A service evaluation describing a nurse‐led prostate cancer service in NHS,Ayrshire and Arran

From 1999, the NHS Ayrshire and Arran Health Board implemented an innovative nurse‐led collaborative care model for the management of patients with prostate cancer (PC). This article describes the model and presents the results of a local evaluation to assess its impact. The evaluation comprised a retrospective audit of the service against national standards for PC management, undertaken in 2012. Seventy‐one patients, who were under the care of the service during June 2008, were included. Patient and staff satisfaction were also assessed using questionnaires distributed to 75 patients undergoing outpatient or telephone reviews during April 2012 and 7 one‐to‐one semi‐structured staff interviews. The patient audit showed good compliance with standards relating to selection of appropriate PC treatments according to tumour stage and grade; radiotherapy dosing and referral‐to‐treatment times. Areas requiring improvement were the documentation of patients' risk and performance status and provision of verbal and written information to patients and carers. Seventy‐three per cent of the patient questionnaires were returned, with 96% of respondents rating their overall care as ‘excellent’ or ‘very good’. Staff satisfaction was also high and interviewees described many benefits of the service for patients, hospital staff, GPs and the NHS/health board. Negative responses related mainly to demand/capacity issues. Overall, the evaluation showed good compliance with many national standards and high levels of patient and staff satisfaction. This suggests that with trained and competent nursing staff and collaborative multidisciplinary team working, safe and appropriate care can be achieved for more complex, as well as very stable PC patients.     

Developing a nurse‐led urodynamics clinic

Nurse‐led clinics in primary and secondary care settings have been widely acclaimed as a positive step towards improving access to investigation and specialist advice, and offering a solution towards limited clinician resource. Many nurse‐led clinics have been traditionally heavily protocoled, but with the evolution of advanced senior nursing roles corresponding role expansion within the multidisciplinary team has occurred. The development of procedural nurse‐led clinics such as urodynamics is not well published. The interpretation and application of published clinical guidelines into practice can present challenges, particularly if consensus has not been found. The proposal of a new clinic requires a vision and commitment from stakeholders to develop and support the implementation of nurse‐led clinics, which have traditionally sat within the realm of medicine. The decision was made to develop this clinic, so a tailored training package that included formal theoretical training, clinical mentorship and supervision and reflective practice was devised. This approach has been documented as central to good urodynamic practice and is based upon published recommended best practice. The successful implementation has provided our patient population faster access to urodynamics procedures, reducing time to treatment based upon the findings and has freed up over 50 appointment slots per annum, for Urologists to see other patients. With a robust training package and clinical support nurse‐led clinics can have a positive impact not only upon health care delivery but also provide the opportunity for professional development and increased job satisfaction.     

Knowledge gaps in prostate cancer treatment between physicians and clinical nurse specialists

Delphi consultations, a method of gaining consensus by gathering expert opinion, were conducted in order to understand the role of degarelix as a treatment option for advanced hormone‐dependent prostate cancer. During the Delphi consultations, differences were identified between physicians and clinical nurse specialists in terms of their knowledge of therapeutic developments. We argue that disparities in knowledge between physicians and nurse specialists could limit the effectiveness of multi‐disciplinary teams in providing optimal patient care. When such situations arise, communication between patients and nurse specialists, often the patient's primary point of contact, may conflict with information they have received from the physician. This could lead to confusion and uncertainty among patients about whether they are receiving the best possible care. Time and resources should be provided to address the continuing educational needs of nurses, which will ultimately result in the improved care and experience of patients.     

One stop nurse‐led macroscopic haematuria clinic: waiting times and patient satisfaction

In 2011, a large District Health Board Hospital in New Zealand established a nurse practitioner‐led, one stop macroscopic haematuria clinic (OSMC) in an effort to improve the timeliness and quality of the investigative process offered to individuals referred with macroscopic haematuria. Patients were identified during the referrals triage process and graded to be seen at OSMC within 30 d. The OSMC process allows for completion of all basic investigations (urine microscopy and culture, urine cytology, renal tract ultrasound and flexible cystoscopy) by the end of the single clinic visit. This report outlines the OSMC process and reports on adherence to the 30‐d timeframe for the first 100 patients, along with patient satisfaction data from patients 51 to 100. The dates of referral and OSMC visits were recorded prospectively for 100 patients and analysed to determine compliance with the 30‐d timeframe. For patients 51–100, an anonymous, self‐administered questionnaire was utilized to evaluate satisfaction with pre‐appointment information, waiting times, interactions with clinicians and education. Of the first 100 patients at OSMC, 81% were seen within 30 d, with all patients rating the clinic timeframes, processes and personnel highly. While the reliability of the Haematuria Clinic Questionnaire results could have been influenced by multiple factors, the OSMC appears to offer service users timely access to diagnostic investigations with clinics timeframes, processes and personnel they rate highly. While 81% of patients were seen within 30 d, work is needed to increase compliance to 100%. This model of care could be adopted at other public hospitals.     

The Fife hormone service for prostate cancer patients: a cost‐effective and patient‐centric model

Injectable hormone therapy is a key element of treatment for many patients with prostate cancer. In the UK, it is typically administered in primary care. In 2003, National Health Service (NHS) Fife rolled out an innovative service for these patients, in which responsibility was moved from primary care to a specialist nurse‐led service in secondary care. The initial rationale was based on cost savings, but a significant number of other advantages have subsequently been demonstrated. These include a simpler patient journey, improved continuity of care and reduced use of consultant time. Standards of care have also improved, with fewer missed appointments, better provision of patient support and rapid access to specialist physician care when needed. An audit of 377 of 542 patients currently treated within the service has provided supportive evidence for many of these advantages. The Fife service offers a cost‐effective model for locally provided nurse‐led care that could be applied to hormone therapy services for prostate cancer elsewhere in the UK, and to services for other cancers with large numbers of patients requiring long‐term management.     

Evaluation of a multidisciplinary allied health prostate cancer clinic

Prostate cancer is the most common male cancer, with increasingly longer survival, and many treatment options for advanced disease. Men with prostate cancer report a high level of unmet supportive care needs. To evaluate unmet needs of a small cohort of Australian men with advanced prostate cancer, and their partners, and to assess the impact of attendance at a multidisciplinary allied health clinic on meeting these needs. Fifty patients were referred to the clinic by their treating specialists. Prior to their clinic consultations patients and partners completed study questionnaires to determine their unmet needs, prostate cancer and treatment related quality of life, levels of anxiety and depression, exercise patterns and prostate cancer‐related functional status. Questionnaires were completed again 1 month post‐clinic attendance, and pre‐and post‐clinic scores were compared. Patients reported unmet needs in several domains including psychological and sexuality needs. These showed a small reduction when assessed post‐clinic. Partners also reported needs in the psychological and emotional, and information domains. Thirty‐two percent of patients reported clinical levels of distress when assessed pre‐clinic attendance, reduced to 8% reporting the same level of distress 1 month post‐clinic. The identified high levels of unmet needs and levels of distress of this group of patients and partners highlights the necessity for additional resources to assist these men. A multidisciplinary allied health care prostate clinic as described here may further assist in the comprehensive care of these men and their partners.     

Clinical effectiveness and cost‐effectiveness of nurse‐led care in Chinese patients with rheumatoid arthritis: A randomized trial comparing with rheumatologist‐led care

Background and aim

The concept of nurse‐led care (NLC) was not familiar in China. This study was designed to evaluate the clinical effectiveness and cost‐effectiveness of NLC versus rheumatologist‐led care (RLC) in Chinese patients with rheumatoid arthritis (RA).

Methods

Patients of either gender (aged ≥18 years) with RA were enrolled at Wenhai Central Hospital, China (January 2015 to December 2015). The participants were then randomized to NLC or RLC. Outcomes of both the groups were compared in terms of effectiveness by measuring the Disease Activity Score 28, visual analogue scores pertaining to pain and fatigue, and duration of morning stiffness. Costs associated with resource use for RA were assessed and compared between both groups.

Results

A total of 214 RA patients in 2 groups (n = 107 in each group) were enrolled and analysed. Improvements in clinical outcomes (disease activity, pain, fatigue, and morning stiffness) over 12 months were significantly greater in the NLC group compared to RLC (P < 0.001). Overall, costs associated with resource use were higher in the RLC group compared to the NLC group (P < 0.05).

Conclusions

Our preliminary finding suggested that RA patients managed by NLC compared to RLC may have better clinical outcomes and more cost‐effective care in China.     

Management and treatment of men affected by metastatic prostate cancer: evidence‐based recommendations for practice

Currently, 250 000 men are affected by prostate cancer in the UK. Clinical guidance is crucial for nurses involved in the care delivery for men with advanced prostate cancer and for their families to maximize their quality and quantity of life. It is essential that nurses understand how prostate cancer is diagnosed, can recognize signs of disease progression, are familiar with disease management, and can educate patients and manage any symptoms appropriately and effectively. Therefore, the aim of this paper is to review current evidence‐based guidelines in relation to care delivery for men with metastatic prostate cancer in order to optimize best supportive care. A literature review was conducted in a range of electronic databases (DARE, Cochrane, MEDLINE, BNI, PsychINFO, EMBASE and CIHAHL) to identify studies employing qualitative and/or quantitative methods. National (UK) and European clinical guidelines were also reviewed. Methodological evaluation was conducted and the evidence‐based recommendations were integrated in a narrative synthesis. Supportive care is a person‐centred approach to the provision of the necessary services for those living with or affected by cancer to meet their informational, spiritual, emotional, social or physical needs during diagnosis, treatment or follow‐up phases including issues of health promotion, survivorship, palliation and bereavement. A multidisciplinary and proactive approach to the management of men with metastatic prostate cancer ensures safe and effective supportive care delivery. Nurses involved in the care delivery for this patient group need to be aware of the complex physical and psychological supportive care needs, and evidence‐based management care plans to ensure a personalized and tailored support to optimize quality of life.     

Evaluation of a newly established nurse‐led urodynamics clinic: Has it added value?

The objective of this study was to evaluate patient experience of a newly established nurse‐led urodynamics clinic, in comparison to the established consultant‐led urodynamics clinic. The secondary aim was to analyse the impact upon waiting times, cost reduction and creating more consultant time, to enable a greater capacity for more complex patients to be seen. A retrospective cross‐sectional mixed method postal survey was utilized and sent to all patients who attended a urodynamics outpatient appointment between July 2013 and July 2014. The survey was posted to all patients who attended either the nurse‐led clinic or the consultant clinic. This totalled of 97 patients. A text reminder was sent 3 weeks later, with a final repeat postal survey sent 6 weeks later inviting patients to participate, and thanking those who had already. The response rate was 57·7%. The median age was 69 years. Whilst the sample demographics for ethnicity were equal across both groups, the nurse‐led clinic saw more females. Overall, 87·5% of patients who responded were male. The secondary aim regarding the impact upon waiting time revealed a median reduction in waiting time of 50 d, resulting in improved access to the procedure. Survey measurable outcomes included communication, patient experience, involvement in care and patient safety and quality of life. The development of the nurse‐led urodynamics clinic has proven to be as effective as a consultant clinic measured by patient experience, whilst also reducing waiting times significantly and remaining cost‐effective. This evaluation has enabled the identification of areas in the service delivery that can benefit from further refinement. In summary, collaborative practice and supported development of nursing practice is essential not only for the future of nursing but also as a way to address the growing demand for service provision in a financially intelligent way.     

Initial experience of a community‐based prostate cancer risk assessment clinic for men of black and minority ethnicity background

We designed and implemented a community‐based prostate cancer risk assessment clinic targeting men from black and minority ethnicity (BME) background. This service had the dual aims of optimizing detection of prostate cancer within a local BME population, with a secondary goal of encouraging longer‐term engagement with primary care for follow‐up prostate‐specific antigen (PSA) testing in order to facilitate early diagnosis of future disease. “Drop‐in” clinics were set up in strategic locations and, staffed by experienced urology nurses. Risk assessment was offered in the form of a PSA test, and digital rectal examination (DRE). We targeted men of BME background aged between 45 and 75 but all attending individuals were given access to counselling and assessment as appropriate. In total, 312 men attended clinics for risk assessment. We diagnosed nine prostate cancers with histological confirmation, with a further two individuals considered to have prostate cancer based on clinical/biochemical parameters. These findings were consistent with similar previously published reports. Nurse‐led, community‐based targeted risk assessment is feasible, leads to the detection of significant numbers of prostate cancers and is well received by patients.     

Nurse‐led prostate assessment clinics – are they fit for purpose?

Nurse‐led prostate assessment clinics (PACs) have been shown to be both cost‐effective and reduce the workload of urologists. We set out to determine how closely guidelines were adhered to in our PAC and whether the outcomes of these clinics, as determined by set protocols, were producing effective management strategies. The notes of 100 consecutive patients who attended the PAC at a single institution were retrospectively analysed. The presenting symptoms, examination findings, investigations performed and their results were documented, and the consultation outcome was recorded. In particular, we assessed whether the guidelines for investigations and management were followed and whether there were any changes in these following consultant review. Of the 100 patients (mean age 67 years), 79 were referred from primary care. The most common presenting symptoms were frequency and nocturia. Ninety‐two per cent of patients were appropriately assigned to the PAC. Eighty‐two per cent had a complete assessment according to the clinic guidelines. Patient management was appropriate and based on clinic guidelines in 81%. Following consultant review, 78% had no change in their management, while 26% were discharged. Nurse‐led PACs are fit for purpose. Guidelines for assessment and management are closely followed with minimal changes to treatment at consultant review.     

A survey of patients with prostate cancer attitudes concerning being cared for closer to home

Recent guidance recommends that men with prostate cancer on watchful waiting and men who have a stable prostate specific antigen, with no significant complications at least 2 years following treatment, should be offered follow‐up outside hospital. The study presented here represents the views of 442 men in the North East of England who fall into this group. It shows that 70·7% of the men surveyed preferred to be followed up at their local district general hospital, compared to 18·1% preferring to be followed up at their general practitioner (GP) practice. Almost 63·8% of patients in this study preferred to be followed up by the nurse specialist in comparison with 23·9% of patients preferring to be reviewed by a consultant and 9·4% choosing their GP. Patients who live in rural areas with a long journey time to the hospital were more likely to choose to be followed up by their GP. There has been no preparation of patients to change their expectations of lifelong follow‐up in secondary care. Patient survivorship information needs to be developed, so that patients are prepared and supported through this change in follow‐up care. This survey demonstrates that the patients within this particular National Health Service (NHS) Trust are happy with the current system of being followed up by the nurse specialist at their local district general hospital.