Career Pathway and Education Framework for Cancer Nursing

The Career and Education Framework for Cancer Nursing (‘the Framework’) was first published by the Royal College of Nursing (RCN) Cancer and Breast Care Forum, RCN Children and Young People Specialist Care Forum, and the United Kingdom (UK) Oncology Nursing Society (UKONS) in 2017.

The 2017 Framework for UK nurses was the first to include cancer-specific outcomes for pre-registration students, support workers and registered nurses. This updated Framework incorporates cancer-specific outcomes for pre-registration nursing students, nursing support workers/support workers, registered nursing associates (England only)and registered nurses.

The Framework and cancer-specific outcomes are intended to be used as part of professional, education and workforce development to support improvements in the delivery of high-quality care to people affected by cancer (PABC) by focusing on five workforce groups:

1. Pre-registration nursing students to have achieved at the point of registration
2. Nursing support/support workers providing care to people affected by cancer across all ages in non-specialist/general settings and to adults in specialist cancer services
3. Registered nursing associates providing care to people affected by cancer across all ages in non-specialist/general settings and to adults in specialist cancer services
4. Registered nurses providing care to people affected by cancer across all ages in non-specialist/general settings*
5. Registered nurses providing care to adults affected by cancer in specialist cancer services*.

The purpose of this publication is to:

1. Provide a pathway for career development and a framework for training, continuing development and education for pre-registration nursing students, nursing support workers/ support workers, nursing associates and registered nurses who provide care to adults affected by cancer in specialist cancer services*
2. Provide a pathway for career development and a framework for training, continuing development and education for pre-registration students, nursing support workers/support workers, nursing associates and registered nurses who provide care to people affected by cancer (PABC) across all ages in general/non-specialist settings*
3. Set out a framework that will help practitioners, employers, commissioners and PABC understand the level of education/capability which correlates to a particular level of practice or role
4. Provide information relevant to Higher Education Institutions (HEIs), employers, providers of cancer services, commissioners and policy makers for the development of the workforce, roles, learning opportunities and education programmes
5. Provide a point of reference to help identify and develop the knowledge, skills and capabilities in cancer care of the nursing workforce through accredited programmes,and non-accredited learning and workplace-based development opportunities that target not only professional, but local service needs.

* Registered nurses working in paediatric cancer services should follow the ‘Career and Education Framework for CYP cancer nursing’ which is also applicable to children’s nursing students, nursing associates and support workers in paediatric services (forthcoming late spring/early summer 2022). 

This updated Career Pathway and Education Framework for Cancer Nursing and the cancer-specific outcomes have been developed and informed by international, European and UK-wide policy for cancer care. These global policies advocate that, for improvements to be achieved in the delivery of care to PABC, workforce development is essential (WHO, 2020). In addition, education standards for pre-registration students (NMC, 2018b) and Registered Nursing Associates (NMC, 2018a), and career pathways, including advanced level practice guidance, are used.

As part of the development and testing of the 2017 Framework and the cancer-specific outcomes, registered nurses providing general and specialist cancer care were involved in the pilot stages. This pilot also included mapping exercises by HEIs against pre-registration and continuing professional development programmes, as well as feedback from an expert group. The feedback confirmed that the Framework and outcomes had the potential to deliver benefits for the nursing workforce, employers and PABC.

This updated Framework has been developed in consultation with RCN/CCLG Children and Young People Cancer Nurses Community (CYPCN), United Kingdom Oncology Nursing Society  (UKONS), the North-west Cancer Alliances (Greater Manchester Cancer Alliance, Cheshire and Merseyside Cancer Alliance, Lancashire and South Cumbria Cancer Alliance) and Skills for Health using the European Oncology Nursing Society (EONS) (2018) Cancer Nursing Education Framework. The outcomes for Registered Nursing Associates have been proposed by UKONS Board members. In addition, as part of the North-west Cancer Alliances and Skills for Health Cancer Nurse Specialist project (Skills for Health, 2021), mapping of the EONS outcomes has been undertaken with their research findings. This mapping confirmed alignment of the EONS outcomes for Cancer Nurse Specialist roles and identified 2 additional outcomes related to ‘investigation and diagnosis skills’ and ‘independent prescribing’. These two areas are included, additional to the outcomes from the EONS (2018) Cancer Nursing Education Framework.

This publication includes:

• a summary of the contemporary UK policy background informing the development of the Framework
• key definitions relating to the delivery of cancer care, levels of nursing practice and pillars of professional practice to structure the cancer- specific outcomes
• cancer-specific outcomes for pre-registration nursing students to deliver care to PABC across all ages in general/non-specialist settings and to adults in specialist cancer services at the point of registration
• cancer-specific outcomes for unregistered nursing support workers/ support workers who contribute to the delivery of care for PABC across all ages in general settings and to adults in specialist cancer services
• cancer-specific outcomes for registered nursing associates who contribute to the delivery of care for PABC across all ages in general settings and to adults in specialist cancer services
• cancer-specific outcomes for registered nurses providing care for PABC across all ages in general settings
• cancer-specific outcomes for registered nurses practising at registration, enhanced, advanced or consultant practitioner levels in specialist cancer services/roles for adults affected by cancer.

The career pathway, cancer-specific outcomes and education framework form a useful toolkit for practitioners, employers, organisations, HEIs, commissioners and policy makers to:

• provide clarity about the cancer-specific outcomes required by practitioners to deliver high quality cancer care and to support their professional development, career progression and professional revalidation
• enable employers and organisations to develop a model for education and training programmes and learning/development opportunities to ensure that the workforce is able to meet the cancer-pecific outcomes to support the delivery of safe and high standards of cancer care
• assist clinical services/organisations with planning current and future services in cancer care, and to provide an insight into the expertise of their workforce
• assist employers and clinical services with designing role descriptors and job plans incorporating cancer care, and to appropriately develop the expertise of their workforce
• assist HEIs providing pre-registration, post- registration continuing development and postgraduate programmes to design and map curricula, and ensure that teaching, learning and assessment strategies help students to develop and demonstrate their knowledge and skills in cancer care within HEI and workplace settings
• enable commissioners to review workplace opportunities, pre-registration, post-registration and postgraduate programmes, and to undertake a gap analysis to commission programmes and learning opportunities that support the achievement of the cancer-specific outcomes required by pre-registration students, nursing support workers/ support workers, nursing associates and registered nurses delivering care for PABC across all ages in general settings and to adults in specialist cancer services
• provide a common language across the UK for role titles, levels of practice, cancer-specific outcomes. This will encourage consistency and sustainability in cancer education and training, and help practitioners demonstrate learning that can be transferred across settings and organisations and inform their career development
• assist commissioners and services to develop minimum standards and key performance indicators for cancer-specific knowledge and skills of the cancer workforce.

Professor Vanessa Taylor, Chair of Steering Group, Deputy Head of School (Students and Teaching), Chair in Learning, Teaching and Professional Practice (Cancer and Palliative Care), University of Central Lancashire.

Cancer is a complex and critical disease that will affect 1 in 2 during their lifetime. The World Health Organization report on cancer (WHO, 2020) identifies that the global burden of cancer will increase with predicted 29.4 million cancer cases/year globally and 1 in 6 deaths due to cancer. In the United Kingdom (UK), the number of people living with a cancer diagnosis is set to double from more than 2 million in 2021 to 4 million in 2030. Cancer is also the most common cause of death in the UK (CRUK, 2021). At the same time, the diagnosis, treatment and management of cancer are becoming more complex with the advancement of scientific and genetic understanding and technological innovations which have the potential to transform our ability to prevent, diagnose, treat and care for PABC of all ages.

It is a common misconception that cancer in children and young people is rare. A child’s cancer risk rises from being very low (1 in 4700) in the first year of life, rising rapidly until 5 years of age (1 in 1000), achieving moderate risk by 15 years, (1 in 450) and a substantial risk by 20 years (1 in 320). These risks are similar to other common childhood conditions such as diabetes, epilepsy and bacterial meningitis, and it is imperative that the whole nursing workforce from pre-registration through to advanced clinical practitioners in primary and secondary care have this awareness (Walker, 2021) There are few clearly evidenced ‘red flag’ symptoms for childhood cancer, although a study by Dommett et al., concluded that three visits with the same symptoms (from a set of 12 common symptoms identified) within three months raised the risk for a cancer diagnosis by ten-fold (Dommett, 2013). Two evidence based public awareness campaigns are trying to influence the public’s perception of childhood cancer, one already published for brain tumours, HeadSmart, and the second, Child Cancer Smart for all other cancers in childhood is in progress (2021). Cancer is also the biggest cause of death by disease in children over one year of age. 

Demographic statistics also show increasing numbers of older people in the population. By 2031, 26% of the population will consist of individuals over 65 years, with those over 80 years comprising 8.2%. The ageing population profile points not only to an increasing incidence of cancer in the future, but also to an increase in cancer in individuals who will be living with other chronic conditions. 

Never has the time to focus upon the cancer workforce been more critical. This has been emphasised in the implementation plan in Chapter 08, of the WHO report. The report’s recommendations numbers 8 and 9 confirm the need to train and optimise the workforce. The importance of developing the cancer workforce has also been emphasised within Europe and the UK. The European Oncology Nursing Society (EONS, 2018) Cancer Nursing Education Framework, for example, identifies the fundamental knowledge and skills required for post-registration nurses working with PABC. The significant role of the nursing and the allied health professions workforce in supporting people to live well with and beyond cancer has been acknowledged in multiple cancer and workforce policies in the UK (NHS England, 2018; 2019a; 2019b; HEE 2019; Macmillan Cancer Support, 2021) including the NHS Long-Term plan (NHS England, 2019a) which sets out a list of key deliverables and milestones for services caring for PABC. Numerous calls have been made to develop the nursing and AHP cancer workforce through establishing nationally agreed career pathways with associated education and development opportunities (NHS England, 2018; 2019a; 2019b; HEE, 2019; Macmillan Cancer Support, 2021; RCN, 2017) to ensure the right number of cancer nurses and AHPs, and a cancer workforce with the knowledge, skills and capabilities to effectively deliver the care PABC need.

The overall purpose of this Framework is to provide guidance regarding the knowledge, skills and capabilities required by unregistered nursing support workers/ support workers, registered nursing associates, registered nurses who care for PABC of all ages in general settings and those who care for adults in specialist cancer services and roles as part of multi-professional teams across the UK nations. These members of the workforce make a critical contribution to the delivery of cancer care and cancer services across primary, secondary, tertiary and community settings, and in supra-regional centres providing care for patients with rarer cancers, not just for diagnosis and treatment, but as a key part of prehabilitation, rehabilitation, recovery, and living with and beyond cancer (HEE, 2019; Macmillan Cancer Support, 2019; Macmillan Cancer Support, 2018a, 2018b; Andritsch et al., 2017). 

This Career Pathway and Education Framework for Cancer Nursing (the ‘Framework’) has been updated by the Royal College of Nursing (RCN) Cancer and Breast Care Forum working in consultation with the RCN/CCLG Children and Young People Cancer Nurses Community (CYPCN), UKONS, North-west Cancer Alliances and Skills for Health in response to changes in the commissioning and delivery of health services, the introduction of the Registered Nursing Associate role (England only), developments in advanced levels of practice and publications from the four UK Departments of Health. These all advocate that, for improvements to be achieved in the delivery of care to PABC, workforce development is required.

The 2017 Framework was the first UK framework to include cancer-specific outcomes for pre- registration students, unregistered support workers, registered nurses providing cancer care in non-specialist/general services and registered nurses at different levels providing cancer care in specialist services/roles. This updated version includes the Registered Nursing Associate role introduced in England.

The Framework aims to enhance the delivery of care for PABC in general/non-specialist and specialist cancer services by focusing on five groups:

1. pre-registration nursing students to have achieved at the point of registration
2. nursing support/support workers providing care to PABC across all ages in non-specialist/general settings and to adults in specialist cancer services
3. registered nursing associates providing care to PABC across all ages in non-specialist/general settings and to adults in specialist cancer services 
4. registered nurses providing care to PABC across all ages in non-specialist/general settings 
5. registered nurses at registration, enhanced, advanced and consultant levels providing care to adults affected by cancer in specialist cancer services/roles. 

The inclusion of pre-registration nursing students aims to develop a level of knowledge and understanding about cancer, cancer treatment and cancer care for all new registrants at the point of professional registration. The cancer-specific outcomes identified for registered nurses providing care to PABC in general/non-cancer specialist services/roles seek to ensure induction, consolidation and ongoing development of knowledge and skills in cancer care. The level of practice and academic/professional preparation identified for registered nurses providing care to adults in specialist cancer services/roles offers a career pathway with consistency of title, skills, knowledge and preparation across the UK.

As part of the development and testing of the 2017 Framework and the cancer-specific outcomes, registered nurses providing general and specialist cancer care were involved in the pilot stages. This also included mapping exercises by HEIs against pre-registration and continuing professional development programmes, as well as feedback from an expert group. This feedback confirmed that the Framework and outcomes had the potential to deliver benefits for the nursing workforce, employers and PABC. This updated Framework has been developed using evidence gathered through a rapid review of literature and policies, mapping of existing competency and capability frameworks, consultation with RCN/CCLG Children and Young People Cancer Nurses Community (CYPCN); UKONS, mapping by North-west Cancer Alliances and Skills to Health to their research findings and work related to the Cancer Nurse Specialist role. This mapping demonstrated alignment to the European Oncology Nursing Society (EONS) (2018) Education Framework outcomes and identified two additional outcomes focused on ‘Investigation and diagnosis skills’ and ‘Independent prescribing’ which are included in this Framework.

The updated Framework is also aligned to and/or informed by:

• Professional Standards Framework (Royal College of Nursing, 2021b)
• Career Framework for Health (Skills for Health, 2010)
• Enhanced Clinical Practitioner Apprenticeship (Health Education England, 2021)
• Definitions and frameworks for advanced level practice (Health Education and Improvement Wales, 2021; Department of Health Northern Ireland, 2018; HEE, 2017b; NHS Education Scotland, 2021)
• Standards proficiency for registered nurses (Nursing and Midwifery Council (NMC), 2018a)
• Standards of proficiency for registered nursing associates (NMC, 2018b)
• Cancer Nursing Education Framework (European Oncology Nursing Society (EONS), 2018).

The Framework offers a number of potential benefits for nurses, employers, education providers and commissioners and, in response to recommendations made by Lord Willis (2015) and, more recently, Macmillan Cancer Support (2021), by helping to promote a UK-wide career pathway for cancer nursing.

View the Framework

This Framework promotes a consistent, inclusive and flexible approach to learning and development focused on a career pathway for general and specialist cancer care for the nursing workforce. It is aspirational and values previous learning and existing knowledge and skills. It acknowledges the place of formal and informal learning in supporting the workforce providing care to PABC in general/non-specialist and specialist cancer services and roles to develop knowledge and skills, and acknowledges sector and discipline-specific standards and frameworks. The Framework’s flexibility enables it to be used in different ways to support career pathways in cancer, learning and development at individual, service-providers and organisational levels. 

Purpose of the Framework

The purpose of the Framework and outcomes is to:

• provide a pathway for career development and a framework for education, training, and continuing development for pre-registration nursing students, nursing support workers/support workers, nursing associates and registered nurses who provide care to adults affected by cancer in specialist cancer services*
• provide a pathway for career development and a framework for training, continuing development and education for pre-registration students, nursing support workers/ support workers, nursing associates and registered nurses who provide care to people affected by cancer (PABC) across all ages in general/non-specialist settings*
• set out a framework that will help practitioners, employers, commissioners and PABC understand the level of education/capability which correlates to a particular level of practice or role
• provide information relevant to Higher Education Institutions (HEIs), employers, providers of cancer services, commissioners and policy makers for the development of the workforce, roles, learning opportunities and education programmes
• provide a point of reference to help identify and develop the knowledge, skills and capabilities in cancer care of the nursing workforce through accredited programmes, and non-accredited learning and workplace-based development opportunities that target not only professional, but local service needs.

*Registered nurses working in paediatric cancer services should follow the ‘Career and Education Framework for CYP cancer nursing’ which is also applicable to children’s nursing students, nursing associates and support workers in paediatric services (forthcoming late spring/early summer 2022).

Aim

The Framework aims to provide guidance for the preparation and development of:

• pre-registration nursing students to deliver care to PABC at the point of registration
• unregistered nursing support worker/ support worker, registered nursing associates and registered nurses who care for PABC across all ages and the care continuum in general/non-specialist settings and services
• unregistered nursing support worker/ support worker, registered nursing associates, registered nurses practising at registration, enhanced, advanced and consultant levels who care for adults affected by cancer across the care continuum in specialist cancer settings/services and roles.

This Framework is underpinned by the following principles that promote a person-centred, outcomes focused approach to cancer care intended to guide practitioners to deliver high-quality holistic cancer care centred on what matters to people, their families and carers.

• The priorities, needs and experiences of PABC are central to the development of cancer services and to the involvement of nurses in such services
• PABC have many, and often complex, needs throughout their cancer journey. Multidisciplinary/professional and multiagency practice is required for meeting these needs.
• Registered Nurses make an important contribution to assessing and meeting the needs of PABC at all stages of the care continuum and across all ages.
• Consistent with the United Nations Sustainable Development Goals (UN 2015) including SDG 3 focused on “ensuring healthy lives and promote well-being for all at all ages”, Registered Nurses, Registered Nursing Associates and nursing support/support workers working in cancer care will need to:

1. Be responsive to the needs of PABC by incorporating new practice areas and capabilities as they evolve, as well as negotiating their scope of practice with other health and social care professionals involved in cancer care.
2. Continue to develop their knowledge to inform improvements in outcomes for PABC, particularly where they relate to interventions designed to prevent or alleviate health and social care needs across the disease continuum. Development of the knowledge and evidence base will require partnership between nurses working in clinical, education and research roles.
3. Understand practitioner and organisational responsibilities for assurance of quality, safety and value regarding procurement of consumables, medical devises and services.
4. Recognise how digitalisation can transform health and care through technology and identify their own learning needs associated with this.
5. Recognise the impact of developing genetics knowledge for cancer, and the development of personalised treatments and care, through accessing genomics education.

• Consistent with the Equality Act (2010), undertake an Equality Impact Assessment related to the implementation of this Framework, identifying the potential impact on the nine protected characteristics resulting from the criteria and access to opportunities outlined in the Framework. A separate/additional equality impact assessment is needed when implementing this Framework for children and young people with cancer.

People affected by cancer (PABC) refers to people affected by all types of cancer, including those at risk of developing cancer, people living with cancer, cancer survivors, carers, family members and significant others across all ages and continuum of care.

Continuum of care includes the trajectory of the experience of PABC. Whilst this trajectory may vary for each individual, the five main phases that correspond to the critical elements of health services needed by PABC to respond to their disease-related and personal experiences are:

1. Reducing the risk of developing cancer (prevention and health promotion).
2. Finding cancer as early as possible (screening and early detection).
3. Having active treatment (including prehabilitation and rehabilitation).
4. Following and between treatment (rehabilitation and survivorship).
5. Palliative and end of life care if the cancer is not cured.

Cancer is often considered to be a life-limiting illness but is increasingly viewed as a long-term condition (National Cancer Survivorship Initiative, 2013). Developing self-care and rehabilitation processes and involving patients, their families and carers in their care, are all viewed as crucial components in developing future services. Health care services need to respond creatively to the needs of this population, delivering care close to home, reducing inequalities, and sustaining and improving health across diverse communities. Government policies have formalised the vision of cancer service delivery with care for PABC referred to as: 

• general cancer care
• specialist cancer care.

General cancer care is delivered by the usual health and social care workforce of the patient and family, integrating cancer care methods and procedures in settings not specialised in cancer care. 

In contrast, specialist cancer care is provided by multi-professional teams specialising in the provision of cancer care to patients and their families, usually in cancer units, cancer centres or via specialist cancer services in the community. 

These models of service delivery recognise that all nurses, regardless of the practice setting, are likely to have contact with PABC and will require to have, as a minimum, an understanding of cancer and its treatment, education in the fundamental principles and practice of cancer care, skills in assessing the cancer care needs of patients and families, and training in communication skills. Some nurses, where their practice requires them to respond to the particular health and support needed by PABC, will require a higher level of cancer-specific knowledge and skills. 

Domains of health include the physical, psychological, emotional, cultural, social, practical, spiritual and informational aspects of a person’s health and wellbeing.

Guidance underpinning the Framework: registration, enhanced, advanced and consultant level practice

In response to the changing landscape of health care delivery, nurses are leading and delivering a range of general and specialist cancer services across a diverse range of health care settings. New models of care provision often rely on a multi-professional team including those practitioners working with enhanced or advanced knowledge and skills to: treat, refer, request diagnostic investigations, prescribe medications and deliver courses of treatment.

Alongside this role development, there has been a growth in role descriptors and job titles. In particular, the range of advanced and specialist job titles is of concern to practitioners, regulators and the public. The use of the term ‘specialist’ is often used to describe the clinical specialist roles that some nurses adopt in practice, for example, clinical nurse specialist in cancer or palliative care. However, job titles themselves do not consistently reflect the educational preparation or level of competence/practice of practitioners. Across the UK, there continues to be varied understanding of the meaning of the titles and the role expectation of nurses using them. Significant progress is, however, being made to clarify levels of practice for enhanced, advanced and consultant practice through national work on apprenticeship standards (Health Education England,2021), workforce standards (RCN, 2021b) and advanced practice (Health Education and Improvement Wales ,2021; Department of Health Northern Ireland, 2018; HEE, 2017a; NHS Education Scotland, 2021). 

To provide a common language, the development of this Framework has used these national guidelines on career frameworks and advanced practice to:

• harmonise titles – by referring to levels of practice a practitioner may be working at instead of role or job title
• distinguish levels of practice
• inform academic preparation
• identify the cancer-specific nursing outcomes for the different levels of practice.

The Career Framework for Health (Skills for Health, 2010)

The Skills for Health Career Framework for Health also differentiates between levels of practice rather than clinical/organisational context or client group by describing nine levels of roles grouped according to their level of complexity and responsibility, and the level of experience and knowledge necessary to carry them out.

At the time of writing, the term ‘enhanced’ is emerging and currently being defined as a level of practice, and ‘advanced’ and ‘consultant’ level practice are used for describing benchmarked developmental levels. The term ‘specialist’ is used to define specific contextually-focused role types (Example - Advanced Clinical Practitioner – Cancer Care or Palliative and End of Life Care). It should also be noted that the nine levels relate to a practitioner’s level of practice and does not automatically read across from Agenda for Change (AfC) pay bands.

This 2022 Framework has adapted the Career Framework for Health (Skills for Health, 2010) with these developments in enhanced, advanced and consultant levels to provide a common language for role title, level of practice, and career development. This Framework focuses on levels 2-8 and is used to define the level of practice and the cancer-specific outcomes expected of pre-registration students at the point of registration, nursing support workers/support workers, registered nursing associates, registered nurse providing general cancer care and those practising in specialist cancer care at registration, enhanced, advanced and consultant practitioner levels.

The UK Departments of Health (Health Education and Improvement Wales 2021; Department of Health Northern Ireland 2018; HEE 2017; NHS Education Scotland 2021) identify four pillars for advanced level practice, albeit with slight variations in terms, as focused on:

1. Clinical.
2. Leadership and collaborative practice.
3. Improving quality and developing evidence-based practice.
4. Educating and developing self and others.

These four pillars reinforce the continuing development of role aspects achieved by pre-registration students to meet the education standards for registration (NMC, 2018a,b).

To meet the challenges of delivering and advancing high quality nursing care to PABC, this Framework advocates for pre-registration nursing students to have the opportunity to achieve nationally agreed cancer-specific outcomes during their pre-registration programmes and to have achieved these at the point of registration. For nursing support workers/support workers, registered nursing associates and registered nurses, opportunities to develop and extend their cancer-specific knowledge and skills are also required. This development should be through lifelong professional learning and workplace-based opportunities appropriate to their level of practice and role requirements.

For those practising at enhanced, advanced and consultant levels, the standards and generic capabilities across four pillars of practice for practitioners working at an advanced level are being developed (Health Education and Improvement Wales, 2021; Department of Health Northern Ireland, 2018; HEE, 2021; 2017b; NHS Education Scotland, 2021). In England, area-specific/specialist credentials are also being developed for advanced clinical practitioners, including for cancer and palliative and end of life care.

There is the expectation that practitioners working at this advanced level of practice will have achieved this through ‘extensive clinical and practice experience’ and following ‘completion of a master’s level education/ learning or its equivalent’ (HEE, 2017b).

This Framework has adopted the four pillars of professional practice to differentiate the cancer- specific outcomes for the different levels of cancer practice undertaken. This approach should enable practitioners, from pre- registration students to consultant level registered nurses, to demonstrate their current level of knowledge, skills and competence, as well as to identify any areas for development. Development may be achieved through a range of opportunities including workplace-based learning, continuing professional development (CPD) events and university accredited modules and programmes.

As nursing within the UK is a graduate profession, it is anticipated that, to progress from registration level to enhanced level, workplace learning, CPD and postgraduate education will be undertaken, and that by advanced practitioner level, master’s level will be achieved. Doctoral level qualification has previously been recommended for consultant practitioner roles (DH, 1999) and work is currently being undertaken to define consultant level practice in England.

Contribution to personal, professional development and career enhancement

It is recommended that Registered Nursing Associates and Registered Nurses develop evidence to demonstrate their level of knowledge, skills and practice appropriate to their role requirements in the delivery of care to PABC. This evidence can be linked to individual Personal Development Plans (PDP) as well as for meeting any professional requirements for revalidation. The Framework and outcomes can also be mapped to local models of care as roles/functions may differ across organisations and settings to reflect flexible and integrated care. Nursing support workers/support workers, registered nursing associates and registered nurses can interpret and address the cancer outcomes in line with their organisational policies and protocols.

Using the Framework and outcomes

The dynamic and complex nature of contemporary practice environments means it is not possible to provide absolute definitions of the scope of practice or discrete levels of practice. One group of unregistered nursing support workers/support workers, one group of registered nursing associates and two broad groups of registered nurses involved in the delivery of care to PABC are defined in this Framework. These groups do not constitute a hierarchy of practice but are intended to represent the levels of practice and identify the associated cancer-specific outcomes required for working in different contexts, at different levels, along the cancer continuum.

Cancer-specific nursing outcomes have been identified for the following groups:

• Pre-registration nursing students, working under supervision, to have achieved at the point of registration to deliver care to PABC across all ages in general settings and to adults in specialist cancer services. For example, some of the key cancer care concepts identified as relevant for nurses entering practice include fundamental- level skills in communication, psychological, social and emotional support, conceptualisation of the meaning of cancer, and an understanding of carcinogenesis and cancer treatment.
• Nursing support workers/Support workers who contribute to caring for PABC in general/non-specialist and to adults in specialist cancer services.
• Registered nursing associates and registered nurses at all levels who provide care to PABC in general/non-specialist settings. Registered nursing associates and registered nurses, regardless of practice setting, will work collaboratively with PABC to address their health needs. At all stages of life, and at several points across the cancer continuum, PABC will require services from registered nurses in general settings such as primary care, diagnostic services, community services and services in secondary/acute care. PABC may also have co-morbidities and may live with the consequences of cancer beyond an active diagnostic and treatment phase, through survivorship or at end of life. When caring for PABC of all ages, registered nursing associates and registered nurses need to have a level of knowledge, skill and competence capable of meeting the health needs of these individuals.
• Registered nurses at registration, enhanced, advanced and consultant levels who provide care to adults in specialist cancer services/roles. Within this group, cancer specific outcomes relating to each level of practice are identified. These registered nurses may participate more frequently, or for short intensive periods in the care of adults affected by cancer due to their expertise in addressing specific health needs, or because of their practice context. For example, some nurses will practice within cancer care in dedicated cancer services at registration and enhanced levels. They may be primarily responsible for care of adults at a specific phase of their journey (for example, radiotherapy or chemotherapy treatment), or across all phases of the cancer journey. Some registered nurses, at registration or enhanced level practice, will be delivering care in specialist cancer services in areas such as head and neck or breast surgery, infection control, stoma therapy, or palliative care. These registered nurses may demonstrate the application of cancer-specific outcomes at registration and enhanced levels in the particular contexts in which they practice. They may require access to workplace learning opportunities, further development, or accredited education in areas of cancer care with a direct application to their role. Some registered nurses may develop their practice to advanced or consultant levels. These registered nurses will build on the outcomes defined within this Framework through additional experience and education at a master’s or doctoral level or equivalent. 

The cancer-specific nursing outcomes have been mapped to the four pillars of professional practice. It is anticipated that, as their practice advances, registered nurses will demonstrate more effective integration of theory, practice and experience in the four pillars of practice (DH, 2010; NMC, 2018a,b) along with increasing degrees of autonomy in judgements and interventions for PABC. 

Table 2 identifies the suggested level of academic award and/or workplace/clinical learning and development opportunities to meet the cancer-specific outcomes and progress through the career pathway. Nursing support/ support workers, registered nursing associates and registered nurses providing care to PABC in general/ non-specialist settings/roles may demonstrate achievement of the cancer-specific outcomes through CPD and work-based learning opportunities. This will require organisational commitment to facilitating consolidation and on-going development of knowledge and skills related to the cancer-specific outcomes, with the goal of improving care to PABC in the organisation.

For registered nurses working towards, or at, an advanced level of practice, the four nation advanced practice frameworks indicate that this would be achieved through extensive clinical and practice experience, and following completion of a master’s level education/learning or its equivalent. The cancer-specific outcomes for registered nurses providing care to adults in specialist cancer services/roles have been designed to enable registration (RP), enhanced (EP), advanced (AP) and consultant (CP) level practitioners to consolidate and acquire skills, competence and knowledge to support professional requirements for career progression.

The cancer-specific nursing outcomes are identified in the Cancer-specific outcomes section.

An Assessment and Workplace Development tool is provided, see: Action plan to achieve cancer-specific outcomes to assist practitioners to use the cancer-specific outcomes in their practice and record their evidence of achievement.

A mapping tool is provided in Appendix 1 to assist HEIs and clinically based educators to map their pre-registration and CPD programmes against the cancer-specific nursing outcomes.

An individual’s progression through the cancer-specific outcomes and levels of practice will depend on their access to, and engagement with, learning and development opportunities, service needs, individual preferences and role requirements. The Framework does not require achievement of certain outcomes or academic attainment prior to engagement. 

One of the first steps in the development process is to review and reflect on current practice against the cancer-specific outcomes for a practitioner at a particular level of practice. This may be undertaken by the individual practitioner, service lead/manager, educator and/or commissioner. This will provide insight to benchmark practice, interpret findings and create a development plan for the individual or service. 

To facilitate this, this Framework provides a toolkit consisting of:

1. Cancer-specific outcomes for different levels of practice – these detail the outcomes for each practitioner providing general or specialist cancer care at the different levels across the four pillars of practice.

2. An assessment and workplace development plan – this tool supports practitioners, service leads/managers and commissioners to:

• reflect on their current practice and level of performance, service delivery, career aspirations and development opportunities
• review and evaluate evidence against the cancer-specific outcomes recording existing knowledge, skills and strengths alongside gaps and areas for development
• develop an action plan to meet learning and development needs and opportunities for individuals, teams and services 
• evidence and review progress aligned to the cancer-specific outcomes to meet role and service needs and career aspirations.

3. A mapping tool for educators – this tool supports educators in clinical services and higher education institutions to:

• reflect on their current education provision, curriculum and development opportunities
• review and evaluate evidence against the cancer-specific outcomes recording existing knowledge, skills and strengths alongside gaps and areas for development
• develop an action plan to meet learning and development needs and opportunities for individuals, teams and services 
• evidence and review progress aligned to the cancer-specific outcomes to meet role and service needs and career aspirations of the workforce.

How to use the Framework toolkit

The Framework and outcomes are intended to have a stand-alone function. As identified in the Alignment/mapping to national transferable standards section, they may also be used in conjunction with other frameworks and with local, national or international guidelines. View the Framework toolkit.

For the practitioners identified, the Framework and cancer-specific outcomes may be a useful tool for:

• developing and reviewing job/role descriptions
• assessing clinical competence for different levels of practice
• developing personal goals
• performance appraisal.

Practitioners may find it helpful to use the Assessment and Workplace Development Tool template section:

• identify current level of practice and role expectations/requirements within own care context (general or specialist cancer care)
• identify and develop knowledge and skills in aspects of cancer care to realise the potential of own role
• plan a personal career pathway by identifying learning and development needs
• identify opportunities to influence the development of cancer nursing practice
• discuss the Framework and cancer-specific outcomes at performance review/appraisal meetings to identify learning, development and support needs, and to review progress to demonstrate achievement of the cancer-specific learning outcomes
• develop an action plan and summarise the evidence which demonstrates personal achievement of the cancer-specific outcomes relevant to own role or career aspirations.

Evidence may include examples of:

• care plans developed
• short reflective accounts of specific cases incorporating reference to relevant theory and research
• copies of care/clinical pathways contributed to the development of
• analysis of key local, national and international policy documents
• service improvement projects led or contributed to
• mentor/peer observation
• higher education accredited modules and programmes.

View the Framework toolkit

For Registered Nursing Associates and Registered Nurses collate evidence relating to the cancer-specific learning outcomes for NMC revalidation.

Templates for compiling and recording your evidence for NMC revalidation are available, see: Revalidation

To use the Assessment and workplace development plan, practitioners, be they individuals, service leads/managers or commissioners, are encouraged to:

• consider the purpose of their assessment: this may be for performance review and development, revalidation, for career planning, role design/development, service enhancement or redesign
• practitioner level: identify the level of practice (column 2) and review the aligned coloured cancer-specific outcomes – consider each outcome and its relevance to own purpose. Tick if the outcome is relevant or cross if this is not relevant. Discuss these with team members, line manager, service leads to help prioritise any outcomes or development needs
• self-assessment (column 3): record if you are able to evidence achievement of the outcome. State ‘yes’ or ‘no’ in this column for each of the identified outcomes. If ‘yes’ – evidence can be collected in professional portfolio/document file. If no, identify in the ‘Action plan’ column 4 what knowledge and skills you need to develop and describe what actions you will undertake and the evidence you will provide to whom to demonstrate achievement of this outcome
• identify a ‘review date’ and confirm ‘yes’ when this has been achieved and agreed.

View the Action plan to achieve cancer-specific outcomes (p.21-36)

The Career Pathway and Education Framework for Cancer Nursing offers the following  benefits for nurses, employers, education providers, commissioners and policy makers:

• a UK-wide standard for cancer education in pre-registration nursing courses to prepare new nursing registrants with a minimum level of cancer-specific knowledge and skills to deliver care to PABC
• guidance to support workers, registered nursing associates, registered nurses at  registration, enhanced, advanced and consultant levels, who provide care to PABC in general settings and to adults in specialist cancer settings and those who aspire to a particular career level in this specialist field. The Framework identifies learning opportunities/outcomes to meet their role requirements
• a UK-wide standard for professional development aligned with appropriate learning/ academic preparation for those practising at registration, enhanced, advanced and consultant practitioner levels. The Framework also helps with progression to the next level of a career pathway
• guidance to education providers, including professional organisations and higher education institutions, to develop and deliver learning opportunities, modules and awards at different academic levels for pre-registration nursing students and registered nurses which meet the range of learning/education needs of practitioners providing care to PABC in general/non-specialist settings and to adults in cancer specialist services/roles
• assistance to service providers to develop role descriptors/job plans and to identify professional development requirements for prospective and current roles in cancer nursing
• information to commissioners of cancer services and professional education to create a consistent and sustainable approach to learning and education opportunities for practitioners working in cancer care across the UK
• assistance for commissioners and services to develop minimum standards and key performance indicators for cancer-specific knowledge and skills of the nursing workforce to support service redesign
• a career pathway and education framework for policy makers to develop the cancer workforce providing general and specialist cancer care.

Each of the different target groups can use this Framework and outcomes in a number of ways.

The individual registered nurse/registered nursing associate/nursing support worker/ support worker 

As a tool for:

• determining individual professional development needs
• developing a professional development plan within the performance development and review (PDR) framework
• evaluating different postgraduate modules and programmes in cancer nursing
• developing a career pathway
• identifying a range of development opportunities to undertake self-directed learning
• producing evidence for NMC revalidation.

The clinical educator or service manager

• As part of professional development planning processes to establish and negotiate practice progression pathways.
• To review orientation and annual progress requirements.
• To review the organisation’s in-service programmes to focus their content on guiding practitioners to meet the outcomes relevant to their scope and level of practice.
• To develop curricula and in-service programmes, plus identify learning experiences for general areas to improve their capability to meet the outcomes for nurses in cancer care.
• To evaluate role/job descriptions and person specifications for the support worker, registration, senior, advanced and consultant level roles.
• To identify opportunities for ongoing quality improvement and audit.
• To develop recruitment and retention, and workforce plans.

Higher education institutions

• To map the outcomes to the current pre- registration nursing curriculum and integrate the learning within the curriculum to support pre-registration students to meet these outcomes.
• Use the outcomes for registered nurses practising at all levels to review postgraduate cancer modules and programmes, and integrate the outcomes to support practitioners to achieve these.
• Use the outcomes for registered nurses at all levels to assess and present their prior learning, modules and programmes that might be suitable for accreditation of prior (experiential) learning in postgraduate courses.
• Review and develop methods of assessing learning that reflect the levels of practice illustrated in the Framework.

Health service commissioners and policy makers

• To define workforce capabilities in different practice settings and regions, according to population needs.
• To allocate resources to support preparation of the workforce to match required service redesign/expansion capabilities.
• To develop new and innovative service models that support the principles inherent in the Framework, including person-centred care, continuity of care, multi-professional practice, and partnerships between nurses and other members of the health care team at various levels of practice.

PABC and users of cancer services

• To develop an understanding of the various roles of support workers, nursing associates and registered nurses in the delivery of cancer care.
• To enhance understanding of what PABC can expect from engaging with specialist cancer services and nurses practising at all levels in specialist cancer services/roles
• To identify opportunities to contribute to information and resources that aim to improve the overall patient experience for PABC.

The Framework will also provide significant opportunities for individuals and organisations to set standards for their service and to evaluate improvements in the professional development of the cancer nursing workforce. 

The following examples of key performance indicators can be used to evaluate the extent to which such improvements have been achieved.

Health service performance indicators

• The proportion of practitioners at all levels who can demonstrate meeting the cancer-specific outcomes.
• The proportion of staff development activities that are clearly linked to the cancer-specific outcomes.
• In general settings, where PABC receive care, the proportion of nurses who have undertaken professional development programmes that support them to meet the Framework cancer-specific learning outcomes of a nurse as applied to cancer care.
• The proportion of position descriptions for roles that are mapped to the Framework.

Education provider performance indicators

• The proportion of theoretical and clinical practice assessments clearly supporting practitioners to meet the cancer-specific learning outcomes.
• The proportion of pre-registration students who have the opportunity to achieve the cancer-specific learning outcomes through classroom content or practice assessment.

References / Bibliography

Andritsch E, Beishon M, Bielack S, Bonvalot S, Casali P, Crul M, Delgado Bolton R, Donati  DM, Douis H, Haas R, Hogendoorn P, Kozhaeva O, Lavender V, Lovey J, Negrouk A, Pereira  P, Roca P, de Lempdes GR, Saarto T, van Berck B, Vassal G, Wartenberg M, Yared W,  Costa A,Naredi P (2017) ECCO Essential Requirements for Quality Cancer Care: Soft  Tissue Sarcoma in Adults and Bone Sarcoma. A critical review, Critical Review Oncology/ Hematology, Feb, 110, pp.94-105. doi: 10.1016/j.critrevonc.2016.12.002. Epub 2016 Dec 8. PMID: 28109409.

Cancer After Cure Nurses United Kingdom (CANUK) (2011) An integrated career and competence framework for nurses working in the field of long-term follow-up and late effects care of children and young people after cancer, London: Royal College of Nursing and NHS Improvement.

CCLG Advanced Clinical Practitioners Forum (2021) Advanced clinical practitioner paediatric oncology and haematology capability document, Leicester and London: CCLG (Childhood Cancer & Leukaemia Group) and Royal College of Nursing.

CRUK (2021) Cancer Statistics for the UK.

Department of Health (1999) Making a Difference: Strengthening the nursing, midwifery and health visiting contribution to health and health care.

Department of Health (2010) Advanced Level Practice, London: DH. 

Department of Health Northern Ireland (2018) Advanced Nursing Practice Framework.

Dommett RM, Redaniel T, Stevens M, Martin R and Hamilton W (2013) Risk of childhood cancer with symptoms in primary care: a population-based case-control study. British Journal of General Practice, 63(606), e22-e29. doi: https://doi.org/10.3399/bjgp13X660742.

EONS (2018) Cancer Nursing Education Framework (PDF). 

Government UK (2010) Equality Act.  

Health Education England (2017a) The NHS Cancer Workforce Plan. 

Health Education England (2017b) Multi-professional framework for advanced clinical practice in England (PDF).

HEE (2019) Exploring the Role of Allied Health Professionals in the Care of People Affected by Cancer: The Patient and Practitioner Voices (PDF). 

HEE (2021) Enhanced Clinical Practitioner Apprenticeship (PDF).

Health Education and Improvement Wales (2021) Professional Framework for Enhanced, Advanced and Consultant Clinical Practice.

Macmillan Cancer Support (2018a) Cancer rehabilitation pathways (PDF).  

Macmillan Cancer Support (2018b) Allied Health Professional Workforce report (PDF).  

Macmillan Cancer Support (2019) Principles and guidance for prehabilitation within the management and support of people with cancer.

Macmillan Cancer Support (2020) A competence framework for nurses - Caring for patients living with and beyond cancer (PDF).

Macmillan Cancer Support (2021) Cancer Nursing on the Line (PDF).

National Cancer Survivorship Initiative (2013) Living With and Beyond Cancer: Taking Action to Improve Outcomes (PDF).

NES and Macmillan Cancer Support (2010) Working with Individuals with Cancer, their Families and Carers. Professional Development Framework for Nurses – Specialist and  Advanced Levels (PDF).

NHS Education Scotland (2007) Advanced Nursing Practice Toolkit. Edinburgh: Scotland.  

NHS Education Scotland (2021) Advanced nursing practice - transforming nursing roles: phase two. 

NHS England (2018) Quick guide: The role of allied health professionals in supporting people to live well with and beyond cancer (PDF). 

NHS England (2019a) NHS Long Term Plan. 

NHS England (2019b) Interim NHS People Plan. 

NMC (2018a) Standards of proficiency for registered nursing associates. 

NMC (2018b) Standards of proficiency for registered nurses.  

Royal College of Nursing (2010) An integrated career and competency framework for nurses working in the field of children and young people’s cancer care, London: RCN.  

Royal College of Nursing (2017) Career and Education Framework for Cancer Nursing. London: RCN.  

Royal College of Nursing (2021a) Advanced Practice Standards.  

Royal College of Nursing (2021b) Nursing Workforce Standards. 

Skills for Health (2010) Key elements of the Career Framework (PDF) 

Skills for Health (2021) Career Pathway, Core Cancer Capabilities in Practice and Education Framework.  

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World Health Organization (2020) WHO report on cancer: setting priorities, investing wisely and providing care for all.

Appendix 1: Mapping template for higher education institutions and clinical education providers

The mapping template has been developed to:

• inform curriculum development
• facilitate assessment of, and demonstrate the extent to which, programmes of learning for pre-registration nursing students enable students to achieve the cancer-specific nursing outcomes at the point of registration
• facilitate assessment of, and demonstrate the extent to which, CPD opportunities and accredited programmes (at undergraduate and postgraduate levels) enable registered nurses to meet the cancer-specific nursing outcomes
• facilitate collaborative working between education providers, employers, service providers and commissioners to promote learning opportunities which enable support workers, registered nursing associates and registered nurses to meet the cancer-specific nursing out.

Professor Vanessa Taylor (Chair)

Deputy Head of School (Nursing) (Students and Teaching)

Chair in Learning, Teaching & Professional Practice (Cancer & Palliative Care) University of Central Lancashire 

Members of Steering Group (2021)

RCN Cancer and Breast Care Forum 

RCN/CCLG Children and Young People Cancer Nurses Community (CYPCN)

UKONS Board

North-west Cancer Alliances (Greater Manchester Cancer Alliance, Cheshire and Merseyside Cancer Alliance, Lancashire and South Cumbria Cancer Alliance)

Skills for Health

Contributors

Jeanette Hawkins, Chief Nurse, Children’s Cancer and Leukaemia Group

Dr Rebecca Verity, Director, The Royal Marsden School

Critical reviewers

Professor Alison Leary, Chair in Healthcare and Workforce Modelling, London South Bank University

Wendy Preston, Head of Nursing Practice RCN, Honorary Consultant Nurse (Warwickshire)

Ofrah Muflahi, RCN Professional Lead – Nursing Support Workers & Long-Term Conditions

Members of the Steering Group (2017)

Ms Maria Noblet, Past Chair of RCN Cancer and Breast Care Forum

Mr Richard Henry, President UK Oncology Nursing Society

Ms Rachel Hollis, Chair of RCN Children and Young People – Specialist Care Forum

Ms Samantha Smith, Head of Nursing and Clinical Services Teenage Cancer Trust

Contributors

UKONS Board

Dr Catherine Wilson, Head of The Royal Marsden School

Professor Sara Faithfull, Professor of Cancer Nursing Practice, University of Surrey

Special thanks to:

Mrs Gillian Knight, Macmillan Lead Cancer Nurse, South Wales Cancer Network