Literature review - Health Workforce Australia

o Reform health workforce roles to improve productivity and support moreeffective, efficient and accessible service delivery models that better addresspopulation health needs.2. Domain 2 – Health workforce capacity and skills developmento Develop an adaptable health workforce equipped with the requisitecompetencies and support that provides team-based and collaborativemodels of care.3. Domain 3 – Leadership for the sustainability of the health systemo Develop leadership capacity to support and lead health workforceinnovation and reform4. Domain 4 – Health workforce planningoEnhance workforce planning capacity, both nationally and jurisdictionally,taking into account emerging health workforce configuration, technologyand competencies.5. Domain 5 – Health workforce policy and regulationoDevelop policy, regulation, funding and employment arrangements that aresupportive of health workforce reforms.Literature review search strategy and methodologyThe search strategy involved an exhaustive search of relevant bibliographical databases; asearch of networked library catalogues for print monographs and related material; and anInternet search using Google Scholar and the advance search functions of Google forwebsites of specific institutions and jurisdictions. This triangulated approach ensured the mostcomprehensive outcome possible through iterative search strategies progressively refined tomatch to functionality of the specific tools used. There is a level of redundancies in thissearch process that is the trade-off for a comprehensive approach.The following bibliographic databases were searched: MEDLINE, the Cumulative Index ofNursing and Allied Health Literature (CINHAL); the Australasian Medical Index (AMI), theCochrane Library; and Scopus. This combination of databases provides the most effectivesearching of the health sciences peer reviewed literature relevant to the Australian healthsystem. A more detailed summary of the databases searched is provided in Appendix A.National Cancer Workforce Strategy Literature Review Page 3

Summary of key findingsThe following key findings are drawn from the current cancer workforce literature review andsupplemented where relevant from the broader review of health workforce. Many of thegeneric health workforce issues apply equally to the context of cancer.Domain 1: Health workforce reform for more effective, efficient and accessible servicedelivery• Meeting the needs of future cancer patients and an increasing number of cancersurvivors – in the context of a shrinking oncology workforce – requires consideration ofnew and redefined workforce roles and a greater role for primary care.• New ‘non-physician’, advanced nursing and pharmacy roles that have beenestablished in the US and UK have demonstrated potential to increase efficiency andaccessibility of cancer care and reduce oncologists’ workload. Emerging evidencehighlights barriers to acceptance and challenges in implementation of such roles,including the confusion caused by proliferation of role titles and descriptions, whichshould be considered when developing new and redefined roles in cancer care inAustralia.• There is potential for general practitioners (GPs) and other primary health careprofessionals to play an even greater role in cancer care, with evidence of thebenefits, and acceptability to both patients and health professionals, of shared caremodels and primary care-based follow-up and survivorship care.• Greater interdisciplinary communication and collaboration is needed to ensure allhealth professionals who have a role in the care of cancer patients, survivors and/ortheir caregivers have the relevant medical and social information they need toprovide quality and coordinated care.• Optimising health professionals’ capacity to provide patient care effectively andefficiently requires health system and organisational changes that supportinterdisciplinary communication, care coordination and increased productivity.Greater use of technology and administrative support to reduce non-clinicalworkloads will enable health professionals to direct more time to communication with,and care of, individual patients.• Any gains in productivity, such as enabling health professionals to spend more timeproviding direct care to consumers, can effectively and immediately address skillshortages.• Innovative workforce models and work roles often arise at the local level in responseto perceived needs at the front line and there is a critical need to identify and enableproven models that can be adapted for other locations or scaled up nationally.• Connecting local initiatives, reducing duplication of effort and developing acoherent and consistent approach to funding evidence-based, sustainable, longtermworkforce reform activities will provide more rapid and timely solutions.• Initiatives have a higher likelihood of success when time and support are provided forplanning, change management and rigorous evaluation prior to implementation.• Better coordination of survivorship care, new approaches to follow-up and greateruse of appropriate palliative care can better meet the needs of people with cancerafter treatment ends, as well as reduce the demand on cancer specialists andprovide opportunities for other health professionals to expand their scope of practice.Domain 2: Health workforce capacity and skills development• The increasing prevalence of cancer in Australia requires all health professionals,particularly primary care professionals in rural areas who have a substantial role inNational Cancer Workforce Strategy Literature Review Page 4

• A lack of standards in training curricula is a key quality and safety concerns for thecancer workforce• In setting regulatory boundaries regarding workforce roles there is a need to balancethe need for specialist training in working with particular types of cancer with theneeds of hospitals and health services for more generalist skills.• Providing appropriate support, training and educational opportunities as well as clearcareer paths is critical to aid cancer workforce retention.• Non clinical interventions such as psychosocial interventions and early referral topalliative care are effective and have the potential to reduce financial costs oftreatment. However, public subsidisation of medical services and pharmaceuticalsmay act as an incentive for consumers to seek medical interventions and drugs assolutions over non-medical options.• Decisions regarding the inclusion of occupation groups into the Medicare providersystem influence work option decisions, as well as individuals’ decisions to work inpublic or private settings.National Cancer Workforce Strategy Literature Review Page 8

DOMAIN 1: Health workforce reform for more effective,efficient and accessible service deliveryReform health workforce roles to improve productivity and support moreeffective, efficient and accessible service delivery models that better addresspopulation health needsReview of the cancer workforce literature related to Domain 1Continuing growth in the number of newly-diagnosed cancer patients, combined with anincreasing number of long-term cancer survivors – many with chronic health problems – islikely to overwhelm Australia’s available cancer workforce, as predicted in other developedcountries (Shulman et al, 2009). Current and anticipated shortages in the cancer workforceare forcing examination of new models of care to meet the future needs of patients andsurvivors. Advances in cancer care including new treatment modalities, and greaterrecognition of the needs of people affected by cancer – for better organisation andcoordination of care, a ‘key contact’ person, sufficient and timely information and greaterattention to psychosocial and support needs (Walsh et al, 2010a) – are also driving changesto cancer service and workforce models.This review of literature identifies support for workforce reform aimed at better addressing theneeds of people diagnosed with cancer, cancer survivors and their caregivers through:• new service delivery models and new and refined workforce roles to meet patientand population health needs• system and organisational changes that enhance interdisciplinary communicationand coordination of cancer care and enable greater productivity to improve patientcare• new models of post-treatment follow-up and survivorship and increased referral topalliative care.New service delivery models and workforce rolesChanging approaches to, and models of, cancer care – including greater focus on patientcentredcare, the increasing shift of care to ambulatory and community settings andinterdisciplinary practice – necessitate workforce redesign and development of new roles tomeet patient and community needs. When designing and implementing new and redefinedroles, the literature reviewed suggest the need to ensure the definition and scope of roles isclear and communicated effectively given organisational resistance to embracing new roles(Bennett et al, 2007), and evidence of existing confusion and role ambiguity among careproviders (Taplin et al, 2010;Farrell et al, 2011) as well as patients and carers (Walsh et al,2010b). Role descriptions may need to be tailored to particular contexts, as studies showdemands differ depending on geographic location (Jones et al, 2010).Growing reliance on ‘non-physician providers’ in the USIn response to its predictions of a severe shortage of oncologists in the US, the AmericanSociety of Clinical Oncology has recommended more collaboration with other specialties,primary care physicians and non-physician providers (Shulman et al, 2009). Non-physicianproviders such as nurse practitioners (NPs) , physician assistants(Pas) and lay health workersare well established in the US and other countries, but introduction of such roles has facedbarriers in Australia (Health Workforce Australia, 2011).In the US, PAs and NPs are increasingly included in oncology teams and manage manyroutine patient concerns (Levit et al, 2010). Survey findings show two-thirds of oncologists whoNational Cancer Workforce Strategy Literature Review Page 9

lamed for creating confusion and hindering research (Farrell et al, 2011). After reviewingthe relevant literature Farrell and colleagues concluded that role developments and nurseledclinics have been ad hoc and poorly evaluated.For more than a decade there have been calls for creation of new advanced practice rolesthat “formally recognise the expertise of an experienced and highly educated nursingworkforce” (Barrett and Yates, 2002). Several Australian studies, mostly in the context ofbreast cancer, have demonstrated the value and acceptability of specialist cancer nurses(Barrett and Yates, 2002). However, there was little discussion in the literature returned fromthe search about new roles for nurses in cancer care in Australia. Morcom and colleagues(2005) described an Australian nurse practitioner-led colorectal cancer screening clinicwhich, based on an audit of sigmoidoscopy patients, had service and procedural outcomesthat compared favourably with other colorectal screening services and had a high level ofpatient satisfaction (Morcom et al, 2005).There is limited description of new roles for specialist practice nurses in the primary caresetting. Australian research has highlighted the complexity of relationships between GPs andpractice nurses based on factors such as professional domains, power imbalances, generalpractice ownership, history and “the politics of health service provision” (Hallinan, 2010).Despite efforts to increase the number of credentialed practice nurses (PNs) and financialincentives aimed at increasing the number of Pap smears provided by PNs in generalpractice, uptake has been limited by general practice ‘structure and context’ (Hallinan,2010). Studies addressing the use of a nurse genetics specialist in the primary care settinghave shown high levels of patient and doctor satisfaction and reduced costs of such amodel (Holloway et al 2004 and Westwood et al 2006, cited in (Scheuner et al, 2008)).Expanded roles for pharmacistsDiscussion about the predicted shortfall of oncology health professionals has largely focusedon specialists and nurses, and emphasised the potential for nurse practitioner and physicianassistant roles to help fill the gap. Although the literature is limited, there is emergingevidence that new and extended roles for pharmacists could help meet the treatment, careand information needs of cancer patients and survivors (Sessions et al, 2010). The growth intargeted cancer therapies for patients supports an expanded role for pharmacists ininterpreting pharmacodiagnostic tests to assist in patient selection and assisting patients incompliance with oral targeted therapies (Plevin et al, 2010).In other developed countries the role of pharmacists in cancer care teams is evolving, with ashift in focus from drug-oriented to patient-oriented services and the rise of ‘oncologypharmacy’ as a new discipline with its own curriculum (Döhler et al, 2011). A recent study ofa pharmacist-led supportive care consultation concluded that the shortage of oncologyproviders could be “mitigated by pharmacists working in collaborative practices, withprescriptive authority, in the ambulatory oncology setting” (Valgus et al, 2010). Descriptiveand case studies highlight the contribution to cancer services in one US State of a newlycredentialed role of ‘clinical pharmacist practitioner’ (Sessions et al, 2010;Valgus et al,2011;Valgus et al, 2010). An analysis of patient data showed a pharmacist-led,interdisciplinary team in one service produced an improvement in symptom scorescomparable to that observed in the inpatient palliative care service of the same institution(Valgus et al, 2010).A greater role for primary careMany of the proposed responses to the increasing and changing cancer care needs of thepopulation and the diminishing cancer workforce recommend an expanded role in cancercare for general practitioners (GPs) and other primary health care professionals.National Cancer Workforce Strategy Literature Review Page 11

The GP’s role in cancer care has already evolved in recent years in response to the risingincidence of cancer and increasing emphasis on recognising and including the GP as amember of the multidisciplinary cancer care team (Mitchell 2008). In the future most GPs arelikely to face more frequent contact with patients with cancer, including some with complexneeds (Jiwa et al, 2008;Weller and Harris, 2008).Shared care between hospital-based and community-based/primary care healthprofessionals has been developed and tested with patients with other chronic conditions, butlittle explored as a model for cancer care during the initial treatment phase (Sussman andBaldwin, 2010). A randomised controlled trial of a shared care program for newly diagnosedcancer patients found the intervention increased the number of contacts the patient hadwith their primary care provider and decreased their feelings of being left ‘in limbo’ (Nielsenet al, 2003). A Cochrane review of the impact of shared care in the management of chronicdiseases found little demonstrated benefit apart from improved prescribing (Smith et al,2007). However the review did identify common elements of successful models of sharedcare, including the use of care paths and guidelines, identification of a care coordinator,and enhanced communication tools and templates.There is evidence that GPs are willing to, and can safely and effectively, provide follow-upcare to their patients with cancer (Han and Rayson, 2010). Survivors support GP involvementin their post-treatment follow up and survivorship care, but generally in a supportive role, withtheir oncologists also having a role 1 . Similarly, patients at the end of life value the continuedinvolvement of their primary care provider as well as specialist physicians (Han and Rayson,2010).In the US, the concept of a patient-centred medical home has been described as a “pivotalinnovation in the transformation of health care delivery”, which has potential to improvecoordination of cancer care (Collins et al, 2010). The program aims to transform primary carepractice, encouraging team-based care, better coordination and integration of care (e.g.by assigning a personal primary clinician to each patient and increasing use of informationtechnology), and focusing on outcomes measurement (Collins et al, 2010). Evaluations ofdemonstration projects have shown improved outcomes and patient satisfaction (Rosenthal,2008).Several barriers to greater involvement of GPs and other primary care providers in cancercare have been identified. Australia’s primary care workforce is already experiencingshortages, particularly in rural and remote areas, which are predicted to increase in thefuture. In the US many practicing oncologists surveyed expressed concern about thecapacity of primary care practitioners (PCPs) to help address cancer workforce shortages(Association of American Medical Colleges, 2006), possibly because of the increasingcomplexity of cancer care and predicted shortages of PCPs in the future (Erikson et al, 2007).Although a survey of PCPs found they had “considerable involvement in most phases ofcancer care” (Klabunde et al, 2009), qualitative research has found that many PCPs wereconcerned about their ability to be care navigators for cancer patients (Wagner et al, 2010).Similarly, while studies have suggested GPs will be at the frontlines of the integration ofgenomics into medical practice, a literature review found the primary care workforce in theUS feels “woefully underprepared to do so” (Scheuner et al, 2008). Greater interdisciplinarycommunication is needed to ensure GPs have comprehensive information to support theirongoing role in the care of their patients with cancer. GPs have expressed interest in1 Further discussion of research exploring the potential for GPs to play a greater role in followupafter cancer treatment and survivorship care and references are in the section ‘Newmodels of post-treatment and survivorship care’ below.National Cancer Workforce Strategy Literature Review Page 12

eceiving relevant medical and social information from all members of the multidisciplinaryteam, not just specialists (Rowlands et al, 2010).Health system/organisational changeThe Cancer Multidisciplinary TeamIncreased medical knowledge, particularly innovations in imaging, surgery, radiotherapy andpharmaceuticals, has made it possible to offer a higher probability of cure to some cancerpatients. For many other cancers, modern treatment means that a patient is more likely todie with a cancer, rather than of it; even if the cancer is not cured or eradicated, the patientmay die from some other cause, not as a consequence of the cancer (Coleman et al 2008).These developments have enormous consequences for health services. The management ofcancer increasingly involves a complex package of interventions, requiring carefulcoordination of a wide range of professionals (oncologists, surgeons, imaging specialists,pathologists, specialist nurses, psycho-oncologists, etc) in multidisciplinary teams. This radicalshift challenges the traditional role of the individual medical specialist.The complexity of cancer treatment requires specialists to keep up to date with the rapidand continuing evolution of scientific evidence on diagnosis, treatment and care in order toachieve the best possible outcome for their patients (Robotin et al 2010). Greaterunderstanding of the human needs of cancer patients is also focusing attention on previouslyneglected areas of care, in particular patients’ psychosocial needs and care at the end oflife. Patients who receive psychosocial services to help with the psychological impact ofcancer, the consequences of treatment and (when cure is not possible) palliative care, maybe enabled to reach the end of their lives with dignity and without pain (Coleman et al2008).The coordination of cancer care treatment through multidisciplinary teams has beenaccepted as best practice for more than a decade. However the knowledge base abouthow these teams should operate, who they should include and how this varies betweencancers is still evolving (Fennell et al 2010). Multi-modal therapies increasingly requireextensive team consultation along the cancer care continuum (Zapka et al 2003) and thesevary by cancer type.Improving interdisciplinary communication and care coordinationThere is evidence that focuses on organisational strategies that improve the efficiency andcoordination of healthcare, such as multidisciplinary teams and integrated care services,can improve patient outcomes (Health Workforce Australia, 2011).Better communication and cooperation among all members of the medical team andhealth professionals providing care to people with cancer and their caregivers is essential tofacilitate effective care coordination (Walsh et al, 2010b) and an interdisciplinary approach.Achieving effective interdisciplinary practice requires a fundamental change to “longstandingworking practices characterised by professional separation and medical authority”(Hudson, 2002) that feeds professional insecurity and rivalry (McCallin, 2001). Interdisciplinaryrivalry may be a factor in the lack of respect between some medical oncology andpalliative care specialists (Ward et al, 2009). Interdisciplinary training may improveunderstanding of other disciplines (Ward et al, 2009). Case studies show putting nursepractitioners and family physicians in a common clinical practice does not automaticallyproduce interdisciplinary collaboration; orientation and education about role expectations isneeded (Bailey et al, 2006). Efforts to increase interdisciplinary communication andcollaboration have focused on the role of the multidisciplinary team, with suggestions thatmore regular meetings of the entire team could improve understanding and recognition ofNational Cancer Workforce Strategy Literature Review Page 13

professional roles, especially that of the care coordinator (Walsh et al, 2010a). However, anAustralian survey found that multidisciplinary team meetings are still dominated by medicalspecialists, with limited presence of psychologists and allied health staff such as socialworkers, physiotherapists and occupational therapists (Harrison et al, 2008). Clinicians believea multidisciplinary approach will provide better care (Zorbas et al, 2003;Harrison et al, 2008).The effectiveness of interdisciplinary practice may be hampered by inter-specialtydifferences in perspectives on evidence and willingness to use different forms of evidence inmaking treatment decisions (Broom et al, 2009). Broom and colleagues (2009) qualitativeresearch, undertaken on a small sample of oncologists and cancer nurses, highlighted atension between views of haematologists, medical oncologists and cancer nurses about thequality and thus ‘usability’ of different types of evidence, underpinning their approaches tocancer care.Studies highlight that in focusing on an interdisciplinary approach there is still the need for anidentified ‘key contact’ for each person diagnosed with cancer. Greater use of carenavigators or managers has been recommended given patients’ desire for guidance andsupport through cancer diagnosis, staging and treatment planning (Wagner et al, 2010).Patients want one person as their main contact (Walsh et al, 2010b), and it does not seem tomatter whether coordination is managed by a nurse or another team member (Thomas et al,2009). Evaluation of the cancer nurse coordinator (CNC) role in NSW found that clinicians feltCNCs had a high impact on improving patient-centred care, improving multidisciplinary careand coordinating patient access to appropriate services (Thomas et al, 2009). There isevidence that specialist nurses improve continuity and coordination of care for women withbreast cancer in Australia (Jones et al, 2010). Thomas and colleagues noted that furtherwork is needed for CNCs to effectively act as a conduit between clinicians based at thecancer service and the referring GP, and between clinicians based at the cancer careservice and other members of the cancer care team based elsewhere (Thomas ref).Like oncologists and GPs, cancer care coordinators are in limited supply and over-worked(Walsh et al, 2010a). Care coordinators in rural and regional areas who were not specialisedand thus dealt with all cancer streams felt “particularly pressured and time poor whenattempting to identify and address patients’ needs” (Walsh et al, 2010a). This wasexacerbated by a shortage of GPs, particularly in rural areas, meaning local carecoordinators often were contacted by patients with concerns that should be addressed bytheir GP (Walsh et al, 2010a). These ‘flow on’ impacts of shortages in different disciplinesproviding cancer care need to be carefully considered in workforce redesign.Increasing productivity and time for patient careOptimising health professionals’ capacity to provide quality cancer care may requirechanges to workflow, work load and work environments. Examples cited in the literaturereviewed include: ensuring adequate space for private consultations and administrativesupport for psychosocial staff (Rankin et al, 2011); providing clerical or other support staff todo non-nursing work enables nurses to direct more of their time and skills to direct patientcare (Barrett and Yates, 2002), and introduction of an MDT coordinator or use of otheradministrative support for multidisciplinary team meetings to reduce the burden of organisingand facilitating meetings on health professionals – often cancer care coordinators or nursespecialists – and to enable them to spend more time providing direct care to patients (Walshet al, 2010a).There is increasing evidence that ‘effective and empathetic’ communication affects cancerpatients’ outcomes, but the heavy workloads of cancer specialists may be reducing theircapacity for effective communication (Dimoska et al, 2008). Oncologists have reported thatNational Cancer Workforce Strategy Literature Review Page 14

time constraints are a barrier to providing adequate information to patients (Graham andRamirez, 2002) and to involving them in treatment decisions (Shepherd et al, 2008a). Timeconstraints also may underpin observed deficiencies in addressing the psychosocial andsupport requirements of cancer patients (Dimoska et al, 2008), and the demand for secondmedical opinions, which have a significant impact on the workload of many cancerspecialists (Philip et al, 2010). A high proportion of Australian medical oncologists (82%) in asurvey sample reported seeing between one and five patients seeking second medicalopinions per month, mostly prompted by patient concerns around communication with theirfirst doctor and desire for reassurance (Philip et al, 2010). Enabling adequate time forconsultations with new patients, and ensuring availability of relevant patient information mayreduce patients’ needs to seek a second medical opinion (Tattersall et al, 2009).Greater use of technology and systems has been recommended to reduce the non-clinicalworkload of health professionals and enable them to allocate more of their time to directcare of patients. American oncologists have cited excessive paperwork and regulations as afactor reducing their productivity and effectiveness, and suggested electronic medicalrecords would reduce this barrier (Association of American Medical Colleges, 2006).Australian studies describe strategies developed in response to local needs or opportunitiesthat may be suitable for extension to other centres. Enabling nurse-led teams to conductelectronic toxicity scoring for patients having head and neck radiotherapy, and usingelectronic medical records to record and analyse toxicity data, allowed oncology nurses tosee patients more frequently and thus increase patient adherence (Fox et al, 2011). Apaperless working environment in a private regional radiation oncology facility was creditedas making a “huge impact on workflows and communication” and reducing costs (directcosts such as printing and postage, and potentially staff costs through greater efficiencies)(Poulsen et al, 2010).There is emerging research focused on the potential of information and communicationtechnologies, particularly used in telemedicine (or ‘teleoncology’), to support workreorganisation and the impact of such on health professionals’ work satisfaction and staffretention (Gagnon et al, 2011) as well as increase accessibility to cancer care and supportfor people in rural and remote areas. Australian studies show patient and cliniciansatisfaction with videoconference consultations. Patient satisfaction levels are comparablefor face-to-face and videoconference consultations (Weinerman et al, 2005;Barton et al,2006;Sabesan and Brennan, 2011). Videoconferencing has been established as an effectivemeans of overseeing management of medical oncology patients from rural and remotetowns in the health service district (Sabesan and Brennan, 2011). Research into the use oftechnology to provide counselling to cancer patients in rural areas has recently beenreviewed, with the authors reporting encouraging findings in research about the use ofvideoconferencing and Internet platforms, but a need for more rigorous research (Shepherdet al, 2008b;Beckmann et al, 2007).Increasing use by patients of technology such as email, online portals and electronictreatment plans to directly communicate with their practitioners may reduce the workload ofhealth professionals by reducing the need for face-to-face consultations (Levit et al, 2010).However a review of (mostly UK) studies investigating the effectiveness of the patient-heldrecord (PHR) in cancer care concluded that PHR interventions had not achieved the benefitsdescribed in other care contexts (Gysels et al, 2007). The review also found diverse attitudesof patients towards PHR: most welcomed it, but some rejected it (Gysels et al, 2007). Moreresearch is needed on the optimal use and cost of technologies intended to improveefficiency (Levit et al, 2010) and the conditions in which technology such as patient-heldrecords can be used most effectively (Gysels et al, 2007).National Cancer Workforce Strategy Literature Review Page 15

New models of post-treatment follow up and survivorship and increased referral to palliativecareIncreasing survival rates mean cancer is increasingly considered and managed long-term asa chronic disease. There has been growing focus on the needs of people with cancer aftertreatment ends – for survivorship care and ongoing follow-up, or for appropriate and wellcoordinatedpalliative care. Survivorship, palliative care, family caregiving and the ‘medicalhome’ have emerged as key models of care in oncology in the US (Levit et al, 2010).Improving follow-up and delivery of survivorship careSurvivorship is now recognised as a distinct phase of the cancer trajectory. In recognition ofcancer survivors’ ongoing physical and psychosocial needs, new models of care areevolving to improve follow-up and coordination of care and reduce demand on oncologists.It has been suggested these needs could be addressed by transitioning care of most cancersurvivors to primary care or community-based health professionals following treatment(Hewitt et al, 2006; Potosky et al, 2011; Brennan et al, 2011). Ensuring a smooth transition andmeeting survivors’ complex care needs would require better communication andcoordination of care between all health professionals involved in post-treatment care,particularly cancer specialists and primary care providers (Hewitt et al, 2006;Brennan et al,2011). Treatment summaries and written survivorship care plans are effective and essentialways of improving communication between care providers and coordination of follow-upand survivorship care (Hewitt et al, 2006;Potosky et al, 2011;Brennan et al, 2011).Randomised controlled trials have demonstrated the safety, cost-effectiveness andacceptability of primary care follow-up of women with breast cancer (Grunfeld et al, 2006)and of colorectal cancer patients (Wattchow et al, 2006) when compared with specialistfollow-up. There is evidence that primary care professionals expect/are willing to providefollow-up care to their patients with cancer (Wattchow et al, 2006;Bulsara et al, 2005;Cheunget al, 2009) but there is continuing confusion over roles and responsibilities with both primarycare providers and oncologists expecting to be the lead physician in follow-up (Cheung etal, 2009). In Australia there has been lack of consensus among survivors, GPs, surgeons andoncologists about which type of clinician is best to coordinate follow up (Baravelli et al,2009). Survivors expect or prefer their oncologists to provide all or a lot of follow-up care(Bulsara et al, 2005;Cheung et al, 2009). Although studies show survivors support increasedinvolvement of their GP (Baravelli et al, 2009), a breast physician (Brennan et al, 2008) or aspecialist nurse (Jiwa et al, 2009) in survivorship care, it is primarily in a supportive rather thantreatment role (Bulsara et al, 2005;Brennan et al, 2011).Hence, models of ‘shared care’ between GPs and specialists may be more successful andacceptable to survivors than a complete transfer of care to a GP or nurse (Brennan et al,2011). Patient preferences for specialist-based model of care are most likely related toconcerns about GPs, nurses or other care providers not having the skills or knowledge toprovide the required level of care without additional training (Brennan et al, 2011). The needfor increased training in follow-up and survivorship care is supported by findings of a survey ofcommunity-based primary care physicians (PCPs) in the US. Findings demonstrated that whilePCPs provided the bulk of care for long-term survivors, only a small subset reported providingmultidimensional survivorship care (i.e. screening for medical late effects, addressing sexualdysfunction and addressing mental health issues as well as monitoring for cancer recurrence)(Bober et al, 2009). Oncologists have questioned the capacity of primary care providers toconduct appropriate testing for cancer recurrence and care for late effects in women withbreast cancer (Potosky et al, 2011). However randomised controlled trials have shown thatwhen PCPs were given explicit directions for follow-up care (similar to a brief survivorship careplan) they achieved the same outcomes as specialists (Grunfeld et al, 2006).National Cancer Workforce Strategy Literature Review Page 16

Emerging research shows some cancer follow-up can be managed effectively by nursespecialists (Beaver et al, 2009; Oeffinger and McCabe, 2006; Verschuur et al, 2009) and thereis the potential of alternative nurse-led models to meet survivors’ needs, such as telephoneconsultations (Cox and Wilson, 2003; Beaver et al, 2009). In the UK, nurse-led follow up iscommon across several cancer groups including breast, lung, ovarian and testicular cancer;as well as following radiotherapy treatment (Farrell et al, 2011). While nurse-led clinics seemgenerally acceptable to patients (Cox and Wilson, 2003) there has been little formalevaluation to assess their impact (Farrell et al, 2011). A pilot trial of telephone follow-up by aspecialist colorectal nurse in addition to standard clinical follow-up for patients after surgeryfor colorectal cancer showed improvements in quality of life and reduction in unplannedhealth service use of more than 10% (Harrison et al, 2011). An Australian nurse-led survivorshipprogram was found to be both clinically acceptable and highly valued by patients (Jeffordet al, 2011).Increasing promotion of self-management and peer supportAs cancer survivors face many health, psychological and socioeconomic challenges thatare similar to those for people with chronic disease the literature shows increasing interest inthe usefulness of chronic disease self-management programs for people with cancer(Wagner et al, 2010).Evaluations of self-care support programs for cancer survivors have found participants haveincreased self-efficacy (Cimprich et al, 2005). Survivors prefer cancer-specific rather thangeneric programs, valuing the opportunity to mix with others who had experienced cancer(Beckmann et al, 2007). Australian research has established the value of peer support groupsfor people with cancer, including the benefits of being with ‘others like them’, gaininginformation about cancer (Ussher et al, 2006;Butow et al, 2007), and increasing confidenceand a sense of control (Ussher et al, 2006;Butow et al, 2007). Nonetheless studies suggest fewpatients actually receive referral to community support services or groups (Beesley et al,2010;Steginga et al, 2008). Encouraging adoption of self-care behaviours and peer supportwere vital components of a nurse-led survivorship program that was highly valued bysurvivors (Jefford et al, 2011).Increased referral to, and better integration of, palliative careIncreased, and more integrated, use of palliative care services has been recommended tobetter support people with advanced cancer and to reduce pressure on the oncologyworkforce. There is growing evidence of the benefits of referral to specialist palliative care(SPC) services (Haines, 2011;Currow et al, 2008), yet a study in one of Australia’s busiest acutehospitals found less than half of patients who die of advanced cancer were referred to aSPC service (Le and Watt, 2010). While oncologists in Australia reportedly favour early referraland a concurrent rather than sequential model of palliative care (Ward et al, 2009), patientsare usually referred late (Haines, 2011). New models are needed to ensure patients andcaregivers with unmet needs (physical, psychological and/or information) are identified andoffered specialist palliative care (Johnson et al, 2010;Rainbird et al, 2009).Greater integration of SPC into the management of patients with advanced cancer requireseffective collaboration between SPC and oncologists in the acute sector (Ward et al,2009;Bailey et al, 2006). While the level of collaboration between SPC and oncologists inAustralia is already higher than studies suggest it is in Europe and the US, (Ward et al, 2009)oncologists suggest it could be improved by more SPC resources, particularly specialists(Ward et al, 2009).In the US, recognition and increased use of palliative care specialists and nurse practitionerswho specialise in palliative care has been recommended as a strategy to relieve some ofNational Cancer Workforce Strategy Literature Review Page 17

the burden of care from oncologists (Levit et al, 2010) given the predicted shortage in thefuture. Yet this strategy may be undermined by a predicted shortage of hospice andpalliative medicine specialists (Lupu and American Academy of Hospice and PalliativeMedicine Workforce Task Force, 2010). Alternative methods for developing a trainedpalliative care workforce in the US have been suggested, including social work and nursepractitioner fellowship positions, and programs to train palliative care nurse practitioners(Abrahm, 2011). Board-certified palliative care nurse practitioners are replacing physicianson palliative care teams at many sites (Abrahm, 2011). However caution has been urged inapplying US palliative care research in Australia, given systemic differences in the delivery ofSPC services (Ward et al, 2009;Johnson et al, 2008).Like most of the other strategies recommended for cancer workforce reform, greaterintegration of palliative care in cancer care demands an interdisciplinary approach, whichwould require “changes in care delivery systems and processes and in the belief systems andpractices of providers” (Griffith et al, 2010).National Cancer Workforce Strategy Literature Review Page 18

DOMAIN 2: Health workforce capacity and skillsdevelopmentDevelop an adaptable health workforce equipped with the requisitecompetencies and support that provide team-based, interprofessional andcollaborative models of careReview of the cancer workforce literature related to Domain 2The evolving nature of cancer control and care necessitates continual development ofeducational and training programs to prepare and support all health care professionals whowork with people affected by cancer. Australian and international literature highlights theneed to prepare an effective and informed workforce for cancer care at all health carelevels (Cunningham et al, 2006). There is general consensus that this requires neweducational and training approaches that will enable health professionals of all disciplines togain and maintain skills and competencies required to meet the needs of patients andcommunities (Health Workforce Australia, 2011b).Workforce skills to meet the needs of cancer patients and their communitiesThis review supports the need to shift the focus in education and training to skills andcompetencies required to meet the needs of patients and their communities, rather thantraditional paths to professional qualifications (Health Workforce Australia, 2011b). Increasingrecognition of the level of unmet needs of people with cancer (Sanson-Fisher et al,2000;Rainbird et al, 2009) and of cancer survivors (Barrett and Yates, 2002;Boyes et al, 2009)has necessitated a focus on increasing the knowledge, skills and competencies of all healthprofessionals whose work involves cancer care. A survey of NSW oncology services foundthat more than half of the sites could provide only limited or very limited psycho-oncologyservices (Rankin et al, 2011). In addition, staff providing cancer care at other sites, particularlyspecialist oncology nurses and social workers, could benefit from specific strategies toidentify and support distressed patients (Rankin et al, 2011).The literature reviewed highlights health professionals’ self-reported and assessed needs forgreater skills and confidence in meeting the psychosocial and supportive care needs ofpeople with cancer and their families. Lack of confidence and skills in communicating withcancer patients and their families are key issues adversely affecting professional roles (Turneret al, 2009;Turner et al, 2011;Dimoska et al, 2008b). Studies have found that the effectivenessof health care professionals’ communications with patients who have cancer can beimproved after training (Fellowes et al. 2004; Gysels et al. 2004). However, the impact onpatient outcomes is less clear. A recent systematic review found inconclusive evidence onthe effectiveness of communication skills training on patient satisfaction and patient distress.One reason posited for the inconclusive results was the absence of adequate transferstrategies that support the transfer of acquired skills from training to the workplaceenvironment (Uitterhoeve et al, 2010).Australian studies have suggested that participation in a well-targeted cancer educationprogram enhances nurses’ perceived skills in communication and psychosocial care(Steginga et al, 2005;Wyatt, 2007). Furthermore, after targeted training in decision support,nurses and other allied health professionals are better able to support patients inunderstanding information about cancer and making cancer-related decisions (Stacey et al,2008).Recognising and meeting the particular needs of Aboriginal and Torres Strait Islanders andAustralians of culturally and linguistically different backgrounds with cancer requires attentionNational Cancer Workforce Strategy Literature Review Page 19

to developing the cultural competence of health professionals (Shahid et al, 2009;Barlow-Stewart et al, 2006;Butow et al). Health professionals need to develop a greaterunderstanding of Aboriginal beliefs and perceptions of cancer that inform their care-seekingbehaviour, which will contribute to changing the “practice, skills and behaviour of the healthsystem” to remove barriers and incorporate ‘culture’ into service delivery (Shahid et al, 2009).Increasing Aboriginal and Torres Strait Islanders’ awareness about cancer and addressing thecultural barriers that impede their access to cancer services also requires building thecapacity of the Indigenous health workforce (Croager et al, 2010). Participating in a short,culturally-appropriate course increased the cancer knowledge and confidence ofparticipating Aboriginal health professionals in the short term, but ongoing education andsupport of participants is needed to maintain confidence and to ensure cancer knowledgeis passed on to the community in a culturally appropriate way (Croager et al, 2010).Given an increasing focus on cancer prevention, competency-based training is needed toenhance the public health workforce capacity to deliver evidence-based cancer controlinterventions (Brownson et al, 2009). A needs assessment of an Australian regional populationhealth (broader) workforce showed high self-assessed need for greater understanding of,and skills in, evidence based practice and strong interest in training (Adily and Ward, 2004).Increasing cancer knowledge and skills of all health professionalsThe growing incidence of cancer and increasing survival rates means that healthprofessionals across all disciplines and sectors increasingly interact with people affected bycancer. It has been recommended that all health professionals need more training aboutcancer in their undergraduate education. Accordingly, it has been suggested that allgraduating medical students need a basic understanding of common cancer preventionstrategies, methods of diagnosis, treatment modalities and potential treatment effects(Barton et al, 2006) as well as skills in communicating with and supporting people affected bycancer (Turner et al, 2009). Additionally it is proposed all medical graduates should have aworking knowledge of radiation oncology and radiotherapy, as the majority (about 60%) ofcancer patients receive radiotherapy (Barton et al, 2006). In support, a 2010 internationalreview concluded that teaching radiation oncology should begin early in theundergraduate process, should be mandatory for all students, and should impart knowledgerelevant to future general practitioners rather than detailed information only to oncologists(Dennis and Duncan, 2010). Given the high prevalence of skin cancer in Australia, and thecosts of treatment, there has been an argument for ensuring all medical graduates arecompetent in clinical recognition of skin cancers (Commens, 2007). This is supported by theevidence that a high ratio of benign lesions are excised for every melanoma excised (Youl etal, 2007) and that excisions are increasingly associated with complex and expensive surgicalrepairs (Askew et al, 2007). Increasing competency in skin cancer diagnosis and treatmentrequires ‘new paradigms, educational technologies and collaborations’ (Commens, 2007).University skin cancer courses for medical postgraduates may lack sufficient face-to-faceclinical contact with patients; and training and education should provide supervised clinicalattachments and assess competence (Commens, 2007).Better and more equitable population health outcomes have been associated with higherratios of ‘generalist’ health professionals providing primary care (Health Workforce Australia,2011b). Providing cancer-related education and training to a broad range of primary careprofessionals apart from GPs, such as nurses, practice staff, pharmacists and allied healthprofessionals will not only improve community-based cancer management but is likely tofacilitate good multidisciplinary care (McAvoy et al, 2007). The increasing shift of cancercare from an inpatient to an ambulatory care setting means that community ‘generalist’nurses need more knowledge about cancer therapies and care in order to meet the needsNational Cancer Workforce Strategy Literature Review Page 20

of cancer patients in the community during and after treatment (Chan et al, 2010).Delivering cancer education to primary care practitioners requires improved coordination,increased funding, and support to enable GPs and other primary health care providers toaccess training. A national audit in 2004 found that 87 organisations were providing trainingor educational activities on cancer issues to Australian primary care professionals (McAvoy etal, 2007).Scarcity of resources and increasing demand mean rural GPs and nurses have a substantialrole in providing ongoing care to people in their regions with cancer (Dewar et al, 2003).Hence they need targeted education in cancer management that acknowledges theirbroad scope of practice (McCarthy et al, 2003), and in palliative oncology (Rosenberg andCanning, 2004), that includes the potential side effects of emerging targeted cancertherapies (Koczwara et al, 2010). However access to palliative care professionaldevelopment and support is limited for these practitioners due to professional isolation andconstraints of distance, travel and staffing shortages (Rosenberg and Canning, 2004). There isevidence of the effectiveness of well-targeted cancer education interventions for ruralhealth professionals (Dalton et al, 2006;Steginga et al, 2005) which are designed to meetparticipants’ learning needs (Steginga et al, 2005;Volker et al, 2011). The educational needsand preferences of rural health professionals may be different. For example rural nursesprefer face-to-face, hands-on education delivered by clinical educators (McCarthy et al,2003). However, it is important to keep in mind the limitations of self-reporting in learningneeds assessments. Often participants report self-identified, ‘felt needs’ rather than actualknowledge or skills deficits (Volker et al, 2011). In addition, reported competencies may beassociated with skills necessary to function in a particular work setting, and thus educationmay need to be targeted to the needs of different audiences in different settings (Zebrack etal, 2008).Ensuring adequate preparation for practiceAustralian and international studies with cancer professionals highlight that clinicalcompetency is not enough: while oncology-trained health professionals have the requisitecancer knowledge and clinical skills, many feel unprepared for the ‘non-clinical’ demands ofoncology practice and/or caring for people affected by cancer. More than 50% ofAustralian gynaecological oncologists surveyed felt they were not adequately prepared forpractice by the fellowship program (Stafford and Judd, 2010). They identified the mainsources of stress as issues related to management, such as taking on managerialresponsibilities, insufficient input into unit management, difficulties in relationships withadministrative staff, applying for/maintaining grant support and conflicting demands on time(Stafford and Judd, 2010). Newly appointed radiation oncology consultants in the UKreported that to adequately carry out their clinical work they needed to be able to“navigate the maze of emotions, relationships and management structures contained in theclinical and organisational contexts of their work”, and to develop non-clinical skills such ashospital management, information management and technology, coding and classification,and dealing with clinical complaints and litigation (Benstead, 2006).Shortening timeframes for training may help address workforce shortages (Health WorkforceAustralia, 2011b) but research findings warn of the potential impact on preparedness forpractice. New UK radiation oncology consultants reported that shortening clinicalexperience and a workload that “necessitated high service without appropriate feedback”impacted negatively on their confidence in their clinical judgement and decision-makingskills and removed the opportunity to develop important non-clinical skills (Benstead, 2006).Cancer surgeons have stressed the need to retain mentorship as a ‘critical component’ ofsurgical training programs – despite the emergence of novel training methods such asNational Cancer Workforce Strategy Literature Review Page 21

surgical simulation – and one that may be increasingly important with the emergence ofminimally invasive approaches to surgery (Buscarini and Stein, 2009).Competency-based education and trainingThe National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015 recommends an approach to education and training that ensures all healthprofessionals receive appropriate generalist training in their chosen discipline and are trainedto be adaptable (HWA, 2011a). Health professionals need to be able to access continuingand flexible training and professional development to respond effectively to changingpatient needs, new developments in cancer detection and treatment, and new models ofcancer care. For example, the lack of suitably trained staff has been identified as the mainfactor limiting implementation of new and emerging technologies (such as advancedradiotherapy techniques) in the UK (Coles and Spooner, 2011) and limiting utilisation inAustralia of pharmacodiagnostic tests that assist in patient selection for new targetedtherapies (Plevin et al, 2010).Reliance on increased student intake will be insufficient to meet future health workforcerequirements (Health Workforce Australia, 2011a). Expanding the development pipeline forcancer specialists requires a long-term investment, but short-term action is needed to meetexisting shortages (Smith and Lichtveld, 2007). Smith and colleagues (2007) suggest definingcore competencies that are needed by all members of the general health workforce is thefirst step toward expanding the [US] cancer workforce. This has been exemplified in Australiaby the development of the National Professional Development Framework for CancerNursing 2 , which defines a national standard of educational preparation and competenciesfor all nurses who work with people affected by cancer in primary care, generalist andspecialist health care settings.While competency-based educational approaches have been championed as the wayforward in health professional training (Health Workforce Australia, 2011a), there is little in thepeer-reviewed literature about outcomes of competency training for health professionalsproviding cancer care. Pilot-testing of a competency-based cancer education program byfour US cancer centres has demonstrated measurable improvements in the knowledge, skillsand attitudes of non-oncology health professionals to meet the needs of people with cancer(Smith et al, 2009). Such educational approaches provide students and professionals with a“meaningful and relevant opportunity for professional growth and development” (Smith etal, 2009). Beyond the increased competencies of individual employees, competency-basedtraining programs may deliver benefits to the health service or organisation such as astronger workforce and an “improved image in the surrounding community of patients andprofessionals” (Smith et al, 2009). Developing a competency-based program fosterscollaboration among experts serving as faculty (Smith et al, 2009), and fosters a “culture ofstaff and leadership development”, promotes career progression and increases staffretention and satisfaction (Marble, 2009).Developing and assessing core competencies for the cancer workforce will require newcurricula and resources, skilled educators and trainers, appropriate and timely courses,formal assessment of learning and continuing support from specialist services (Bennett et al,2007). Assessing competence (of medical students) requires an ‘end process’ assessmentfocused on how an attribute is used in practice (Starmer et al, 2010).In response to the lack of standardisation in medical curricula in Australia, Starmer andcolleagues (2010) note the development of various frameworks listing core attributes2 http://www.edcan.org/pdf/EdCanFramework1-6.pdfNational Cancer Workforce Strategy Literature Review Page 22

deemed necessary for medical graduates at various levels and an Ideal OncologyCurriculum for Medical Schools 3 . They claim the first task in assisting educators to “translatethe overarching goals from these frameworks into specific learning objectives” is to definethe knowledge, skills and attitudes that demonstrate competence in each of the broaderdomains. For example, the identify how to assess whether a student has achievedcompetency (Starmer et al, 2010). In the UK competence frameworks have been developedfor many different health professions describing activities that cover a patient pathway,practitioner role or specialty area and the underpinning knowledge, understanding andattitudes 4 . An evaluation of piloting of new roles in cancer genetics in the UK (see Domain 1)has confirmed the practical relevance of the Genetics Competence Framework and thepotential to adapt ‘mainstream’ patient pathways and competences to a specialty field(Bennett et al, 2007).3 http://www.cancer.org.au/policy/Publications/IdealOncology.htm4 http://www.skillsforhealth.org.uk/National Cancer Workforce Strategy Literature Review Page 23

DOMAIN 3: Leadership for the sustainability of the healthsystemDevelop leadership capacity at all organisational levels to support and leadhealth workforce innovation and reformReview of the cancer workforce literature related to Domain 3Health care organisations face the constant challenge of how to do more with less, andcancer care services are no exception. They must manage the quality and safety issuesfacing an overextended workforce, and at the same time seek ways to improve productivityand efficiency for the sake of improved patient access to timely and appropriate treatment.The quality of leadership in the cancer care workforce directly and indirectly affects thequality of patient care, and is shown to be an important factor supporting best practice.Leadership exists at various levels of cancer care services (governance, management, clinicalcare). A large body of research indicates that the quality of leadership affects people, theirsatisfaction, trust in management, commitment, individual and team effectiveness, theculture and climate of organisations, and ultimately individual and collective performance(Bell et al. 2004; Burke et al.; DeGroot, Kiker & Cross 2000; Dirks & Ferrin 2002; Gernster & Day1997; Kouzes & Posner 2007). Other factors such as economic stability, political agendas,organisational and industry history, and individual differences may also influence theseoutcomes, but leadership plays a central role in mobilising people towards a common goal(Avolio, Walumba & Weber 2009; Kouzes & Posner).The importance of leadership in health systems was demonstrated by the findings of a studyof 1,300 hospitals across the US and Europe, which found that well-managed hospitals withclinically qualified leaders produced a higher standard of patient care (Dorgan et al. 2010).Further evidence for the importance of leadership comes from health workforce surveys inthe UK which have shown that the higher the leadership quality of senior managers (as ratedby staff), the higher the organisation rates in performance and the lower the number ofpatient complaints (Care Quality Commission 2011).A recent study suggests that: leaders who can encourage disengaged staff to becomeengaged can lift individual performance by up to 57%; clearly illustrating the alignmentbetween individual and corporate objectives can improve employee effort by up to 28%; andproviding unbiased, accurate and fair feedback to employees can improve effort by up to39% (Roebuck 2011). Several other recent studies verify this strong linkage betweenleadership and positive outcomes in health care organisations (Adamasachew & Dawson inpress; Topakas, Adamasachew & Dawson in press). Effective clinical leadership and itsdevelopment are clearly vital in the Australian cancer care workforce.What is effective leadership?Over the last 60 years a multitude of leadership theories have risen and fallen in popularity.The trait theories of the fifties and sixties, which were preoccupied with the individualcharacteristics of effective leaders that differentiated them from followers (Stogdill 1948;McClelland 1961), gave way to theories concerned with the behaviours displayed byeffective leaders (Hemphill & Coons 1957). These theories were then superceded bycontingency or situational theories which melded together the two earlier schools of thoughtand posited that it is the leadership context that dictates which behaviours and traits aremost effective (Fielder 1967). More recently, transformational leadership has become thedominant contemporary theory of leadership and remains the most evidence-based modelon which to develop training programs (Bass & Avolio 1994; Judge & Piccolo 2004; Kouzes &National Cancer Workforce Strategy Literature Review Page 24

Posner 2007). This person-oriented style of leadership acknowledges the value followers havein the processes surrounding leadership and organisational change and is traditionallybroken into four individual factors: charisma, inspiration, intellectual stimulation and individualconsideration (Bass 1990). However, a recent re-evaluation of transformational leadership inthe context of healthcare has shifted the focus from a 'Heroic' style with an emphasis on anextraordinary person leading from the front with charisma and inspiration to an 'engaging'style of leadership with an emphasis on distributed and collaborative leadership by ordinary,vulnerable, humble and transparent people (Alimo-Metcalfe & Alban-Metcalfe 2005; 2006;2008; Hockey & Ley 2010; Turnbull James 2011; Kings Fund 2011). This engaging style ofleadership encourages people across professional boundaries and all levels of anorganisation to engage in leadership, not because they are inspirational, charismatic orpersonally exceptional, but because “they can see what needs doing and can work withothers to do it” (Turnbull James 2011). An engaging style of leadership seeks to identify goalsand values that are agreed upon by all group members because this has been found to instila greater motivation in employees to contribute to the improvement of the organisation andto collaborate in creative thinking, problem-solving and the trialling of innovative ways ofworking (Stamm 2009). It is ultimately the formally appointed leader’s role, as the personcontractually assuming responsibility for the organisation to demonstrate a shared approachto leadership and to foster the elements which encourage a culture of collaboration and atall levels in the organisation (Masood, Dani, Burns & Backhouse 2006; Stamm 2009; Sarros,Cooper & Santora 2008).The number of studies investigating effective leadership and management in cancer careservices is very limited. In a recent study of the work environment factors that affectoncology nurses’ job satisfaction, relational leadership (a leadership style similar to the‘engaging’ style grounded in emotional intelligence and focused on building andmaintaining relationships in a workplace (Cummings, Hayduk & Estabrooks 2005)) was foundto have a significant positive effect on nurse autonomy, support for innovative ideas,supervisor support in managing conflict, and opportunities for development, which in turn ledto increased job satisfaction (Cummings, Olson & Hayduk 2008). The implications of thisfinding add support to the recommendations of Hayes and colleagues who advise thatleaders of oncology services seeking to improve staff retention should: develop orientationprogrammes catered to the needs of both new and experienced oncology nurses; supportthe professional development of experienced oncology nurses; and help nurses gain insightinto their practice by providing opportunities to reflect on the emotional stress associatedwith oncology nursing such as retreats and reflective practice rounds (Hayes, Ponte &Coakley 2005).Clinical LeadershipA recent report identified the lack of clinician involvement in leadership as one of the centralweaknesses of the UK’s National Health Service (Kings Fund 2011). The development ofeffective clinical leadership in cancer care services is considered vital in the currentAustralian context of healthcare reform and change. There is a specific need for frontlineclinical leaders, who will be well placed to influence best practice at the service level, as wellas indirectly at the organisational level (Edmonstone 2008; Ham 2003; McKenna, Pugno & Frist2006; Victorian Quality Council 2005). In fact, a growing body of literature suggests thatclinical leadership must be in place for effective change to occur in the health care sector(Ham 2003; Reinerstsen 1998; Ward 2005).Limited consensus exists for a universal definition of clinical leadership. A recent discussionpaper on the UK National Health Service’s definition of clinical leadership adopted theposition that managerial leadership is primarily focused on the overall needs of theNational Cancer Workforce Strategy Literature Review Page 25

organisation (macro-level: budgeting, planning, analysing and controlling), while clinicalleadership is focused on enabling and championing best practice, progression towards bestpatient outcomes, and meeting service-level needs (micro-level: quality of patienthealthcare)(Edmonstone 2008). In Australia, the Victorian Quality Council (2005) definedclinical leadership as “both a set of tasks to lead improvements in the safety and quality ofhealth care, and the attributes required to successfully carry them out.” A reportcommissioned by the Clinical Leaders Association of New Zealand (2001) for the Ministry ofHealth described clinical leadership as, “leadership by clinicians of clinicians.” This simplifieddefinition extended to all health professions involved in direct patient care. Taking thesedefinitions together, clinical leadership can be defined as an ongoing process ofengagement between a credible healthcare professional and fellow service providers andsupport staff, where the locally connected clinician champions the cultivation of high qualitypatient care at the service- and individual-level.Effective clinical leadership is thought to involve identifying issues, insights and solutionsarising from activity at the service level and feeding these upwards to management tosupport sustainable change (Ham 2003). It also encompasses the identification of mutuallynegotiated goals and targets, and providing the support and motivation needed to achievethose goals and targets, processes which require clinical leaders to engage effectively withfellow clinicians (Davidson, Elliott & Daly 2006). However this may present clinical leaders witha unique challenge as highly educated and autonomous professionals can be unwilling tofollow colleagues in a leadership role (Davison et al. 2006). To promote clinician followershipand sustain change in service delivery, a leader must therefore not only be connected to thefrontline, but also be perceived as credible amongst their peers (Kouzes & Posner 2007).Clinical leaders are also more likely to gain traction with their fellow clinicians when theyadopt the distributed and collaborative ‘engaging’ style of leadership discussed earlier inwhich collegiate relationships are reinforced through opportunities for shared problemsolving and colleagues take turns leading on issues most important to them and on whichthey are the expert. Whilst some clinicians may be unwilling to follow their clinical colleagues,they are more likely to be influenced by clinical leaders who have “walked a mile in theirshoes” than leaders without a clinical background (Reinertsen 1998). Additionally, due to theinverted power structure found in healthcare, clinical leaders at the ‘bottom’ often havegreater influence over decision making and day-to-day business than the managers andpolicy makers at the ‘top’ (Ward 2005). For these reasons, clinical leaders are powerfulleverage points for improvements in the health sector (Ward 2005).For clinical leaders to be effective the literature acknowledges the importance of supportingand equipping clinical leaders with the high level skills they will require (e.g. leading anddeveloping teams, understanding organisational systems, processes and interdependencies,and redesigning services)(Ham 2003; Reinertsen 1998). The literature also suggests that theremust be recognition and reward systems in place for clinical leaders, and organisationalcultures that value and encourage clinical leadership as a vehicle for improving servicedelivery and performance (Ham 2003; Reinertsen 1998).A recent evaluation of Cancer Australia’s Cancer Service Networks National DemonstrationProgram found that effective clinical leadership was a critical success factor for cancerservice network development (Cancer Australia 2011). Cancer service networks and theregions within them that struggled with clinical leadership also made less progress and ingeneral had poorer outcomes (ibid). Collectively, the CanNET experience illustrated theimportance of forming a powerful guiding coalition by engaging respected clinicians whowere capable of creating a vision, promoting the network to their peers and making changehappen where it was needed (ibid). The majority of network members consulted during theevaluation highlighted the importance of developing clinical leaders at all levels of theNational Cancer Workforce Strategy Literature Review Page 26

network, from clinicians delivering services on the ground up to the most senior decisionmakers (ibid). Key barriers to effective clinical leadership identified by the evaluationincluded: workloads; clinicians lacking the leadership skills required for the role; and a lack ofadequate support for clinicians who take leadership roles.It is widely agreed that clinical leadership roles should be developed in the cancer workforceto promote innovative practice and change in cancer care and improve the retention ofexperienced and motivated cancer care workers (Barrett 2004). Health service executivesand managers of cancer care services therefore have an important role to play in identifyingclinicians with leadership potential and providing and equipping them with the time, space,resources, information and skills required to make change happen (ibid).Leadership program development - what works and what doesn’tA review of the literature on what works in leadership development programs suggests thatprograms should be structured in a way which will enable participants to learn an array ofcomplex skills that address the ‘real-world’ leadership challenges they are facing and offerthem the opportunity to apply these new skills in their workplace with support from theirsuperiors (Salas & Cannon-Bowers 2001). Leadership development programs should offerspaced learning (the repeated practice of a concept)(Voss, Wiley, Carretero M 1995),incorporate multiple methods such as error learning (identifying and rectifying mistakesmade by oneself, peers)(Joung, Hesketh, & Neal 2007) and reflection (Styhre 2008), provideongoing support in the form of mentoring (Baker 2011) and coaching (Kombarakaran, Yang,Baker & Fernandes 2008), and enable trainees to monitor their progress in relation to a settraining and development plan (Riggio 2008).Leadership development program contentTo ensure the return on investment in leadership development is maximised and leaders ofcancer care services are capable of addressing the complex challenges facing them theliterature suggests the content of leadership programs should:• incorporate the previously discussed findings of recent re-evaluations of thetransformational leadership style which shifts the focus from a ‘heroic’ style, centredaround an extraordinary person with charisma leading from the front, to an engagingand distributed style of leadership• emphasise the importance of bridging the divide between physicians, nurses, alliedhealth staff and administrative staff and provide techniques to achieve this aim, suchas:- how to clearly communicate cross-disciplinary organisational goals, values andsuccesses;- how to model relationships and appropriate behaviour with other professionalgroups; and- how to foster and facilitate consensus building (Bartunek 2011).• provide education on how to transform an organisation’s culture to foster innovation,creativity and change, including:- training in innovation and improvement methods, such as building ‘innovationfactories’ (small-scale functional units with strong processes and support/rewardmechanisms that enable and encourage employees to develop and trial newideas in the workplace)(Snowdon, Shell & Leitch 2010)- using flat organisational structures with flexible, empowered, autonomous andcooperative teams (Martins & Terblanche 2003)National Cancer Workforce Strategy Literature Review Page 27

- creating support mechanisms that reward creative and innovative behaviour(ibid)- encourage management teams to feel comfortable with acceptable risk and toevaluate ideas fairly (ibid)- developing open communication styles that build trust (ibid)• develop health leaders’ ability to think in system terms and effect change in complexadaptive systems (systems where an intervention in one part of the system will impacton many other areas in anticipated and unanticipated ways that can be bothdesirable and undesirable (Plsek & Greenhalgh 2001)), by training them in the skillsneeded to:- address interconnected issues;- build coalitions among disparate stakeholders;- form intra- and inter-organisational partnerships and networks; and- monitor and measure outcomes at the system, organisational, personnel,consumer, and community levels (Bennington & Hartley 2009).• build understanding that consumer feedback and information is an essential sourceof the intelligence necessary to inform the kinds of innovation, improvement andredesign of health systems that will reflect the patient experience, and supportpopulation health outcomes (Chesbrough 2003)• introduce leaders to effective techniques for consumer engagement and feedback,such as :- experience-based co-design – captures the subjective experiences of bothpatients and staff at crucial points in the care pathway and uses it to redesign allor part of a process to bring about sustained improvements in those experiences(Cottam & Leadbeater 2004);- co-Leadership - involves users in activities such as sitting on management boardsand interview panels (Greenhalgh 2010);- mutual learning - incorporates user experiences into student and staff training(Repper 2006; Livingston 2004); and- primary health care councils/citizens’ juries – education and informationexchange processes that allow evidence-informed consultation with communitymembers about principles and priorities of health service delivery (Mooney 2010).National Cancer Workforce Strategy Literature Review Page 28

DOMAIN 4: Health workforce planningEnhance workforce planning capacity, taking account of current andemerging health needs and changes to health workforce configuration,technology and competenciesReview of the cancer workforce literature related to Domain 4Growing demand on the cancer workforceThe need for enhanced capacity in health workforce planning is particularly pressing in thecase of cancer in light of the growing burden of disease caused by cancer, and widespreadshortages in the cancer workforce. The rate of cancer has increased markedly over the pastquarter century. The age-standardised incidence rate for all cancers 5 combined has risenfrom 383 cases per 100,000 people in 1982 to 485 cases per 100,000 people in 2007 (AIHW2010). This means that by the age of 85 years, 1 in 2 males and 1 in 3 females will have beendiagnosed with cancer at some stage in their life (AIHW 2010).In 2005, for the first time, there were over 100,000 new cases of cancer diagnosed in Australia.It was projected that this number would grow by over 3,000 more cases per year during 2006-2010, owing to the ageing of Australia's population and a small increase in the underlyingcancer incidence rate (AIHW 2008). In 2010, cancer was estimated to be the leading causeof the burden of disease in Australia, accounting for 19% of the total burden (AIHW 2010).At the same time, workforce shortages are found in almost every category of cancer-relatedoccupations, including specialised cancer nurses, radiation therapists, medical physicists,pharmacists and cancer specialist clinicians (Koh et al 2008). Shortages are most evidentoutside major capital cities. There is a particular deficit in radiotherapy staffing and alsoequipment, resulting in long waiting lists and times for various cancers (Koh et al 2008).Workforce planning challenges and considerationsHWA was established with a particular brief to address national health workforce datacollection and planning methodologies. The organisation collaborates with agencies tocollect improved data on professional groups, including AHPRA in relation to nationallyregulated professions. HWA is currently building an authoritative National Statistical Resourcewhich is bringing AHPRA data on regulated professions together with other relevant datasources and integrating computerised modelling tools to underpin future health workforceanalysis and planning across the system. HWA is also exploring ways to apply the nationalminimum data set for regulated health professions to a range of self-regulated and unregulatedallied health professions in order to further expand national access to relevanthealth workforce data.A number of challenges confront planning for cancer services and the workforce to deliverthem, many of them consistent with challenges facing the broader health workforce. Inaddition to the growing number of cancer cases, key challenges include disparities inpatient outcomes across population groups (AIHW 2010), system fragmentation acrossmultiple tiers, priorities based on organisational requirements rather than healthcare needs, alack of training curricula standards and credentialing, bureaucratised government-fundedhealth services, an overuse of high-cost clinical specialists, a lack of infrastructure to5 Excluding non-melanoma skin cancerNational Cancer Workforce Strategy Literature Review Page 29

encourage technological change, and a lack of a national approach to data collectionand use (COSA et al 2003).Two further issues particularly pertinent to the cancer workforce are the lack of a cleardefinition of the cancer workforce in the literature, and substantial gaps in health workforcedata (Cancer Australia 2008).One of the reasons it is difficult to define the cancer workforce is that it encompasses arange of occupations from different levels of the health system, many of which conduct onlya proportion of their work in cancer care (Willis & King 2010). In addition, there is limited dataindicating the amount of work that is dedicated to cancer care. No comprehensive medicaloncology workforce data have been routinely collected in Australia at a national or statelevel to date (Medical Oncology Group of Australia Inc 2009). There are gaps in data aboutspecific cancers (Willis & King 2010) and about diagnostic and treatment patterns(information shown to be important in planning health and supportive care services) (Baadeet al 2010).Indigenous status is under-reported in cancer registries and other health records(Roder & Currow 2008).Issues in data collection are widely recognised, and Cancer Australia has developed ANational Cancer Data Strategy to provide direction for collaborative efforts to increase theavailability, consistency and quality of data (Cancer Australia 2008). Continued focus indevelopment in this area will be essential.Limitations of previous approaches to workforce planningIt is argued that previous approaches to planning for the broader health workforce havefocused on existing occupational groups, existing service usage, illness-based models of careand population age projections. These are now seen as insufficient to support innovationand reform and can perpetuate inefficiency (Birch et al 2007; Birch et al 2009).In Australia it is evident that market models based on supply and demand that focusprimarily on adjusting occupational intakes, have not been successful (Willis & King 2010).Some key reasons include long lag times in training, difficulties in measuring changes indemand, and differences across the public and private sectors (Willis & King 2010). Policiesfor creating more graduates in existing professions may also have unintended impacts onother occupations (Leggat 2009) or on micro-level initiatives and new service delivery models(British Medical Association 2006; Duckett 2009). Given these limitations, it is argued thatproductivity gains through organisational initiatives in fact address workforce shortages morequickly and effectively than adjustments of education places (Birch et al 2007; Birch et al2009; Jeon et al 2010).In the context of the cancer workforce, the argument for productivity gains throughorganisational initiatives is an important one, because there are notable recruitment andretention barriers that are influencing workforce supply. A 2009 survey of the Australianoncology workforce (Girgis et al 2009) found that Australian cancer care workers experienceconsiderable occupational distress. More than 90% of those completing the survey (includingnurses, oncologists and palliative care physicians, other health professionals and researchand administration staff) had to moderate or high levels of (self-defined) burnout. Predictorsof burnout included high levels of patient contact, dissatisfaction with one’s leavearrangements, and a reported need for training in communication skills. Other studies andreports have documented recruitment and retention barriers including poor workingconditions, unstructured career paths, a lack of diversity in healthcare professional roles, andthe absence of a national framework to facilitate staff movement or re-entry across thesystem (COSA et al 2003; Willis & King 2010).National Cancer Workforce Strategy Literature Review Page 30

Shifts in workforce demographics and work preferences over time, such as an increasedinterest in part time work and research involvement, also mean a reduction in the workcapacity of an individual health worker (Dear et al 2011). A study of oncologists’ workpreferences proposed that future workforce planning should account for the possibility thatoncologists may spend only two-thirds of their working week in clinical work (Dear et al 2011).Meanwhile, there are examples of organisational initiatives that have increased productivityand system efficiencies. These include a study of the workings of a medical oncology unit inSouth Australia that has resulted in improved efficiencies and quality of care (Okera et al2010); a fast tracking system trialled in Canada which decreased wait times, improvedpatient care and better utilised existing resources (Hendershot et al 2005); and programs inNSW to help staff define and develop their psychosocial services, including patientpopulation identification and tailoring of suitable interventions, triage tools, therapies andprograms to meet demands (Rankin et al 2011). Some studies also indicate that extendingradiation therapy treatment hours may provide a higher patient throughput and betterutilisation of equipment (Brown et al 2009; White et al 2007).Factors influencing supply and demandIn considering workforce demand factors, planning models need to be responsive todisparities in cancer mortality and morbidity across population groups (AIHW 2010); accessissues, particularly in rural and regional Australia (Underhill et al 2009); and the changingneeds of population groups (Birch et al 2007). Among the Aboriginal and Torres Strait Islanderpopulation, cancer profiles and service requirements differ sufficiently from other Australianto require special attention in cancer-service planning (Roder & Currow 2008).Cancer prevention activities will also influence demand so must be factored into workforceplanning. Preventive and screening measures and technology changes may lead to earlierdiagnosis (Wallace et al 2010), affecting the number of cancers detected early in differentpopulation groups (Chang & Collie 2009). Some efforts may place additional burden on thehealth system. For example, Robotin et al (2010) studied the impact of implementing aprogram of screening, surveillance and treatment of chronic hepatitis B in high riskpopulations on health service use. They estimated that the program would result in asignificant increase in demand for specialist services and primary care services.On the supply side, immediate issues influencing workforce include recruitment, retentionand work preferences. However, there are more complex supply factors that must beconsidered in planning models. They include the option for more professions to have accessto Medicare billing as private practitioners, the increasing shift of hospitals and privatepractices to corporate ownership, the shift to community based care, the increased role ofthe private sector and non-government organisations (NGOs) in providing health services,and the interactions between health workers and labour markets, particularly where there iscompetition between public, private NGO employers (Grepin & Savedoff 2009; Palmer &Short 2010). In the health workforce at large, an increasing proportion of people work in theprivate sector. This is partly due to access to work in private hospitals, but also due to theinclusion of new (non-medical) occupational groups into the Medicare provider system (Willis& King 2010).Changing practices in cancer care also directly affect workforce supply and demand. Sincethe development of State and Territory Cancer Control Plans there has been a shift fromconsidering cancer as an acute condition to its identification as a chronic condition, with anemphasis on patient-centred, multi-disciplinary care, and on triaging patients to ensureefficient use of health professionals (Willis & King 2010).National Cancer Workforce Strategy Literature Review Page 31

Another changing practice in cancer care is the increased specialisation of cancertreatment (Gordon et al 2005). It is argued this has led to the overuse of high-cost clinicalspecialists where other professionals could provide services (COSA et al 2003).Palliative care is another key area of growth in cancer care, as evidence mounts for its manybenefits to patients and carers. It is increasingly recognised as fundamental in the startingline-up of care choices for patients with advanced cancer, although referral to palliativecare services remains patchy (Haines 2011).Another trend is that cancer is increasingly treated in the community (Koh et al 2008).General practitioners often diagnose and treat cancer despite not having specificqualifications in cancer care (McKenzie 2007). Many patients also need relatively complexcancer care at home, typically from registered nurses, after being discharged early fromacute care hospitals (McKenzie 2007).There are also trends in providing rural and remote cancer services. The deficiencies incancer services outside of metropolitan areas are well known (Underhill et al 2009) andpatients face significant travel and cost barriers to accessing metropolitan services. Toimprove services in these areas, new cancer centres have opened in major country towns inVictoria and NSW (Koh et al 2008). Other forms of service delivery include outreach programsand shared care, supported by telehealth that allows long distance consultations,transmission of radiology and pathology results, psychosocial support, multidisciplinary teamcare, education and administration (Adams et al 2009). The successful use of theseapproaches relies on a broader specialised system, as well as local primary care providerswho work collaboratively with the specialised services to ensure continuity of care for thepatient (Adams et al 2009).A new approach to workforce planningAn encouraging model for estimating future prostate cancer service needs in Australia hasrecently been developed (Yu et al 2011). The study results have not yet been reported, but aprotocol has been published that outlines how they will model the number of prostatecancer patients who will need medical attention in the near future, and what types ofservices they will need as they move through the trajectory of the disease. The data will bebroken down by patient subgroup, using data from the cancer registry, Medicare andPharmaceutical Benefits data, and a study investigating patterns of care. Limitationsidentified so far are the substantial data demands of the software, and the large number ofdecisions and assumptions about incidence and survival that will be required.To be most effective, workforce planning models need to identify and plan the types ofhealth roles that will best meet the needs of consumers, reflecting consumer preferences,new technologies and treatments, the emergence of new roles, the availability of existingroles such as ‘expert patients’, lay health workers, carers and unpaid health support workersin the home and community. It needs to be responsive and adaptable, using better andmore detailed information to test scenarios. Planning models and frameworks should also bemade available to local planners at the service level to inform the development of microlevelinitiatives.National Cancer Workforce Strategy Literature Review Page 32

DOMAIN 5: Health workforce policy, funding andregulationDevelop policy, regulation, funding and employment arrangements thatsupport health workforce reformReview of the cancer workforce literature related to Domain 5Health workforce policy challengesThe challenges faced by health workforce policy makers are well known and apply equallyin the context of the cancer health workforce. There are marked inequities in health serviceaccess and health outcomes between Indigenous and non-Indigenous Australians, andbetween those residing in metropolitan and non-metropolitan areas (AIHW 2010; Underhill etal 2009). The healthcare system itself is complex, with funding provided by the Australian,state and territory governments, the private sector and individuals. Service provision spansthe public and private sectors and non-government providers such as the Cancer Councilsand volunteer services. Workforce shortages have been found in almost every category ofcancer occupations, in particular outside major capital cities (Koh et al 2008). The costs of,and demand for, drugs and technology are increasing (Koh et al 2008). Each of these issuesinfluence quality of care and this is at a time when cancer is estimated to be the leadingcause of the burden of disease in Australia (AIHW 2010).The international literature on health policy development suggests a common approach is todevelop a national health plan, then address services and service models and then look toinformation technology, capital and workforce (Gorman 2010). In the field of cancer mostStates and Territories have now developed and implemented a cancer plan which sets out avision for a desired network of cancer services. Challenges in implementation, however,include that those producing the plans do not necessarily have the authority to execute andimplement them (Reis 2006) and that there is not always the evidence base to guidedecisions. The need to improve cancer data in Australia has been widely acknowledged(COSA et al 2003; Willis & King 2010) due to gaps and inconsistencies in data and nationaldata definitions. The National Cancer Data Strategy for Australia will play an important role inproviding direction for collaboration in increasing data availability, consistency and quality(Cancer Australia 2008).Policy leversThere are three policy levers that are typically employed by governments to influence thehealth workforce. These include education, occupational regulation and health carefinancing and organisation (Palmer & Short 2010).EducationThe limitations of education policy levers have been discussed in Domain 4. Educationpolicies in any one period have serious implications for policies on health care provision in thefuture (Palmer & Short 2010; Pick 2008). Accordingly, strong links are needed between theeducation and health portfolios, and elements of the education and health systems need toalign with each other and with patient needs (Gorman & Brooks 2009). Education providersmust respond quickly to changing needs in health workforce development, and thenevaluate the effectiveness of their programs using indicators of practice outcomes (Izadi etal 2009).Occupational regulationNational Cancer Workforce Strategy Literature Review Page 33

Public policy defines which employees are qualified to carry out particular work and whichprofessions can determine access to the health care system (Palmer & Short 2010). Thesedecisions also influence other aspects of the workforce, such as the distribution between thepublic and private sector (Willis & King 2010).In the past, professional bodies have had responsibility for regulation, training and supply.Previous efforts by national co-ordinating agencies tasked with co-ordinating cross-sectorplanning of the workforce were unsuccessful. Key contributing factors were competitionbetween professional groups for resources and an approach to workforce planning basedon jurisdictional boundaries and professional silos (Willis & King 2010). The new Australianregulatory framework seeks to overcome previous limitations. It involves Health WorkforceAustralia (HWA) as the centralised national agency that provides information on thedemand, supply and distribution of the workforce, and that standardises clinical educationfor health professionals. In addition the Australian Health Practitioner Regulation Agency hasresponsibility for accreditation and registration of ten health professions, thus aiming toeliminate cross state border restrictions on movement of health professionals.A key challenge for these new agencies will be in managing the differing interests of the selfregulatingprofessional bodies, the tertiary education sector, health service providers andconsumer needs (Willis & King 2010). Points of contention relate to responsibility for training,accreditation and standard setting, determining specialist qualifications for the medicalprofession (AMA 2009; RCPA 2009), multidisciplinary education and training, thestandardisation of clinical hours and development of professional competencies (AMA 2009).Specific to the cancer workforce, the lack of credentialing of individual practitioners andaccreditation of healthcare services was a key concern cited by the Clinical OncologySociety of Australia and the Cancer Council Australia in their 2005 health workforcesubmission to the Productivity Commission. Another of their concerns was a lack of standardsin training curricula. The recommendation was to introduce a system of credentialing, basedon standard competencies and designed to facilitate career paths and staff movementacross the system (COSA & Cancer Council Australia 2005).One important issue to consider is the potential for regulatory boundaries to limitopportunities for enhancing roles of health workers or substituting one type of health workerfor another (Sibbald et al 2004). Regarding the roles of nurses and allied health professionalsin the cancer workforce, there is a need to balance the need for specialist training in workingwith particular types of cancer with the needs of hospitals and health services for moregeneralist skills. Coordination of training will need to be undertaken in close association withprofessional associations and health services at the local level (Willis & King 2010). Anotherissue with implications for training and credentialing is the growing evidence of a relationshipbetween case volume and patient outcomes (Jones 2005), for example in surgicalprocedures (McGrath et al 2005; Diaz Montes et al 2006; Bristow et al 2009) andmammography screening (Buist et al 2011).Another factor for consider includes the established Australian Radiation Protection andNuclear Safety Act 1998, and Drugs, Poisons and Controlled Substances Act 1981.All health professionals need to be supported to provide services to the full extent of theircurrent knowledge, training, experience and skills. For the cancer workforce there are callsfor advanced training in palliative medicine (Cherny 2010), training in recognisingpsychosocial, cultural and spiritual needs (Johnson et al 2008, Rainbird et al 2009),communication skills (Rainbird et al 2009), inter-professional collaboration (Ward et al 2009),developmental needs and differences (Palmer et al 2007). Clinicians operating in rural andNational Cancer Workforce Strategy Literature Review Page 34

It is important to recognise that changes in one part of the system will impact on others. Anational approach should achieve consistency and reduce duplication of effort.Collaboration with relevant government portfolios, professional bodies and acrossjurisdictions and sectors will be crucial.National Cancer Workforce Strategy Literature Review Page 36

their families: The Individual Cancer Assistance Network (ICAN) Model. Social Work inHealth Care, 43(4): 71-83Bober SL, Recklitis CJ, Campbell EG, Park ER, Kutner JS, Najita JS & Diller L (2009). Caring forcancer survivors: A survey of primary care physicians. Cancer, 115(SUPPL. 18): 4409-4418Boyce R (2008). The health workforce: innovations, substitution and reform in Barraclough Sand Gardent H (eds) Analysing Health Policy: a problem-oriented approach. MarrickvilleElsevier.Boyes AW, Girgis A, Zucca AC & Lecanthelinais C (2009). Anxiety and depression amonglong-term survivors of cancer in Australia: Results of a population-based survey. Med JAust, 190S94-98Brennan M, Butow P, Spillane A & Boyle F (2008). Survivorship care after breast cancer.Australian Family Physician, 37(10): 826-830Brennan ME, Butow P, Marven M, Spillane AJ & Boyle FM (2011). Survivorship care after breastcancer treatment - Experiences and preferences of Australian women. Breast, 20(3): 271-277British Medical Association (2006). 21,000 into 9,500 won’t go – BMA raises concerns aboutjunior doctor employment. London: BMA 14 June 2006 press release.Broom A, Adams J & Tovey P (2009). Evidence-based healthcare in practice: a study ofclinician resistance, professional de-skilling, and inter-specialty differentiation in oncology.Social Science & Medicine, 68(1): 192-200Brown, A. M., Atyeo, J., Field, N., Cox, J., Bull, C., & Gebski, V. J. (2009). Evaluation of patientpreferences towards treatment during extended hours for patients receiving radiationtherapy for the treatment of cancer: a time trade-off study. Radiotherapy & Oncology,90(2), 247-252.Brownson RC, Ballew P, Kittur ND, Elliott MB, Haire-Joshu D, Krebill H & Kreuter MW (2009).Developing competencies for training practitioners in evidence-based cancer control.Journal of Cancer Education, 24(3): 186-193Bulsara C, Ward AM & Joske D (2005). Patient perceptions of the GP role in cancermanagement. Australian Family Physician, 34(4): 299-300Burke CS, Stagl CS, Klein C, Goodwin GF, Salas E, Halpin SM (2006) What type of leadershipbehaviors are functional in teams? A meta-analysis. The Leadership Quarterly 17: 288–307Buscarini M & Stein JP (2009). Training the urologic oncologist of the future: Where are thechallenges? Urologic Oncology, 27(2): 193-198Butow PN, Goldstein D, Bell ML, Sze M, Aldridge LJ, Abdo S, Tanious M, Dong S, Iedema R,Vardy J, Ashgari R, Hui R & Eisenbruch M Interpretation in consultations with immigrantpatients with cancer: how accurate is it? Journal of Clinical Oncology, 29(20): 2801-2807Butow PN, Kirsten LT, Ussher JM, Wain GV, Sandoval M, Hobbs KM, Hodgkinson K & Stenlake A(2007). What is the ideal support group? Views of Australian people with cancer and theircarers. Psycho-Oncology, 16(11): 1039-1045Cancer Australia (2008). A National Cancer Data Strategy for Australia. Canberra:Commonwealth of Australia. http://canceraustralia.gov.au/cancer-data/nationalcancer-data-strategyCancer Australia (2011). CanNET National Support and Evaluation Service Final NationalEvaluation Report. Retrieved 16 November 2011 from:National Cancer Workforce Strategy Literature Review Page 39

http://canceraustralia.gov.au/sites/default/files/publications/natl_cannet_eval_report.pdfCare Quality Commission (2011). Previous NHS Staff Surveys [online]. Available at:www.cqc.org.uk/aboutcqc/howwedoit/engagningwithproviders/nhsstaffsurveyes/perivoussurveys.cfmChan R, Gardner G, Webster J & Geary A (2010). Building research capacity in the nursingworkforce: the design and evaluation of the nurse researcher role. Australian Journal ofAdvanced Nursing, 27(4): 62-69Chang, S., & Collie, C. L. (2009). The future of cancer prevention: will our workforce be ready?[Research Support, N.I.H., Extramural]. Cancer Epidemiology, Biomarkers & Prevention,18(9), 2348-2351.Chesbrough H (2003). Open Innovation: the New Imperative for Creating and Profiting fromTechnology. Boston: Harvard Business School PressCheung WY, Neville BA, Cameron DB, Cook EF & Earle CC (2009). Comparisons of Patientand Physician Expectations for Cancer Survivorship Care. Journal of Clinical Oncology,27(15): 2489-2495Cimprich B, Janz NK, Northouse L, Wren PA, Given B & Given CW (2005). Taking charge: Aself-management program for women following breast cancer treatment. Psycho-Oncology, 14(9): 704-717Clinical Leaders Association of New Zealand (2001). Clinical Leadership and ClinicalGovernance: A Review of Developments in New Zealand and Internationally. Wellington:Ministry of HealthClinical Oncological Society of Australia, The Cancer Council Australia & the NationalCancer Control Initiative (2003). Optimising Cancer Care in Australia. National CancerControl Initiative, Melbourne.Coles CE & Spooner D (2011). Lifelong learning in clinical oncology editorial series:introduction and overview. Clinical Oncology, 23(5): 309-311Collins LG, Wender R & Altshuler M (2010). An opportunity for coordinated cancer care:intersection of health care reform, primary care providers, and cancer patients. CancerJournal, 16(6): 593-599Commens CA (2007). Skin cancer: changing paradigms of practice and medical education.Medical Journal of Australia, 187(4): 207-208Copp G, Caldwell K, Atwal A, Brett-Richards M & Coleman K (2007). Preparation for cancercare: Perceptions of newly qualified health care professionals. European Journal ofOncology Nursing, 11(2): 159-167Cottam H & Leadbeater C (2004). Red Paper 01 Health: Co-creating services. London: TheDesign CouncilCox K & Wilson E (2003). Follow-up for people with cancer: nurse-led services and telephoneinterventions. Journal of Advanced Nursing, 43(1): 51-61Croager EJ, Eades T, Pratt IS & Slevin T (2010). Impact of a short, culturally relevant trainingcourse on cancer knowledge and confidence in Western Australia's Aboriginal HealthProfessionals. Australian & New Zealand Journal of Public Health, 34 Suppl 1S76-79National Cancer Workforce Strategy Literature Review Page 40

Cummings G, Hayduk L & Estabrooks C (2005) Mitigating the effects of hospital restructuringon nurses: the responsibility of emotionally intelligent leadership. Nursing Research 54; 1–11Cummings G, Olson K, Hayduk L et al. (2008) The relationship between nursing leadership andnurses’ job satisfaction in Canadian oncology work environments. Journal of NursingManagement 16: 508-518Cummings GG, Olson K, Hayduk L, Bakker D, Fitch M, Green E, Butler L & Conlon M (2008). Therelationship between nursing leadership and nurses' job satisfaction in Canadianoncology work environments. Journal of Nursing Management, 16(5): 508-518Cunningham SM, Copp G, Collins B & Bater M (2006). Pre-registration nursing students'experience of caring for cancer patients. European Journal of Oncology Nursing, 10(1):59-67Currow DC, Eagar K, Aoun S, Fildes D, Yates P & Kristjanson LJ (2008). Is it feasible anddesirable to collect voluntarily quality and outcome data nationally in palliativeoncology care? Journal of Clinical Oncology, 26(23): 3853-3859Dalton L, Luxford K, Boyle F, Goldstein D, Underhill C & Yates P (2006). An educationalworkshop program for rural practitioners to encourage best practice for delivery ofsystemic adjuvant therapy. J Cancer Educ, 2135-39Davidson PM, Elliott D & Daly J (2006) Clinical leadership in contemporary clinical practice:Implications for nursing. Australian Journal of Nursing Management 14: 180-187Dear, R. F., Tattersall, M. H., McGeechan, K., & Vaughan, M. (2011). Factors associated withAustralian and New Zealand oncologists' future work preferences. Asia-Pacific Journal ofClinical Oncology, 7(1), 56-64. doi: 10.1111/j.1743-7563.2010.01371.xDeGroot T, Kiker DS & Cross TC (2000) A meta-analysis to review organizational outcomesrelated to charismatic leadership. Canadian Journal of Administrative Sciences 17: 356-371Dennis KEB & Duncan G (2010). Radiation oncology in undergraduate medical education: aliterature review. International Journal of Radiation Oncology, Biology, Physics, 76(3): 649-655Dewar AM, Steginga SK, Dunn J, McCarthy A, Yates P, Beadle G & Lancaster L (2003).Delivering cancer-nursing education to regional, rural and remote area nurses inQueensland. Cancer Forum, 27(2): 111-114Dimoska A, Butow PN, Dent E, Arnold B, Brown RF & Tattersall MHN (2008). An examination ofthe initial cancer consultation of medical and radiation oncologists using the Cancodeinteraction analysis system. British Journal of Cancer, 98(9): 1508-1514Dimoska A, Girgis A, Hansen V, Butow PN & Tattersall MHN (2008b). Perceived difficulties inconsulting with patients and families: a survey of Australian cancer specialists. MedicalJournal of Australia, 189(11-12): 612-615Dirks KT & Ferrin DL (2002). Trust in leadership: Meta-analytic findings and implications forresearch and practice. Journal of Applied Psychology 87: 611-628; Gernster CR & Day DV(1997). Meta-analytic review of leader-member exchange theory: Correlates andconstruct issues. Journal of Applied Psychology 82: 827-844Döhler N, Krolop L, Ringsdorf S, Meier K, Ko YD, Kuhn W, Schwalbe O & Jaehde U (2011). Taskallocation in cancer medication management - Integrating the pharmacist. PatientEducation and Counseling, 83(3): 367-374National Cancer Workforce Strategy Literature Review Page 41

Dorgan S, Layton D, Bloo N, Homke R, Sadun R & Van Reenen J (2010). Management inHealth care: Why Good Practice Really Matters [online]. Report by McKinsey & Co andthe Centre for Economic Performance. Available at:http://cep.lse.ac.uk/textoly/_new/research/productivity/management/PDF/Management_in_Health care_Report.pdf (accessed on 6th June 2011)Duckett S (2009). Interdependence of the Health and Education Sectors in Meeting HealthHuman Resource Needs. Healthcarepapers 9(2): 30–4; discussion 60–3.Edmonstone J (2008). Clinical leadership: the elephant in the room. International Journal ofHealth Planning and Management 24(4):290-305Eide MJ, Weinstock MA, Clark MA (2009). The association of physician-specialty density andmelanoma prognosis in the United States, 1988 to 1993. Journal of the AmericanAcademy of Dermatology 60:51–58.Erikson C, Salsberg E, Forte G, Bruinooge S & Goldstein M (2007). Future supply and demandfor oncologists: Challenges to assuring access to oncology services. Journal of OncologyPractice, 3(2): 79-86Farrell C, Molassiotis A, Beaver K & Heaven C (2011). Exploring the scope of oncologyspecialist nurses' practice in the UK. European Journal of Oncology Nursing, 15(2): 160-166Fellowes D., Wilkinson S. & Moore P. (2004) Communication skills training for health careprofessionals working with cancer patients, their families and/or carers. CochraneDatabase of Systematic Reviews (Online) Issue 2, CD003751.Fielder FE (1967). A Theory of Leadership Effectiveness. New York: McGraw-HillFleissig A, Jenkins V, Catt S & Fallowfield L (2006). Multidisciplinary teams in cancer care: arethey effective in the UK? Lancet Oncology, 7(11): 935-943Fox E, Barrett-McNeil K, Khoo LH & Middleton M (2011). Nurse led electronic toxicity scoring inhead and neck radiotherapy. European Journal of Oncology Nursing, 15(2): 112-117Friese CR, Hawley ST, Griggs JJ, Jagsi R, Graff J, Hamilton AS, Janz NK & Katz SJ (2010).Employment of nurse practitioners and physician assistants in breast cancer care. Journalof Oncology Practice, 6(6): 312-316Gagnon M, Pare G, Pollender H & al. e (2011). Supporting work practices through telehealth:impact on nurses in peripheral regions. BMC Health Services Research, 11Girgis A, Hansen V & Goldstein D (2009). Are Australian oncology health professionals burningout? A view from the trenches. European Journal of Cancer, 45(3): 393-399Glasgow MES & Dreher HM The future of oncology nursing science: who will generate theknowledge? Oncology Nursing Forum, 37(4): 393-396Gordon, L. G., Scuffham, P., Battistutta, D., Graves, N., Tweeddale, M., & Newman, B. (2005).A cost-effectiveness analysis of two rehabilitation support services for women with breastcancer. Breast Cancer Research & Treatment, 94(2), 123-133.Gorey KM, Luginaah IN, Holowaty EJ, Fung KY, Hamm C (2010). Physician supply and breastcancer survival. Journal of the American Board of Family Practice. 23:104–108.Graham J & Ramirez AJ (2002). Improving the working lives of cancer clinicians. Eur J CancerCare, 11188-192National Cancer Workforce Strategy Literature Review Page 42

Grant M, Elk R, Ferrell B, Morrison RS & von Gunten CF (2009). Current status of palliative care--clinical implementation, education, and research. CA: a Cancer Journal for Clinicians,59(5): 327-335Greenhalgh T (2010). User Involvement in Health Care. Hoboken, NJ: Wiley-BlackwellGrepin K & Savedoff WD (2009). 10 best resources on health workers in developing countries.Health Policy and Planning 24: 479–82.Griffith KA, McGuire DB & Russo M (2010). Meeting Survivors' Unmet Needs: An IntegratedFramework for Survivor and Palliative Care. Seminars in Oncology Nursing, 26(4): 231-242Grunfeld E, Levine MN, Julian JA, Coyle D, Szechtman B, Mirsky D, Verma S, Dent S, Sawka C,Pritchard KI, Ginsburg D, Wood M & Whelan T (2006). Randomized trial of long-termfollow-up for early-stage breast cancer: A comparison of family physician versus specialistcare. Journal of Clinical Oncology, 24(6): 848-855Gysels M., Richardson A. & Higginson I.J. (2004) Communication training for healthprofessionals who care for patients with cancer: a systematic review of effectiveness.Supportive Care in Cancer 12, 692–700Gysels M, Richardson A & Higginson IJ. (2007). Does the patient-held record improvecontinuity and related outcomes in cancer care: a systematic review (Structuredabstract). Health Expectations [Online]. Available:http://www.mrw.interscience.wiley.com/cochrane/cldare/articles/DARE-12007005524/frame.htmlHaines IE (2011). Managing patients with advanced cancer: the benefits of early referral forpalliative care. Medical Journal of Australia, 194(3): 107-108Haines, I. E. Managing patients with advanced cancer: the benefits of early referral forpalliative care. Medical Journal of Australia, 194(3), 107-108.Hallinan CM (2010). Program logic: a framework for health program design and evaluation -the Pap nurse in general practice program. Australian Journal of Primary Health, 16(4):319-325Ham C (2003). Improving the performance of health services: The role of clinical leadership.Lancet 361: 1978-1980Han PK & Rayson D (2010). The coordination of primary and oncology specialty care at theend of life.Harrison JD, Choy ET, Spillane A, Butow P, Young JM & Evans A (2008). Australian breastcancer specialists' involvement in multidisciplinary treatment planning meetings. Breast,17(4): 335-340Harrison JD, Young JM, Solomon MJ, Butow PN, Secomb R & Masya L (2011). Randomizedpilot evaluation of the supportive care intervention "CONNECT" for people followingsurgery for colorectal cancer. Diseases of the Colon & Rectum, 54(5): 622-631Hayes C & Ponte P, Coakley A et al. (2005) Retaining oncology nurses: strategies for today’snurse leaders. Oncology Nursing Forum 32 (6): 1087–1090Health Workforce Australia (2011). National Health Workforce Innovation and ReformStrategic Framework for Action 2011-2015: Background paper. Adelaide: HealthWorkforce AustraliaHealth Workforce Australia (2011a). National Health Workforce Innovation and ReformStrategic Framework for Action 2011-2015. Adelaide: Health Workforce AustraliaNational Cancer Workforce Strategy Literature Review Page 43

Hemphill JK & Coons AE (1957). Development of the leader behavior descriptionquestionnaire. Leader Behavior: Its Description and Measurement 6: 38Hendershot, E., Murphy, C., Doyle, S., Van-Clieaf, J., Lowry, J., & Honeyford, L. (2005).Outpatient chemotherapy administration: decreasing wait times for patients and families.Journal of Pediatric Oncology Nursing, 22(1), 31-37.Hewitt M, Greenfield S & Stovall E (2006). From cancer patient to cancer survivor: Lost intransition. Washington, DC:Hockey J & Ley I (2010). Leading for Engagement: How Senior Leaders Engage Their People.Report for National School of GovernmentHudson B (2002). Interprofessionality in health and social care: the Achilles' heel ofpartnership? Journal of Interprofessional Care, 167-17Hussainy SY, Marriott JL, Beattie J, Nation RL & Dooley MJ (2010). A palliative cancer careflexible education program for Australian community pharmacists. American Journal ofPharmaceutical Education, 74(2): 24Institute of Medicine (2009). Ensuring Quality Cancer Care Through the Oncology Workforce:Sustaining Care in the 21st Century.Jefford M, Lotfi-Jam K, Baravelli C, Grogan S, Rogers M, Krishnasamy M, Pezaro C, Milne D,Aranda S, King D, Shaw B & Schofield P (2011). Development and pilot testing of a nurseledposttreatment support package for bowel cancer survivors. Cancer Nursing, 34(3): E1-10Jeon Y-H, Glasgow N et al (2010). Policy options to improve leadership of middle managers inthe Australian residential aged care setting: a narrative synthesis. BMC Health ServicesResearch 10: 190.Jiwa M, Halkett G, Deas K, Ward P, O'Connor M, O'Driscoll C, O'Brien E, Wilson L, Boyle S &Weir J (2009). How do specialist breast nurses help breast cancer patients at follow-up?Collegian: Journal of the Royal College of Nursing, Australia, 17(3): 143-149Jiwa M, Saunders CM, Thompson SC & al. e (2008). Timely cancer diagnosis andmanagement as a chronic condition: opportunities for primary care. Med J Aust, 18978-82Johnson C, Girgis A, Paul C, Currow DC, Adams J & Aranda S (2010). Australian palliativecare providers' perceptions and experiences of the barriers and facilitators to palliativecare provision. Supportive Care in Cancer, 19(3): 343-351Johnson CE, Girgis A, Paul CL & Currow DC (2008). Cancer specialists' palliative care referralpractices and perceptions: results of a national survey. Palliative Medicine, 22(1): 51-57Jones L, Leach L, Chambers S & Occhipinti S (2010). Scope of practice of the breast carenurse: a comparison of health professional perspectives. European Journal of OncologyNursing, 14(4): 322-327Joung W, Hesketh B, Neal A (2007). Using ‘war stories’ to train for adaptive performance: Is itbetter to learn from error or success? Applied Psychology: An International Review 55:282-302Judge TA & Piccolo RF (2004). Transformational and transactional leadership: A metaanalytictest of their relative validity. Journal of Applied Psychology 89(5): 755-76Kings Fund (2011). The Future of Leadership and Management in the NHS: No More Heroes.Report by The King’s Fund Commission on Leadership and Management in the NHSNational Cancer Workforce Strategy Literature Review Page 44

Klabunde CN, Ambs A, Keating NL, He Y, Doucette WR, Tisnado D, Clauser S & Kahn KL(2009). The role of primary care physicians in cancer care. Journal of General InternalMedicine, 24(9): 1029-1036Koczwara B, Francis K, Marine F, Goldstein D, Underhill C & Olver I (2010). Reaching furtherwith online education? the development of an effective online program in palliativeoncology. Journal of Cancer Education, 25(3): 317-323Koh, E. S., Do, V. T., & Barton, M. B. (2008). Frontiers of cancer care in Asia-Pacific region:Cancer care in Australia. Biomedical Imaging and Intervention Journal, 4(3). doi:10.2349/biij.4.3.e30Kombarakaran FA, Yang JA, Baker MN & Fernandes PB (2008). Executive coaching: It works!Journal of Practice and Research 60(1): 78-90Kouzes JM & Posner BZ (2007) The Leadership Challenge (4th ed). San Francisco CA: Jossey-BassLawson KA, Chew M & Van Der Weyden MB (2004). The new Australian medical schools:daring to be different. Med J Aust, 181662-666Le BHC & Watt JN (2010). Care of the Dying in Australia's Busiest Hospital: Benefits of PalliativeCare Consultation and Methods To Enhance Access. Journal of Palliative Medicine, 13(7):855-860Leggat S (2009). Moving beyond obsolescence: an important role for educational institutionsin health human resources needs. Healthcarepapers 9(2): 21–4; discussion 60–3.Leslie K, Curtis M & Lunn D (2003). Education to achieve symptom control for patients withcancer. Nursing Standard, 99(16): 34-36Levit L, Smith AP, Benz Jr EJ & Ferrell B (2010). Ensuring quality cancer care through theoncology workforce. Journal of Oncology Practice, 6(1): 7-11Livingston G (2004). User and carer involvement in mental health training. AdvancedPsychiatric Treatment, 10: 84-92Lupu D & American Academy of Hospice and Palliative Medicine Workforce Task Force(2010). Estimate of current hospice and palliative medicine physician workforce shortage.Journal of Pain & Symptom Management, 40(6): 899-911Marble SG (2009). Five-step model of professional excellence. Clinical Journal of OncologyNursing, 13(3): 310-315Martins EC & Terblanche F (2003). Building organisational culture that stimulates creativityand innovation. European Journal of Innovation Management 6(1): 64-74Masood SA, Dani SS, Burns ND & Backhouse CJ (2006). Transformational leadership andorganizational culture: The situational strength perspective. Proceedings of the Institutionof Mechanical Engineers, Part B: Journal of Engineering Manufacture, 220(6): 941-949McAvoy BR, Fletcher JM & Elwood M (2007). Cancer education and training in primary healthcare--a national audit of training providers. Australian Family Physician, 36(11): 973-976McCallin AM (2001). Interdisciplinary practice - a matter of teamwork: an integratedliterature review. Journal of Clinial Nursing, 10419-428McCarthy A, Hegney D, Brown L, Gilbar P, Brodribb R & Swales J (2003). The chemotherapyeducation needs of nurses working in rural and remote areas of Queensland.Toowoomba: Department of Nursing, University of Southern QueenslandNational Cancer Workforce Strategy Literature Review Page 45

McClelland DC (1961). The Achieving Society. New York: Van Nostrand ReinholdMcKenna M, Pugno P, Frist W (2006). Physicians as Leaders: Who How and Why Now? Oxford:RadcliffeMcKenzie, H., Boughton, M., Hayes, L., Forsyth, S., Davies, M., Underwood, E., & McVey, P.(2007). A sense of security for cancer patients at home: the role of community nurses.Health & Social Care in the Community, 15(4), 352-359.Medical Oncology Group of Australia Incorporated. (2009). Australian Medical OncologistWorkforce Study 2009. http://www.moga.org.au/news-events/australian-medicaloncologist-workforce-study-2009Mooney G (2010). A Handbook on Citizens’ Juries. Available at www.gavinmooney.comMorcom J, Dunn SV & Luxford Y (2005). Establishing an Australian nurse practitioner-ledcolorectal cancer screening clinic. Gastroenterology Nursing, 28(1): 33-42Nielsen JD, Palshof T, Mainz J, Jensen AB & Olesen F (2003). Randomised controlled trial of ashared care programme for newly referred cancer patients: bridging the gap betweengeneral practice and hospital. Quality & Safety in Health Care, 12(4): 263-272Oeffinger KC & McCabe MS (2006). Models for delivering Survivorship care. Journal of ClinicalOncology, 24(32): 5117-5124Okera, M., Baker, N. A., Hayward, A. M., & Selva-Nayagam, S. (2011). Oncology workforceissues: The challenge of the outpatient clinic. Internal Medicine Journal, 41(6), 499-503.doi: 10.1111/j.1445-5994.2011.02506.xPalmer G & Short S (2010). The Health Workforce. Health Care and Public Policy: An AustralianAnalysis. Palgrave Macmillan.Perkins A & Kron T (2007). Continuing professional development needs of Australian RadiationOncology Medical Physicists - An analysis of applications for CPD funding. AustralasianPhysical and Engineering Sciences in Medicine, 30(3): 226-232Philip J, Gold M, Schwarz M & Komesaroff P (2010). Second medical opinions: the views ofoncology patients and their physicians. Supportive Care in Cancer, 18(9): 1199-1205Plevin DM, Ward HM, Ward MB, Sorich MJ & McKinnon RA (2010). Pharmacists' role intargeted cancer therapy in Australia and implications for pharmacy education.American Journal of Pharmaceutical Education, 74(9): 168Plsek PE & Greenhalgh T (2001). The challenge of complexity in health care. BMJ, 323(7313):625Potosky AL, Han PKJ, Rowland J, Klabunde CN, Smith T, Aziz N, Earle C, Ayanian JZ, Ganz PA& Stefanek M (2011). Differences Between Primary Care Physicians' and Oncologists'Knowledge, Attitudes and Practices Regarding the Care of Cancer Survivors. Journal ofGeneral Internal Medicine, 1-8Poulsen M, Middleton M, McQuitty S, Ramsay J, Gogna K, Martin J, Khoo E, Wong W,Fairweather R & Walpole E (2010). Comparison of a Commonwealth-initiated regionalradiation oncology facility in Toowoomba with a Queensland Health facility. Journal ofMedical Imaging & Radiation Oncology, 54(4): 368-374Rainbird K, Perkins J, Sanson-Fisher R, Rolfe I & Anseline P (2009). The needs of patients withadvanced, incurable cancer. British Journal of Cancer, 101(5): 759-764National Cancer Workforce Strategy Literature Review Page 46

Rankin NM, Barron JA, Lane LG, Mason CA, Sinclair S & Bishop JF (2011). Psychosocialoncology services in New South Wales. Australian Health Review, 35(2): 156-163Reinertsen JL (1998). Physicians as leaders in the improvement of health care systems. Annalsof Internal Medicine, 128(10): 833-838Repper J (2006). User and carer involvement in the training and education of healthprofessionals: a review of the literature. International Journal of Nursing Studies 44(3): 511-519Riggio RE (2008). Leadership development: current state & future expectations. ConsultingPsychology Journal: Practice and Research 60: 383-392Robotin, M. C., Kansil, M. Q., George, J., Howard, K., Tipper, S., Levy, M., . . . Penman, A. G.Using a population-based approach to prevent hepatocellular cancer in New SouthWales, Australia: effects on health services utilisation. BMC Health Services Research, 10,215.Roder, D., & Currow, D. (2009). Cancer in aboriginal and Torres Strait Islander people ofAustralia. Asian Pacific Journal of Cancer Prevention: 10(5), 729-733.Roebuck C (2011). Developing Effective Leadership in the NHS: A Short Report for The King'sFund [online]. Available at www.kingsfund.org.uk/leadershipcommission.htmlRosenberg JP & Canning DF (2004). Palliative care by nurses in rural and remote practice.Australian Journal of Rural Health, 12(4): 166-171Rosenthal TC (2008). The medical home: Growing evidence to support a new approach toprimary care. Journal of the American Board of Family Medicine, 21(5): 427-440Rowlands S, Callen J & Westbrook J (2010). What information do general practitioners needto care for patients with lung cancer? A survey of general practitioners perceptions.Health Information Management Journal, 39(1): 8-16Sabesan S & Brennan S (2011). Tele Oncology for Cancer Care in Rural Australia. In:RAKOWSKY, G. G. A. S. (ed.) Telemedicine Techniques and Applications. InTechSalas E & Cannon-Bowers J (2001) The science of training: a decade of progress. AnnualReview of Psychology 52: 471-499; Aguinis H & Kraiger K (2009). Benefits of training anddevelopment for individuals and teams organisations and society. Annual Review ofPsychology 60: 451-474Sanson-Fisher R, Girgis A, Boyes A, Bonevski B, Burton L & Cook P (2000). The unmet supportivecare needs of patients with cancer. Cancer, 88(1): 226-237Sarros JC, Cooper BK & Santora JC (2008). Building a climate for innovation throughtransformational leadership and organizational culture. Journal of Leadership &Organizational Studies 15(2): 145Scheuner MT, Sieverding P & Shekelle PG (2008). Delivery of genomic medicine for commonchronic adult diseases: a systematic review. JAMA, 299(11): 1320-1334Segal L & Bolton T (2009). Issues facing the future health care workforce: The importance ofdemand modelling. Australia and New Zealand Health Policy 6(12).Sessions JK, Valgus J, Barbour SY & Iacovelli L (2010). Role of oncology clinical pharmacists inlight of the oncology workforce study. Journal of Oncology Practice, 6(5): 270-272National Cancer Workforce Strategy Literature Review Page 47

Shahid S, Finn L, Bessarab D & Thompson SC (2009). Understanding, beliefs and perspectivesof Aboriginal people in Western Australia about cancer and its impact on access tocancer services. BMC Health Services Research, 9132Shepherd H, Tattersall M & Butow P (2008). Physician-identified factors affecting patientparticipation in reaching treatment decisions. J Clin Oncol, 261724-1731Shepherd L, Goldstein D, Olver I & Parle M (2008b). Enhancing psychosocial care for peoplewith cancer in rural communities: what can remote counselling offer? Australian HealthReview, 32(3): 423-438Shulman LN, Jacobs LA, Greenfield S, Jones B, McCabe MS, Syrjala K, Diller L, Shapiro CL,Marcus AC, Campbell M, Santacroce S, Kagawa-Singer M & Ganz PA (2009). Cancercare and cancer survivorship care in the United States: Will we be able to care for thesepatients in the future? Journal of Oncology Practice, 5(3): 119-123Sidhom M, Holt T, Fanous D, Morarji K & Kua B (2007). 'Give me understanding and I shall live':radiation oncology teaching in 2017. 58th Annual Scientific Meeting of Royal Australianand New Zealand College of Radiologists, Melbourne, 4-7 October 2007. Australas Radiol,51A83Smith AP & Lichtveld MY (2007). A competency-based approach to expanding the cancercare workforce. MEDSURG Nursing, 16(2): 109-117; quiz 118Smith AP, Lichtveld MY, Miner KR, Tyus SL & Gase LN (2009). A competency-based approachto expanding the cancer care workforce: proof of concept. MEDSURG Nursing, 18(1): 38-49; quiz 50Smith SM, Allwright S & O' Dowd T (2007). Effectiveness of shared care across the interfacebetween primary and specialty care in chronic disease management. CochraneDatabase of Systematic Reviews, (3):Snowdon A, Shell J & Leitch K (2010). Innovation Takes Leadership. Report by Ivey Centre forHealth Innovation and LeadershipStacey D, Chambers SK, Jacobsen MJ & Dunn J (2008). Overcoming barriers to cancerhelplineprofessionals providing decision support for callers: an implementation study.Oncology Nursing Forum, 35(6): 961-969Stafford L & Judd F (2010). Mental health and occupational wellbeing of Australiangynaecologic oncologists. Gynecologic Oncology, 116(3): 526-532Stamm B (2009). Leadership for innovation: what you can do to create a culture conduciveto innovation. Strategic Direction 25(6): 13-15Starmer DL & Barton MB (2009). Advances in cancer management: at what cost to medicalstudent education? Journal of Cancer Education, 24(3): 233-237Starmer DL, Chapman E & Millward MJ (2010). Applying global frameworks to assessment inmedical education: an example of a nationally produced curriculum for cancereducation. Journal of Cancer Education, 25(3): 285-289Steginga SK, Campbell A, Ferguson M, Beeden A, Walls M, Cairns W & Dunn J (2008). Sociodemographic,psychosocial and attitudinal predictors of help seeking after cancerdiagnosis. Psycho-Oncology, 17(10): 997-1005Steginga SK, Dunn J, Dewar AM, McCarthy A, Yates P & Beadle G (2005). Impact of anintensive nursing education course on nurses' knowledge, confidence, attitudes, andNational Cancer Workforce Strategy Literature Review Page 48

perceived skills in the care of patients with cancer. Oncology Nursing Forum, 32(2): 375-381Stogdill RM (1948). Personal factors associated with leadership: A survey of the literature.Journal of Psychology 25: 35-71Styhre A (2008) Coaching as second order observations: learning from site managers inconstruction. Leadership and Organisation Developmental Journal 29(3): 275-290Sussman J & Baldwin LM (2010). The interface of primary and oncology specialty care: Fromdiagnosis through primary treatment.Taplin SH, Clauser S, Rodgers AB, Breslau E & Rayson D (2010). Interfaces across the cancercontinuum offer opportunities to improve the process of care. Journal of the NationalCancer Institute. Monographs, 2010(40): 104-110Tattersall MHN, Dear RF, Jansen J, Shepherd HL, Devine RJ, Horvath LG & Boyer ML (2009).Second opinions in oncology: the experiences of patients attending the Sydney CancerCentre. Medical Journal of Australia, 191(4): 209-212Thanacoody PR, Bartram T & Casimir G (2009). The effects of burnout and supervisory socialsupport on the relationship between work-family conflict and intention to leave: a studyof Australian cancer workers. Journal of Health Organization & Management, 23(1): 53-69Thomas R, Lean C, Murray P & Sinclair S (2009). Evaluating the effectiveness of cancer carecoordination in New South Wales. incite. Cancer Institute NSWTopakas A, Admasachew L & Dawson J (in press). Outcomes of Staff Engagement in the NHS:A Trust Level Analysis. Aston UniversityTurnbull James K (2011). Leadership in Context: Lessons from New Leadership Theory andCurrent Leadership Development Practice [online]. URL:www.kingsfund.org.uk/leadershipcommissionTurner J, Clavarino A, Butow P & al. e (2009). Enhancing the capacity of oncology nurses toprovide supportive care for parents with advanced cancer: Evaluation of an educationalintervention. Eur J Cancer, 451798-1806Turner J, Kelly B & Girgis A (2011). Supporting oncology health professionals: A review. Psycho-Oncologie, 5(2): 77-82Uitterhoeve RJ, Bensing JM, Grol RP, Demulder PH & Van Achterberg T. (2010). The effect ofcommunication skills training on patient outcomes in cancer care: a systematic review ofthe literature (Provisional abstract). European Journal of Cancer Care [Online]. Available:http://www.mrw.interscience.wiley.com/cochrane/cldare/articles/DARE-12010006511/frame.htmlUnderhill, C., Bartel, R., Goldstein, D., Snodgrass, H., Begbie, S., Yates, P., . . . Grogan, P. (2009).Mapping oncology services in regional and rural Australia. Australian Journal of RuralHealth, 17(6), 321-329.Ussher J, Kirsten L, Butow P & Sandoval M (2006). What do cancer support groups providewhich other supportive relationships do not? The experience of peer support groups forpeople with cancer. Social Science & Medicine, 62(10): 2565-2576Valgus J, Jarr S, Schwartz R, Rice M & Bernard SA (2010). Pharmacist-led, interdisciplinarymodel for delivery of supportive care in the ambulatory cancer clinic setting. Journal ofOncology Practice, 6(6): e1-e4National Cancer Workforce Strategy Literature Review Page 49

Valgus JM, Aimee F, Gregory KM, Sandra J, Scott S, Stephen C, Walko CM, Jiyeun K &Bernard SA (2011). Integration of a clinical pharmacist into the hematology-oncologyclinics at an academic medical center. American Journal of Health-System Pharmacy,68(7): 613-619Verschuur EML, Steyerberg EW, Tilanus HW, Polinder S, Essink-Bot ML, Tran KTC, van der GaastA, Stassen LPS, Kuipers EJ & Siersema PD (2009). Nurse-led follow-up of patients afteroesophageal or gastric cardia cancer surgery: a randomised trial. British Journal ofCancer, 100(1): 70-76Victorian Quality Council (2005). Developing the Clinical Leadership Role in ClinicalGovernance: A Guide for Clinicians and Health Services.Volker DL, Watson J, Becker H & Scott T (2011). Assessing cancer-related learning needs oftexas nurses. Cancer Nursing, 34(5): E20-E27Voss J, Wiley J, Carretero M (1995). Acquiring intellectual skills. Annual Review of Psychology46: 155-181Wagner EH, Bowles EJA, Greene SM, Tuzzio L, Wiese CJ, Kirlin B & Clauser SB (2010). The qualityof cancer patient experience: Perspectives of patients, family members, providers andexperts. Quality and Safety in Health Care, 19(6): 484-489Wallace, A. H., Havrilesky, L. J., Valea, F. A., Barnett, J. C., Berchuck, A., & Myers, E. R. (2008).Projecting the need for gynecologic oncologists for the next 40 years. Obstetrics &Gynecology, 116(6), 1366-1372.Walsh J, Harrison JD, Young JM, Butow PN, Solomon MJ & Masya L (2010a). What are thecurrent barriers to effective cancer care coordination? A qualitative study. BMC HealthServices Research, 10132Walsh J, Young JM, Harrison JD, Butow PN, Solomon MJ, Masya L & White K (2010b). What isimportant in cancer care coordination? A qualitative investigation. European Journal ofCancer Care, 20(2): 220-227Ward AM, Agar M & Koczwara B (2009). Collaborating or co-existing: a survey of attitudes ofmedical oncologists toward specialist palliative care. Palliative Medicine, 23(8): 698-707Ward M (2005). Leadership and clinically managed networks Queensland Health SystemReview Final Report. Retrieved 27 August 2007 from:http://wwwhealthqldgovau/health_sys_review/final/Wattchow DA, Weller DP, Esterman A, Pilotto LS, McGorm K, Hammett Z, Platell C & Silagy C(2006). General practice vs surgical-based follow-up for patients with colon cancer:randomised controlled trial. British Journal of Cancer, 94(8): 1116-1121Weinerman B, den Duyf J, Hughes A & Robertson S (2005). Can subspecialty cancerconsultations be delivered to communities using modern technology?--A pilot study.Telemedicine Journal & E-Health, 11(5): 608-615Weller DP & Harris MF (2008). Cancer care: what role for the general practitioner? Med J Aust,18959-60White, L., Beckingham, E., Calman, F., & Deehan, C. (2007). Extended hours working inradiotherapy in the UK. Clinical Oncology, 19(4), 213-222.Willard C & Luker K (2007). Working with the team: strategies employed by hospital cancernurse specialists to implement their role. Journal of Clinical Nursing, 16(4): 716-724National Cancer Workforce Strategy Literature Review Page 50

Willis E, King D (2010). Independent regulatory agencies and Australia’s health workforcecrisis. Lessons from the gynaecological cancers workforce. International Journal ofSociology and Social Policy 31(1/2): 21-33.Wyatt D (2007). How do participants of a post registration oncology nursing course perceivethat the course influences their practice? A descriptive survey. European Journal ofOncology Nursing, 11(2): 168-178Youl PH, Baade PD, Janda M & al. e (2007). Diagnosing skin cancer in primary care: how domainstream general practitioners compare with primary care skin cancer clinic doctors?Medical Journal of Australia, 2007(187): 215-220Yu, X. Q., Smith, D. P., Clements, M. S., Patel, M. I., McHugh, B., & O'Connell, D. L. (2011).Projecting prevalence by stage of care for prostate cancer and estimating future healthservice needs: Protocol for a modelling study. British Medical Journal Open. doi:10.1136/bmjopen-2011-000104Zebrack B, Walsh K, Burg MA, Maramaldi P & Lim J-w (2008). Oncology social workercompetencies and implications for education and training. Social Work in Health Care,47(4): 355-375Zorbas H, Barraclough B, Rainbird K & al. e (2003). Multidisciplinary care in the Australiancontext: what does it mean? Medical Journal of Australia, 179(10): 528-531National Cancer Workforce Strategy Literature Review Page 51

Appendix A: Database search strategyMEDLINE is the U.S. National Library of Medicine's premier bibliographic database containingover 18 million references to journal articles in life sciences with a concentration onbiomedicine. A distinctive feature of MEDLINE is that the records are indexed with NLMMedical Subject Headings (MeSH). This enhances precision in retrieval. CINHAL indexes abroader range of health sciences literature and includes document types not covered byMEDLINE including as well as journal articles: books, book chapters, audiovisual items,pamphlets, software, dissertations, or research instruments. AMI indexes Australian and NewZealand health sciences journals not indexed by Medline. AMI and CINAHL also use modifiedversions of MeSH indexing. Scopus is currently the largest single abstract and citationdatabase with over 45.5 million records. These include the social sciences and policy studiesas well as the health sciences literature. Scopus has the added feature of being about toprospectively track citations for articles after their publication date. This enhances thetraditional method of hand searching the retrospective references of individual articles.The search strategy used for MEDLINE started with a narrow focus on ‘cancer’ and‘workforce’ using the MeSH heading ‘neoplasms’, used for all cancers and tumors combinedwith the text word “cancer”. The second set was built around the MeSH heading ‘healthmanpower’ which covers human resources, personnel, etc and the text word ‘workforce’.These two sets were combined and the subject indexing of the resulting references wasexamined in detail.These initial search results indicated the need to broaden considerably the search strategy toinclude the subheading ‘manpower’ for the MeSH terms ‘oncologic nursing’, ‘radiationoncology’ and ‘medical oncology’ and a range of other aspects of workforce aroundeducation, training and service planning. The following sets of MeSH terms and key phraseswere searched and combined with the inital ‘neoplasm’ and ‘cancer’ set.Set 1 - health care reform; delivery of health care; health care costs; health planning; healthservices needs and demand; healthcare disparities. Key phrases also used in Set 1included‘human resource$’, ‘model$ of care’, ‘Integrated cancer’.Set 2 - clinical competence; professional competence/st [Standards]; competency-basededucation/og [Organization & Administration]; education, nursing, continuing/og[Organization & Administration]; inservice training/og [Organization & Administration];education, medical, continuing; evidence-based medicine/ed [Education].These search strategies were replicated in CINAHL, the Cochrane Library and AMI. The resultswere limited to post publication date of 2005 inclusive. Additional searches were undertakenin AMI to ensure comprehensive coverage of all indexed Australian publications dating from2000 relevant to the cancer workforce, its education and training and the cancer treatmentservice planning and delivery. The search results were scanned at the title and abstractlevels then captured in Endnote where duplicates were removed. Six thousand citationswere scanned in these processes and 600 citations captured for further analysis. Reviewingabstracts with reference to the National Health Workforce Innovation and Reform StrategicFramework for Action Domains and focus excluded approximately 200 articles and full textfor approximately 400 journal articles was retrieved for review.Targeted key phrase searching in Google Scholar and Scopus confirmed the bibliographicdatabase search results. This searching in Google Scholar was also used in the developmentof the search strategy for the environmental scan for this project. Searching in two UniversityLibrary web catalogues for monographs and edited textbooks did not retrieve any resultsthat specifically addressed cancer workforce planning and development that had not beenNational Cancer Workforce Strategy Literature Review Page 52

previously identified in the CINAHL and Google Scholar searches. There is however aconsiderable monograph literature on the clinical aspects of cancer treatment and cancerpatient care.Cancer specific literature was supplemented as appropriate by relevant literature on moregeneric health workforce development issues. Many studies were relevant to more than oneAction Domain.Excluded studies and limitationsAfter review of full text, we excluded:• articles that were predominantly anecdotal or commentary/opinion pieces with littleor no reference to peer-reviewed literature• reports of research in countries with very different health systems/workforces toAustralia’s• descriptive case studies unless the setting was Australian.Most of the studies reviewed are descriptive in nature and report mostly qualitative findingsbut given the dearth of cancer workforce research (particularly Australian) these articleshave been included as their findings may be informative in developing the cancer workforcestrategy. Many of the studies had small sample sizes, single settings and/or timepoints, andrely on self-report.No formal grading or rating of the literature was carried out.National Cancer Workforce Strategy Literature Review Page 53