The number of people diagnosed and living with cancer in the UK continues to rise, which places increasing demands on specialist cancer care services (Independent Cancer Taskforce, 2015). The incidence and prevalence of neuroendocrine tumours (NETs) have also increased (Public Health England (PHE), 2016). NETs remain a rare cancer with specialist needs, and clinical nurse specialist (CNS) teams are ideally placed to support these patients. Oncology clinics are becoming increasingly pressured and the need to think of innovative ways of reducing this pressure while maintaining and enhancing the patient experience is essential. Internal patient experience surveys at the author's Trust had shown increased waiting times for patients.
The advanced nurse practitioner role
As Lead Nurse of the Royal Free London NHS Foundation Trust Neuroendocrine Tumour Unit (a European Neuroendocrine Tumour Society (ENETS) centre of excellence), the author wanted to help improve the experience for patients within the oncology clinic and systemic anti-cancer therapy (SACT) pathway. The author, a clinical nurse specialist (CNS), had completed advanced communication skills training, which is an integral part of CNS development. The CNS had also already established and run nurse-led clinics within the unit alongside the other NET CNSs and had completed a non-medical prescriber (NMP) qualification 7 years previously, along with advanced history taking and examination modules. Because the CNS regularly prescribed medication within the clinic setting independently to help provide seamless care, it was thought that this would be transferable to the SACT setting and within the author's scope of practice (Nursing and Midwifery Council (NMC), 2018).
The idea was for the CNS to review patients in the clinic and prescribe the SACT treatment. It was hoped that incorporating an experienced CNS, who was also a NMP, into the SACT clinic template alongside the medical team would improve the quality of patient reviews, enhance the patient experience, allow a more streamlined pathway through the department and reduce waiting times for patients. This would potentially free more time for the consultants to spend with patients with more complex needs.
The proposed advanced multidisciplinary team (MDT) SACT clinic template was discussed with the Trust's consultant lead for chemotherapy, the lead chemotherapy nurse, lead consultant of the NET service and the Trust lead for NMP. Other CNS teams around the country were consulted to discuss best practice and development of services. This would represent a novel pathway; other CNS teams are involved in toxicity checks with patients receiving SACT, but do not prescribe the treatment itself. The existing CNS NMP protocol was changed to include SACTs.
The MDT SACT clinic template needed to be transferable to other specialties within the Trust. It was important to ensure the CNS was supported by the team while being able to develop advanced skills and knowledge. It was also important to ensure that the patients were happy with the new clinic and that they were content to be seen by a nurse for pre-chemotherapy toxicity reviews, and for prescribing of the medication. The new clinic template was agreed and included regular audits of practice, with the first audit to be carried out 3 months after the clinic began.
Minimal education and experience requirements were agreed and set out in the NMP protocol and MDT SACT clinic template to help ensure safe practice and support for the CNS NMP role. These were:
Patient selection
During discussions on patient selection criteria it was agreed that the oncology medical team would review the patients at predetermined points in the treatment journey. This was to ensure patients continued to have the benefit of reviews by the whole MDT specialist team. The regimens prescribed by the CNS NMP were standard regimens used for NET patients, therefore within her scope of practice. These were agreed by the Trust's NMP lead, chemotherapy lead and the NET oncology consultant. Up-to-date protocols for these regimens were put in place to ensure the NMP had a safe framework on which to base clinical decisions.
Consent
Consent to treatment would be obtained by the medical team. The predetermined times for the oncology medical team reviews were: before cycle 1 (at point of consent), after restaging scans and at the end-of-treatment review. At all other times the MDT SACT clinic template allowed the CNS and medical team to review patients interchangeably. This allowed quick and easy communication and could also potentially reduce the need for any unnecessary delays in the pathway. The design allowed the CNS easy access to the medical team to discuss any issues that may have arisen during a patient consultation and examination. A Cochrane review found that many NMPs frequently have medical support available to support collaborative practice (Weeks et al, 2016; Duarte et al, 2017).
At the end of each clinic the CNS NMP met with the lead consultant to review all the patients seen and discuss decisions made. The CNS also discussed each patient with the chemotherapy pharmacist to ensure blood test results were reviewed and plans were confirmed for all NET SACT patients in the clinic.
Audit
The CNS kept a record of prescribing behaviour and an audit was undertaken after 3 months to ensure that safe effective prescribing was being carried out within the clinic. Studies, such as that by Latter et al (2012), reviewed the prescribing practices of non-medical prescribers in clinical situations and confirmed that in the majority of cases they were prescribing appropriately. The clinic audit included a review of prescriptions carried out by the CNS, the patient experience survey and consultant colleague survey.
Results
The audit reviewed practice between October 2016 and January 2017, from the first SACT prescription by the CNS. During this period a total of 38 prescriptions were written for 19 patients.
CNS prescribing and new regimens
The CNS would prescribe only those regimens that were specified in the protocol. During the period of the audit, new regimens were introduced. Patients on these could still be reviewed by the CNS but new SACTs were not prescribed until the CNS and medical team felt confident with the regimens and until protocols were developed. Therefore nine of the prescriptions described above were not prescribed by the CNS. These regimens were not included in the audit because the CNS did not prescribe them; however, since completion of this audit, these SACT regimens have been added to the CNS's prescribing list.
Once these prescriptions were removed from the audit the total number of SACTs prescribed by the CNS was 29, for 15 patients.
The regimens prescribed by the CNS were:
On review by the SACT pharmacist and the prescribing CNS, there were no errors on the prescriptions. All the SACT prescriptions had been confirmed by the CNS and then authorised by the chemotherapy pharmacist.
Issues during prescribing
The CNS had 13 reviews/discussions with consultants during the clinics. The CNS sought advice and discussed clinical issues where appropriate. Reasons varied and included the need for dose reductions due to toxicities related to the SACTs, and disease-related issues. Toxicities warranting dose reductions included grade 2 stomatitis for sunitinib patients. One patient receiving FCiSt chemotherapy attended with a chest infection. The patient was prescribed antibiotics by the oncology consultant and the patient's chemotherapy was deferred by 1 week. The patient was then reviewed by the CNS and continued with the cycle of treatment.
A patient with metastatic insulinoma (an insulin-secreting pancreatic NET) reported that he had had a fall 2 days previously and had multiple facial bruises. Although he felt well, the CNS discussed his blood sugar control as a possible precursor to his fall. The patient had complex polypharmacy that included specialist medication such as somatostatin analogues and diazoxide to ensure adequate glucose/insulin control was maintained alongside the SACT. During the clinic the CNS discussed her concerns with the wider MDT, including the oncology consultant and consultant endocrinologist, to ensure the patient remained safe and well.
History taking
As well as SACT toxicities, the CNS assessed patients' general health and wider disease-related issues during history taking. One patient had a history of metastatic Merkel cell carcinoma. When the patient was reviewed by the CNS, a new skin lesion was observed. The CNS sought the advice of the oncology consultant who also examined the lesion, and an urgent dermatology review was organised for the same day as the SACT treatment. This allowed the patient to avoid extra hospital visits and ensured a quick specialist review, without the need for any treatment delays.
During history taking and examination of a patient, a new symptom of shortness of breath was described with associated chest pain. The CNS discussed the patient's symptoms with the consultant team, investigations for pulmonary embolism were organised and the patient began treatment for this.
One instance occurred when SACT treatment had not been allocated by the consultant at the point of consent and cycle 1, therefore the CNS was unable to confirm the treatment. The CNS discussed the patient at the time of review and the prescription was organised without any delay to the patient journey.
Changes to prescriptions
The CNS made changes according to the protocols and dependent on the patient's examination. Changes made were as follows:
Patient experience survey results
Of the 15 patient experience questionnaires distributed, 14 were returned completed (Table 1). Results from the consultant questionnaire are presented in Table 2. Some patient comments are listed in Box 1.
| Patient survey question | Result (n=14) |
|---|---|
| How long was your waiting time? | Up to 15 minutes: 70% |
| How would you rate the quality of the nurse review? | Excellent: 84% |
| Did you have confidence in the nurse's level of knowledge? | Yes: 100% |
| Were all your questions answered by the nurse and did you understand all the information? | Yes: 93% |
| Were you given enough time to discuss any concerns? | Yes: 100% |
| Did you feel involved in decision making? | Yes: 100% |
| Did you receive enough information regarding your treatment and your NET? | Yes: 100% |
| Was a doctor required to review you in the nurse-led clinic? | No: 79% |
| Would you have preferred to see a doctor? | No: 93% |
| How satisfied were you with the experience of the combined nurse-led and medical review clinic? | Extremely satisfied: 57% |
| Did you find any benefit to seeing a nurse? | Yes: 58% |
| Oncology consultant survey question | Result (n=5) | Comments |
|---|---|---|
| Are you confident in the knowledge of the nurse? | Yes: 100% | |
| Was safe SACT prescribing practice observed? | Yes: 100% | |
| Did the nurse discuss issues with the wider SACT team appropriately? | Yes: 100% | |
| Did you feel decision making by the nurse regarding SACT prescribing and patient assessment (including physical examination) was appropriate and safe? | Yes: 100% | |
| In your opinion, do you think this clinic allowed the medical team more time to review more complex patients within the clinic? | Yes: 100% | |
| Were you asked to review the patient alongside the nurse within the nurse-led clinic appointment? | No: 100% | ‘Nurse discussed cases and issues appropriately while patient in clinic with medical team’ |
| How satisfied were you with your experience of the combined nurse-led and medical review clinic? | Extremely satisfied: 100% | |
| How would you rate the quality of the nurse-led review? | Excellent: 100% | ‘The non-medical prescriber provides an excellent service’ |
Discussion
Safe practice was observed with no incorrect prescriptions. When the SACT needed to be delayed, these issues were highlighted, and patients informed. The bloods were then rechecked and patients contacted by telephone to confirm they had recovered and SACT could be given. Other toxicities were highlighted and prescriptions delayed, for example, in one patient, cisplatin was stopped because of neuropathy.
Avoiding delays
Discussions with the medical team were timely; they did not appear to cause any delay in the patient pathways and patients felt reassured that these discussions were possible. One patient commented:
‘Nurse has more time and to see a doctor as “back up” is very comforting.’
Referral
Discussions did not always revolve around toxicities; for example a new skin lesion found on physical examination led to urgent referral to a dermatologist. The consultants felt the CNS and medical team discussions were necessary and appropriate and did not negatively impact upon the confidence the medical team had in the CNS.
Availability
The availability of the medical team to the CNS also helped to encourage discussions regarding general issues faced by SACT patients. An example of this was a discussion regarding what the consultants would advise when a patient had been deferred 2 weeks in a row due to low platelet or neutrophil counts. The CNS felt extremely supported and encouraged to discuss any issues or concerns raised during these clinics.
Confidence
Patients and the medical team reported that they felt confident in the CNS's knowledge. The patients reported that they wanted to be reviewed by the medical team to discuss scan results and this is a process built into the new MDT SACT clinic. The patient questionnaire included the question: ‘Would you have preferred to see a doctor?’ One patient replied: ‘It depends on what is being reviewed. Results of scans—doctor please.’
The allocation of oral agents by a consultant is needed to ensure the CNS can confirm the SACT regimens. In future, the medical team will allocate on the electronic prescribing system the next 3 months of the regimen. The allocation of regimens is a safety feature built into the electronic prescribing system to ensure patients are assessed at key points in their treatment pathways, ie after scans. Once allocated electronically, the CNS can then prescribe the treatments after they have assessed the patients.
Waiting times
Waiting times appear to be short, with the majority of patients reporting a waiting time of up to 15 minutes and one patient mentioning a wait of up to 30 minutes. As these patients then often go on to have SACT, this is a positive outcome because it allows the patient minimal time in the clinic and therefore reduces their overall time in the hospital setting. For all cancer patients time is precious and anything that allows the individuals and their carers to spend as much time as possible away from the hospital is to be encouraged.
Feedback
Another positive outcome was the feedback from the patients that they felt 100% involved in decision-making. Cancer patients often report feeling powerless and any aspect of care that helps limit this feeling and encourages patients to feel in control of their lives is a positive step. The patients also reported that they had received enough information about their treatment and this may have added to them feeling involved in decision-making, which highlights the importance of informed consent.
Abating concerns
However, in additional comments one patient stated:
‘There are a lot of unknowns regarding the treatment, so some of my concerns/questions cannot be answered. More literature could be handed out.’
This is a similar finding to what was reported in the National Cancer Patient Experience Survey carried out by the NET Patient Foundation/Quality Health in 2014. Patients reported that they were not given sufficient written information regarding their diagnosis or treatment. All patients receive written information regarding their SACT and are given time to read this through before consenting and commencing treatment; however, this comment by one patient highlights that patients may not take in this information and need this to be repeated and discussed throughout their cancer journey.
Crucial interactions
Time spent on their care was highlighted as important by patients. They felt that they had more time to discuss any issues when they were reviewed by the CNS compared with a medical review. Another interesting response from a patient concerned the quality of the review. The patient stated:
‘I don't get the thorough examination I get with the nurse specialist; it would therefore worry me if I didn't get to see her and only saw a doctor. In addition, the doctors don't give you as much time to discuss your concerns.’
The CNS physically examines all patients reviewed in the MDT SACT clinic, which appears to differ from the medical team. This may be due to time pressures for the medical team or due to some of the medical team basing the need for physical examination upon the toxicity review and discussion. The CNS considers that the physical examination is a very important aspect of the review because issues outside of the toxicity review may become apparent that will need to be addressed.
Communication
The differences in communication techniques were also highlighted. Two patients commented:
‘Sometimes nurse is easier to talk to.’
‘Questions are dealt with … in a very reassuring way, using their knowledge, expertise and experience. They deliver a message in a very compassionate way, often more so than the doctor.’
This may be due to time constraints on the medical team because they combined this MDT SACT clinic with a large hepatocellular carcinoma clinic, which adds additional pressures. This may also be due to the increased communication skills training that is included in the development of advanced nurse practitioners and the relationship that develops between the CNS and the patients over time.
Valuing expertise
The patient experience in this clinic has been largely positive and highlights the impact that can be made by innovative clinics that combine the expertise of both independent nurse practitioners and the medical team.
One patient commented:
‘I have found the nurses to be invaluable in my care and feel their job is as critical as [that of] the doctors. They have helped me emotionally as well as medically. It is so reassuring knowing they are at the end of the phone to help answer any questions or concerns I have between clinics. They do an amazing job, I am grateful they are there.’
This confirms what was shown in the Cochrane review by Weeks et al (2016) and reviewed by Duarte et al (2017), which highlighted that NMPs can be as effective as doctors in aspects of prescribing, including adherence to treatment, overall satisfaction and patient quality of life.
The SACT non-medical prescribing list within the MDT SACT clinic continues to grow as the regimens available for these patients increase and, as the clinic grows, there is increased availability for the patients to be reviewed both by the expert nurse team and the medical team. Once the CNS NMP has completed 3 months of toxicity reviews alongside the oncology team the new regimens will be added to the NMP SACT protocol. The clinic will also include other NET CNSs once they have completed the SACT course. Currently, other NET CNSs are carrying out toxicity reviews for everolimus and sunitinib but not prescribing SACTs. The clinic can be used as a template by other specialist CNS teams.
Job satisfaction
As an NMP, the author felt increased satisfaction in her role in the clinic. It encourages a deeper understanding of the concerns felt by patients undergoing SACT and allows the CNS team to develop more in-depth relationships with the patients and their carers throughout this treatment pathway.
Limitations
This article discusses experience in one NET centre with an engaged wider MDT. The author is aware that the development of the clinic described may be more challenging in hospitals/trusts without that support network.
Conclusion
The clinic experience has been positive for both patients and clinicians. This service innovation has highlighted the positive impact of clinics that combine the expertise of independent nurse practitioners and the medical team. This has paved the way for further clinics of this kind within the Trust and within the NET service. The experience of developing this clinic has increased the confidence and knowledge of the CNS related to service development and organisational change management, alongside improving the patient pathway and patient experience.
Recommendations for future practice
The template described in this article is currently being used to develop similar clinics throughout the Royal Free London NHS Foundation Trust and is transferable to other hospitals. Audits of the service will continue to ensure the clinic remains responsive to the ever-changing needs of cancer patients.