VOL: 103, ISSUE: 13, PAGE NO: 33
Karen Harrold, BSc, RGN, is clinical nurse specialist for chemotherapy, Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust
The concept of establishing innovative pre-chemotherapy treatment assessment clinics was developed by nurses in the cancer unit at Mount Vernon Cancer Centre. The nurses wanted to provide a low-stress setting that would help patients to receive and fully absorb the information they needed about their disease and its treatment.
The impetus for the advent of pre-treatment assessment clinics came from nurses caring for patients who were scheduled to receive oral chemotherapy. The most common form of this is capecitabine for the treatment of colorectal and breast cancer. Oral capecitabine is self-administered at home, making it convenient for most patients.
Originally, patients who were offered oral chemotherapy were given information on managing their treatment in the same appointment at which they received their first prescription for the drug. As a result of this, nursing staff were concerned about the impact of the amount of information patients received at the time of their treatment and their ability to absorb this at such a difficult time. Patients were in a stressful situation and focused primarily on the physical process they were undergoing. In addition, having appointments scheduled in this way did not give them any opportunity to reflect on important aspects of their treatment, such as efficacy and management of side-effects, or to ask any questions.
Since the establishment of pre-treatment assessment clinics, patients who have attended have felt supported by the service. This has encouraged nurses in the unit to extend it to patients receiving intravenous (IV) therapy. In addition to the information session provided during the clinic, patients on IV therapy are shown round the chemotherapy suite. They often feel nervous about the environment in which they will receive their IV treatment, so the tour helps to dispel any negative or preconceived images as they see the relaxed atmosphere within a bright and airy unit.
Pre-treatment assessment clinics mean that the patients are better informed and better prepared for their treatment, while the chemotherapy nurses have expanded their role and gained the opportunity to develop further their communication skills.
The pre-treatment assessment
Patients attend the clinic in the same week that they are due to start treatment. The pre-treatment appointment lasts for approximately an hour to an hour-and-a-half. Any blood tests and baseline observations (for example height, weight and blood pressure) that are needed are taken at this time.
The nurse explains what chemotherapy treatment is and how it works in general terms, then gives the patient more specific information about the drugs prescribed, their actions and side-effects. Patients are also told how to manage any side-effects, which can include sickness, diarrhoea, sore mouth or high temperature. These side-effects are manageable and therefore it is important to make patients aware of any signs or symptoms to ensure they are effectively dealt with, should they arise.
The nurse will explain how the drugs are made up in the chemotherapy reconstitution unit and why this takes time. This helps patients to understand why they may have to wait a certain length of time before receiving their treatment.
The session also covers whether the patient is currently taking other medications, making sure they have informed staff if they are (including over-the-counter medicines, as well as vitamins and minerals).
If a patient is planning to continue working throughout treatment the nurse will discuss how to pace and plan work activities. For those not planning to continue working, a discussion of benefit entitlements may be relevant at this point.
The importance of avoiding people with coughs, colds and obvious infections is discussed, as well as what leisure activities are appropriate during treatment. Patients often want to talk about holidays (both abroad and in the UK). This is a good time to discuss travel insurance and give advice on taking adequate care in the sun.
It is important for patients to maintain a good diet during treatment so nutrition is also discussed. The subject of alcohol is often raised at this point and advice will be given about whether a small glass of wine or beer is safe, depending on the drug regimen. Drinking spirits should be avoided during treatment.
Each patient is different and will therefore have a different range of concerns, so the subjects discussed during pre-treatment assessment appointments vary. Other topics commonly raised include prescription charges and whether or not patients need to be accompanied to appointments, as well as fertility issues.
A pre-chemotherapy consultation checklist is completed to ensure an accurate record is kept of what information the patient has received and to document any referrals made to other members of the multidisciplinary team. This, plus a general question-and-answer session at the end of the consultation, gives patients the opportunity to explore other anxieties or issues not previously raised.
Nurse-led adjuvant oral chemotherapy clinic
Another innovation is the establishment of nurse-led clinics for patients with colorectal cancer who are receiving adjuvant oral chemotherapy. These clinics opened in September 2006.
The pressure of limited resources and lack of capacity has highlighted opportunities for nurses to expand their role and take on some of the work traditionally managed by doctors (Cancer Capacity Coalition, 2005). The recent extension of oral chemotherapy, in the form of capecitabine, to patients with primary colorectal cancer, is one example of where the role of the chemotherapy nurse has expanded and now includes the overall management of these patients.
Oral chemotherapy has been used as a palliative treatment for patients with metastatic colorectal and breast cancer for some time but, due to the advanced nature of their disease, these patients are seen by the oncologist. However, patients receiving adjuvant oral chemotherapy for primary colorectal cancer are generally well. Since September 2006 these patients have been seen in a nurse-led clinic. They are treated over a six-month period and need to be seen every three weeks for blood tests, assessment and prescription of the next treatment cycle. These patients see a doctor for their first treatment cycle but see a nurse in the nurse-led clinic for the remaining seven cycles.
All patients, whether receiving IV or oral therapies, are assessed for chemotherapy-related toxicities and performance status before each cycle of treatment. This is done with the aid of a multidisciplinary assessment tool, which has been adapted and developed for use from the common toxicity criteria (National Cancer Institute, 2006) and is used in the assessment of patients in clinical trials. In the nurse-led clinic it is the nurse’s responsibility to decide whether the patient is well enough to continue treatment in accordance with a specifically developed protocol or to refer the patient to a doctor in the parallel clinic if a dose adjustment is required.
In addition to the convenience of an oral treatment that patients can take at home, one of the advantages of having a nurse-led clinic alongside the conventional outpatient clinic is that the workload can be divided, thereby significantly reducing the amount of time that patients may be waiting. They may have travelled up to 30 miles and, as many are working, they do not want to spend any longer than is necessary at the clinic.
Another advantage is continuity of care - patients see the same nurse at each clinic visit and are able to contact the nurse between visits to discuss any concerns or questions. Patients attending outpatient clinics often see many different doctors.
More time is allocated for giving information and for questions at the nurse-led clinic than in outpatient clinics, which is important as the patient is self-administering and self-monitoring at home.
This clinic provides an important opportunity in the development of cancer nursing services, as nurses are responsible for the whole treatment pathway.
Chemotherapy nurses have a wide range of skills that they use daily and that are now being used fully in the development of chemotherapy nurse-led clinics. The extension of the chemotherapy nurse role offers benefits for both patients and nurses. In addition, there are wider implications for trusts that run the nurse-led clinics: acute trusts are under considerable pressure to make best use of resources and increase capacity (Cancer Capacity Coalition, 2005).
Implications for practice
- Research has shown that if cancer patients received information before their first appointment for treatment, they were better prepared emotionally for a visit to a cancer unit (Huchcroft et al, 1984).
- Patients in a stressful situation focus primarily on the physical process they are undergoing, which does not give any opportunity for reflection or to ask questions on aspects of treatment such as side-effects.
- Patients often feel nervous about the hospital environment. A tour of the chemotherapy suite helps to dispel any negative or preconceived images.
- Pre-assessment clinics ensure that patients are better informed and prepared for their treatment.
- Nurse-led clinics can contribute to increasing capacity and relieving pressure on resources (Cancer Capacity Coalition, 2005). Background
- Patient information is vital in improving patient understanding of the disease and its treatment. However, many medical staff do not have the time to spend with patients to provide the detailed information they need.
- Research shows that patients lack basic knowledge about their cancer and its treatment, and for three out of four patients it will be the nurse or doctor who is the source of new information (Berner et al, 1997).
This article has been double-blind peer-reviewed