Treatments for prostate cancer are evolving all the time, which means that, often, more demand is being put on the acute setting. Survival rates are now higher because of these newer treatments, which means demands on urology services to monitor these patients are stretching an already lean service.
Historically, consultants headed the team and made all judgements about patient care. However, due to the complexity of the healthcare environment today, one discipline no longer has all the knowledge and skills in an area. Today, the NHS is about interprofessional working.
Increasing demands on the NHS and its workforce mean that hospitals are seeing more patients with complex chronic conditions, including cancers (Hofler and Thomas, 2016). The lack of resources means that the workforce is often stretched. Change within health care often means looking at how to run a leaner service and be more cost-effective.
A new role
In 2019 I took up the new role of prostate cancer nurse. Part of the role was to look at how an overstretched oncology clinic with a waiting-list of 80 follow-up patients could be improved. All patients were followed up by one consultant who reviewed all cases both pre- and post-treatment. Because of a lack of funding and resources, the team comprised one full time nurse and one part-time nurse (30 hours a week), and one oncology consultant working one day a week, who was subcontracted from another hospital.
A project was set up to look at how a nurse-led clinic could affect three keys areas, as follows:
- Improving the patient experience: a nurse-led clinic could reduce waiting times and ensure patients' holistic needs are met
- Implementing National Institute for Health and Care Excellence (NICE) guidance: a nurse-led clinic could ensure patients were monitored in line with NICE guidance (NICE, 2021)
- Improving the prostate cancer pathway: many patients were not having a holistic needs assessment because of a lack of resources and time in the clinic.
A nurse-led clinic project
NHS England/NHS Improvement's Quality, Service Improvement and Redesign tools and the Plan, Do, Study, Act model (2021; 2022) and research into the science of improvement were used to look at the prostate cancer pathway and see which patients could be followed up by a nurse.
The first cohort of patients identified were second-generation hormone patients who needed regular review and prescribing of drugs by the consultant. These patients needed to be reviewed at specific times and those appointments could not be moved. There was a large number of patients waiting for follow-up and there were only 14 follow-up slots available each week.
By monitoring the clinics over a 3-week period, it was found that around seven appointments a week were for this cohort, who were taking up nearly half of the available follow-up clinic slots. We also found that a lot of patients who had undergone radiotherapy or brachytherapy were having their post-treatment appointments cancelled because of a lack of consultant time.
The consultant worked with the nursing team to introduce the first nurse lead for the second-generation hormones clinic. Guidance was written with the help of the oncology pharmacist, the trust chief pharmacist and the oncology consultant. Working with all stakeholders is important in implementing change.
As the prostate cancer clinical nurse specialist (CNS), I was already a non-medical prescriber, which meant that I was in a good position to take on this role. So a period of training was necessary to ensure that I had key knowledge of medications and patient monitoring to ensure patient safety.
Patient experience was key and it was felt that a clinic with seven nurse-led clinic slots taking 30 minutes each would be given to patients to allow a holistic needs assessment to be carried out. Clinics would cover not only monitoring of the medication in a timely manner, but would also ensure that both emotional and physical wellbeing issues would be addressed. This would free slots for the consultant's clinic. There would still be issues with clinic capacity and we still needed to review other cohorts of patients to see what nurses could do to improve these once we had got the first clinic running.
Effects of the pandemic
The first nurse-led clinic for the second-generation hormone patients was due to start in March 2020 following my training and research into how to achieve an effective change. However, COVID-19 hit and this could have stopped the whole project going ahead.
Emergency plans were made for patients to have blood tests and blood pressure (BP) measurements taken by their GPs when they attended for luteinising hormone-releasing hormone (LHRH) agonist injections. Some patients had their own BP devices at home and could forward readings to me. I would then follow up patients with a telephone call and, if all was well, second-generation hormone medication would be couriered to them. If there were any concerns, then we would ask them to come to clinic for a face-to-face appointment.
The clinic has been running now for 3 years. Since the first nurse-led clinic we have conducted a review and increased its capacity, so I am now responsible for nine clinic slots. It is clear from patient feedback that they feel they are given time in consultations to talk about concerns and that referrals to appropriate services are carried out in a more timely manner. Nearly all our patients now have a holistic needs assessment at various points in their prostate cancer journey. An additional two second-generation hormones are now being used for prostate cancer, increasing the need for more nurse-led clinics within the trust.
Achieving change
This project shows that, with the right research and leadership skills, changes can be made and effective evidence-based care can be provided.
Nurses can pave the way to making effective change that will improve patient care. De Leeuw and Larsson (2013) suggested that nurse-led clinics are important for patients because they can help with rehabilitation and help identify both emotional and physical needs. It is therefore important to ensure that enough time is available to achieve the aims identified for this change in the pathway. Finding time can often be an issue with the demand on services.
Having the right stakeholders with the same passions and goals can help achieve change. There may be stakeholders who say that it is not a nurse's job to take on certain clinical roles. Some may even say it is not a nurse's job to implement change.
Therefore, it is important to understand why some people resist change and how to make change happen. As Weberg et al (2019) stated, at some point in a nurse's career, he or she will realise that there are better ways of providing patient care or better ways to organise a service. Therefore, it is important that nurses have the necessary skills in change management because they will need to learn how to deal with stakeholders who are not on board with the project.
Based on the lessons learnt in this clinic, a further clinic was set up for patients who have had radiotherapy and chemotherapy and are on prostate-specific antigen monitoring. At present, I run this as a telephone clinic. In March 2022, a nurse-led active surveillance pathway and clinic was set up to ensure that patients were reviewed in a timely manner and to ensure that national and local guidance is adhered too. Another project has started this year to make this a remote monitoring pathway, with patients monitored using a digital tracking system. This is still in the early stages and requires an IT upgrade. Only patients with ongoing issues and concerns will be offered telephone or face-to-face appointments. Patients receiving remote monitoring will still have access to the nursing team if needed.
The team has now expanded and I have been joined by two full-time urology oncology CNSs and a support worker.
There is still a need for improvement within the prostate cancer pathway, and we are reviewing many areas. It is hoped that there will soon be a nurse-led transperineal biopsy clinic. At present this clinic is being led by the excellent urology consultants and we are looking at the workforce issues involved.
Nurse-led projects can be implemented not only in the prostate cancer service, but in any pathway. This was the first nurse-led cancer clinic within the Trust. Other cancer services within the Trust have adapted this project and set up similar clinics.
My experience shows that one small change can lead to bigger changes that improve patient services and the patient experience. This example of change shows how nurses can play a big part in making changes. My advice would be to start with one small project to improve your confidence – this will lead to personal development and the satisfaction of making an improvement in patient care.
There are some moments of frustration and times where it may feel that nothing is going to change. But take a step back, persevere and keep the passion to improve patient care. Nurses working in urology need to keep pushing to evolve how we work.
I was pleased to have had my work acknowledged by achieving a silver award in the BJN Awards 2023.