Karen Kilburn, BSc (Hons), RN.
Urology Nurse Practitioner, University Hospital of North Tees, North Tees and Hartlepool NHS Trust, StocktonAround 13 200 new cases of bladder cancer are diagnosed each year, making it the fifth most common cancer in the UK (Cancer Research Campaign, 2000). To meet a service need and to improve the continuity of patient care, the urology team at the North Tees and Hartlepool NHS Trust discussed the possibility of developing the nurse practitioner role to include carrying out flexible cystoscopy on patients already diagnosed with transitional cell carcinoma of the bladder or kidney.
The increasing incidence of bladder cancer was having an impact on waiting times for the procedure at the author's trust. Patients already diagnosed were given a slot on the flexible cystoscopy list for their routine follow-up. New patients needing a diagnostic cystoscopy to investigate their lower urinary symptoms were put on a waiting list and given an appointment when one became available.
Medline, UKCC, Department of Health and NHS Executive databases were searched for the years 1995 to 2002 using the key words 'audit', 'protocol', 'nurse-led' and 'practice development'. Most searches referred to areas of nurse development outside their traditional roles but few were specifically related to flexible cystoscopy. There were no definite recommendations on treatment patterns for patients with transitional cell carcinoma of the bladder. One document did relate to the training required to undertake this role and this was a draft document from the British Association of Urological Surgeons, which discussed recent developments and clinical skills required.
In adults the bladder lies deep in the symphysis and is pear shaped. It can be felt when it becomes more oval shaped as it fills with urine. It rests on the prostate in men and, in women, on the anterior wall of the vagina. The bladder is separated from the rectum by a double layer of peritoneum, which is fused together (the facia of Denonvilliers). This layer forms a barrier that can prevent bladder cancer spreading to the rectum or prostate gland (Blandy, 1998). The bladder acts as a reservoir for urine. In adults with an intact nervous system, the rising pressure associated with a full bladder signals impulses to be sent to the brain that the person needs to pass urine (micturate). If the nervous system is fully developed, micturition can be delayed until it is convenient (Blandy, 1998).
Flexible cystoscopy is a procedure used to enable the nurse practitioner or doctor to examine the internal surfaces of the bladder and urethra. A local anaesthetic gel is instilled into the urethra and the flexible cystoscope is passed along the urethra and into the bladder. Sterile water is run through the cystoscope to distend the bladder, ensuring that all surfaces can be examined. The nurse practitioner or doctor will examine the urethra, sphincter, prostatic urethra (in men) and bladder neck as the cystoscope is introduced. The flexibility of the instrument allows the examination of the bladder and an internal view of the bladder neck and, in men, the prostate.
The urology nurse practitioner at this trust carries out flexible cystoscopy on 12 patients a week in the day-case unit.
Clinical audit is a clinically led initiative that seeks to improve the quality and outcome of patient care (NHSE, 1998). In this case, the nurse practitioner examined her own practice and patient treatment plans against a set protocol. This encouraged the team to critically analyse the protocol and review its validity, resulting in revision of the protocol and the formulation of guidelines for the follow-up of patients diagnosed with transitional cell carcinoma of the bladder. The aims of the audit were:
The urology team agreed that a review of the protocol was needed to ensure that all patients would have the same standard of treatment and investigation. Their treatment plan would be decided by the grade of tumour at last biopsy and would not be influenced by age, ethnicity or where the patient lived. The consultant and nurse practitioner agreed that the last positive biopsy result taken from the bladder would be the basis on which the next flexible cystoscopy was planned.
Table 2 shows the revised protocol now in use. Notes were added to ensure that all patients were offered the same investigations and that there were guidelines to follow if any difficulties were encountered during the procedure (Box 3). The team is aware that the nurse practitioner or doctor carrying out the procedure may in some cases need to deviate from the protocol if this is in the best interests of the patient.
This innovation in nursing practice is an example of how meeting demand for a service can greatly impact on the quality of care offered to patients. Developing protocols and regular audit is essential to meeting the needs of patients and the agenda of clinical governance to have continuous quality improvement programmes in place (Elcoat, 2000). It is hoped that other trusts may adopt this protocol if they feel that it would help meet the needs of their patients.
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