The publication in 2004 of the Nursing and Midwifery Council (NMC) document The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics has allowed nurses to consider extending their roles formally in order to enhance the holistic approach to patient care. The document states that the nurse must be satisfied that each aspect of practice is directed to meeting and serving the interest of the patient. It also states that the nurse must ensure that any adjustment to the scope of his or her personal practice must be accompanied by an acknowledgement of his or her personal limits in knowledge and skills.
3.3.1 Role boundaries – medical and nursing overlap
MacAlister and Chiam (1995) argues that, in the past, allied healthcare professionals delegated to nurses tasks they found inconvenient or boring. Shepherd (1993) suggests that the undertaking of medical tasks enhances the professional status of nurses, a view which could be understood as seeming to demean the nursing profession as a whole (Porrett 1996). Gee (1995) highlights the argument that anyone with manual dexterity and a degree of comprehension could be taught to perform certain medical tasks. However, it is not the action of the medical task but the responsibility and accountability associated with the task. Errors made by nurses who extend their practice will be judged by the standards of practice of a reasonable doctor and therefore their competencies are measured within a framework which is nurse owned to determine their skills where the main focus is to enhance patient care and maintain the therapeutic relationship of nurses and their patients (Gee 1995). The interface between nursing and medicine in specialist practice should include psychosocial assessment and intervention with patient teaching, counselling, health education, caring and comfort (Dressler 1994 cited in Gawlinski and Kern 1994, p183-190).
3.3.2 The emergence of Nurse Practitioners
The need to develop cancer services to support patients in treatment and survivors of cancer has been reinforced by government policy in the United Kingdom. The National Cancer Plan (DOH 2000) redesigned care to ensure that patients and their families had timely access to treatment. NICE (2004) specifies greater detail in timely follow-up for cancer patients and their families. The Nursing Contribution to Cancer Care (DOH 2000b) sets out a strategic programme for cancer to improve information during and after treatment and more recently „Action for London‟ (2007) discusses the diverse needs of patients in London with cancer and an educated workforce to meet their needs. This is also in line with the changing demographics and health inequalities discussed in The Cancer Reform Strategy (DOH 2007 and Darzi 2007). These changes in the population and policy have been major influences on the expansion of nursing roles and responsibilities. Recent reforms specify much greater pressure on NHS Trusts to provide high quality services to tackle cancer and improve the patient pathway. Therefore, specialist nurses are in prime position to understand the issues surrounding the extension of nursing roles and are made aware of all the implications of the NHS reforms to take control of the situation and, as Castledine (1996) requests, to bring coherence to a potentially fragmented healthcare system. Lemp (1995) takes the view that the emergence of a nurse practitioner should not mean that the nurses replace doctors, but that they are able to provide to the public a better quality and wider choice of services. As Pennery et al. (2000) point out in breast cancer follow-up, their research was not to prove supremacy in quality of care between the professions but evidence based discovery of the subtle differences between what doctors and nurses offer and the best professional service to enhance the patient experience in breast cancer follow-up. The concept of devolving aspects of care to nurses is not new. Midwives function effectively with a large degree of autonomy in a significant proportion of normal deliveries.
James, Guerro and Brada (1994) in Sutton piloted a nurse-led follow-up for new patients with central nervous system tumours during radiotherapy treatment. These patients are often disabled during radiotherapy and the majority have a poor prognosis, and all require clinical consultations dealing with issues of treatment, rehabilitation, care and support. It was a short audit over only eight weeks of the care of eighteen highly dependent patients.
The transfer of care from conventional outpatient clinic to a nurse „on treatment clinic‟ and the use of „telephone clinic‟ decreased the patient work load. Unfortunately the authors cannot confidently claim that some patients may have wanted to see the doctor as the efficacy of the clinic was measured by its effect on work load, compliance and questions posed by the nurse herself, which may have caused bias. However, the authors report that the patients appeared satisfied with the nurse specialist clinic and that there was a 30% reduction in the medical outpatient work load. The implementation of the „telephone clinics‟ offers an effective alternative to conventional outpatient clinics and is more convenient for patients.
Hammond, Chase and Hogbin (1995) described a nurse practitioner service that they had developed within The Royal Sussex County Hospital. In the breast clinic a nurse practitioner assessed new patients with non-worrying symptoms such as breast pain and she triaged referral letters from GPs. The research project was undertaken over a five-month period and its aim was to assess the effectiveness of a nurse practitioner as compared with that of two senior house officers, one male and one female. Following the patients‟ consent they were given several questionnaires including the Medical Interview Satisfaction Scale (Wolf, Putnam, James and Stiles 1978). The patients who saw the nurse practitioner expressed higher satisfaction than those who saw the male or female house officer. Where the possibility of cancer was present, the patients who consulted the nurse practitioner were less anxious than those who saw either of the two house officers.
The article did not document the statistical values or numbers of patients interviewed. It is
difficult to review the results objectively but even with this small scale study in the 1990s nurse led interventions within breast care were being developed.
Earnshaw and Stephenson (1997) evaluated nurse-led follow-up clinics for breast patients.
There were 191 clinic visits for breast cancer. Twenty four were for pre-operative counselling and 167 for up. From the paper it is difficult to ascertain whether follow-up was meant to be within medical guidelines, once treatment had finished, or that the nurse would give interim follow-up support similar to the pre-operative information and support provided. In the course of the discussion the authors highlight the benefits of nurse-led care in continuity for patients and in longer appointments than those in general clinics. However, the opinions of the patients have not been ascertained and statistical analysis has not been provided. It is agreed by the authors that nurse-led clinics are cost effective and a clinically acceptable way of conducting breast cancer follow-up but that this is very hard to prove without formal scientific comparison.
3.3.3 Patient satisfaction with nurse-led services
Garvican, Grimsey, Littlejohns, Lowndes and Sacks (1998) describe a study that assesses patient satisfaction with a nurse-led clinic and screening for breast disease in London and evaluates the clinical expertise of the nurses. The nurses distributed a specifically designed patient satisfaction questionnaire to 150 consecutive new referrals during a six-week period. One hundred and nineteen questionnaires were returned after a postal reminder - a response rate of 79%. A Likert scale was used to rank satisfaction. Forty seven (40%) out of 117 women responding to this question were satisfied with the amount of time they spent waiting at the hospital and 30 (35%) out of 113 women responding were satisfied with the facilities in the clinic. Only five women had expected to see a nurse. All women were satisfied or very satisfied with the clinical care received, and 19 (16%) out of 118 added specific praise to their responses. Overall, data showed that the patients were
significantly more satisfied with the nurses (p=<0.0001) than with other aspects of hospital care. Postal questionnaires were also sent to GPs. One hundred and two out of 150 (68%) were returned. Ninety nine questionnaires were analysed but only 91 were included for unspecified reasons. Sixty four out of ninety one (70%) GPs were aware of the role of the nurse but only 8/91 (7%) had informed their patients that nurses ran the clinic. Again this aspect of nurse-led care in assessing new patients is different from that of nurse-led cancer follow-up but, even so, nurses were acceptable to patients and general practitioners. The nurses‟ clinical skills compared favourably with that of other clinicians except for a lower percentage of inadequate samples which were aspirated by the specialist nurses compared with the rest of the team.
Faithfull, Corner, Meyer, Huddart and Dearnaley (2001) advocate specialist nurses as an important and cost effective resource in the care of men with prostate or bladder cancer.
They compared nurse-led care in relation to the physical and emotional impact of treatment with conventional care. The study sample was of men who were prescribed radical radiotherapy (>60 Gy). The men completed a self-assessment questionnaire for symptoms and quality of life during the first week of treatment and at weeks three, six and twelve. One hundred and fifteen of 132 gentlemen agreed to enter the randomized trial.
Six (4%) refused and 11 (8%) were missed for inclusion in the study. Results indicated that, although the nurse was unable to influence the extent of the side effects from treatment or improve quality of life, the nurse-led intervention was effective in managing symptoms. Satisfaction with the nurse-led service was greater than with conventional care (p=<0.002) and costs were cut by half. However, in this study the views of the patients were not discussed.
Cox et al. (2006) investigated patient preferences in relation to follow-up after treatment for lung cancer and sought to assess the nurse-led option. Over a 34-week period 72 patients
who were deemed to be eligible for nurse-led follow-up attended 487 follow-up appointments. The inclusion criteria were patients with small cell or non-small cell lung cancer receiving follow-up care. Patients who were in other research trials or required urgent medical attention were not included. Sixty patients were approached and 54 (90%) agreed to participate. A questionnaire and vignette of different scenarios were used (nurse led, telephone, GP or standard follow-up). Thirty four out of fifty four (63%) of eligible patients completed the forms, as did 10/20 carers (50%), 20/31 (65%) of staff and 11/38 (29%) of GPs. Following the weekly lung MDT meetings, patients indicated whether they were interested in taking part in the project. The research team explained the project further and gained consent. At the same time the researcher asked the patient to nominate a family member to whom the questionnaire could be given. Likert scales were used to rate acceptance of scenarios. The patients were happier to see the doctor (p=0.18) than to see the nurse but happier to see the nurse than to see the GP (p=0.12).
All groups were satisfied with nurse-led follow-up if there was medical backup and if the nurse was empowered to refer the patient onwards, if needed. Again most useful about the visit was the reassurance given, adequate treatment if necessary, update in condition and relevant advice and information.
Corner et al (2002), at the Royal Marsden London, entered 203 lung cancer patients to a randomized control trial to validate the acceptability of nurse led follow-up. These patients had completed their initial treatment and were expected to survive for three months or more. The acceptability of nurse-led follow-up was high and there was no significant difference between the groups in their overall satisfaction. There was no difference in survival between the nurse-led and the conventional medical-led service. However, the nurse recorded progression of symptoms sooner than the doctors (p=0.01). But the potential for bias must be recognized. There were differences in the co-morbidity between the two groups, which were not fully addressed in the discussion. The differences were
mainly in cardiac disease where the nurse group had 29 patients and the doctor group had four. The nurse group also had 28 patients with gastrointestinal disease while the doctor group had 20. The randomisation was not fully described in the paper and as there were more patients with co-morbidity in the nurse-led group than in the controls, earlier detection of symptoms would occur as disease progressed rather than by a difference in the quality of care provided (Mongelli 2002). Furthermore, the paper describes 100 patients within the nurse-led group and 103 in the conventional group of medical follow-up.
One patient was excluded which meant the total was 202 patients. The patients in the nurse led group had access to two Clinical Nurse Specialists without appointment and telephone contacts which were three per month for a mean of three minutes. Rodger (2002) advises caution on the grounds that the study compares open and frequent access as against infrequent hurried consultation with a different registrar at every visit.
McCaughan and Sorley (2007) explored the healthcare needs of women attending a consultant-led breast cancer review clinic and the healthcare professionals‟ perceptions of ways in which the service could be delivered more efficiently and more effectively. A qualitative design was adopted, using observation during seven outpatient oncology and surgical breast clinics. Interviews were carried out with a convenience sample of twenty one women, three breast care nurses, four oncologists, three surgeons and an out-patient sister. Although the women saw themselves as returned to a pre-cancer state they still had fears of recurrence and a need for reassurance. Although this need was met during the clinic visit, they identified many psychosocial needs as not having been met. It could be argued that nurses seemed to be underused as a potential source of support for patients in the follow-up setting. Medical and nursing staff recognised that the women condition is needed to be reviewed but acknowledged that appropriately prepared nurses could deliver a more holistic and efficient service.