Development and Implementation of a Surgical Oncology Intensive Nurse Education Program for an Inpatient Progressive Care Unit

Abstract

A surgical oncology unit administered a structured educational program for nurses that included recorded prework and a live session featuring simulations, case studies, gallery walks, and lectures focused on postoperative care fundamentals, surgical emergencies, and procedure-specific knowledge. Average nurse test scores improved from 79% preintervention to 97% postintervention.

AT A GLANCE

• ■ A structured education program about the postoperative care of patients with cancer who underwent surgery can improve nurses’ knowledge about caring for this patient population.

• ■ Incorporating providers into education sessions can support collaboration and communication between nurses and provider teams.

• ■ Simulations help surgical oncology nurses recognize potential postoperative complications and improve understanding of interventions.

Surgical oncology is a highly specialized field of medicine and nursing. Patients with cancer undergo complicated surgical procedures that can include multivisceral resections, high-risk anastomoses, and prolonged operative times. These patients require a high-acuity level of care postoperatively. A 24-bed progressive care–level surgical oncology unit in a community hospital in northeast Florida with a growing comprehensive cancer center transitioned from a combined medical oncology–surgical oncology unit to a newly designated fully surgical unit. An oncology intensive education program was already in place for nurses hired for the previous unit; however, it had minimal surgical content and focused primarily on aspects of medical care and chemotherapy administration. The surgical oncology provider team identified a need for specialized training of nurses in postoperative care for this patient population, including understanding expected clinical progression, properly assessing for and managing surgical drains and tubes, recognizing early signs of surgical complications, managing surgical emergencies, and providing real-time reporting of clinical issues to the surgical teams. The unit covers general surgical oncology, including hepatopancreatobiliary, colorectal, urologic, head and neck, and breast surgical oncology.

The unit is staffed by many new graduate nurses hired from the organization’s nurse residency program. At the time of this education program, 29 of 44 nurses on the unit had less than three years of nursing experience. Nurse residency orientation programs provide transition-to-practice structures for new nurses and have been shown to be effective in the ambulatory oncology setting (Lambson et al., 2023). However, little has been published on surgical oncology–specific education programs for inpatient nurses.

Curriculum Development

A task force, including providers, executive leadership, and nursing education team members, supported the development of this education initiative. Surgeons and advanced practice providers (APPs) who admit patients to the surgical oncology unit identified gaps in knowledge and areas for improvement in the delivery of patient care. Conversations with providers, discussions during surgical oncology interprofessional rounds, and reviews of patient safety events and outcomes identified key content areas. Oncology nurse educators performed a preliminary knowledge assessment via face-to-face discussions during rounds to further elucidate the gaps in nursing clinical knowledge.

During three months of planning, a content outline was developed through collaboration between the surgical oncology provider team and the system education team. It included the basics of postoperative care; commonly used drains, lines, and tubes; recognizing early signs of surgical complications; surgical emergencies; and procedure-specific information. The team incorporated topics around interprofessional teaming, including communication with providers, reporting of critical assessment findings, and escalation strategies. The primary goal of the program was to offer interactive sessions that incorporated realistic clinical scenarios to improve the participants’ clinical knowledge, critical thinking skills, and confidence in caring for patients in the postoperative setting. The executive leadership team supported three eight-hour in-person sessions that were mandatory for unit nursing staff and unit nursing leadership to attend.

Program Overview

Participants completed a clinical scenario–based pretest, distributed through the organization’s online learning management system, to assess baseline knowledge prior to beginning any prework or attending the in-person session. Scenarios tested general knowledge of postsurgical care as well as understanding of expected nursing interventions in response to clinical assessments. Prework lectures established foundational knowledge on the topics of vital signs, the importance of monitoring intakes and outputs, common surgical complications, and surgical emergencies, as well as frequently used surgical drains, lines, and tubes. The facilitators recorded these lectures and assigned them to every nurse and nurse leader on the unit through the learning management system. Each participant had to complete the prework prior to attending the in-person session.

The surgical oncology providers created a reference of common procedures, anatomic considerations, key points of postoperative care, and associated complications. This reference incorporated information on procedures across all surgical oncology subspecialities treated on this unit, including general complex, colon and rectal, urologic, breast, and head and neck surgical oncology. Table 1 is a sample of this reference. Nursing leadership distributed hard and electronic copies of this guide to all nurses on the unit for reference. This reference of common oncology surgical procedures was foundational for the team to design interactive in-person education sessions, including a variety of active teaching–learning methods, gamification, and educational models. These included lecture-style presentations, teach-back methods, a gallery walk, simulation sessions, group activities, and unfolding case studies. These strategies have been described in education literature and have been shown to improve learner engagement (Buchwach & Hill, 2017; Leynes-Ignacio, 2023; Seymour et al., 2023). An outline of the topics covered during the in-person sessions is presented in Figure 1.

TABLE 1.

SAMPLE OF REFERENCE HANDOUT FOR COMMON SURGICAL ONCOLOGY PROCEDURES

PROCEDURE	INDICATIONS	OVERVIEW OF PROCEDURE	ANATOMIC CONSIDERATIONS	KEY POSTOPERATION POINTS	COMPLICATIONS
Distal pancreatectomy and splenectomy	■ Tumors in the body/tail of the pancreas (e.g., pancreatic adenocarcinoma, pancreatic neuroendocrine tumors) ■ Large pancreatic cysts in the body/tail	■ Typically performed robotic- or laparoscopic-assisted; involves removal of pancreas distal to area of tumor, spleen, and associated lymph nodes ■ Uses intraoperative ultrasound to identify lesion	■ No anastomoses ■ Staple line on the pancreas; at risk for pancreatic leak/fistula	■ Generally has a quicker recovery than a Whipple procedure, smaller incisions, and no anastomoses ■ Unstable glucose trends from operating on the pancreas: sliding scale insulin and often a diabetes management consultation ■ Jackson–Pratt drain: Monitor for blood, pancreatic fluid, and chyle.	■ Common complications: pancreatic leak/fistula, ileus, and chyle leak ■ Major complications: postpancreatectomy hemorrhage
Gastrectomy	■ Primary gastric malignancies (e.g., gastric adenocarcinoma, gastrointestinal stromal tumors) ■ Gastric masses	■ Performed robotic- or laparoscopic-assisted or via open, midline incision ■ Involves removal of part, most, or all of the stomach ■ Jejunal feeding tube is typically placed at time of surgery for total gastrectomies.	■ Total gastrectomy (i.e., removal of the entire stomach) is performed for more proximal lesions, reconstruction via esophagojejunostomy and jejunojejunostomy anastomoses ■ Subtotal or distal gastrectomy (i.e., removal of 50%–70% of the stomach) is performed for more distal lesions; reconstruction is typically performed via Roux-en-Y gastrojejunostomy. ■ Partial gastrectomy (i.e., removal of about 20%–30% of the stomach) is performed for nonadenocarcinomas; usually does not involve a reconstruction	■ Total gastrectomy: NGT until postoperative day 3, then study esophagojejunal anastomosis to ensure there is no leak. ■ NGT should never be replaced by the nursing staff in any patient who underwent a gastrectomy because of the stomach anastomosis. ■ Diet changes: Patients will need to be educated about eating small, frequent meals.	■ Common complications: ileus ■ Major complications: anastomotic leak
Hepatectomy	■ Primary malignancies of the liver (e.g., hepatocellular carcioma, cholangiocarcinoma, gallbladder cancer) ■ Metastatic lesions from other primary tumors (colorectal cancer most common)	■ Performed robotic- or laparoscopic-assisted or open via a subcoastal or midline incision depending on the tumor location and size of the liver resection ■ Uses intraoperative ultrasound to identify lesion	■ Liver resections can be minor or major depending on the type, number, size, and location of the tumor. ■ Can include wedge resection, segmental resection, right/left hepatectomy, or right/left extended hepatectomy ■ Larger resections sometimes have bile-duct reconstructions.	■ Avoid hepatotoxic agents: no acetaminophen for patients with major liver resections until directed by surgical team ■ PCA for open cases ■ Will follow liver function tests, bilirubin, and international normalized ratio until normalized ■ Jackson–Pratt drain for major liver resections to monitor for bleeding and bile leak	■ Common complications: ileus, transaminitis, bile leak ■ Major complications: liver ischemia and/or liver failure
Whipple	■ Tumors in the head of the pancreas (e.g., pancreatic adenocarcinoma, neuroendocrine tumors) ■ Tumors of the ampulla ■ Cholangiocarcinoma	■ Typically performed through a midline laparotomy incision ■ Involves removal of the distal portion of the stomach, head/body of pancreas, duodenum, and gallbladder, as well as reconstruction with anastomoses of the bile duct to the jejunum, the pancreatic duct to the jejunum, and the stomach to the jejunum	■ Patients have multiple anastomoses; at risk for leaking (e.g., gastrointestinal tract contents, bile, pancreatic fluid/amylase) ■ Patients have about 30% less stomach; be careful about placing NGT.	■ Midline incision will generally have a PCA. ■ Unstable glucose trends from operating on the pancreas: sliding scale insulin and often a diabetes management consultation ■ Will typically have a feeding tube (Dobhoff versus gastrojejunostomy) ■ Jackson–Pratt drain: Monitor for blood, pancreatic fluid, and chyle.	■ Common complications: delayed gastric emptying, pancreatic leak/fistula, ileus, and chyle leak ■ Major complications: anastomotic leak, postpancreatectomy hemorrhage

NGT—nasogastric tube; PCA—patient-controlled analgesia

FIGURE 1.

AGENDA FOR IN-PERSON EDUCATION SESSIONS

“A structured education program about the postoperative care of patients on a surgical oncology unit can improve nurses’ critical thinking skills and confidence.”

Nurse educators led an interactive hands-on activity about surgical drains and tubes using the teach-back method. Educators divided cohorts into pairs and gave them a commonly used surgical drain or tube. Participants identified the type of tube, the anatomic location, the tube purpose, troubleshooting techniques, and worrisome signs and symptoms that would warrant contacting the surgical team. To increase engagement and knowledge retention, each group presented the knowledge learned using the devices and visuals, as well as conducted question-and-answer sessions with their peers.

Gallery walks are an active teaching strategy that includes posted stations around a room that participants visit individually or in groups (Tan & Perrault, 2025). A gallery walk included stations for each of the subspecialty areas and highlighted common procedures from each area. These included a Whipple procedure, hepatectomy, cystectomy, prostatectomy, mastectomy, low anterior resection, ileostomy reversal, laryngectomy, and free-flap reconstruction for head and neck tumors. Participants answered questions about the postoperative care of patients who underwent these procedures, such as indications for the procedure, postsurgical anatomy, pain management considerations, common complications, and possible life-threatening complications. Surgeons and APPs from each section (i.e., service line) were available to draw diagrams and answer questions about each procedure.

Simulations developed for this program highlighted three key areas: tracheostomy/airway management, deep inferior epigastric perforator flap reconstruction, and urinary retention secondary to blood clots following nephrectomy. Simulations have been well studied in the literature and have been shown to be an effective teaching strategy in nursing education. A systematic review by Cant and Cooper (2010) and a review by Koukourikos et al. (2021) showed that simulations using mannequins improved knowledge, critical thinking, and confidence for nurses. Askew et al. (2012) looked at the use of a simulation in a patient receiving surgical oncology care to identify opportunities to decrease failure to rescue. The study showed improved quality outcomes with a decrease in cardiac and respiratory arrest events in the year following the implementation of the simulation intervention (Askew et al., 2012).

The tracheostomy scenario helped nurses understand the proper care and management of surgical patients with head and neck cancer with a tracheostomy. The focus of the simulation was to recognize signs and symptoms of airway distress and promptly intervene and to gain confidence with proper suctioning and troubleshooting techniques. The simulation used a high-fidelity mannequin with a tracheostomy in place. The inner cannula, moulaged with glue, simulated a mucous plug. A secondary goal was to show the differences between tracheostomy and laryngectomy postoperative care. Participants and facilitators debriefed after the simulation for an average of 10 minutes and highlighted significant differences.

The deep inferior epigastric perforator flap reconstruction scenario focused on the identification of the signs of flap failure. The education team designed objectives to help the nurse identify the Doppler signals used to assess flap perfusion, recognize normal and abnormal findings during assessment, and verbalize what constitutes an emergency. A high-fidelity mannequin simulated a postoperative day 2 deep inferior epigastric perforator flap reconstruction developing flap congestion and loss of vascular signals. Nurses were required to talk through their assessment process, ask the patient questions, and verbalize their findings. They worked in groups of three to four to promote discussion. The facilitator was present in the room and asked critical-thinking questions. The goal was for the nurses to recognize potential venous congestion by assessment and loss of signal on the venous Doppler. They were successful when they found that the patient’s flap was in danger of failure and simulated a telephone call in Situation, Background, Assessment, Recommendation (SBAR) format to the surgical team. Once the simulation was over, debriefing promoted discussion and answered remaining questions about points of uncertainty that nurses had when caring for these patients.

The urinary retention scenario emphasized nurses’ identification of signs and symptoms of urinary retention secondary to blood clots, and taught clinical skills of manual irrigation of a Foley catheter and continuous bladder irrigation setup. This simulation focused on the nursing assessment of a patient postoperatively, and communicating findings initially to a charge nurse and then escalating to a provider. A group of learners performed assessments on their patient a total of three times; each assessment identified a unique set of symptoms that increased in severity as the simulation progressed. After each assessment, the learners provided a report to the facilitator using the SBAR communication tool. Participants then had the opportunity to demonstrate the hands-on skills of proper Foley catheter irrigation and continuous bladder irrigation setup, with proctored feedback.

Group activities reviewed emergency postoperative scenarios. Participants identified warning signs and indicators of potential problems on clinical assessments and discussed how they would escalate these to the provider, as well as what nursing interventions would be warranted for the patient. The surgical emergencies included a closed-loop bowel obstruction, a catastrophic anastomotic leak, an airway emergency, postoperative bleeding events, and a fascial dehiscence.

Participants walked through an unfolding case study by one of the surgical oncology APPs involving a patient who had undergone surgical resection for pancreatic cancer and developed a postpancreatectomy hemorrhage. This case study emphasized the importance of early recognition of postoperative complications and appropriate intervention to prevent a catastrophic event.

The session concluded with a case study that had previously occurred on the unit, highlighting the importance of nursing diligence in proper clinical assessment, communication with the surgical team, emergency intervention, and escalation of care. The surgical team provided an update on the patient, who is now two years postsÍurgery and has no evidence of disease recurrence, to connect the participants back to the overarching goal of quality care for patients.

Assessment of Knowledge

A clinical scenario–based pretest assessed baseline knowledge, and participants completed this prior to beginning any prework or attending the in-person session. Participants completed a similar post-test, which had different clinical scenarios than the pretest to reduce carryover bias, after completing the in-person session. Pre- and post-tests covered similar content. These tests were multiple-choice and included questions on knowledge of surgical procedures, accurate patient assessment, required nursing interventions, and appropriate escalation of care. The post-test included an explanation of the correct answer and information about the clinical scenario to further the learners’ knowledge.

Results

A total of 38 nurses attended the in-person class. One participant did not complete the pretest prior to attending the class, and one participant did not complete the post-test because of a leave of absence. Ultimately, the analysis of pre- and post-test scores included 36 participants’ scores, and the analysis of post-class evaluations included 37 participants’ scores (see Table 2).

TABLE 2.

SURGICAL ONCOLOGY CLASS EVALUATIONS (N = 37)

CRITERIA	STRONGLY DISAGREE	DISAGREE	NEUTRAL	AGREE	STRONGLY AGREE
	n	n	n	n	n
I am able to meet the participant objectives.	–	–	–	2	35
The content presented was accurate and current.	–	–	1	2	34
The content met my professional education needs.	–	–	–	2	35
The teaching method(s) was (were) effective.	–	–	–	3	34
The information offered was presented in an easily understood manner.	–	–	–	2	35
The information was offered at an appropriate level.	–	–	–	2	35

The team paired and analyzed the pre- and post-test data. The average score on the pretest was 79%, and the average score on the post-test was 97%. The difference between pre- and post-test averages was an improvement of 18 percentage points, which was statistically significant using a paired t test to review the means across the two related groups (p < 0.0001).

All nurses who participated in the education initiative completed a course evaluation and scored the experience on a five-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree) regarding the effectiveness of the intervention, appropriateness of the content offered, and whether it met their professional educational needs. There were 34 participants who responded “strongly agree” to all of the criteria.

The team also included a section for free-text comments in the evaluation. Common themes extracted from the comments included appreciation for the chance to interact with the providers, a better understanding of the drains and tubes used in their patients’ care, and the positive impact of the case study–based sessions. Participants found it effective to hear the providers’ perspectives on the different clinical scenarios, particularly the emergency scenarios. Opportunities for improvement were identified in the clarity of instruction for some of the game-based sessions.

Implications for Nursing Practice

This intervention demonstrates how a structured education program about the postoperative care of patients on a surgical oncology unit can improve nurses’ critical thinking skills and confidence. Nurses, particularly those new to practice, are not often exposed to these oncology procedures during their didactic training and clinical rotations. They need targeted education to develop a working understanding of the anatomic considerations, typical postoperative courses, concerning signs and symptoms, and appropriate nursing interventions.

Incorporating proven patient safety techniques, including the use of SBAR and debriefing, in this type of education program also emphasizes the focus on quality patient care. SBAR improves communication during handoffs and discussion of patient care issues, facilitates rapid decision-making between nursing staff and other members of the medical team, increases teamwork, and decreases adverse patient safety events, particularly among surgical nursing teams (Bonds, 2018; Pazar et al., 2024). A meta-analysis by Niu et al. (2021) found that debriefing after educational interventions improved learning outcomes. Debriefing after critical events, particularly on oncology units, improves teamwork, identifies process improvement opportunities, and provides support to the involved nursing team members (Joyce & Itano, 2024). Teaching these methods in the context of real clinical scenarios helps incorporate them into clinical nursing practice.

Limitations

There are some limitations to this study. This analysis did not include descriptive statistics of the intervention population, limiting the ability to assess generalizability to other nursing units. In addition, the study did not examine the variability of years of experience in general nursing and on the surgical oncology unit in particular, as well as its impact on baseline knowledge.

This program did not include a clinical competency assessment for nursing skills, only a knowledge assessment. It also did not look at the impact on patient outcomes or patient safety reports. In addition, feedback was not directly elicited from the providers on their view of the nurses’ levels of clinical understanding pre- and postintervention.

Conclusion

Providing a structured education intensive about the postoperative care of patients with cancer who underwent related surgery can improve the clinical knowledge of surgical oncology nurses. Collaboration between surgical providers and the nursing education team, with leadership support, was key to the program’s success. The team will conduct ongoing evaluations of the program’s impact through staff rounding, provider feedback, and observations of behavior change. This model could be used in other facilities, incorporated into nurse residency, or used in transition-to-practice programs. Follow-up studies to examine the impact on patient outcomes following such an initiative are warranted.

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Consider how you can apply findings from this article to your own practice using the following questions:

• ■ What challenges have you or your coworkers experienced managing postoperative care for patients with cancer undergoing surgery, and how could an interprofessional education initiative help address these challenges?

• ■ In what ways could incorporating simulations and interactive learning methods, as outlined in the article, enhance the early recognition of postoperative complications and improve patient outcomes in your practice?