VOL: 103, ISSUE: 3, PAGE NO: 30
Caroline Buchanan, MA, BA, RGN, is breast care nurse specialist at Queen Elizabeth Hospital, Gateshead
The one-stop symptomatic breast clinic sees women referred with breast symptoms and aims to investigate, discharge or diagnose breast conditions in the course of a single visit. Traditionally consultants and their registrars run these clinics.
Research has revealed that women with breast cancer place a lot of importance on receiving continuity of care (Cox and Wilson, 2003).
A project was set up to advance nurse specialists’ practice and provide a service that ensured quality and continuity for women attending the clinic. This role would also put the breast care nurse specialist in the unique position of providing complete continuity of care for women with breast cancer. Care would include meeting them before diagnosis in the diagnostic clinics, during diagnosis in a supportive role, during treatment and also follow-up.
At the outset of the project the views of other healthcare professionals (the director of nursing, line manager, lead cancer nurse, consultant and breast care nurse colleagues) were sought. Resource implications were addressed and a clinical supervisor approached. Training needs were identified and a training plan was developed. This included a period of observing the consultant in the clinic, a period of supervision by the consultant and then working unsupervised to a set of agreed protocols and guidelines assessing and diagnosing women attending the one-stop clinic.
A diary was kept and updated throughout the project to enable reflection and continual learning, and to evaluate practice. Audits were carried out on personal clinical findings, radiologist findings and the overall outcome of the patient following her or his assessment.
- To provide a service that ensures quality of care for women attending the diagnostic clinics;
- To improve staffing at the clinic by making better use of professional skills;
- To provide continuity of care to women diagnosed with cancer at the one-stop clinic;
- Provide continuous professional development for breast care nurse specialists, developing their skills and expertise.
Evaluation is essential for identifying the contribution of the nurse-led clinic to nursing practice, to patients and to healthcare delivery in general. It is also an important tool for verifying and justifying the continuing development of the clinic.
With the increase in the numbers and diversity of nurse-led clinics in recent years, it is imperative that their benefit both to patients and to the delivery and outcome of care is clearly established (Armstrong et al, 2002). The purpose of most formal evaluation is to produce evidence of the extent to which the clinic positively or negatively influences patient care.
Impact on the patient
Patients’ views are important and recent government policy lends support to the concept of patient-centred care with more emphasis on user involvement and a high-quality health service that is shaped around the needs and preferences of patients (Department of Health, 2001). Similarly, The NHS Cancer Plan (DH, 2000) stresses the importance of empowering patients with choice and control in all aspects of their care.
If we wish to monitor continuity of care, improve health outcomes, satisfaction and quality of life of those we care for then patient satisfaction needs to be part of the process. Patient satisfaction surveys have indicated a high level of satisfaction from patients seen by the nurse specialist in our clinic. Some women have indicated a preference to see a female. Within a multidisciplinary clinic, patients are empowered by having choice and control over aspects of their care.
The nurse specialist has audited and continually assessed her practice by keeping records of all the patients she has seen unsupervised, plus records of her clinical findings and those of the radiologist following ultrasound scans and/or mammography and overall outcome following assessment.
Impact on nursing
The nurse specialist has developed skills beyond her clinical practice with increased confidence, morale and motivation. If the aims of The NHS Cancer Plan are to be achieved, it is vital that morale and motivation of staff are given high priority within organisations.
The DH (2001) recommends a framework of lifelong learning in the NHS. The NMC charges each nurse to adapt a culture of lifelong learning by developing professional knowledge and competence.
If nurses are able to develop and take on new roles and responsibilities then this will increase their motivation and hopefully keep experienced nurses in the profession. It may also provide new career opportunities for nurses, develop clinical experts and increase the profile of the profession.
The nurse specialist has now completed training and is working alongside the consultant in a multidisciplinary clinic. This includes assessing a group of patients unsupervised and requesting appropriate investigations as per protocols. She then interprets results depending on the full assessment of the patient and advises the patient on the results. The nurse specialist then passes on information on treatment and outcomes to primary care.
From the project it is clear that nurses work at all levels in breast care helping to provide a joined-up service. Breast care nurse specialists are also recognised as key members of the cancer team and the role is pivotal in improving the service and ensuring continuity of care for breast patients.
The nursing profession is changing all the time due to external influences on the NHS, such as reduction in junior doctors’ working hours, government initiatives and internal forces such as the increasing emphasis on career development and lifelong learning. Greater organisation and specialisation has allowed nurses to develop their careers and expand their roles to incorporate some of the skills of medical colleagues. However, adaptation of specialist roles and skills must be accompanied by appropriate education, training and practice-based experience.
The nurse specialist believes that the service has provided a high quality of care to women who attend the clinic through continual audit.
I believe that quality of care has improved as the project progressed and this is due to the nurse specialist’s holistic approach to care, knowledge of breast disease and good communication skills. Women diagnosed with breast cancer have had continuity of care, having the same key worker through diagnosis, treatment and aftercare. Staffing levels have improved at the diagnostic clinic as the consultant no longer attends the clinic alone.
Multidisciplinary working has proved to be effective, with medical staff and nurses complementing each other. The nurse specialist has benefited from continuous professional development and the opportunity to increase expertise. Continuous audit has proved that this role can be safely filled by an advanced practitioner, as long as it encompasses adequate training, supervision, support, reflection and working to agreed protocols and guidelines.
While providing a high-quality seamless service to patients and achieving government targets, this project has enabled the breast care nurse specialist to develop skills beyond clinical practice, increase confidence and practise at a higher level, thereby increasing the level of nursing morale and motivation.
Nurse-led services enable nurses to develop new roles and provide new career opportunities. They also develop nurses who are clinical experts, which will inevitably increase the profile of the profession.
- Breast cancer is the most common cancer in women (Cancer Research UK, 2004) with around 30,000 women and 200 men diagnosed each year in England and Wales.
- The rise of nurse-led clinics accelerated in the 1990s (Hatchett, 2003), increasing the autonomy of the nursing role and giving nurses the power to refer to others including medical staff and professionals allied to medicine.
- Patients are often more satisfied with nurse practitioners than with doctors as they spend longer with patients, and offer more detailed and helpful advice.
- Research suggested that women are uncomfortable raising emotional concerns with doctors because consultations often focus on physical issues (Cox and Wilson, 2003).
- Team working, blurring of boundaries, the development of new and more flexible careers and expansion of the workforce have become the current political issues in healthcare (DH, 2000).
Implications for practice
- Women attending the clinic who are diagnosed with breast cancer have had the same key worker through diagnosis, treatment and aftercare, thus providing continuity of care.
- The nurse-led initiative has helped to improve staffing levels at the clinic.
- Continuous audit has proved that this role can be safely filled by an advanced practitioner. Adequate training, supervision, support, reflection and working to agreed protocols and guidelines need to be provided.
- Nurse-led services enable nurses to develop new roles and provide new career opportunities, raising morale and increasing motivation.
This article has been double-blind peer-reviewed