1. INTRODUCTION1.1 Background of the StudyCancer is the second leading cause of death globally. It is estimated that, global cancer rates could increase by 50% to 15 million new cases in the year 2020. One in 5 men and one in 6 women develop cancer throughout lifetime, and one in 8 men and one in 11 women die from cancer. Almost 70% of deaths from cancer occur in low- and middle-income countries. The total number of people with the 5-year prevalence is estimated to be 43.8 million. Approximately, one third of deaths from cancer are due to the 5 leading behavioral and dietary risks: high body mass index, low fruit and vegetable intake, lack of physical activity, tobacco use, and alcohol use (WHO, 2019). In Southeast Asian region, death rates from cancer have been rising every year, and Myanmar stands one to fifth highest positions in the region. Currently, 150 out of 100,000 people are suffering from cancer in Myanmar; and the three hospitals: Yangon General Hospital, Mandalay General Hospital and Sao San Tun Hospital are providing care of more than 7,000 cancer patients cancer patients every year (Aung, 2016). In addition, there are two pediatric oncology and hematology centers in Myanmar, located at Yangon and Mandalay Children’s Hospitals. Pediatric malignancies are also becoming the leading cause of death among children in developed world and in children between the ages of 0 to 14 years (Mon et al., 2018). Cancer patients experience many problems that can lead to suffering, discomfort and emotional, social and spiritual consequences, and cause disability of patients and their family. By providing comprehensive care, the quality of life in patients and their families can be improved and dignified, and comfortable death would be provided for the patient, and a support system would be provided for their family. However, studies have often shown that patients and their families have received poor services which are indicated by untreated symptoms and unmet personal, mental and social needs, also increased burden of care on caregivers and decreased satisfaction of patients and their families (Sansom-Daly, 2015). This might be because of the shortage of health care providers in treating cancer patients.The dramatic rise in cancer incidence in developing countries is stretching the already limited resources and equipment. Shortage of qualified staff and equipment are growing constraints in treating cancer efficiently across major developing countries where insufficient funding in the healthcare delivery system is the order of the day (Nwozichi et al., 2017). In addition to oncologists, support staff such as oncology nurses, onco-pharmacists, pharmacy technicians, and palliative care specialists is also needed. The number of oncology nurses, onco-pharmacists and pharmacy technicians needed is based upon the number of beds occupied daily by cancer patients while the number of palliative care specialists is based on the number of new cancer cases per year. The oncology nursing staff for each 24-bed oncology unit (operating 24 hours a day, 7 days a week) comprises of one head nurse and a nurse specialist as well as 13 nurses working 8-hour shifts, 5 days per week (WHO, 2019).Specifically, nurses are the backbone of the healthcare system of every region or country. It is needed that the nurses should prepare to deal with the growing needs of at-risk individuals or cancer patients (Bialous, 2017). Nurses fulfill the cancer patients’ needs by doing nursing practices. Nurses provide care to the cancer patients from diagnosis stage until possible death (Gill and Duff, 2010). Moreover, oncology nurses in health care team play important roles in cancer care including health promotion, cancer prevention and screening, treatment and symptom management in acute, long term, community and palliative care (Velji, Ontario, Love and Boblin, 2001). Furthermore, the oncology nurses’ position includes administering and evaluating treatment plans, assessing patients’ physical and emotional status independently, educating patients and families, contributing in clinical cancer research, developing nursing practice guidelines related to cancer care, and treating side effects or other complication (Yarbro, Frogge, Goodman and Groenwad, 2005 cited in Mick, 2007). National Cancer Action Team (2010) stated that the roles undertaken by oncology nurse depend on core clinical practice functions and level of practice. Oncology nurse as registered nurse who has graduate level of nursing preparation would usually be expected to be prepared at Master’s level. These oncology nurses are experts in nursing practice within a specialty such as population (e.g. young people), type of care (e.g. palliative care), type of problem (e.g. lymphoedema), and type of treatment (e.g. chemotherapy) or tumor type (e.g. lung cancer). For countless reasons, oncology nurses have detailed knowledge of cancer regarding biological and psychological dimensions. An experienced, professional oncology nurse can contribute significantly to patients’ well‑being and clinical outcomes, in addition to advancing the art and science of oncology nursing (Nwozichi, Ojewole & Oluwatosin, 2017).Like other developing country, Myanmar oncology nurses are needed to be well trained specialist in the oncology nursing. Moreover, Myanmar Oncology nurses need to take an active, participative role in discharge teaching program as they are needed in developing prevention programs for cancer. However, in Myanmar such an oncology specialty nursing training program cannot be established until now. Inadequate manpower and equipment, not having specialized oncology training for nurses, and increasing number of cancer patients in oncology wards in Myanmar might cause many challenges for nurses in their everyday practices. Therefore, the challenges among oncology nurses in Myanmar should be uncovered. Furthermore, how these nurses could handle these challenges by their own way, and the ways to improve oncology nursing along with limited human and material resources should also be identified.The nurses at oncology wards perform nursing practices for the cancer patients. However, considerations of personal ability to enhance performing nursing practices are still in limited. Action research can promote the improvement of the nurse as ‘practitioner researcher’ and empowering nurses to convey about change of the lives and work. Collaboration is one of the key skills for the nurse. Transformational nursing processes will drive collaboration to the front position since nurses take part in the transformation of the health service (Winter and Munn-Giddings, 2001). The participatory action research (PAR) could provide a guide to implement this intention because the PAR is a very practical in improving nursing autonomy practice-based knowledge and the goal is to reduce health disparities and study participants have an active role in every phase of research process (Breda, 2015). PAR which is applied in critical theory is a process in which the participants involve together in acyclic manner corresponding problem identification, planning, taking action, and evaluating that action and further planning (Mosqueda-Diaz, Vilchez-Barboza, Valenzuela-Suazo and Sanhueza-Alvarado, 2014). According to Kemmis and McTaggart (1988) the position of PAR is to empower the nurses through the building of own knowledge and enables nurses to control own practice. To influence work practices empowerment is related to nurses’ ability (Glasson, Chang, and Bidewell, 2008). Therefore, it is expected that nursing practices in oncology wards of Mandalay General Hospital and (300) Bedded Children Hospital could be enhanced markedly through participatory action research. In addition, knowledge gained from this study will be generated in relation to the roles of nurses in caring for cancer patients. It is expected to create a deeper self-awareness regarding enhancement to oncological nursing practice by using PAR. 1.2 JustificationIncidence of cancer and mortality are growing worldwide. In developing countries including Myanmar, the people suffer and die from cancer because of social and life style factors. Lung or oral cancer, which is associated to smoking and betel chewing, is the most prevalent cancer among Myanmar. The main cancer risks are cervical and breast cancer which is linked to inadequate or early annual screenings and early interventions.In Mandalay, cancer wards at Mandalay General Hospital and (300) Bedded Children’s Hospital are the two major centers treating cancer patients. At oncology ward of Mandalay General Hospital, estimated admission rate of total cancer patients is above one hundred per month. Most of the cancer patients admitted at oncology unit of Mandalay General Hospital are patients diagnosed with lung cancer, liver cancer, stomach cancer, breast cancer, cervix cancer, non-Hodgkin’s lymphoma, esophagus cancer, ovarian cancer, connective tissue, other soft tissue cancers and colon cancer. Approximately, 16 nurses are providing nursing care for these cancer patients in each cancer ward. In Hametology and oncology ward of (300) Bedded Children’s Hospital, the children have received from cancer treatment for solid tumors, leukemias, acute myeloblastic leukemia, Non-Hodgkin’s lymphoma, retinoblastoma, brain tumours, Hodgkin’s lymphoma, Burkitt’s lymphoma, Wilm’s tumour, neuroblastoma, germ cell tumour and rhabdomyosarcoma. In this ward, the average number of admitted cancer patients per month was 60 and 12 nurses provide nursing care to these patients in morning, evening and night shifts. Nurses at both oncology units initiate on a longstanding nursing practices to provide the best possible care to patients diagnosed with various types of cancer. Nurse and patient ratio of both oncology wards are 1: 16 and 1:5 respectively. Nurses at these oncology wards perform nursing and non-nursing practices including instructing the workers doing ward cleanliness, doing ward round, assessing vital signs, performing routine nursing care such as administration of medication, blood transfusion, recording and reporting about cancer patients and checking and maintaining drug usage, preparation and administration of chemotherapeutic drugs, preparation and providing of diet for cancer patients, preparation of discharge plan and follow-up for cancer patients. Furthermore, nurses are dealing to cancer prevention, diagnostic methods, treatments side effects and management as well as living life of cancer patients after cancer throughout the duty time. In these wards the most commonly nursing practice of nurses is the administration of chemotherapy drugs to cancer patients. The nurses followed the medical oncologist’s prescriptions, ensuring the correct drug dose is administered to the correct patient via the correct route. These nurses continue to take responsibilities for caring the patients pre-, during and post-chemotherapy. Performing routine nursing practices including administration of chemotherapeutics drug was time consuming because there was disproportionate number between nursing staff and patients in both wards. Furthermore, there was not documented local guideline concerning administration of chemotherapeutics drug in both wards. In addition, receiving specialty training course was rare and assigned ward duty rotation was done every six-month. There is no specifying nursing staff to coach the new coming nursing staff. Therefore, local guidelines for administration of chemotherapeutics need to be developed. The nurses at oncology wards managed both the symptoms of a patient’s disease and the side effects of various cancer treatments. Nurses also provided care to the patients with nausea, vomiting and fatigue that are the most common side effects of cancer treatments, especially chemotherapy. Furthermore, these nurses play a part in ensuring each cancer patient and their families to provide health education about their disease, its treatments and expected side effects of cancer medication, ways to relieve side effect symptom during admission or discharge from hospital. Providing health information is essential for cancer patients. However, providing health information is the matter of the day that was very full of activity in the wards. Therefore, this issue will be solved to provide health information by utilizing pamphlet and video clip. Nurses perform varieties of the nursing and non-nursing practices with stereotypic actions and these nursing performances are also task oriented. Moreover, nursing practices at both oncology wards are based on medical orders and the medical model that is focused on disease. Although the nurses at these oncology wards performed the nurses’ work dutifully, their performances are invisible. Furthermore, nursing staff are less emphasis upon documentation practice in spite of presence of nursing assessment form. Hence, enhancing documentation practice should be initiated. Moreover, the nurses are facing with many challenges throughout their duty time to perform harmoniously these routine nursing practices because of manpower shortage. The nurses at both oncology wards hold certificate of nursing diploma course and B.N.Sc degree. Most of the nurses have no special training of oncology nursing. These nurses performed nursing activities based on their experiences acquired from other general wards and their critical thinking. However, nurses do not consider enhancing their nursing practices autonomously. Nurses should perform nursing practice independently, to control their own practice and also to identify ways to overcome challenges to improve their practice. On the other hand, in order to provide such complex care, it is necessary to have a nursing workforce that has the appropriate knowledge and skills. The advancement of knowledge is identified by way of education and research. Research conduction is a fundamental component of educational process and a tool to find out the problems of nursing practice in clinical area. PAR is a suitable approach to identify issues in clinical practice and working collaboratively with others to develop potential solutions in order to improve practice. Therefore, researcher chose research methods based on the concept of critical social science or emancipatory paradigm that is appropriate to strengthen oncological nursing practice that are reflected on the performance of nurses at oncology wards. Moreover, to meet the healthcare needs of the growing cancer population is one of the challenges of nursing today. By utilizing PAR, strategies to enhance oncological nursing practices can be explored this in turn also to fulfill needs of the cancer patients. It is expected that this study supports to strengthen the practice of oncology nurses in clinical care settings and to develop ward policies and guidelines regarding oncological nursing practice that gears toward high quality care provision of cancer patients. 1.3 Significance to NursingExploring clinical problems by doing action research is fundamental to gain innovative knowledge (Maheshwari, 2012). It is anticipated that the result of this action research study could support to generate new knowledge concerning oncological nursing practice in clinical area. In addition, knowledge can be gained by doing enhancing oncological nursing practice, and also this practice would be applied in caring to the cancer patients. All registered nurses have the responsibility for developing and maintaining the scope of practice statement and standards that are applied to the practice of all professional nurses as it serves as an outline for evaluation of nursing specialty practice (American Nurses Association (ANA), 2015). Result of this study can be used as a template to perform oncological nursing practice, clinical decision making and overall patient care. Furthermore, findings of this study may serve as a basic to develop patient education guideline. In this way, role of the nurses will be expanded in health education practice. In nursing education, these findings are added the review and revise of nursing curriculum concerning oncological nursing practices. In addition, the result of this study can be used by the hospital management in decision making in policies that are aimed at strengthening oncological nursing practices and caring of cancer patients. This study may be applied as essential information for conducting future research related to oncolological nursing practice. Moreover, research culture based on critical social science at clinical area could be established.