Mary Murray R'G'N' Onc' Cert' MSc

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NCNM Masterclass 2006

• Mary Murray R.G.N. Onc. Cert. MSc
• Advanced Nurse Practitioner
• Breast Care
• St. Vincents University Hospital

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(No Transcript)
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• Be prepared to challenge
• To be challenged and speak out
• Not afraid of articulating a nursing voice
• Attend and actively take part in meetings where
  decisions are to be made
• Dont be afraid to criticise policy where changes
  need to be made

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The development and integration of the Advanced
Nurse Practitioner into a practice setting has
implications for

• Patients
• Nursing profession
• Other health care providers

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ANPs in the oncology setting play a pivotal role
in assisting patients across the cancer trajectory

• From time of diagnosis through to rehabilitative
  phase of cancer care.
• The skills and knowledge of CNS and ANPs are
  essential to patient receiving high quality,
  comprehensive cancer care.

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• Patients with breast cancer are now living longer
  with their disease.
• Clinicians are also faced with managing other
  chronic diseases that affect the adult population.

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• Given there changing demographics the role of the
  ANP in breast care needs to be developed.
• To meet the increasing healthcare needs of our
  surviving chronically ill population.

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• Oncology nursing practitioners work differently
  to physicians by bringing a nursing perspective
  and nursing skills to patient encounters

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• Breast care ANPs provide holistic care to
  patients either collaboratively or independently.

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Role of ANP in Breast Care includes

• Holistic assessment.
• Screening and monitoring.
• Facilitating compliance.
• Co-ordinating the care pathway.
• Ensuring consistency of contact with health care
  professionals.
• Communication, health promotion.
• Health education activities.
• Commitment to ensuring post registration nursing
  programmes are developed to meet the challenge of
  Advanced Nursing Practice.

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• Advanced practice in oncology nursing has
  developed internationally and nationally.
• Commission on nursing (1998) recommended a
  clinical career pathway leading from
• Registration
• ?
• Clinical Specialisation
• ?
• Advanced Practice

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The position of ANP breast care is a new
initiative within the afore mentioned clinical
career pathway

• It aims to enhance the care of people with breast
  problems benign and malignant.
• Develop and expand the role of oncology/breast
  care nurses.

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The cancer strategy in Ireland proposed that care

• Must be planned and led by nurses with post
  registration education in oncology.
• That nursing services must be structured to
  ensure patients access to specialist nurses

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WHO document Europe Health 21

• Nurses are singled out as having a key role to
  play throughout the continuum of care.

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In particular nurses are seen as working with

• Individuals, families and communities to promote
  health and prevent ill health.
• As well as
• To care for people when they have disease
• Supporting those in the terminal stages of
  disease as well as family and friends.
• Ensuring a peaceful, dignified death are also
  perceived as crucial oncology nursing functions.
• Oncology Advanced Nurse Practitioner are
  attributed with quickly and interviewing
  skilfully to prevent serious complications
  (Whittey 1992).
• Practitioners, their enormous background of
  patient care experience.
• Enhanced with post graduate education
• Quickly able to assess a clinical situation.
• Accurately target problems.

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ANPs (oncology) play a critical role in leading
efforts to improve

• Healtcare access.
• Promot clinical excellence and quality of life.
• Increase cost effectiveness.

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Breast care ANP fucntion primarily in the

• Medical domain using a nursing framework as
  clinical experts in oncology by providing direct,
  epiosodic health care to prevent and meet the
  acute asymptomatic or palliative care needs of
  patients with cancer.

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ANPs scope of practice includes

• Comprehensive health assessments.
• Differential diagnosis.
• Ordering, supervising and interpreting diagnostic
  tests.
• Developing a therapeutic plan in collaboration
  with a physician partner.
• Screening to prevent illness and promote
  wellness.

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Breast care ANP manages the care of patients with
complex needs

• Instructs other nurses about the care of these
  patients.
• Is responsible for the quality of patient care.
• (Gift 1998)

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• Comprehensive individualised and holistic care is
  not new to oncology nursing in Ireland.
• Specialist breast care nurses have been at the
  forefront of inter disciplinary care.
• Having in many instances established true
  partnerships' with physicians.

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National Cancer Strategy identified the following
objectives that apply to Advanced Practice
Oncology Nursing

• To take all steps possible to reduce rates of
  illness and death from cancer.
• To ensure that those who develop cancer receive
  the most effective care and treatment.
• To ensure the patients quality of life is
  enhanced to the greatest possible extent.

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Recent decades breast cancer detection and
management strategies have changed dramatically

• Implementation of National Breast Screening
  Programme.
• Identification of BRCA1 and BCCA2 genes.
• More breast conserving surgery and breast
  reconstructive procedures.
• Increased use of adjuvant therapies.

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DEVELOPMENT OF ANP SERVICE

• Early detection Long term follow up
• Age of population Complexity of
  treatment
• Long term
• survival
• Health Promotion Holistic Care
  Survivorship issues

The majority of persons with breast cancer are
now treated in the ambulatory setting Treatments
and surgery administered as day cases Nurse Led
Clinics
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Clinical practice associated with Advanced Care
Nursing

• Promoting breast awareness.
• Family history and genetics.
• Benign breast disease.
• Breast screening.
• Patients newly diagnosed with cancer.
• Breast surgery and breast reconstruction.
• Chemotherapy (and related side effects).
• Radiotherapy (and related side effects).
• Endocrine therapy (and related side effects).

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• Prosthesis fitting.
• Management of menopausal symptoms.
• Management of disease related symptoms e.g.
  lymphoedema, fatigue.
• Management of fungating wounds.
• Metastatic disease.
• Recovery, rehabilitation and follow-up.

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Expanded roles undertaken by ANP (Breast care)

• Nurse led follow-up and consultation.
• Family history screening and surveillance.
• Diagnostic examination, Punch bx, FNAC.
• Seroma drainage.
• Tissue expander, inflation/deflation.
• Micropigmentaion (tattooing).
• Accepting direct referrals fatigue, fungating
  wounds.
• Risk assessment and counselling about the risk of
  developing breast cancer.

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Reported numbers of breast cancer has increased
over the past 20 years

• Better statistical reporting.
• Better screening methods.
• Increased life expectancy.
• Increased exposure to carcinogens.
• Changes in lifestyle.

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• Age remains the greatest risk/action, with most
  breast cancers occurring in the post-menopausal
  age group.
• 2002 before 2348 women diagnosed with breast
  cancer.
• Many years we can truly reflect on the evidence
  and real benefits of breast screening or overall
  survived.

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Services needs addressed by post

• Increased pressure on breast clinics to see
  patients more quickly.
• Part due to breast awareness campaigns.
• More women being screened.
• Referrals from family planning clinics are
  increasing.
• Results
• Higher numbers of patients need to be seen
  efficiently with individualised treatment plans
  devised to suit their needs.

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Pilot study of 24 patients seen at Nurse led.

• 22 stated they would prefer to received part of
  their follow-up in the future at NFU.
• Other benefits cited
• Continuity of care same person at each visit.
• Appointments runs to time less hurried.
• Improved co-ordination and timing of visit.
• Improved adherence to protocol on frequency of
  mammograms.

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Services needs

• Patients who develop lymphoedema should be
  offered assessment.
• Assessment of patients complaining of breast
  lumps, pain, discharge.
• Seroma management.
• Follow-up of patients with breast cancer/family
  history.
• Micropigmentation.

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CASELOAD

• 2 Nurse Led Clinics per week
• Symptomatic /TAC Clinic
• 1 session with plastics
• Patient caseload average per week
• Lymphoedema assessment 2-3 (inpatient and
  outpatient)
• Fatigue assessment 2
• Areola micropigmentations 4-6
• Tissue expansion/deflation 4-5
• New patients complaining of
• breast lumps, nipple discharge,
• mastalgia and infection 17-20
• Seroma aspiration/wound review 9
• Follow up patients with breast cancer 26-30
• Follow up patients with positive family
  history 2-4

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• Aim of nurse led breast care clinic is to ensure
  that patient receive consistent review by a named
  member of the team with appropriate specialist
  knowledge, ensuring continuity of a high quality
  standard of care.

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Work across role boundaries

• Communication.
• Liaise with multidisciplinary teams
  oncology/plastics
• Intercede as patient advocate.
• Make transparent the role of ANP.

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Leadership

• Strengthen team cohesiveness.
• Mentor newer staff members.
• Getting involved and staying involved
• Create opportunities for others to develop their
  maximum potential
• Balancing professional and private life
• Team building is an essential skill

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• Work independently.
• Physical and psychosocial assessment.
• Early recognition of complications.

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Referral process to ANP

• Surgeons, Medical Oncologists, Plastic
  Reconstructive surgeons, specialist nurses breast
  screening.
• Key members of multidisciplinary team, physio,
  social worker.
• Patient/family referral for education and support
  services.

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Autonomy in breast care nursing

• Diagnosis and treatment of breast disorders
  within specific clinical guidelines.
• Devising an individual care plan includes both
  nursing and medical management of care.
• Comprehensive health assessments.

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Services provided

• Promoting breast awareness breast screening.
• Early identification of breast problems.
• Management of breast conditions.
• Rehabilitation, follow-up, supportive care.

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Expert Practitioner

• Specific clinical expertise, in depth knowledge
  and understanding of breast disease/cancer.
• Chooses interventions based on sound rational and
  accepted practice.
• Make decisions where precedents do not exist.
• Develops, implements and improves standards of
  breast care nursing.
• Creates a culture of reflective practice
• Initiates practice development initiatives

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Clinical Leadership

• Communication skills desire to hear and
  understand another point of view.
• Commitment giving of self personally and
  professionally.
• Getting involved and staying involved.
• Developing ones own style.
• Willingness to collaborate.

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Education

• Is integral to Advanced Practice.
• Identifies organisational learning needs.
• Planning delivery of education nationally and
  internationally.
• Develops teaching skills in others.
• Develops relevant education materials for
  patients and staff.
• Credible to teach all members of MDT.
• Partnership with Higher Education Establishments

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Researcher

• Competency/Collaborative Research
• Evaluating practice.
• Conducting research.
• Audit.
• Priority index on effectiveness of Nurse Led
  Clinics
• (Murphy, Cowman 2006)

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• ANP works collaboratively within a
  multidisciplinary health team
• Responsible for providing comprehensive and age
  appropriate care to both well or ill patients
  under the direction of a consultant.

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• Clinical Support
• Management Support
• Administration Support

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Clerical/Administration

• Medical records
• Scheduling
• Registration
• Pulling/filing back

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Management Support

• Business plan
• Financial plan funding
• Site visit

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Clinical Support

• Supervised hours
• Support network
• Professional tensions - ? Nursing
• Position within nursing organisation

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Personal Specification

• Registered nurse.
• MSc.
• 7 years or more post registration and 5 years
  experience in specialist area.

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Professional Regulations

• An Bord Altranais.
• Code of Professional Conduct.
• Scope of Practice.
• Dont forget safe administration of cytotoxic
  medical preps.

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Liability

• Vicarious liability.
• Guidelines for good practice.

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Benefits for patients from ANP service

• ? number of patients receiving ambulatory care.
• ? number older patients.
• Model of care which is mainly ambulatory care
  following surgery directly mainly by ANPs.
• Preventive care, screening, secondary care,
  active treatment control of side effects.

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Breast Clinic Numbers 2005

• Total Number of patients 7339

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Future ANP in breast care will play a crucial
role in

• Breast diagnostic centres via nurse led clinics
• Community in a supportive/educative role.

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Benefits of Nurse Led Clinics

• Holistic assessment.
• Facilitating compliance.
• Improving liaison with other services e.g.
  radiotherapy.
• Patients understood their treatment better.
• More likely to comply with treatments.
• Improved co-ordination of care due to continuity
  of contact.
• (Mackie 1996)
• (Murray 2006)

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IMPROVEMENT IN CARE

• Reduced waiting times at clinics from 2 hours to
  less than 10 minutes
• Increasing, easier and more efficient access to
  care for patients
• Operating an outpatient ambulatory facility
  dedicated to specific population of cancer
  patients i.e. breast
• Delivering expert care in accordance with
  protocol/guidelines that are accurate, safe,
  comprehensive and effective
• Co-ordinating plans to establish a speciality
  Breast Clinic Unit within the context of the new
  Ambulatory Day Care Centre (unit opened 25.08.06)
• Recruit suitable post Graduate H.Dip Breast Care
  Nurses
• Developing a programme of professional
  development for all Breast Care Nurses who staff
  the clinic
• ANP is perceived to be approachable, available
  and accessible by the great majority of patients

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• Elderly people have difficulty advocating for
  themselves when confronted with life-threatening
  illness. Find it difficult to demand equality of
  access to optimal cancer care

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Breast care ANP can do much to

• Promote rights of elderly breast cancer patients.
• Ageist and fatalistic attitudes can be challenged
  through public and professional education.

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• Development of nursing roles such as ANP can only
  result.
• In a higher quality of care for patients.
• Take action now. Do not wait standing still is
  not an option

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Development of ANP service will enhanced the care
provided by

• Developing an outcome oriented care plan that is
  individualised, holistic, culturally sensitive,
  cost effective and based on nursing diagnosis and
  incorporated cancer prevention, detection,
  treatment, rehabilitation and supportive care.
• Increasing access to care and patient education.
• Developing a clinical career pathway for
  experienced nurses in oncology.
• Applying research to oncology/breast care nursing
  practice.

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• Its all about Teamwork
• Complementing the service

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Consistency of services with unit philosophy

• Mission of the unit
• To lead in the provision of easily accessible
  high quality care for women with breast
  complaints through information, education,
  diagnosis, screening treatment and research.

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Driving force for ANP role

• Hanly Report
• EU directives regarding reducing junior doctors
  hours.
• National health strategy QF.
• Primary Health Care strategy.
• Commission on nursing.
• NCNM/NMPDU.
• Cancer strategy.
• Plan for womens health.

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ANP in breast care demonstrated many of the
principles of QF (document).

• Role provides a
• People centred service that demonstrates clear
  accountability where quality is to the fore.

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A service underpinned by equality and fairness

• ANP led services must be population focused and
  of benefit to the people they serve.
• (Cassidy 2002)

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We must become the change we want to see