Plenary 2: Inter-professional Plenary 2: Inter-professional Collaboration Between Medicine and Collaboration Between Medicine and NursingNursing

This session will examine key issues and critical success factors for This session will examine key issues and critical success factors for inter-professional collaboration between medicine and nursing inter-professional collaboration between medicine and nursing through key learning from policy and theory, and at the coalface of through key learning from policy and theory, and at the coalface of education and practice education and practice

Maurene McQuestion John Waldron

SummarySummarySummarySummary• Inter-professional collaboration between

Medicine and Nursing in the Management of Patients Undergoing Radiation Therapy for Head and Neck Cancers

• Radiation Oncology• Management of H&N Cancer With Radiation• Patients Journey and Inter-professional

Collaboration Along This Journey

• Inter-professional collaboration between Nursing and Medicine: literature and implementation of roles

Radiation OncologyRadiation OncologyRadiation OncologyRadiation Oncology

• Approximately 50% of patients with cancer require radiation treatment

• Radiation treatment requires a considerable technical infrastructure (linear accelerators, simulators) and human resources (therapists, physicists, nurses, oncologists)

• Radiation delivery centralized 38 cancer centers across Canada

Radiation OncologyRadiation OncologyRadiation OncologyRadiation Oncology

• 330 Radiation Oncologists in Canada

• 200-300 new patients seen per Oncologist/year

• 80,000 Canadians per year

Head and Neck CancerHead and Neck Cancer

•5000 cases per year in Canada•2000 in Ontario•Oral cavity•Oropharynx•Larynx

•Managed with radiation, surgery and chemotherapy

•Most patients have radiation

Background – PMH H&N Radiation Background – PMH H&N Radiation Therapy ProgramTherapy Program

• 600 patients treated per year at PMH• 80-100 on treatment at any one time• 8 pairings of Radiation Oncologists and Nurse Case Managers• 2 Advanced Practice Nurses

– Clinical Nurse Specialist– Nurse Practitioner

• Speech Pathologist, Clinical Dietician, Social Worker

• 20 Radiation Therapists• 10 Radiation Dosimetrists and Planners• 4 Medical Physicists

• Dentists, Surgeons, Medical Oncolgists, Radiologists, Pathologists

5 to 7 weeks2 weeks 5 – 10 Years

Daily

Radiation TherapistsWeekly

Radiation Oncologist Nurse Case Manager Advanced Practice Nurse (CNS/NP)

PRN RD, Social work

Admission Chemotherapy Feeding tube Supportive care

Follow-Up Radiation Oncologist Nurse Case Manager APN**

Consultation Radiation Oncologist Nurse Case Manager

Preparation Nurse Case Manager Radiation Therapists Dentistry Radiation Oncologist Medical Oncologist

5 to 7 weeks2 weeks 5 – 10 Years

Daily

Radiation TherapistsWeekly

Radiation Oncologist Nurse Case Manager Advanced Practice Nurse (CNS/NP)

PRN RD, Social work

Admission Chemotherapy Feeding tube Supportive care

Radiation TreatmentRadiation Treatment

• Outpatient treatment• Daily fractions Monday to Friday• Over 5 to 7 weeks• Patient remains supine in an immobilization

device during 20 minutes of treatment• Examined weekly

– Oncologist– Nurse Case Manger

• Complex cases– Referred or self-referred

To APN

Acute Symptom Management Acute Symptom Management ChallengesChallenges

– Pain– Dysphagia

• Malnutrition• Dehydration• Aspiration

– Nausea– Fatigue– Psychological Distress

• Fear & anxiety• Insomnia• Depression• Altered body image• Social & financial issues

– Infection• Pneumonia• Oral• Sinus• Soft tissues, febrile neutropenia

Radiation Nursing ClinicRadiation Nursing Clinic

•staffed by Nurse Case Mangers and APNs• regular and prn assessment of patients on treatment

Collaborative ApproachCollaborative Approach• Nurse Case Manager

– Works with the Oncologist in every clinic

– Meets new patients as they are initially seen

– Provides direct nursing care in the outpatient clinics

– Provides education and critical navigation in the period leading up to treatment

– First line for patient contacts and queries

• Advanced Practice Nurse– Run an independent clinic for patients on treatment

– Triage their degree of involvement

– Manages complex acute toxicity issues independently yet in collaboration with Oncologists

– Development and dissemination of management expertise

– Advancement of symptom management and survivorship program

Increasing Treatment ComplexityIncreasing Treatment Complexity

Increasing Treatment ToxicityIncreasing Treatment Toxicity

• Addition of concurrent chemotherapy

• Introduction of molecular targets agents

• More intense radiation schedules– Hyperfractionation– Accelerated radiation

• Survival benefit but at a cost– Increased acute side effects– Increased late effects

Lessons Learned:Lessons Learned:Diversification, Specialization and Diversification, Specialization and

CollaborationCollaboration• Increasing both complexity and toxicity of

treatments requires the diversification and specialization of patient care beyond traditional models

• Specialization permits the advancement of expertise– Patient care– Research– Education

• Advancement of expertise with associated inter-professional collaboration improves the patient experience and outcomes

CollaborationCollaboration

“Collaborative practice is an inter-professional

process for communication and decision

making that enables the separate and shared

knowledge and skills of care providers to

synergistically influence the client / patient

care provided”

Way, Jones & Busing, 2000

Navigating the SystemNavigating the SystemH&N CancerH&N Cancer

Living with uncertainty

- Wanting to return to normal- Creating a new normal

Diagnosis in community

Referral to Cancer or Treatment Centre

Consultations & Further Tests

- CT, MRI, PET, medical oncology, dental, ……

Treatment 4 - 7 weeks

Daily visits Mon – Fri

Ambulatory +/- Hospital Admission

1 – 3 months acute recovery, intermediate recovery 6 months +

Treatment Decision

Long term follow up

Collaborative PracticeCollaborative Practice

• Interprofessional– Staff physicians, residents, clinical fellows

• Radiation, medicine, surgery, psychiatry

– Family physicians– Allied health – SW, RD, SLP, MRT, OT, PT, RT, Chaplain

• Intraprofessional– Registered Nurses

• Inpatient, ambulatory, community

– Advanced Practice Nurses• Clinical Nurse Specialists (CNS)

• Nurse Practitioners (Adult NP / Child NP / RNEC)

• CNS/NP

• Primary NP (PHCNP)

Continuum of APN Roles

Clinical Practice Role

Integrated Role Domains

CNS NP

Professional development

Organizational leadership

Research

Education

Advanced Nursing Practice

Expanded clinical functions requiring Extended Class (EC) License

(Bryant-Lukosius, 2004)

APN Roles in Cancer CareAPN Roles in Cancer Care

• Site based roles with high volume, high risk populations

• Rapid Diagnostic Clinic

• Community liaison clinics

• Urgent care clinic

• Symptom management & supportive care

• Palliative Radiation Oncology Program / Rapid Referral Program

• Pain & palliative care

• Home Care / CCAC

• Infectious diseases

• Wound care

Outcomes of APN RolesOutcomes of APN Roles

• Improve access, coordination & continuity of care

• Improve patient and provider satisfaction• Prevent or reduce side effects and

complications• Improve health, functional capacity, QOL and

survival for high risk patient populations• Lower acute care costs - LOS, ER visits and

readmissions• Improve uptake of EBP

www.oapn.ca

Concepts / Essential ElementsConcepts / Essential Elements of Collaboration of Collaboration

• Sharing

• Partnership

• Interdependency

• Power

• Process

• Patient centred

• Responsibility and

accountability

• Coordination

• Communication

• Cooperation

• Assertiveness

• Autonomy

• Mutual trust and respectD’Amour, et. al., 1999, 2005

APN-Physician CollaborationAPN-Physician Collaboration

Experience of

• Mutual trust and respect

• Defined practice role

• Maintains a nursing perspective

• Lives a positive experience

• Establishes collegial relationships

Critical Success Factors for Critical Success Factors for Interprofessional CollaborationInterprofessional Collaboration

• Collaborative skills• Role clarity & understanding• Clearly defined goals• Support structures & resources• Generation and culture

Outcomes of CollaborationOutcomes of Collaboration

Good

• Engagement• Complementary practice• Improved patient

outcomes and quality of care

• Staff satisfaction• Fewer errors• Improved patient safety• Improved access to care• Reduced costs

Poor

• Power dynamics• Poor communication

patterns• Lack of role understanding• Conflicts due to varied

approaches to care• Fragmentation in care• Patient & staff

dissatisfaction• Delays in implementation of

interventions• errors

Challenges to Interprofessional Challenges to Interprofessional CollaborationCollaboration

Discipline

• Lack of understanding or role and scope of practice

• Discipline based socialization, language & communication

• Intergenerational & cross cultural professional workforce

• Perceptions of power• Perceived competition

Organization• Organizational structures

& complexities• Workload• Documentation systems

Education• Undergraduate programs• Access to IPE and

mentorship

Policy• Legislation & provider

resistance to rolesStolee, et. al., 2008; Way, et. al., 2000

Examples of CollaborationExamples of CollaborationPMH & H&N Site GroupPMH & H&N Site Group

• PMH

– RN Case Manager / Physician clinics– APN / Physician – Symptom Management – Urgent care clinic (REACH)– Radiation Nursing Clinic– Smoking Cessation Program / SHL referrals– Ambulatory Redesign

Examples of CollaborationExamples of CollaborationPMH & H&N Site GroupPMH & H&N Site Group

• H&N

– Feeding tube program – SDA-NDD-outpatient program– Nursing & resident education – Organizational Guidelines for the management of H&N

cancer– Academic – research & publications

– Retreat – implementation of NP role

The PEPPA Framework

1. Define Patient Population & Describe Model of Care

9. Determine Future Needs

8. Evaluate APN Role & Model of Care

2. Identify Stakeholders & Recruit Participants

3. Determine Need for a New Model of Care

4. Identify Priority Problems & Goals to Improve Model of Care

5. Define New Model of Care & APN Role

6. Plan Implementation

Provide Education, Resources & Supports

Develop APN Role Policies & Protocols

Begin Role Development & Implementation

ROLE OF NURSING PROFESSION

& APN COMMUNITY

7. Initiate APN Role Evaluation Plan

(Bryant-Lukosius & DiCenso, 2004)

RecommendationsRecommendations

• Inter-professional Education – undergraduate & graduate

• IP mentorship• Reduce barriers to practice, open opportunities

for collaboration• Implement APN roles across the health care

system based on assessment of gaps and health care needs

• Improve collaboration between tertiary care centres & community