surveymonkey analyze - export€¦ · web viewq5 do you have access to your medical colleagues if...
TRANSCRIPT
A framework to support the Lung Cancer Nurse Specialist in
the development and evaluation of nurse-led clinics
Copyright © Lung Cancer Nursing UK 2019Registered offices: Miria House, 1683B High Street, Knowle, Solihull, B93 0LL
https://www.lcnuk.orgEmail: [email protected]
Telephone: 01675 477607
1
The National Lung Cancer Forum Workshop Members
Name of the Lung Cancer Nurse
Specialist
Hospital Email Address
Jeanette Draffan North Tees and Hartlepool NHS Trust [email protected] Beattie Aintree University Hospital [email protected]
Josie Roberts Rotherham NHS Foundation Trust [email protected] Savory University Hospitals of Leicester [email protected] Morgan Hywel Dda UHB Carmarthenshire, Wales [email protected]
Diana Borthwick Edinburgh Cancer Centre [email protected] Morley King's Mill Hospital , Nottinghamshire [email protected] Bolton Harrogate and District NHS Foundation Trust [email protected]
Jackie Fenemore Christie Hospital NHS Foundation Trust [email protected] Field Northern General Hospital, Sheffield [email protected]
Christine Thomas Leeds Teaching Hospitals NHS Trust [email protected] Rees Hywel Dda UHB Carmarthenshire, Wales [email protected] Davies Mid Yorkshire Hospitals NHS Trust [email protected]
Suzanne Vizor Imperial College, London [email protected]
2
Foreward
I am delighted to have been asked to write the foreward for this document. The Lung Cancer Nursing UK is committed to ensuring high quality, patient-centred services that are readily accessible to patients and their family members throughout the UK. The work contained in this document recognises the key role that nurses can play in achieving this ambition.
The landscape in relation to the management of lung cancer and mesothelioma has changed considerably during my thirty-year nursing career, and is likely to change at an even faster pace over the next decade. In the last fifteen years, the role of the lung cancer nurse specialist has evolved. This role, in particular, has been pivotal in developing and shaping lung cancer services according to the needs of patients and their families, and local organisations and environments. Indeed, the development and implementation of nurse-led initiatives such as the clinics discussed in this document demonstrate how effective nurse specialists have been in driving innovation, reducing inefficiency and improving the quality of services.
We still have further to go if we are to improve the experience of care and outcomes for all patients with lung cancer and mesothelioma. However, there is no doubt in my mind that many services could be reconfigured to make better use of resource, and meet the needs of patients and their family members more effectively. This document may help us to move faster towards this goal.
This short guide is designed to support nurses as they consider how nurse-led initiatives may improve their local lung cancer pathways. It is an honour to be able to commend it to you.
Sally MooreNursing Research Fellow/Mesothelioma Nurse SpecialistRoyal Marsden NHS Foundation Trust/Mesothelioma UK
3
Your 7-Step Guide
Introduction
There has been a huge growth in nurse-led clinics over the past two decades. However, practical guidance to assist specialist and advanced practice nurses in the development, structure and evaluation of these initiatives is somewhat limited. This Framework aims to address the deficit by drawing on insights from a selected literature review, policy documents and expert opinion from members of the Lung Cancer Nursing UK (LCNUK). In particular, the document offers seven essential steps to consider when setting up and running a nurse-led clinic for patients with lung cancer. Within these steps, emphasis is placed on careful planning, competency and training, governance, and the need to evaluate the service to ensure its effectiveness.
Background
The literature supporting nurse-led clinics is expanding and suggests a variety of potential benefits to patient care (Wilson-Barnett & Beech 1994; Moore et al 2002; Corner 2003; Williamson et al 2007; Lewis et al 2009; NICE 2011). For example within the oncology follow-up setting, studies demonstrate that nurses can provide care that is safe, effective, cost-effective; leading to higher levels of emotional wellbeing and satisfaction for patients (Faithfull et al 2001; Brown et al 2002; Moore et al 2002; Koinberg et al 2004; Bell et al 2006; Lewis et al 2009).
Literature pertaining specifically to nurse-led clinics for people with lung cancer is more limited. However, findings from published studies, audits and practice reviews are generally consistent with those reported in the wider literature (Moore et al 2002; Corner 2003; White 2006; Bell et al 2006; Williamson et al 2007). For example, Moore et al (2002) compared nurse-led with conventional medical follow-up in a randomised controlled trial of 203 patients with lung cancer and mesothelioma. In this study, no statistically significant difference in survival or time to objective disease progression was identified between the two groups. However, patients receiving nurse-led follow-up reported significantly less severe breathlessness, better emotional functioning and higher levels of satisfaction with care than patients receiving usual care. Moreover, acceptance of nurse-led care was high in that 75% of those invited to participate were happy to be randomised and, at the end of the study, patients still alive who had experienced nurse led follow-up were happy to remain with this model of care.
A further evaluation in the context of lung cancer reported similar findings in relation to patient satisfaction with nurse-led follow-up care (Williamson et al 2007). In this study, 40 patients attending a nurse-led follow-up clinic were asked to complete a satisfaction questionnaire following their clinic consultation. The responses suggest that patients were very satisfied with the service, consultation with the nurse specialist and information offered. For example, all patients rated their satisfaction with the consultation at eight out of ten or above (with 10 being ‘very’ satisfied and 1 ‘Not at all’ satisfied). Also, 95% of patients reported they were given information in a manner they could understand, 30% of patients were able to discuss some issues they would not with a doctor, and no patient said they would have preferred to see a doctor than a nurse for the consultation.
4
A further study conducted in the surgical follow-up setting describes how specialist nurses, working with other allied health professionals (in this case, a physiotherapist) and using a pulmonary rehabilitation approach, are able to address the specific concerns of patients having surgery for lung cancer, particularly in relation to the illness, their future, their family and their emotional well-being, and also in relation to symptoms such as breathlessness, pain, constipation and weight loss.
Two more recent studies confirm the acceptability of nurse-led initiatives for people with lung cancer (Sandeman and Wells 2011; Krishnasamy et al 2011). For example, in a qualitative interview study comprising ten patients with lung cancer, Sandeman and Wells (2011) examined the meaning and significance that follow-up care held for people. Although small, the study highlights that patients have a desire and expectation that follow-up care should continue following completion of treatment and that it should be provided by the oncology service, rather than for example the general practitioner. However, patients also indicated they were prepared for their follow-up care to be delivered by a nurse specialist rather than a doctor.
Similarly, a survey conducted in Australia identified that patients who had completed treatment for lung cancer were supportive of nurse-led follow-up when offered it in the context of a model of shared care (Krishnasamy et al 2011). This study also identified the aspects of follow-up care patients considered important including consistency in relation to the personnel seen, ease of access to help and advice in between appointments, and being able to bring appointments forward if necessary. The authors conclude that patient preferences appear to be more driven by the content and purpose of follow-up, rather than who provides it.
Current guidance from the National Institute for Health and Care Excellence (NICE 2001) recommends that following completion of treatment for lung cancer, all patients are offered:
an initial specialist follow-up appointment within six weeks of completing treatment, and
protocol-driven follow-up by a lung cancer clinical nurse specialist as an option for patients with a life expectancy of more than 3 months.
The recent Good Practice Guide published by the LCNUK (2014) identifies that specialist nurses are actively involved in a broad range of nurse-led initiatives including not only nurse-led follow-up after the completion of treatment but also:
Nurse-led telephone follow-up Nurse-led results clinics including in the home setting if preferred Nurse-led clinics for breaking bad news to newly diagnosed patients with lung cancer and
mesothelioma Nurse-led TKI (Tyrosine Kinase Inhibitor) toxicity assessment clinics Nurse-led management of pleural effusion in patients with lung cancer or mesothelioma Nurse-led breathlessness clinics.
Furthermore, a recent survey (Appendix 4 at the end of this document) of LCNUK members conducted for the purpose of developing this guidance provides additional examples of successful nurse-led activity including:
5
Communicating key multidisciplinary team (MDT) decisions Post-thoracic surgery rehabilitation Virtual nurse-led assessment clinic prior to CT scanning.
It is clear, therefore, that for many nurse specialists, nurse-led clinics have become an important component of their overall role. It is hoped that this document may help and facilitate other nurses wishing to add nurse-led initiatives to their clinical practice.
Aim
This Framework aims to support Lung Cancer Nurse Specialists (LCNS) in the development and implementation of a nurse-led clinic service. In a series of seven steps and drawing on the work of Hatchett (2008), it outlines the tools, information and support LCNSs may need in order to achieve success.
Step 1 : Aims and Objectives
Consider the following:
What is being offered to your patients? What type of clinic – telephone, health and wellbeing, follow up, TKI, results for example What are the specific criteria for patients attending the clinic e.g. pre, during and/or post
treatment, MDT outcome.
Appendix 4 presents the findings of the LCNUK survey mentioned briefly above. The findings describe some of the clinics already being led by LCNSs across the UK. This may offer some ideas of the type of clinic that may suit your clinical setting.
Step 2: Planning and Consultation
It is important that any plan to extend practice is within the scope of the LCNS role within your trust and reflected in your job description.
It is also important to incorporate local and national strategies and policy drivers, develop local protocols and guidelines to support the extended practice role, and discuss proposals with your Trust’s relevant stakeholders, for example operational manager, financial accountant/business manager, relevant medical colleagues, senior nurses and clinical director.
During this phase you will need to:
Identify existing services locally, e.g. other nurse-led clinics, how they operate etc.
Discuss with your immediate line manager to gain support
6
Consider existing local infrastructure, resources and personnel available Map the patient pathway to identify where resources could be used more efficiently and
effectively, potential cost savings and added benefit of a streamlined service creating a shorter patient pathway and improved patient satisfaction
Estimate of the number of patients that could be seen by the LCNS including the number of clinics needed to accommodate this number per week
Agree with the wider team the criteria for patients who might attend the nurse-led clinic Agree the minimum level of knowledge, experience and competencies for the LCNS
(consider whether a LCNS with less than one year’s experience has the required competence to lead on the initiative)
Consider whether the LCNS running the clinic should be a Non Medical Prescriber Be mindful of the NMC code of conduct (2015): ‘You must make sure that you have an
appropriate indemnity arrangement in place relevant to your scope of practice’ (Statement 12.1). Within the NHS, the majority of nurses already meets this requirement and will not need to take any further action
Create a robust business plan. There should be a focus on service improvement and liaison with the Trust’s business manager. Consider using the Roy Castle Lung Cancer Foundation’s ‘Guide to creating a business case for a lung cancer nurse specialist role’ (2015) and also the LCNUK Website which can be found at: http://documents.roycastle.org/LCNS%20business%20case%20guide%20-%20FINAL1%20(2).pdf.www.LCNUK.org
Step 3: Multi-disciplinary support
The development of nurse-led services aims to improve the patient pathway and patient experience, and ensure that new delays are not introduced.
The support of the wider lung cancer multi-disciplinary team (MDT) is essential for ensuring the overall success of the initiative.
Step 4: Infrastructure
Consider the wider infrastructure of what is needed to deliver a successful lung cancer nurse-led clinic, for example:
Clinic protocol (see Appendix 1 for examples) Resources e.g. computer, phone etc. Location – off and on-site service, clinical area, office setting Timing – time of clinic and duration of appointments, need for access to medical support Frequency of reviews Investigations that may need to be ordered and by who
Process for reviewing investigation results in a timely fashion Availability of clinical support e.g. Health care assistant to ‘height and weight’ patients
7
Availability of clerical support e.g. to register patients arrival on computer systems, pulling of medical notes if required
Availability of secretarial support e.g. to book appointments, type and send clinical letters Protocol for follow up of DNA’s e.g. how to follow up DNAs Documentation e.g. use of case notes / electronic records Nurse-led clinic codes.
Step 5: Promoting the nurse-led service
Decide how you will promote or advertise the service. Consider:
Who can refer to the nurse-led clinic? Possibly consider referrals from both primary and secondary care settings
Providing a leaflet advertising the nurse-led service to patients.
Appendix 2 provides a guide to producing a leaflet to publicise the new service to patients.
Step 6: Professional development
Consider the elements that will ensure a competent service including:
The level of knowledge, experience and competency required for the LCNS Any clinical skills training required Knowledge of new developments in lung cancer and mesothelioma Knowledge of biological agents / chemotherapy / radiotherapy /surgery Knowledge on specific side effect management and symptom management Attendance of regular training days / courses / conferences Further training needs, for example requesting investigations, non-medical prescribing
(NMP) Clinical supervision NMC revalidation Job descriptions and work plans that reflect the nurse-led clinic workload, leadership and
management components.
Step 7: Audit and Evaluation
Consider collecting both qualitative and quantitative data that can be used to evaluate the clinic and as part of your annual report. This data, in turn, can be used to develop your nurse-led services further.
Data may include:
8
Number of patients seen over a year Source of referrals Reason for referral / type of consultation Number and type of investigation ordered Nature of consultation e.g. Shared or not shared follow-up Number and type of referrals made Number and type of Interventions offered Description of medications prescribed if NMP
Appendix 3 provides an example of a patient satisfaction evaluation audit tool.
9
References
Bell N, Davison V and Peat M (2006) Nurse and physiotherapy led follow-up for lungcancer patients after surgery. Cancer Nursing Practice 5(7), 29-33
Corner J (2003) The role of nurse led care in cancer management. The Lancet Oncology 4(10), 631-636
Faithfull S, Corner J, Meyer L, Huddart R and Dearnley D (2001) Evaluation of nurse-led follow up for patients undergoing pelvic radiotherapy. British Journal of Cancer 85(12), 1853-1864
Hatchett R (2008) Nurse-led clinics: 10 essential steps to setting up a service. Nursing Times 104(47), 62-64
Krishnasamy M, Ugalde A, Carey M, Duffy M and Dryden T (2011) Patient expectations and preference for follow-up after treatment for lung cancer: A pilot study. European Journal of Oncology Nursing 15(3), 221-225
Lewis R, Neal RD, Williams NH, France B, Wilkinson C, Hendry M, Russell D, Russell I, Hughes DA, Stuart NS and Weller D (2009) Nurse-led vs. conventional physician-led follow-up for patients with cancer: Systematic review. Journal of Advanced Nursing 65(4), 706-723
Moore S, Corner J, Haviland J, Wells M, Salmon E, Normand C, Brada M, O’Brien M and Smith I (2002) Nurse led follow up and conventional medical follow up in management of patients with lung cancer: Randomised trial. British Medical Journal 325: 1145-1147
National Institute for Care and Health Excellence (NICE) (2011) Lung Cancer: Diagnosis and management (Clinical guideline 121). Available at: https://www.nice.org.uk/guidance/cg121 (Accessed 13 November 2015)
National Lung Cancer For Nurses (LCNUK) (2014) Good Practice Guide (3rd Edition): Excellence and innovation in specialist lung cancer nursing services. Available at: www.LCNUK.co.uk (Accessed 13 November 2015)
NMC (2015) Code of conduct: Professional standards of practice and behaviour for nurses and midwives. Available at: http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revised-new-nmc-code.pdf (Accessed 13 November 2015)
Sandeman G and Wells M (2011) The meaning and significance of routine follow-up in lung cancer: A qualitative study of patients' experiences and interpretations. European Journal of Oncology Nursing 15(94), 339-346
White J (2006) Developing a nurse-led follow up protocol for lung cancer. Cancer Nursing Practice 5(2), 31-34
Williamson G, Collinson S and Withers N (2007) Patient satisfaction audit of a nurse-led lung cancer follow-up clinic. Cancer Nursing Practice 6(8), 31-35
10
Wilson-Barnett J and Beech S (1994) Evaluating the clinical nurse specialist: A review. International Journal of Nursing Studies 31(6), 561-571
11
Appendix 1: Examples of protocols for nurse led clinics
NHS Yorkshire Cancer Network Group (2010) The protocol for the provision of lung cancer nurse specialist support and follow up for patients with lung cancer. Available at: http://www.ycn.nhs.uk/html/downloads/ycn-thoracic-lcnsupportfu-jul2010.pdf (Accessed: 15 November 2015)
Royal Marsden NHS Foundation Trust Policy (1653) (2013) Strategic Framework for Nurse and Allied Health care Professional (AHP) Led clinics at the Royal Marsden NHS Foundation Trust. Available on request in printed form from a member of staff at the Royal Marsden.
12
Appendix 2: Developing a patient information leaflet about the clinic
Patient information materials should reflect best practice and local and national guidance.
Some things to consider:
Check information provided for nurse-led clinics already available on your Trust Intranet and from your local Strategic Clinical Networks
Refer to evidence base
Seek approval from local clinical governance forum
Collaborate with lead clinician and relevant professionals involved in the service (for example MDT members)
Include relevant information based on current NHS guidelines & national policy
Circulate draft to appropriate patient/service user groups for appraisal
Seek input from Research and Audit Department.
Information needs to include:
o Title/heading that describes the serviceo Objectives of clinico Contacts and details for further informationo Date of publication and review date.
You can check the literacy level of your written information by using the reading ease test in Microsoft Word.
Some links and references for examples of patient information leaflets and guidance: http://www.wirralct.nhs.uk/attachments/article/19/CP68DevelopingPatientInformationLeaflets19Feb13.pdf
http://www.nhsidentity.nhs.uk/tools-and-resources/patient-information/written-information%3A-general- guidance
Contact colleagues at the following Trusts via the LCNUK for further examples:
The Leeds Teaching Hospital NHS Trust: Patient Information Policy
Guy’s and St Thomas’ NHS Foundation Trust: Nurse Led Systemic Therapy on-Treat Clinic for Lung Oncology. Patients receiving treatment Proposal and Operational Policy
13
Bwrdd Lechyd Hywel Dda Health Board Information Leaflet Carmarthenshire Nurse Led Local Clinics for people affected by Lung Cancer
14
Appendix 3: An example of a patient satisfaction tool to evaluate a nurse-led clinic
Include an explanation of the evaluation, and instructions on how to complete and return the questionnaire.
Strongly agree
Agree Neither agree nor disagree
Disagree Strongly disagree
The purpose of the clinic review appointment was made clear to me
The lung cancer nurse specialist was polite
The clinic review appointment was scheduled at a convenient time
I was kept waiting longer than I expected
I felt my needs and concerns were addressed by the lung cancer nurse specialist
I felt I was treated as a person rather than a disease or illness
The follow-up review was helpful
I was satisfied with the care I received
If you have any other comments about your appointment with the lung cancer nurse specialist please write them below
15
Appendix 4: Survey of LCNUK members’ activity in relation to nurse-led clinics
A survey questionnaire was e-mailed to all members of the Lung Cancer Nursing UK (n= 267) on 15 th May 2015 to identify activity in relation to nurse-led clinics. The questionnaire was developed by the 2015 Lilly Workshop project group and comprised 18 questions covering a range of areas pertinent to nurse-led clinics.
Approximately 60% (58%, n=154) of the membership responded to the survey although not questions were answered by each of the members.
Over half of the respondents reported they were involved in nurse-led clinics (Q1). A wide range of clinics were identified including telephone clinics, results clinics, post-surgery clinics, health and well-being clinics, TKI clinics and breathlessness clinics (Q2).
Although members are active in relation to developing and implementing nurse-led clinics, 67% of respondents had not evaluated or audited the clinic (Q8). In addition, 74% of respondents do not have a patient information leaflet to explain their nurse-led clinic (Q3).
The survey identified that almost 96% of respondents have access to medical cover for their clinic, although help from medical colleagues is rarely requested (Q5,6).
The majority of nurses have an individualised clinic code for their service (Q13).
An example of some of the questions and responses are listed below in graph form:
Q1 Do you run/participate in a nurse-led clinic?Answered: 154 Skipped: 0
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Yes 54.55% 84
16
No 45.45% 70
Total 154
Q2 If yes what type of clinic do you run? (Please mark all that apply)
Answered: 61 Skipped: 93
Results
Breathlessness
Telephone
clinic
TKI
Post-surgery
General follow-up
Health and well-being /...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Results 27.87% 17
Breathlessness
14.75% 9
Telephone clinics 65.57 40
TKI 13.11% 8
Post-surgery 29.51% 18
General follow-up 52.46% 32
Health and well-being / survivorship 29.51% 18
Total Respondents: 61
17
Q3 Do you currently use a patient information leaflet to explain your nurse-led clinic?
Answered: 72 Skipped: 82
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Yes 26.39% 19
No 73.61% 53
Total 72
Q4 Would you be willing to share it with us?Answered: 17 Skipped: 13
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Yes 100.00% 17
No 0.00% 0
Total 17
18
Q5 Do you have access to your medical colleagues if required?
Answered: 70 Skipped: 84
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Yes 95.71% 67
No 4.29% 3
Total 70
Q7 How frequently do you request help from your medical colleagues per clinic?
Answered: 61 Skipped: 93
Never
Rarely
Less than once
per clinic
Several timesper clinic
Frequently at every clinic
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
19
Q8 Have you evaluated/audited your clinic?Answered: 67 Skipped: 87
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Yes32.84% 22
No 67.16% 45
Total 67
Answer Choices Responses
Never 0.00% 0
Rarely 52.46% 32
Less than once per clinic 36.07% 22
Several times per clinic 9.84% 6
Frequently at every clinic 1.64% 1
Total 61
20
Q12 Are willing to share the information? Answered: 13 Skipped: 141
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Yes 84.62% 11
No 15.38% 2
Total 13
Q13 Do you have an individualised nurse clinic code (rather than a medical or directorate code) to capture your activity?
Answered: 64 Skipped: 90
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Yes 82.81% 53
No 17.19% 11
Total 64
21
Answered: 11 Skipped: 143
Q15 Do you have an example of a nurse-led clinic that works well?
Answered: 64 Skipped: 90
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Yes 67.19% 43
No 32.81% 21
Total 64
Q16 Would you be willing to share it?Answered: 37 Skipped: 117
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
22
Yes 89.19% 33
No 10.81% 4
Total 37
23
Q17 Have you previous experience of running a nurse-led clinic which wasn’t successful?
Answered: 129 Skipped: 25
Yes
No
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Answer Choices Responses
Yes 6.98% 9
No 93.02% 120
Total 129
24
25
26