Developing a specialised metastatic breast cancer
nursing role at your organisation: factors to
consider Gillian Kruss
Metastatic breast cancer nurse practitioner candidate
Development of a MBC nursing role at Monash Health – topics to cover
• History of role and how it evolved at MH
• Use of current resources and processes to integrate the role at MH
• Model of care/clinical pathway developed
• Referral pathways used
• Skills/knowledge required
• Anecdotal benefits and challenges of the role
• Recommendations for establishing similar roles at your organisation
History of the role at Monash Health
• 2012 – local consumer identified local supportive care gap; validated by international/national reports
• 2013 – SMICS project to develop a specialist MBC nurse framework: researched existing roles and sc gaps / gathered local statistics/ explored funding options / considered local resources/ engaged key stakeholders
• 2014 - DOH funding obtained to develop a MBC NP role at MH
• 2015 – employed MBC NPC at MH
Joy Knight - consumer
Specialist Metastatic
Breast Care Nurse
FrameworkFinal Project Report
Prepared by:
www.smics.org.au / [email protected]
Report outlines:• Results of research• Local statistics• Model of care and
clinical pathway for MBC CNC role
• Recommended KPIs for role
• Recommended credentials for CNC role
• Other recommendationsfor developing a CNC role
• Guidelines used to help develop role at MH
Used local statistics to support the need for the role
• Southern Melbourne hospitals treated the largest number of breast cancer patients in the state in 2012
• Approximately 1000 new diagnoses of breast cancer in Southern Melbourne hospitals, and 1/3 of these developed and died of MBC (2008-2011)
• At Monash Health 327 MBC patients had 1955 episodes of care (2011-2012)
Identified supportive care gap for MBC patients
Physical
Social
PsychologicalSpiritual
Information
SC needs are heightened at key times of distress:•at diagnosis•when treatment changes•when disease progresses
Five inter-related domains
of supportive care
Supportive care needs of MBC pts:complex, unmet, vary over time
Specialised skills and time are required to assess and address these needs
Engaged key stakeholders to help develop the role at MH
• Vic Integrated Cancer Services
• Director of Nursing / business manager
• Funding sources: McGrath Foundation, DOH, charity organisations, private benefactors
• Medical and nursing staff
• Consumers
Examined resources and processes to integrate the role into Monash Health
Resources and processes
Put picture of hospital
Breast cancer services Breast screen Theatres Inpatient surgical, oncology, palliative care units 2 x breast oncology clinics Other specialised clinics Chemotherapy Day Unit Radiotherapy (Peter Mac) Pharmacy Diagnostic imaging Pathology Physiotherapy Oncology research Hospital in the Home Breast cancer social worker Weekly breast oncology MDT Oncology NP
NP
Wellness prevention
support
Ad
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MBC NP Model of Care
Why a NP model of care at Monash Health?
• The extended scope of practice of a NP can efficiently and effectively meet the supportive care needs of MBC patients. NPs can work autonomously and collaboratively across settings to provide:
• Advanced nursing assessment, planning and management of side effects/symptoms
• Prescribe certain medications
• Order diagnostic tests
• Make referrals to medical staff
• Better scope to manage those on oral anticancer therapies (cease medications, decrease dose, recommence medications, prescribe medications for symptom Mx)
• A CNC can also effectively work in a MBC nursing role: different processes required ie: collaboration with medical staff to perform some of the above tasks
Table 1: Recommended MBC Nurse Practitioner (NP) Clinical Pathway (An adaption of both the NBCC Specialist Breast Nurse clinical pathway and NEMICS Advanced Breast Cancer Best Practice Pathway)
Diagnosis of MBC
MDT
MBC NP clinical pathway
Treatment
surgery
chemotherapy
radiotherapy
endocrine therapy targeted therapy
best supportive care
Progressive disease
End of life care
home (+/- community palliative care)
aged care / hospice setting
local hospital
Referral to the MBC N.P
at any time during the advanced breast cancer trajectory pathway from any of the following:
MDT
surgeon
oncologist
radiation
oncologist
nurses
BCN’s
clinical trials staff
palliative care
allied health professionals
OR
GP
self-referral
community- based support services
Care provided by the MBC NP (Aims: to promote wellness; to delay disease progression; to prevent complications of disease and hospital admissions; to facilitate direct to ward admissions and MDT care; to decrease length of stay ) Information, support and communication:
introduce self and role; provide contact details; introduce treatment team / purpose of MDT meeting
assess patient's levels of distress in the 5 domains of supportive care (physical, social, psychological, spiritual, information): o use of supportive care screening tool at key intervals / milestones (at diagnosis, at changes in
treatment, at disease progression, and at times of increased stress)
discuss (as deemed appropriate): o diagnosis / prognostic issues / treatment goals and options / practical issues o values, beliefs, any cultural/religious/sexuality/intimacy/financial/family issues o response to diagnosis, feelings, problems, solutions, concerns on intimacy / relationships o personal support networks o possible complications / side-effects of treatment and their prevention and management o relevant clinical trials available o family history of breast/ovarian cancer o plans of care / advanced care plans o offer discussions with family / support persons
provide counselling /practical strategies/ reassurance/ advocacy/ self -management strategies
provide ongoing individual support and information / facilitate community monthly support, information and wellness groups
Advanced assessment/ triage, diagnostic workups, therapeutic interventions and technical skills:
phone/clinic triage and assessments of disease symptoms/treatment side effects, complications and/or oncology emergencies
advanced planning; conduct diagnostic work ups
advanced symptom management and interventions; prescribe appropriate medications
arrange direct to ward/A&E admissions when required Care co-ordination:
communicate with care providers/teams: provide updated plans of care, updates on patient status/patient requests
assist with implementation of MDT treatment plan / patient's advanced care plans / home supports
Education and resource to the MBC patient's treatment team Clinical research, quality activities and data collection
Offer resources and referrals as needed:
Hospital based:
medical staff
dietician
social worker
palliative care consultant
physiotherapist
occupational therapist
psychiatrist
clinical trials staff
clinics (lymphoedema; pain; menopausal; plastics; familial cancer clinics)
support groups
other specialist nurses
imaging and pathology Community based:
offer BCNA H&H’s kit
Living Centre/ Breacan /OF/ BCNA/ CCV relevant pamphlets and services
GP
palliative Care
psychologists / counsellors
support groups and
programs: drug co; LGFB; LWC.
prosthesis / wig retailers
preparation of will/ funeral kits
other community services Centrelink; child-minding; retreats.
Advanced breast cancer
trajectory
Key principles: This role works to enhance the existing Oncology and Breast Cancer Services to provide the best care for MBC patients in the southern Melbourne region.
This role is designed to utilise the expert clinical knowledge and skills of the MBC NP to fill the supportive care gaps that currently exist for the MBC patients, and meet their growing complex needs.
Sources of referral at Monash Health (2015-2016)
number of patients (170)
medical oncologists nurses surgeons self referrals
MDT physiotherapists social workers clinical trials staff
MBC NP duties at Monash Health
To work collaboratively with all those involved in caring for MBC pts and fill gaps in care
Accessible contact person for patients who have questions or who need to report side effects/symptoms/ supportive care needs
Contacts are via the telephone, at clinics or on the ward/CDU
Assist patients who have complex supportive care needs
Provide information, support, referrals and continuity of care
Educational resource for patients and the healthcare team
MBC NP duties cont:Co-ordinate and present at the fortnightly MBC MDT
meeting
Co-ordinate/ stream-line care by communicating
plans of care to the patient’s healthcare team
Administration of s/c or IM Rx’s:
goserelin acetate/ fulvestrant/ denosumab/ trastuzumab
Monitor/manage patients on oral anticancer therapies
Review and interpret blood results
Early management of side effects of treatment / symptoms of disease
Triage and rapidly review patients with side effects/symptoms
Anecdotal benefits of the role
• Received positive feedback from patients, medical and nursing staff (future qualitative research required to gather evidence based reports)
• Improved supportive/ multidisciplinary/ co-ordinated care of MBC patients
• Early identification and management of side effects / symptoms – prevents hospital admission; improves patients QOL
• Facilitated admissions direct to hospital/hospice and/or avoidance of ER admissions (benefits the patient, staff and organisation)
• Appropriate referrals made in a timely manner
• Development of effective processes for managing patients on oral anticancer therapies
• Personally rewarding
Anecdotal challenges of the role
• Unable to provide supportive care to all MH patients when required (employed .8 EFT; multi-campuses)
• Time pressures
• Potential for compassion fatigue/burn-out
• Inadequate cover for annual leave (consider job sharing)
• Challenges involved in establishing the fortnightly MBC MDT
• Ineffective collection method of relevant statistics
• Establishing nurse led clinics and appropriate funding – currently exploring type C admissions (s/c medications)
Recommended credentials
• Role can be developed as a NP or CNC role: refer to SMICS report for CNC guidelines or MH MOC/ job description for NP guidelines
• Oncology experience and knowledge mandatory
• BCN / palliative care experience and knowledge desirable
• Knowledge of MBC treatments – safe administration, monitoring, management of side effects
• Symptom management knowledge
• Knowledge of early identification and management of oncological emergencies
• Established collaborative relationships with breast oncology and palliative care medical / nursing staff
• Effective communication/counselling skills
Conclusion / keys to
• Use MOC guidelines to develop a NP/CNC role at your organisation - adapt to meet local needs and available resources
• Consider job sharing a full time role (to provide optimum supportive care to all patients and each other; cover leave; work across different sites/settings)
• Develop KPI’s and data base to collect useful statistics and measure effectiveness of role
• Explore a variety of funding sources
• Involve key stakeholders when developing the role (nursing executive, medical/nursing staff, consumers)
• Establish collaborative relationships (medical and nursing staff) to establish referral pathways and ensure ongoing effectiveness of the role
• Credentials: oncology experience and knowledge of MBC treatments/ symptom management essential; breast care/palliative care nursing experience desirable.