Within my scope of professional practice as a nurse consultant with over 20 years' clinical experience within haematology and oncology, I initiated an innovative workforce planning opportunity setting up a dedicated advanced clinical practice service within a secondary NHS service. The first advanced clinical practitioner (ACP) commenced in post in 2015, and we currently have a team consisting of a nurse consultant working as the lead ACP, one ACP for haematology and two ACPs for oncology.
Clinical practice
As well as the ability to autonomously conduct history taking and physical examination skills, the ACPs in the team complete several clinical procedures including bone marrow biopsies, central venous access device (CVAD) insertion, ultrasound-guided lumbar punctures and skin biopsies for patients with suspected graft versus host disease. Competency documents were devised for all clinical procedures alongside clinical guidelines and standard operational procedures to ensure we had a robust clinical governance framework and used best evidence-based practice. Table 1 demonstrates some of the procedures with associated income stream performed by the ACP team within the last 12 months
Table 1. Procedures completed by ACPs and income generation
| Activity | Tariff per procedure | Number completed | Total revenue |
|---|---|---|---|
| Bone marrow biopsy | £409 | 610 | £249 490 |
| PICC insertions | £375 | 206 | £77 250 |
| ACP reviews | £57 | 539 | £30 723 |
| Telephone consultations | £24 | 880 | £21 120 |
PICC=peripherally inserted central catheter
Non-medical prescribing is a key element of the role and all our ACP team are fully qualified independent and supplementary prescribers. Most of the ACP team have completed the non-medical authorisation of blood products course, which has been essential considering the number of blood products required to support haematology and oncology patients. Within our remit, the ACP team run weekly clinics to assess patients receiving systemic anti-cancer therapy (SACT). In the haematology field we also manage patients in the non-malignant setting, this is predominantly for haemochromatosis although we are now developing ACP clinics for iron-deficiency anaemia and idiopathic thrombocytopenic purpura. ACPs also review patients with non-malignant haematological conditions in a clinic based in the Channel Islands. Within the haematology and oncology chemotherapy day units the ACP team review patients presenting as unwell following SACT as well as after high-dose chemotherapy or stem cell transplantation for haematological malignancies. In order to ensure that patients have instant access to radiological investigations the ACP team have all completed training on the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) and can request ultrasound, X-ray, CT, MRI and bone scans using the governance of a Trust-wide policy. We have recently set up an ACP-led totally implantable vascular access device (TIVAD) service for patients to have a port inserted when they require long-term vascular access for metastatic cancer (Figure 1).
Figure 1. Insertion of a totally implantable vascular access device
Facilitating learning
Facilitating learning is a core element of the teams' roles. As part of my nurse consultant/lead ACP role I teach within the trust both in the clinical setting as well as at two local universities and internationally at the University of Bethlehem in Palestine. All the team undertake teaching activities both locally and nationally. Trainee ACPs are supported by the ACP team and wider medical team with teaching in the clinical setting taking place on a weekly basis. All the qualified ACP team hold an MSc in nursing and in addition to their MSc and non-medical prescribing studies they have completed the postgraduate certificate in advanced clinical practice at the University of Warwick.
Support from the haematology and oncology medical teams has been pivotal to developing the service. Not only are the ACPs fully integrated within the teams, but we are also actively encouraged to attend courses, conferences locally, nationally and internationally. Teaching from the medical team has really benefited us all with our professional development. All the ACP team receive 15 hours a month protected study time in order to work on audit and research as well as spend time with other departments to further enhance their roles.
I have already started a PhD and will be researching the management of low-risk febrile neutropenia. The PhD route is open to all members of the team and actively supported by the clinical director.
Leadership
Elliot et al (2016) warned that failure to identify and address barriers to the leadership aspect of advancing practice has the potential to endanger the long-term success of the role. As previously discussed, one of the key factors to driving forward the ACP agenda has been the overwhelming support of the clinical director, senior medical colleagues and the senior management team. We are very fortunate to have a strong ACP leadership team within the organisation and well-established ACP teams within other clinical areas. The main two elements to advanced practice leadership are deemed to be clinical and professional (Lamb et al, 2018). From a professional perspective, as ACPs we all serve as role models, provide a flexible, reactive and proactive service to the team and most importantly the patients for whom we care for. From a clinical leadership perspective, we are always seeking new ways of working to develop advanced clinical practice to enhance the care delivered to our patients as well as provide support to the nursing, medical and allied health professional teams within our unit.
Gathering evidence, research and development
During the last 12 months, as a team we have expanded significantly and undertaken hundreds of procedures, clinics, telephone consultations and day case reviews. Audit is pivotal within the team; rates of CVAD infections, venous thromboembolism (VTE), lumbar puncture service and quality control of bone marrow biopsy samples (Figure 2) are all audited and shared with the team. We have recently gained funding for full-time administrative support for the team, which will support further audit and research. From a development perspective we are seeking to expand the team and develop the role of the ACP within the inpatient setting as well as the ambulatory setting with the aim of avoiding unnecessary admissions. At present the ACP team use ultrasound for CVAD insertion as well as lumbar punctures; we plan to undertake further training with the use of ultrasound to further enhance the diagnostic pathway for our patients including paracentesis.
Figure 2. Undertaking a bone marrow biopsy.
In summary, the success of the ACP role within haematology and oncology has been championed by the senior medical team and this has been key to the success of the role. As the nurse consultant and lead ACP I am passionate about advancing practice, supporting the team and most importantly promote a culture whereby ‘we know what we don't know’.