Welcome back

1. Welcome back

2. Nurse-led chemotherapy review CNS or chemotherapy nurse? Elaine Lennan Consultant Nurse Sponsored by Pierre-Fabre

3. Background • The NHS Cancer plan 2000 • The NHS plan 2000 • Cancer Reform Strategy 2007 • National Chemotherapy Advisory Group 2009 • UKONs position statement 2012

4. CNS John Mc Phelim Chemo Nurse Carolyn Maynard The debate

5. Brownie French fancy Voting

6. Brownie French fancy Who is the best 007?

7. Brownie French fancy

8. CNS Chemo nurse Should it be a CNS or chemo nurseundertaking nurse-led chemotherapy clinics?

9. Oral poster presentations

10. The Case for Chemotherapy Nurse Assessment Carolyn Maynard Lead Chemotherapy Development Nurse

12. Nurse-led chemotherapy in Kent 2009 Cancer Unit 1990 Cancer Centre 2005 Outreach site

13. Streamlined patient pathway Wait 10m Sample 4m Process sample 30m Consultation 15m Pharmacy wait 74m Chemo prep 30m Chemo admin 60m IV agents NAVELBINE ORAL NAVELBINE ORAL Day-before blood test NAVELBINE ORAL Nurse/pharmacy-led clinic Day-before pharmacy and blood test Wait 35m Wait 35m Wait 10m Sample 4m Process sample 30m Con 15m Pharmacy 30m Chemo prep 20m Admin 6m Wait 35m Con 15m Pharmacy 30m Chemo prep 20m Admin 6m Nurse/pharm led clinic 0h 1h 2h 3h 4h 5h 24.03.2009 Adapted from Taylor 2005

14. Second Step-Nurse review for All 2008 expanded service for all oral and intravenous chemotherapy (oncology) Protocol and competencies amended Senior Nurses Clinic Mon-Fri 09.30-13.00 (11 slots 20 min) Consultant referral via electronic action sheet Meet with oncology pharmacist post clinic Average 200-250pts/month

15. Lung CNS-Role Challenges2010 • UK Lung Cancer Coalition (UKLCC) this month highlights 12 areas that could be improved • Access to Lung Cancer nurses specialists limited. • Ratio 1-127 patients • Roles to be protected and expanded • Is this the right time to be undertaking chemotherapy review?

16. Excellence in Care-the contribution of the CNS to cancer care-NCAT 2010 Access Inequity between tumour sites Workforce Shortages High Quality Patient Care 9 key areas Skills diverted Not good value for money Variable case loads

17. Workforce Census 2011 Increase in posts 2007-2011 (brain/CNS, lung, haematology and upper GI). Not expanding sufficiently to keep pace increase in cancer prevalence. (3.2% per yr) Inequities in provision remain Ratio of CNS to caseload to achieve quality of care not as yet available National patient experience survey (2011)

18. No to CNS Chemotherapy review Compromise current high quality impact on patient care Value for Money Involvement in treatment pathway Existing workload/new workload average 250 reviews/per month Access and equitable care Division/Line management Chemotherapy competency Sustainability/ floodgates Education and Training (additional investment) Knowledge & Skills

19. CNS perspective-snapshot “As a cns we carry out lots of different clinics and support our patients through their cancer journey. The ability to follow them through there oncology treatment however is extremely lacking due to lack of funding, as it would require extra sessions building into current job plans. The idea is lovely however, you also need to aware that chemotherapy trained nurses are highly skilled and provide an excellent service for patients. The cns needs to be aware of all the treatments and side effects in order to care for her patient but I personally feel that this area should be lead by those with chemo expertise.” (Urology CNS) “Chemo nurses and oncologists who see the patient’s during their chemotherapy regime would seem the best people to identify toxicity”. (upper GI CNS)

20. Why Chemotherapy NursesPatient Benefits • Knowledge (not just about chemotherapy) , Skills and Competence • Continuity-Team of Nurses, have set days to run clinic. • Assess, manage , treat and provide 24hr support. • Clear understanding of the treatment pathway • Equitable (all cancers) and sustainable service for all cancer patients receiving chemotherapy

21. Yes to chemotherapy nurses Workforce and Training • Accredited Chemotherapy Training • Expertise with Chemotherapy and Chemotherapy Assessment/Management • Better use of available skills within workforce (8 nurses-potential to train many more) • Sustainable for all cancers • Cost effective (Band 5-7) NHS £20 billion efficiency savings 2013-2014 • Enhances multiprofessional working and learning-not de-skilling • Role Development/Retention

22. Yes to chemotherapy NursesNational Agenda • National Emphasis on chemotherapy nurses developing roles to support patients to ensure safety and quality in chemotherapy delivery. • UKONS position statement on nurse led chemotherapy clinics (2012)

23. Options for Debate • CNS undertake oral chemotherapy • Chemotherapy nurse undertake chemotherapy assessment • Hybrid Model-Joint Clinic • CNS with chemotherapy qualification sees the more complex patients-develops all nurses skills (CNS-nurse consultancy) • CNS without chemotherapy qualification does a joint clinic with the chemotherapy nurse

24. To Kill a Mocking Bird (1962) Atticus Finch: If you just learn a single trick, Scout, you'll get along a lot better with all kinds of folks. You never really understand a person until you consider things from his point of view... Until you climb inside of his skin and walk around in it.

25. Oral poster presentations

26. Lung Specialist Nurse specialist(site specific) The Case For ! John McPhelim Lead Lung Cancer Nurse NHS Lanarkshire

27. Chemotherapy specialist nurse v Site Specific Specialist Nurse

28. CHEMO NURSES Are busy Eating cakes……joke !!!

29. It Exists Already

30. UKON’S, NLC 2012

31. We know the disease • MDT member • Detailed disease knowledge • Detailed treatment knowledge • Information regarding prognosis • Relationship with patients / carers • Key contact

32. Patient experience • • Fewer HCP involved in care • • Patient focussed service – not service • • Key relationship with LCNS –already established • Unmet needs, reticent about seeking help • (Li & Girgis 2006) • Better cancer care 2009, Scottish Government • NCAG, 2009

33. We know the patients

34. Governance • CEL 30 (2012) July 2012 [REVISED] GUIDANCE FOR THE SAFE DELIVERY OF SYSTEMIC ANTI-CANCER THERAPY Training Protocols CMG’s Non medical prescribing NMC accountability

35. An evidence reviewcancer clinical nurse specialists Macmillan 2010 • Within MDTs cancer nurse specialists deliver treatment, provide continuity of care, develop post treatment plans and act as the central contact for patients. The Prostate Cancer Charity 2009 • Cancer CNSs hold follow-up clinics for cancer patients reducing the number of follow-up clinics and therefore increasing medical staff capacity to see new patients. Sullivan 2007 Why should chemotherapy assessment not be part of this holistic approach

36. Why develop a nurse led service ? • Patient focussed - continuity • Increasing numbers – all cancers / chemo • Capacity • Safety • Quality • Modern patient management • Ukons NLC 2012 Opportunities for LCNS

37. Lung Cancer Nurses • Threats to jobs ? • Not enough of the jobs ! • “Specialist nurses are a valuable resource and save the NHS money” Nicola Bell, Cancer Nursing Practice Nov 2009, V8, No 9, p5 • Call for Roles to be “protected and expanded” Lisa Berry, Cancer Nursing Practice Nov 2009, V8, No 9, p5 • Care better where there is a CNS National cancer patient survey 2011/12

38. Modern oncology (medics) • Site specific • Focus • Develop expertise • Breadth and depth

39. Cancer nursing • Why should nurses caring for patients be any different, in terms of specialisation. • More efficiency, know patients etc • Holistic • Proper team work… not pillar to post?

40. THERE IS A ROLE FOR SITE SPECIFIC CNS’S Team work…… working smart….across boundaries …..patient centred

41. Oral poster presentations

42. How does personal experience of cancer in a relative or close friend impact on the professional practice of a nurse? Victoria Noonan Master of Nursing Science (MNursSci) Staff Nurse – Clinical Haematology – City Hospital Nottingham

43. Introduction • Cancer is a relevant topic at this time as there have been many structural and policy changes in the NHS regarding this area • Personal experience of nurses outside of practice has received little investigation, although literature available does talk about it in the cancer context • Large amount of literature regarding carers of cancer patients but does not acknowledge these carers may also be nurses

44. Aim • Investigate whether personal experiences of cancer has any impact on a nurse in their professional practice • Provide some research that can contribute broadly to the evidence base in this area • Qualitative approach using semi-structured interviews on five respondents

45. Nurses felt practice improved… Improvement in general nursing skills “it’s made my practice more confident” “it gives you a little more caring capacity... when you’ve experienced it personally, and you’ve got that to draw back from, and you really understand what the patients are going through” “I do believe you become more compassionate [after personal experience]”

46. Improved interactions with patients “I think it makes you less detached with patients” “you understand how cancer impacts on lives, and particularly everyday life, and all aspects of peoples’ lives” “the importance of information and time for patients can never be over-emphasised... [the nurse] should always revisit the patient’s understanding of the disease process, their medications, their treatment plans etc.” “I think you’re more understanding of them, their needs emotionally”

47. Improved interactions with cancer patients’ relatives “I had to be there for my friends and so, there’s nothing I wouldn’t do within my scope to make the family comfortable”. “I go out of my way to communicate with families, to make myself available, so I can answer their questions” “I think it’s helped me recognize the impact it has on all the family, as well as just that person who’s ill” “I’m very much aware of what I say and how I say things to relatives now, having experienced it myself”

48. Personal experience caused difficulties in practice “If someone looks to you too much or puts their trust in you too much, or looks for you for every answer...that can sometimes be difficult” “it was just the emotional burden...it had churned up a lot of emotions for me” I’m dealing with cancers and then my friends’ have got cancer and it’s in the back of my mind, sometimes I feel I want to break down.” “as a nurse, that dealing with death, it’s more at the forefront of your mind”

49. Overlaps between personal and professional “he would just phone me and kind of say, ‘they’re doing this, is this right?’...it was really providing support for my dad more than my uncle directly” “It was very difficult for me, as a nurse to take that hat off and be a niece...because I was going through it as well as everybody else” “I want to be her friend...not to nurse her...I don’t want her to be the patient...”.

50. Experience of cancer as a child can influence nursing practice “I’m also very much aware that you need to…involve children, and young family members as well so they understand what’s happening, and what’s going to occur.” “...you do need to talk to children, and let them understand what’s happening because it’s so difficult to have your parents there, one day, and then for the next day, them not be there...”