Summary

Patients traditionally receive all systemic cancer therapy in hospital. The aim was to deliver safe, shared nursing care, between hospital and community health services, for patients undergoing systemic cancer therapy. 

National and regional project management structures were set up to train community nurses, equipping them with the knowledge and skills to safely and competently provide care, at home, for patients undergoing systemic cancer therapy. Training was theoretical and skills based, and delivered over six months. 
Inbuilt safety features of the programme included:

• Examination of the community nurses’ knowledge and skills
• Development of a Community Oncology Resource Book to assist nurses in clinically assessing patients
• Development of a referral form 
• Commitment from the medical oncologist that patients remain her responsibility irrespective of where nursing care is provided
• Arrangement with the treating cancer unit to receive urgent phone calls and/or admissions from the community nurses.

Challenge

Background and rationale

A shared care/integrated approach to providing safe nursing services at home for patients who are receiving systemic cancer therapy was developed between hospital and community health services. The rationale for this Community Oncology Nursing Programme included: 

Response to patient/family needs

Patients visiting the treating cancer unit for nursing interventions related to their systemic therapy, often have to travel long distances, which puts a burden on both them and their families. Many of these patients are unwell. Some of the interventions take as little as 15 minutes to compete and some of this care could be delivered in the home. This holistic patient care includes management of central venous access devices, medication management, symptom control, disconnection of chemotherapy and blood sampling. 

Integration of cancer care between hospital and community health services 

The options and demand for systemic cancer therapy are increasing. Hospital throughput and waiting times to start systemic therapy are increasing. In Ireland, all aspects of this treatment are historically delivered in the hospital setting. Although the role of community nurses is to attend to patients within their geographic area, most do not care for patients who are receiving acute cancer treatment as they are not trained in this specialty. 

Development of safe and creative ways to manage Ireland’s increasing cancer incidence 

Cancer incidence in Ireland will increase by 100 per cent over the next 20 years, due mainly to the ageing population. Hospital resources will remain limited and novel ways to deliver safe care that is appropriate and responsive to patient needs are required. It is a priority of the Health Service Executive (HSE) in Ireland to develop integrated models of care.

Objectives

The main aim of the Community Oncology Nursing Programme was to ensure that community nurses are competent and confident in caring for a defined group of patients safely in the home (patients who are receiving systemic cancer therapy).

The objectives were to: 

• Ensure the community nurses are properly trained to deliver specific nursing interventions related to systemic cancer therapy
• Demonstrate that the patients are cared for safely at home
• Assess the impact of the Programme on the hospital’s treating cancer unit
• Assess the impact of the Programme on the overall community nursing service
• Assess the impact of the Programme on the patients and families
• Make recommendations on the expansion of the Programme nationally.

Solution

In order to achieve the objectives the following actions were taken:

Planning

A national governance structure was set up

This had representation from the National Cancer Control Programme (NCCP), Health Service Executive Nursing Department (Office of the Nursing and Midwifery Services Department), academic nurse specialists and senior nurses with expertise in service delivery and cancer care. This group advised on the strategic development of cancer nursing but also on the objectives of the Programme, the selection of the pilot site, the components of the nurse training, the interventions to be undertaken by the nurses in the community and the monitoring / evaluation criteria. 

Letterkenny General Hospital (LGH) in County Donegal was selected because it had already engaged with community nurses in relation to sharing systemic cancer therapy care. They had senior nursing expertise and they shared the vision and enthusiasm for the Programme. 

A local governance team was set up in the pilot area 

This included a regional consultant in medical oncology, specialist cancer nurses, community nurse leaders and nurse educators. 

A project team was appointed and a project lead was selected

To ensure good communication and consistency in decision making some key members of the project team were also members of both the national and local governance group. 

Implementation

The local governance team in collaboration with the project team undertook the following:

• Wrote the education programme. This included the development of a Community Oncology Resource Book for the community nurses (see attached). 
• Delivered the education programme, including the clinical skills component
• Assessed the competence of the community nurses upon completion of the training
• Developed the referral pathway for patients from the treating cancer unit to the community health service and from the community back into the hospital 
• Monitored and evaluated the programme.

Education Programme
The aim of the education programme was to ensure that the community nurses are equipped with the knowledge, skills and competence to provide safely defined care at home to a selected group of patients who are receiving systemic cancer therapy, within his/her scope of practice The learning outcomes of the education programme were that, following a period of self-directed learning, theoretical input and supervised competency assessment, the community nurse would be able to:

• Critically use evidence-based knowledge so that patients on active cancer treatment can be managed safely in the Primary Care setting
• Demonstrate knowledge and skills to perform competently a comprehensive clinical assessment on a patient with cancer
• Apply clinical decision-making skills to formulate and implement a plan of care and articulate anticipated patient outcomes 
• Demonstrate an understanding of the general principles of cancer as a disease process
• Critically discuss risk factors, prevention, diagnosis and treatment modalities for the most common invasive cancers (breast, lung, colorectal and prostate)
• Demonstrate an understanding of current health policy relating to the structure and organisation of cancer services in Ireland, including the voluntary sector 
• Collaborate with hospital colleagues to provide shared and integrated care between the hospital and the community.

Training was delivered over a six-month period. It included both theoretical and clinical content. The theoretical component consisted of six units of learning with specific learning outcomes. A variety of teaching and learning strategies were used including didactic lectures, case scenarios, discussion/reflective learning and workshops to engage the learner to promote critical thinking skills and decision-making.

The clinical placement consisted of 20 hours whereby the community nurses worked in a variety of clinical oncology settings with the specialist cancer teams. These settings included an oncology day ward, oncology inpatient ward and a variety of clinics. The focus was on consolidation of their learning and working towards competence.

To achieve this goal, learning outcomes were devised and agreed for each clinical practice area and signed off for each community nurse during the clinical placement. A clinical skills training day was facilitated by oncology personnel prior to community nurses undertaking their clinical placement. 

Clinical placements were undertaken in the treating cancer unit under the supervision of the oncology nurse specialists. Learning outcomes were defined prior to the placements to ensure that nurses had maximum benefit from their placements. Course participants had an opportunity to observe oncology nurse specialists performing patient assessments and interventions in the treating cancer unit.

Assessment of learning received meticulous attention. It comprised of a theoretical assessment including a multiple-choice questionnaire, a presented case study and competence assessment. 

The Community Oncology Resource Book 

The chemotherapy policies and procedures of the treating cancer unit were not easily transferable to the community setting and needed to be adapted for the homecare setting. Having established that such a resource was not available nationally or internationally, a tailor-made community oncology resource book was developed. This is a practical informative guide for commmunity nurses who have completed the education programme. It guides them in assessing the patient and in performing safe, quality and seamless oncology care to patients at home.  

It comprises two sections:

1. Section A details the purpose, scope, legislation, roles, responsibilities and governance structures
2. Section B illustrates the patient ‘head-to-toe clinical assessment’, step-by-step guides to each intervention and actions for the community nurse to take when managing potential oncologlogical side effects. It is spiral bound A5 handbag-sized resource for convenient use.

Referral pathway of patients to the community oncology nurse programme
The consultant medical oncologist identified patients who were suitable for community nurse intervention and they were referred to the community oncology nursing programme by the specialist cancer team. A designated referral form was developed (see Resources). This was completed by the treating cancer unit personnel for each referral and sent to the community nurse in advance of their visit to the patient’s home

Interventions carried out by community nurses included: 

• A head-to-toe patient assessment
• Central venous access care and management (flushing, dressing and disconnection of cytotoxic chemotherapy)
• Symptom management
• Medication management 
• Patient education
• Emotional support.

Results

The results are presented as follows:

• Education of the community nurses
• Impact on patients
• Impact on the community nursing service 
• Impact on the treating cancer unit.

Education of the community nurses

The assessment of the education programme was two-fold: theory and skills and competency. 

• Theory was assessed by multiple choice questions. Each nurse had to receive 80 per cent to pass
• Skills and competency assessment was assessed during clinical placements by senior oncology nurse specialists who observed the community nurse undertaking defined clinical interventions. Each nurse was assigned a specific patient to care for under supervision. A case presentation was presented at the end of the programme.

Impact on patients

In-depth interviews were carried out by an independent qualitative researcher with a random selection of 10 patients who participated in the programme. All of these patients expressed their satisfaction with the community nursing service. They commented on the convenience of receiving some of their care at home and in avoiding unnecessary travel to the hospital, the average distance being 60-69kms. The patients remarked that they trusted the community nurse in the work she was doing.

Impact on the community nursing service

A qualitative researcher carried out focus groups with community nurses and their leaders to get their views and assess the impact that the programme was having on their community nursing service. This was undertaken between the February 1, 2012 and March 31, 2012. In addition a specific quantitative survey was undertaken between the February 1, 2012 and March 31, 2012 to quantify the volume and type of interventions that were transferred by the hospital and are now being delivered by these community nurses. In that time period the community nurse undertook 120 patient visits and 486 interventions. These included:

• A head-to-toe patient assessment
• Central venous access care and management (flushing, dressing and disconnection of cytotoxic chemotherapy)
• Symptom management
• Medication management 
• Patient education
• Emotional support.

The delivery of care by community nurses in a patient’s home was found to have had a direct impact on their available time to deliver other traditional nursing services. Nurses spent 30-44 minutes in patients’ homes in the majority of visits (52/120). The community nurses reported that the initial visit would last over an hour but subsequent visits would be shorter. The very nature of cancer treatments and interventions required that care usually had to be delivered at specific times and this led to rescheduling of other work at short notice:

Impact on the hospital treating cancer unit

There were no adverse events reported among the patients who were treated at home by the community nurses. There were no emergency calls made by any of these community nurses to the treating cancer unit. In order to assess if there was a change in activity in the treating cancer unit, a survey of activity levels before and after the introduction of the new service in May – June 2007 and May – June 2010 was undertaken. 

This survey quantified the number of central venous access devices (CVADs) cared for during that period of time. The interventions to be undertaken patients’ home included cleaning and flushing CVADs and the disconnection of ambulatory chemotherapy. (Figure 1)

Figure 1 Trends in specific nursing interventions undertaken in the hospital before and after the Programme commenced

Evaluation

The success of the programme was measured by: 

• Quantifying and documenting the shift in specific oncology nursing clinical procedures from the hospital setting to the community health setting
• Ensuring the community nurses were appropriately trained and competent to deliver defined care to this group of seriously ill patients at home
• Obtaining the views of patients/families, hospital personnel and community nurses on the development and implementation of the service.

Impact

This initiative has impacted on the HSE in a number of ways. 

In relation to HSE policy: It meets the health service prioity of implementing safe integrated care. The programme shows that some oncology nursing care can be transferred safely to the community setting as a shared care initiative between the treating cancer unit and the community nursing service. All such care had previously been delivered in the acute setting. 

In relation to the hospital and treating cancer unit: It has decreased unnecessary admissions to the oncology day ward and reduced the burden on hospital services.

In relation to the community nursing service: It has expanded the role of the community nurse. They are competent and confident in providing this care. However, there are opportunity costs in relation to the delivery of traditional community nurse services. 

In relation to the patients/families: Patients were confident and satisfied in the care they are receiving from the community nurse. It reducd the burden of travel on the patients.  It has responded to the needs of the patients.

In relation to health service leadership: It brought medical and nursing leaders together to develop and implement an innovative approach to shared care for a group of patients with a serious illness. This collaboration engendered partnership, collaboative working, trust and friendship between all the stakeholders.

In relation to adaptability of the programme: This model is adaptable to patients with chronic diseases and it is not limited to patients with minor conditions.

This initiative has informed the NCCP and the HSE in Ireland on how best to expand the programme nationally.