort and convenience. Patients chose
butterfly needles more often than angiocaths
during the assessment period at a mean ratio of
4.04 : 1 (range 1.71 : to 8.08:1). The issue of
patient preference in choosing a butterfly or
angiocath for their chemotherapy administration
was a change brought about by nurses, as
patients did not normally have a choice when
cannulation was performed by medical staff and
often the doctors preferred to use angiocaths
rather than butterfly cannula.
Patient satisfaction survey
Demographic data
A total of 53 subjects were asked to participate in
the study. Three patients failed to return a
completed questionnaire. The overall response
rate was 94% with 50 questionnaires being
returned. There were 24 female subjects (48%)
and 26 males (52%). Their age range was from
39 to 86 years and the mean age was 57.72 years
(SD=11.49). All patients were of Chinese origin
and all were diagnosed with colorectal cancer.

Table 1 Level of patient satisfaction with waiting time
Frequency
Length of wait less than15 minutes
to be treated with 15 to 30 minutes
chemotherapy more than 30 minutes
Very happy (1) to very unhappy (5):
Happy with length of wait
Unit’s system to suit your needs in terms
of appointment date and time
Table 2 Level of patient satisfaction with privacy while receiving chemotherapy
Very happy (1) to very unhappy
(5):
Happy with privacy level when
receiving chemotherapy
Happy to be treated with other
patients around
Preference to (1) with other patients
be treated: (2) private cubicle
(3) no preference
All subjects reported that they had visited the
chemotherapy unit more than 20 times.
Waiting time
There were three items to assess the satisfaction
of waiting time (Table 1). Patients were asked
about their length of stay before receiving
chemotherapy. 90% of patients received treat-
ment within 15 minutes of arrival and a further
8% and 2% of patients waited between 15 to 30
minutes and more than 30 minutes for treatment
respectively. Patients were happy with their
length of wait and also perceived the unit’s
system to suit their needs in relation to appoint-
ment date and time.
Privacy level
Three items were concerned with the privacy
level during chemotherapy (Table 2). Two items
on a 5-point scale assessed the satisfaction with
privacy when receiving chemotherapy. Patients
were also asked about their preference to be
treated alone or with other patients. The data
showed that patients reported a high satisfaction
level with their privacy while receiving treatment.
The majority of patients had no preference either
to be treated alone or with other patients around.
Anxiety
Two items were concerned with the anxiety level
measured on a 5-point scale ranging from very
anxious (1) to very relaxed (5). In the item asking
patients whether they ‘feel anxious before arriv-
ing at the chemotherapy unit’ the mean score was
2.60 (SD=1.16) whilst in the item asking
patients if they ‘feel anxious when receiving
chemotherapy’ the mean score was 2.78
Evaluation of a chemotherapy administrating service 249
Percentage Mean SD
45 90
4 8
1 2
1.38 0.60
1.34 0.51
Frequency Percentage Mean SD
1.42 0.57
1.84 0.74
11 22
6 12
33 66
(SD=1.20). When anxiety was examined with
gender and waiting time, the results showed no
significant differences.
Comments from patients which heightened
their anxiety level included:
 Awful hospital smells
 Nurses’ technical skills in IV cannulation
 Gossips and rumours of bad experiences
from other patients
 Side-effects from the chemotherapy.
Nursing care
Nursing care included both interpersonal care
and technical care. Six interpersonal nursing care
items and four technical care items were assessed
using a Visual Analogue Scale (VAS) with the
minimum score being ‘0’ (very dissatisfied) and
the maximum ‘10’ (very satisfied) Table 3). The
responses to interpersonal care were skewed
towards high values. Among the six items of
interpersonal care, ‘appreciation of patient’s
individual needs’ was the highest item rated with
a mean of 8.41 (SD=1.16). This item received
the highest mean score in the overall nursing care
too. The lowest mean of interpersonal care was
detected in the item of ‘concern for patient’s
relatives or friends’ (mean=7.09, SD=2.09).
One further item asked whether ‘the nurses
could be more approachable’ on a 5-point scale
ranging from strongly disagree (1) to strongly
agree (5) and the mean score was 1.7 (SD=1.11),
suggesting that patients found nurses very
approachable already.
Similar to the responses to interpersonal care,
scores about technical care were also skewed
towards high values. The highest mean and
lowest mean in technical care were in relation
European Journal of Oncology Nursing 5 (4), 244 ^253
250 European Journal of Oncology Nursing

to items about the ‘technical skill in giving
chemotherapy’ (mean=8.25, SD=1.38) and the
‘medical knowledge of the patient’s problem’
(mean=7.99, SD=1.58) respectively.
Patient information
One item assessed satisfaction with explanations
received about the procedures and treatment when
receiving chemotheraphy with a VAS ranging
from 0–10. The mean was 8.33 (SD=1.50),
suggesting high levels of satisfaction with the
explanation received. The source of information
related to treatment was mainly verbal through
the chemotherapy nurses and the consultant
whereas the main source of information related
to the disease was the consultant (Table 4).
Table 3 Level of patient’ satisfaction with nursing
care while receiving chemotherapy
Nursing Care
Interpersonal care
Concern for privacy when taking
personal details
Concern for Privacy when giving
treatment
Appreciation of patient’s
individual needs
Having time to talk to patient
Reassurance and support
Concern for patient’s
relatives or friends
Technical care
Technical skill in giving
chemotherapy
Medical knowledge of
patient’s problem
Awareness of side-e¡ects
Help given in controlling/
reducing side-e¡ects
# Scores can range from ‘0’ (= very dissatisf|ed) to ‘10’
(= very satisf|ed)
Patients also made some comments about
improvements they would like to see in relation
to the information given to them:
 Information on dietetic recommendations
should be culturally adapted to reflect a more
Chinese style, especially, more information
on ‘diet control’ from the Chinese point of
view while receiving chemotherapy
 More information on caring for the side
effects from the chemotherapy
 Detailed explanations about the disease and
its progress, and the status of remission and
relapse
 The role of herbal medicine while the patient
is treated with chemotherapy.
Overall satisfaction
One item assessed overall satisfaction with the
chemotherapy service on a 5-point scale. The
mean was 1.32 (SD=0.47) suggesting high over-
Mean # SD all satisfaction with the service. Overall satisfac-
tion was associated with the level of information
7.96 1.85 received regarding treatment (r=0.36, P=0.011)
and satisfaction with practical advice on caring
8.25 1.26
for the side effects (r=0.35, P=0.012). Correla-
8.41 1.16 tions between the anxiety level when receiving
treatment and privacy or if treated with other
7.89 1.87
8.26 1.46 patients around, technical and interpersonal care
7.09 2.09 and length of time to be treated were calculated.
No correlations between these variables were
8.25 1.38 found. However, when the anxiety level was
examined with the overall satisfaction score, a
7.99 1.58 moderate but borderline significant correlation
8.20 1.56 was shown (r= 0.27, P=0.058) which suggests
8.18 1.95 that anxiety when receiving treatment could be a
satisfaction determinant. Correlations between
age, interpersonal and technical care, privacy
level when receiving treatment and satisfaction

Table 4 Level of patient’ satisfaction with information received

Very happy (1) toVery unhappy (5): Mean SD

Happy with information received regarding 2.12 0.98
treatment
Happy with practical advice about how to care for the side-e¡ects 1.44 0.61
Happy on the advice received about care between the courses of 1.42 0.67
chemotherapy
Information source received Information source received regarding
regarding treatment disease
Frequency Percentage Frequency Percentage
Verbal, from hospital 38 76 30 60
consultant
Written, from hospital 4 8 8 16
consultant
Verbal, from chemotherapy 40 80 3 6
nurse
Written, from chemotherapy 24 48 3 6
nurse
Verbal, from family doctor 0 0 14 28
Written, from family doctor 0 0 4 8
Other 0 0 0 0

European Journal of Oncology Nursing 5 (4), 244 ^253

 Evaluation of a chemotherapy administrating service 251
with the length of waiting time for treatment on
one hand and overall satisfaction on the other
were also calculated but none showed any
associations. Also, there was no difference be-
tween gender and satisfaction on aspects of care.
DISCUSSION
The accuracy of IV cannulation by the first nurse
was only 64% in the first month but the
percentage of successful curve was increased to
89% in the twelfth month. In fact, the success
rate was constantly above 80% from the eighth
month onwards and the number of IV cannula-
tions referred to the medical officer were only
nine. The initial cannulation success rate was
relatively low as the nurses had just started the
practice of cannulation immediately after the
chemotherapy administration training course.
Traditionally, nurses in Hong Kong are not
trained to practice cannulation. However, a few
months after the initiation of the service the
success rate was constantly high. When patients
were assessed about their satisfaction with
technical care, the item of ‘nurses’ technical skill
in giving chemotherapy’ was rated the highest. In
both studies by Sitzia et al. (1996) and Sitzia and
Wood (1998b), technical care and ‘nurses’ skill
with treatment’ also received the highest score.
This reflects that nurses can establish a standard
of technical skill and care when they undertake a
course of development in this area of practice.
Patients’ preference for a butterfly needle to
angiocath infusion set for IV cannulation varied
from 1.17 to 8.08 (mean=4.04). It clearly
showed that patients preferred a butterfly needle
rather than the angiocath needle. Clinically,
patients expressed their concerns on quality of
life, pain and social factors when living with an
angiocath with heparin lock and it would be
worthwhile to further explore factors behind
such preference in future studies.
In the majority of cases, waiting time for
treatment in the nurses’ clinic was less than 15
minutes, and only 2% claimed that they had to
wait for more than 30 minutes. Anderson and
Zwelling (1996) discussed the ‘phantom waiting
time’, a critical issue that contributes to sig-
nificant problems in waiting times. There is a
different perception of ‘patient-perceived waiting
time’ with ‘waiting time’ as defined by the
institution. It is common for patients to arrive
earlier than the scheduled time and patients may
think that they wait longer.
The results showed that the level of informa-
tion received regarding treatment and satisfac-
tion about practical advice on caring for side
effects were determinants of overall satisfaction.
Practical advice on caring for side effects and the
level of information received regarding treatment
are interrelated. As discussed by Sitzia and
Wood (1998a), patient information is crucial
for patients in order to develop skills to prevent
and manage adverse effect from chemotherapy.
A literature review by Sitzia & Wood (1998a)
also suggested two main areas, assessment and
management of adverse effects and provision of
patient information, that needed urgent atten-
tion in terms of patient satisfaction with che-
motherapy. It was also found that the majority
of the sources of information regarding treat-
ment came from the chemotherapy nurses and
hospital consultants in a verbal format. How-
ever, chemotherapy nurses focused on giving
information mainly regarding treatment and not
about the disease; the latter accounted for only
6% in both written and verbal format. It is
possible that the explanations and information
regarding disease were perceived to be of a
medical nature rather than a nursing one. Also,
the information from family doctors was low,
and this is expected in the Hong Kong health
care system, as most patients do not have family
doctors. Usually patients ‘shop’ for a GP when
they have an initial problem, but from the
moment they are referred to a specialist centre
they seldom go back to a GP again. Never-
theless, patients reflected that nurses should have
a role in providing information regarding their
disease.
Patients claimed that they felt a variable
degree of anxiety when receiving chemotherapy.
When anxiety level was correlated with overall
satisfaction, a borderline significant level was
found which showed that anxiety could be a
satisfaction determinant. Sitzia and Wood
(1998a) concluded that certain determinants such
as treatment environment, information support
and interpersonal aspects of care contributed to
the level of anxiety while patients were having
chemotherapy treatment. In the current study,
patients’ comments on nurses’ technical skill of
IV cannulation, ward environment, side effects of
chemotherapy and gossips and rumors about
bad experiences from other patients were also
crucial factors heightening their anxiety. Other
factors contributing to anxiety level need to be
further identified and explored.
Recommendations
Since overall satisfaction was associated with the
level of information received regarding treatment
and satisfaction with practical advice on caring
for side-effects, role expansion of chemotherapy
nurses in symptom management focusing on
both a caring and information giving context is
worthy of exploration in the future. Information-
giving from the viewpoint of health care profes-
sionals and service users can be different (Luker
et al. 1995). Therefore, the identification of
European Journal of Oncology Nursing 5 (4), 244 ^253
252 European Journal of Oncology Nursing
patients’ information needs can facilitate role
expansion and improve the quality of a service.
Culturally compatible information is a priority
for improvement when providing information.
Attention should also be paid to the anxiety
status of patients and to measures taken to
support them and reduce their anxiety levels.
Providing information to patients may well assist
in reducing anxiety (van der Molen 1999).
However, nurses need to assess patients’ under-
standing of information provided and patients’
preconceptions and their feelings in order to gain
the maximum benefit from their intervention.
Further, updated information on the cytotoxic
drugs nurses are using needs to be provided
regularly for them by pharmacists to ensure
continued safe practice. Finally, from the point
of economic rationing, it would be interesting to
investigate elements of cost-effectiveness in rela-
tion to how the healthcare setting is or is not
benefiting from the shift in service. Also,
patients’ expectations and the personal and
social issues surrounding their expectations may
be crucial determinants of their satisfaction with
health care services (Thompson & Sunol 1995)
and these need to be incorporated in future
research of patient satisfaction.
Limitations
Researchers using a personal contact approach
may result in bias from a socially desirable
response on satisfaction level. Therefore, to a
certain extent, patients’ responses are considered
to be biased as they may want to please the
researcher and they may also fear the repercus-
sions of a negative care appraisal (Sitzia & Wood
1998c). This study was confined to one hospital
and the sample size was relatively small and not
randomly selected, therefore, this is a limitation
in the generalization of the findings. Also, a
homogeneous sample of colorectal cancer pa-
tients only was used, limiting the generalisability
of the results to other cancer populations. This is
because key determinants of patient satisfaction
(i.e. educational level or social and economic
circumstances) may vary among cancer patient
groups. Patients were at the end of their sixth
cycle of chemotherapy, and this may affect their
satisfaction level. Additionally, the assessment
tool for the patient satisfaction survey was
adopted from other institutions overseas; refine-
ment of the translated assessment tool is needed
to ensure validity of items. Also, development of
a culturally sensitive assessment tool is war-
ranted.
Conclusion
The patient satisfaction survey revealed a quality
nursing service. It showed that it is perceived as
European Journal of Oncology Nursing 5 (4), 244 ^253
acceptable by patients for nurses to insert IV
cannulas and administer chemotherapy. The
accuracy of IV cannulation was constantly stable
and high, with the accuracy of cannulation being
a patient concern only at the beginning of the
service as judged by their comments. Results also
reflected an improved service provision, which
was one of the clinical objectives of the new
nurse-led service. It would be interesting to assess
in future research patient satisfaction with a
service when this is offered by both doctors and
nurses.
Anxiety is one of the common behavioural
disturbances that patients encounter during the
course of chemotherapy. Information seeking is
a behaviour that many patients use-to cope with
and reduce stress and anxiety (van der Molen
1999). In studies by Lerman et al. (1993) there
were difficulties in understanding and asking
questions when communicating with physicians.
Patients may have difficulty in bringing up
questions or they may not be aware of their
right to know more about their treatment and
disease. Thus, the chemotherapy nurse can act as
a resource and support person to provide
information and to clarify misunderstandings
of patients and their families, especially on how
to care for side effects from the chemotherapy.
The final theme embodies the question of how
chemotherapy nurses should practice in the
future. To chemotherapy nurses, the need to
meet the challenge of operating as an indepen-
dent and discerning practitioner is of utmost
importance. Nevertheless, there should be in-
creased awareness of assuming multiple roles in
innovative nursing practices. However, multi-
disciplinary collaboration should also be empha-
sized in order to provide holistic care. As a
summary, this study has provided evidence that
nurses can provide complex and innovative
practices that meet high quality standards but
also take into account the patient preferences,
satisfaction and needs.
REFERENCES
Anderson E, Zwelling L (1996) Measuring service quality
at the University of Texas MD. Anderson Cancer
Center. International Journal of Health Care Quality
Assurance 9 (7): 9–22
Astedt-Kurki P, Haggman-Laitla A (1992) Good nursing
practice as perceived by clients: a starting point for
the development of professional nursing. Journal of
Advanced Nursing 17: 1195–1199
Blanchard C, Labrecque M, Ruckdeschel J, Blanchard E
(1990) Physician behaviours, patient perceptions, and
patient characteristics as predictors of satisfaction of
hospitalized adult cancer patients. Cancer 65: 186–192
Clearly P, McNeil B (1988) Patient satisfaction as an
indicator of quality. Inquiry 25: 25–36
Coates A, Abraham S, Kaye S, Sowerbutts T, Frewin C,
Fox R, Tattersall M (1983) On the receiving end –
patient perception of the side-effects of cancer
 Evaluation of a chemotherapy administrating service 253
chemotherapy. European Journal of Cancer &
Clinical Oncology 19: 203–208
Dougherty L (1996) The benefits of an IV team in hospital
practice. Professional Nurse 11 (10): 761–763
Fallowfield L, Baum M, Maguire G (1986) Effects of
breast conservation on psychological morbidity as-
sociated with diagnosis and treatment of early breast
cancer. British Medical Journal 293: 1331–1334
Fallowfield L, Baum M, Maguire GP (1987) Addressing
the psychological needs of the conservatively treat-
ment breast patient: Discussion Paper. Journal of the
Royal Society of Medicine 80: 696–700
Fernsler J (1986) A comparison of patient and nurse
perceptions of patients’ self-care deficits associated
with cancer chemotherapy. Cancer Nursing 9: 50–57
Fitzpatrick R (1984) Satisfaction with health care. In:
Fitzpatrick R (ed), The Experience of Illness.
Tavistock: London, 154–175
Hall J, Dornan M (1990) Patient sociodemographic
characteristics as predictors of satisfaction with
medical care: a meta-analysis. Social Science &
Medicine 30: 811–818
Harvey RM, Kazis L, Lee AFS (1999) Decision-making
preference and opportunity in VA ambulatory care
patients: association with patient satisfaction.
Research in Nursing & Health 22: 39–48
Hospital Authority (1994) Working with the community
as partners in health. Special Report, June. Hospital
Authority: Hong Kong.
Hsieh M, Kagle JD (1991) Understanding patient
satisfaction and dissatisfaction with health care.
Health & Social Work 16: 281–290
Kincey J, Bradshaw P, Ley P (1975) Patients’ satisfaction
and reported acceptance of advice in general practice.
Journal of Royal College of General Practitioners 25:
558–566
Kirk S (1998) Trend in community care and patient
participation: implications for the roles of informal
carers and community nurses in the United Kingdom.
Journal of Advanced Nursing 28: 370–381
Krause K (1993) Coping with cancer. Western Journal of
Nursing Research 15: 31–43
Lerman C, Daly M, Walsh W, Resch N, Seay J, Barsevick
A, Birenbaum L, Heggan T, Martin G (1993)
Communication between patients with cancer and
health care providers. Cancer 72: 2612–2620
Luker K, Beaver K, Leinster S et al. (1995) The
information needs of women newly diagnosed with
breast cancer. Journal of Advanced Nursing 22:
134–141
Mendez L (1987) Cost savings approach for justification
of IV therapy team. Journal of the National
Intravenous Therapy Association 10 (5): 348–356
Moorey S (1988) The psychological impact of cancer. In:
Tiffany R, Webb P. (Eds.). Oncology for nurses and
health care professionals. Volume 2: Care and
support. Harper & Row Limited: London, pp 14–35
Oliver R (1981) Measurement and evaluation of satisfac-
tion process in retail setting. Journal of Retailing
57: 25–48
Pascoe G (1983) Patient satisfaction in primary health
care: a literature review and analysis. Evaluation
Program Plan 6: 185.
Rondeau K (1998) Managing the clinic wait: an important
quality of care challenge. Journal of Nursing Care
Quality 13 (2): 11–20
Sitzia J, Fitt J, Buckingham R, Dikken C (1996) Patient
satisfaction on a medical day ward: a comparison of
nurse-led and physician-led services. International
Journal for Quality in Health Care 8 (2): 175–185
Sitzia J, Wood N (1997) Patient satisfaction: a review of
issues and concepts. Social Science & Medicine
45: 1829–1843
Sitzia J, Wood N (1998a) Patient satisfaction with cancer
chemotherapy nursing: a review of the literature.
International Journal of Nursing Studies 35(12):
1–12
Sitzia J, Wood N (1998b) Study of patient satisfaction
with chemotherapy nursing care. European Journal
of Oncology Nursing 2 (3): 142–153
Sitzia J, Wood N (1998c) Response rate in patient
satisfaction research: an analysis of 210 published
studies. International Journal for Quality in Health
Care 10 (4): 311–317
Sitzia J, Wood N (1999) Development and evaluation of
questionnaire to assess patient satisfaction with
chemotherapy nursing care. European Journal of
Oncology Nursing 3 (3): 126–140
Smith J, Sanderson C (1992) What makes outpatient
attendance worthwhile for patients? Quality Assur-
ance in Health Care 4: 125–132
Steptoe A, Sutcliffe I, Allen B, Coombes C (1991)
Satisfaction with communication, medical knowledge,
and coping style in patients with metastatic cancer.
Social Science & Medicine 32: 627–632
Suominen T, Leino-Kilpi H, Laippala P (1994) Nurses’
role in informing breast cancer patients: a comparison
between patients’ and nurses’ opinion. Journal of
Advanced Nursing 19: 6–11
Tanghe A, Evers G, Vantongelen K, Paridaens R, Van der
Schueren E, Aerts R, Lejeune M, Vermeiren P (1994)
Role of nurses in cancer chemotherapy administra-
tion. Retrospective record analysis to improve role
performance. European Journal of Cancer Care 3:
169–174
Thomas C, Glynne-Jones R, Chait I (1997) Is it worth the
wait? A survey of patient’s satisfaction with an
oncology outpatient clinic. European Journal of
Cancer Care 6: 50–58
Thomas L, Bond S (1996) Measuring patients’ satisfaction
with nursing: 1990–1994. Journal of Advanced
Nursing 23(4): 747–756
Thompson AG, Sunol R (1995) Expectations as determi-
nants of patient satisfaction: concepts, theory and
evidence. International Journal for Quality in Health
Care 7: 127–141
van der Molen B (1999) Relating information needs to the
cancer experience: information as a key coping
strategy. European Journal of Cancer Care 8: 238–244
Wiggers J, Donovan K, Redman S, Sansoh-Fisher R
(1990) Cancer patient satisfaction with care. Cancer
66: 610–616
Wilkinson S (1992) Good communication in cancer
nursing. Nursing Standard 7: 35–39
Williams B (1994) Patient satisfaction: a valid concept?
Social Science & Medicine 38: 509–516
Williams S, Calnan M (1991) Convergence and diver-
gence: assessing criteria of consumer satisfaction
across general practice, dental, and hospital care
settings. Social Science & Medicine 33: 707–716
European Journal of Oncology Nursing 5 (4), 244 ^253