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An evaluation of a nurse-led cystoscopy surveillance service

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Julia Taylor, RN, DipNS.

Specialist Urology Nurse, Urology Unit, Hope Hospital, Salford, Manchester

This paper looks at the findings of a postal survey that sought to identify patients' perception of, and satisfaction with, their nurse-led cystoscopy surveillance service. The patients had superficial bladder cancer or transitional cell carcinoma of the kidney.
This paper looks at the findings of a postal survey that sought to identify patients' perception of, and satisfaction with, their nurse-led cystoscopy surveillance service. The patients had superficial bladder cancer or transitional cell carcinoma of the kidney.


The nurse-led cystoscopy service
The nurse-led cystoscopy service was developed in response to a demand for surveillance for patients with superficial bladder cancer. This arose from the findings of a regional audit undertaken in north west England in 1998, which revealed that the population served by Hope Hospital had the highest incidence of this disease in Salford.


Patients with superficial bladder cancer are frequently managed with an ongoing programme of flexible cystoscopy, which is often protocol-driven (Kilburn, 2002). Surveillance, flexible cystoscopy and treatments, including intravesical instillations of both immunotherapy and chemotherapeutic agents, require the patient to have prolonged and continuous care. This is provided by a specialist nurse service, developed in response to the needs of this group of patients.


The study was implemented against a background of literature that advocates the need to measure the impact and effectiveness of specialist nurse roles (Hammerton and Hartley, 1999) and within the wider context of developing evidence-based practice.


Introduction
The urology team (specifically the specialist nurse, consultant urologist and specialist registrar, with support from other members of the wider urology team) has been actively involved in evaluating the specialist nurse service by developing protocols, implementing training programmes locally for nurse endoscopists, providing training for a second nurse endoscopist and undertaking research and audit, which is an integral part of the clinical nurse specialist role (Humphris, 1994). Research had shown that experienced nurses with a special interest in urology can develop the skills for undertaking flexible cystoscopy and become competent at detecting recurrent bladder tumours (Gidlow et al, 2000). Moreover, they are able to determine an appropriate course of action based on their findings (Taylor et al, 2002).


The team felt that there were many positive aspects to developing the role of the nurse endoscopist. These fit in with the suggestion made by Scott (2001) that 'ultimately what matters is that the care required by an individual patient at the particular time is given by the right person with the right skills'.


In view of government proposals to give patients the opportunity to have their voices heard in the debate on changing and developing services (Department of Health, 2001), the team undertook the study described below to explore both patients' perceptions of, and satisfaction with, the nurse-led cystoscopy surveillance service as it currently stands.


Aims
The aims of the study were to explore the understanding of patients attending for surveillance cystoscopy at the nurse-led session. More specifically, the team wanted to:


- Identify the relationship between age, gender and the length of surveillance in the context of patients' understanding of their diagnosis


- Compare the waiting times for the nurse-led service with that for the service that was previously in place


- Identify the appropriateness of information and its timing at points through the patient's journey


- Identify whether the patient's experience of comfort has changed by attending the nurse-led flexible cystoscopy clinic.


Study method
A semi-structured postal survey was sent to the patients whose names were held on the Salford Royal Hospitals urology superficial cancer database. All of them had a diagnosis of superficial cancer and required several surveillance cystoscopies throughout the year. A total of 310 postal questionnaires were distributed, together with stamped addressed envelopes to return to the urology department, of which 187 were returned (a response rate of 60.3%). The age range of those replying was 41-92 years, with the ratio of men to women being 5:3.


Results
Perception and understanding of the diagnosis
Since the service was implemented patients have had the chance to discuss their diagnosis at any point that they felt appropriate along their cancer 'journey'. The data analysis showed that, although all patients had a histological diagnosis of superficial bladder cancer, less than one-third identified this as their diagnosis (Figure 1). More than half (53%) said they had bladder warts. This finding challenged an assumption that all the patients seen by the nurses were aware that they had superficial bladder cancer. The results also showed no differences in understanding by age and gender.


An interesting finding was that patients who had been diagnosed with superficial bladder cancer more than five years previously were five times more likely to have been told they had warts in the bladder.


Over the past two to five years there has been a change in clinical practice locally, with the emphasis shifting from a paternalistic to a more equitable approach to care. One example of this is the replacement of expressions such as 'bladder warts' with clear consistent language to encourage discussion around the word 'cancer' and the implications of having the condition. It is gratifying to see that the survey results are consistent with such changes in clinical practice.


Waiting times All patients surveyed had undergone flexible cystoscopy by a member of the medical team. Thus they were able to compare their experience of both doctor-led and nurse-led care.


A comparison of waiting times at the nurse-led service with those of the previous doctor-led service found that, before implementation of the nurse-led clinic, patients were allocated a slot within the flexible cystoscopy session run for new patients undergoing lower urinary tract assessment with a member of the medical team.


The survey questionnaire asked the patients the following:


- When you attended the review cystoscopy clinic (for the first time) how long did you have to wait?'


Patients attending the flexible cystoscopy with the urology nurse were asked:


- Did you have to wait?'


The patients could choose from the following options:


- No wait


- Under 30 minutes


- 30-60 minutes


- More than 60 minutes.


The data showed that over one-third of patients attending their initial review flexible cystoscopy had to wait 30 minutes or longer. In comparison, when they attended the subsequent nurse-led clinic, about 70% of patients reported being seen in under 30 minutes. Patients were shown to have a significantly shorter waiting time (p<0.0001) at="" this="" nurse-led="">


Relevance of information provided The study aimed to identify the appropriateness of the information given to patients and its timing at points throughout their treatment.


They were asked whether they had received any information about different aspects of the service. In particular:


- What had been seen at their endoscopy


- The importance of regular cystoscopies


- Follow-up arrangements


- Availability of support groups.


The majority of patients stated that they had received adequate or more than adequate information from the nurse-led service, with the exception of support groups.


Opportunity to discuss information It was felt that an important aspect of the service was giving patients adequate time to discuss their concerns. Patients therefore had four options to choose from, ranging from no opportunity to more than adequate opportunity (Table 1).


Patients were asked to comment on whether they felt they had had sufficient opportunity at different stages in their treatment to identify service inconsistencies, such as:


- At the time of diagnosis


- While awaiting admission


- During admission


- After discharge.


The vast majority of patients felt that they had had an adequate or more than adequate opportunity to discuss their anxieties at each of stage of their treatment (Table 1). However, a substantial minority felt they had not had adequate time.


Many patients are given a telephone number to ring the department if they have any concerns, but we also wanted to know whether they felt that being given a contact card might have been helpful, and at what time they might have used it. At least a one-third of respondents said they would have liked to have had this.


Comfort during the procedure To ensure that patients were not experiencing more discomfort than necessary during their flexible cystoscopy they were specifically asked the following:


- When the nurse undertook the endoscopy, how did the procedure feel?


The patients were allowed to respond either more comfortable, no difference or less comfortable; there was also a space for free text under the heading 'other'. The results are shown in Table 1.


The thematic analysis showed that many patients preferred nurses to perform cystoscopy surveillance. Where patients expressed a preference, almost 97% were happier with a nurse undertaking the procedure than a doctor.


Discussion
Introduction of the nurse-led service was found to provide a range of benefits for patients with superficial bladder cancer (Box 1). But it also found that it was crucial for nurses and other health-care professionals not to make assumptions about patients' knowledge and understanding.


It also found the need for improvements with regard to access and time for discussion for patients. Since the study was undertaken, the service has started to provide patients with contact cards for specialist nurses should patients wish to gain access to the service. This has been coupled with providing initial contact time with a nurse, who allows time for discussion at diagnosis, and provides patients with literature as required on an individual basis.


All nurses need to ensure that they continue to evaluate their practice to ensure that the service is developed for the benefit of patients. We can only do this by taking time to listen to patients using the service.


Although it is an integral part of the specialist nurse role to undertake research, influencing services in the NHS and researching and sharing practice should be actively encouraged throughout the nursing profession.


Acknowledgements
The author would like to thank Ms E. Craddock, for data collection, Mr P. Jones for data analysis and staff in the Department of Urology, Hope Hospital, Salford, Manchester

Department of Health. (2001) Involving Patients and the Public in Healthcare: Response to the listening exercise. London: The Stationery Office.

Gidlow, A.B., Laniado, M.E., Willis, B.W. (2000) The nurse cystoscopist: a feasible option? British Journal of Urology International 85: 651-654.

Hammerton, F., Hartley, J. (1999) Role evaluation packs for specialist nurses. Professional Nurse 14: 6, 380-383.

Humphris, D. (ed.). (1994) The CNS: Issues in practice. Oxford: Macmillan Press.

Kilburn, K. (2002) Improving a nurse-led flexible cystoscopy service through audit. Professional Nurse 17: 10, 601-604.

Scott, C. (2002) Specialist or nurse: what defines the role? (editorial). Professional Nurse 18: 4, 182.

Taylor, J.M., Pearce, I., O'Flynn, K.J. (2002) Nurse-led cystoscopy: the next step. British Journal of Urology International 90: 45-46.
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