Developing a specialised metastatic breast cancer

nursing role at your organisation: factors to

consider Gillian Kruss

Metastatic breast cancer nurse practitioner candidate

Development of a MBC nursing role at Monash Health – topics to cover

• History of role and how it evolved at MH

• Use of current resources and processes to integrate the role at MH

• Model of care/clinical pathway developed

• Referral pathways used

• Skills/knowledge required

• Anecdotal benefits and challenges of the role

• Recommendations for establishing similar roles at your organisation

History of the role at Monash Health

• 2012 – local consumer identified local supportive care gap; validated by international/national reports

• 2013 – SMICS project to develop a specialist MBC nurse framework: researched existing roles and sc gaps / gathered local statistics/ explored funding options / considered local resources/ engaged key stakeholders

• 2014 - DOH funding obtained to develop a MBC NP role at MH

• 2015 – employed MBC NPC at MH

Joy Knight - consumer

Specialist Metastatic

Breast Care Nurse

FrameworkFinal Project Report

Prepared by:

www.smics.org.au / gillian.kruss@monashhealth.org

Report outlines:• Results of research• Local statistics• Model of care and

clinical pathway for MBC CNC role

• Recommended KPIs for role

• Recommended credentials for CNC role

• Other recommendationsfor developing a CNC role

• Guidelines used to help develop role at MH

Used local statistics to support the need for the role

• Southern Melbourne hospitals treated the largest number of breast cancer patients in the state in 2012

• Approximately 1000 new diagnoses of breast cancer in Southern Melbourne hospitals, and 1/3 of these developed and died of MBC (2008-2011)

• At Monash Health 327 MBC patients had 1955 episodes of care (2011-2012)

Identified supportive care gap for MBC patients

Physical

Social

PsychologicalSpiritual

Information

SC needs are heightened at key times of distress:•at diagnosis•when treatment changes•when disease progresses

Five inter-related domains

of supportive care

Supportive care needs of MBC pts:complex, unmet, vary over time

Specialised skills and time are required to assess and address these needs

Engaged key stakeholders to help develop the role at MH

• Vic Integrated Cancer Services

• Director of Nursing / business manager

• Funding sources: McGrath Foundation, DOH, charity organisations, private benefactors

• Medical and nursing staff

• Consumers

Examined resources and processes to integrate the role into Monash Health

Resources and processes

Put picture of hospital

Breast cancer services Breast screen Theatres Inpatient surgical, oncology, palliative care units 2 x breast oncology clinics Other specialised clinics Chemotherapy Day Unit Radiotherapy (Peter Mac) Pharmacy Diagnostic imaging Pathology Physiotherapy Oncology research Hospital in the Home Breast cancer social worker Weekly breast oncology MDT Oncology NP

NP

Wellness prevention

support

Ad

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C

are

Co

ord

ina

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MBC NP Model of Care

Why a NP model of care at Monash Health?

• The extended scope of practice of a NP can efficiently and effectively meet the supportive care needs of MBC patients. NPs can work autonomously and collaboratively across settings to provide:

• Advanced nursing assessment, planning and management of side effects/symptoms

• Prescribe certain medications

• Order diagnostic tests

• Make referrals to medical staff

• Better scope to manage those on oral anticancer therapies (cease medications, decrease dose, recommence medications, prescribe medications for symptom Mx)

• A CNC can also effectively work in a MBC nursing role: different processes required ie: collaboration with medical staff to perform some of the above tasks

Table 1: Recommended MBC Nurse Practitioner (NP) Clinical Pathway (An adaption of both the NBCC Specialist Breast Nurse clinical pathway and NEMICS Advanced Breast Cancer Best Practice Pathway)

Diagnosis of MBC

MDT

MBC NP clinical pathway

Treatment

surgery

chemotherapy

radiotherapy

endocrine therapy targeted therapy

best supportive care

Progressive disease

End of life care

home (+/- community palliative care)

aged care / hospice setting

local hospital

Referral to the MBC N.P

at any time during the advanced breast cancer trajectory pathway from any of the following:

MDT

surgeon

oncologist

radiation

oncologist

nurses

BCN’s

clinical trials staff

palliative care

allied health professionals

OR

GP

self-referral

community- based support services

Care provided by the MBC NP (Aims: to promote wellness; to delay disease progression; to prevent complications of disease and hospital admissions; to facilitate direct to ward admissions and MDT care; to decrease length of stay ) Information, support and communication:

introduce self and role; provide contact details; introduce treatment team / purpose of MDT meeting

assess patient's levels of distress in the 5 domains of supportive care (physical, social, psychological, spiritual, information): o use of supportive care screening tool at key intervals / milestones (at diagnosis, at changes in

treatment, at disease progression, and at times of increased stress)

discuss (as deemed appropriate): o diagnosis / prognostic issues / treatment goals and options / practical issues o values, beliefs, any cultural/religious/sexuality/intimacy/financial/family issues o response to diagnosis, feelings, problems, solutions, concerns on intimacy / relationships o personal support networks o possible complications / side-effects of treatment and their prevention and management o relevant clinical trials available o family history of breast/ovarian cancer o plans of care / advanced care plans o offer discussions with family / support persons

provide counselling /practical strategies/ reassurance/ advocacy/ self -management strategies

provide ongoing individual support and information / facilitate community monthly support, information and wellness groups

Advanced assessment/ triage, diagnostic workups, therapeutic interventions and technical skills:

phone/clinic triage and assessments of disease symptoms/treatment side effects, complications and/or oncology emergencies

advanced planning; conduct diagnostic work ups

advanced symptom management and interventions; prescribe appropriate medications

arrange direct to ward/A&E admissions when required Care co-ordination:

communicate with care providers/teams: provide updated plans of care, updates on patient status/patient requests

assist with implementation of MDT treatment plan / patient's advanced care plans / home supports

Education and resource to the MBC patient's treatment team Clinical research, quality activities and data collection

Offer resources and referrals as needed:

Hospital based:

medical staff

dietician

social worker

palliative care consultant

physiotherapist

occupational therapist

psychiatrist

clinical trials staff

clinics (lymphoedema; pain; menopausal; plastics; familial cancer clinics)

support groups

other specialist nurses

imaging and pathology Community based:

offer BCNA H&H’s kit

Living Centre/ Breacan /OF/ BCNA/ CCV relevant pamphlets and services

GP

palliative Care

psychologists / counsellors

support groups and

programs: drug co; LGFB; LWC.

prosthesis / wig retailers

preparation of will/ funeral kits

other community services Centrelink; child-minding; retreats.

Advanced breast cancer

trajectory

Key principles: This role works to enhance the existing Oncology and Breast Cancer Services to provide the best care for MBC patients in the southern Melbourne region.

This role is designed to utilise the expert clinical knowledge and skills of the MBC NP to fill the supportive care gaps that currently exist for the MBC patients, and meet their growing complex needs.

Sources of referral at Monash Health (2015-2016)

number of patients (170)

medical oncologists nurses surgeons self referrals

MDT physiotherapists social workers clinical trials staff

MBC NP duties at Monash Health

To work collaboratively with all those involved in caring for MBC pts and fill gaps in care

Accessible contact person for patients who have questions or who need to report side effects/symptoms/ supportive care needs

Contacts are via the telephone, at clinics or on the ward/CDU

Assist patients who have complex supportive care needs

Provide information, support, referrals and continuity of care

Educational resource for patients and the healthcare team

MBC NP duties cont:Co-ordinate and present at the fortnightly MBC MDT

meeting

Co-ordinate/ stream-line care by communicating

plans of care to the patient’s healthcare team

Administration of s/c or IM Rx’s:

goserelin acetate/ fulvestrant/ denosumab/ trastuzumab

Monitor/manage patients on oral anticancer therapies

Review and interpret blood results

Early management of side effects of treatment / symptoms of disease

Triage and rapidly review patients with side effects/symptoms

Anecdotal benefits of the role

• Received positive feedback from patients, medical and nursing staff (future qualitative research required to gather evidence based reports)

• Improved supportive/ multidisciplinary/ co-ordinated care of MBC patients

• Early identification and management of side effects / symptoms – prevents hospital admission; improves patients QOL

• Facilitated admissions direct to hospital/hospice and/or avoidance of ER admissions (benefits the patient, staff and organisation)

• Appropriate referrals made in a timely manner

• Development of effective processes for managing patients on oral anticancer therapies

• Personally rewarding

Anecdotal challenges of the role

• Unable to provide supportive care to all MH patients when required (employed .8 EFT; multi-campuses)

• Time pressures

• Potential for compassion fatigue/burn-out

• Inadequate cover for annual leave (consider job sharing)

• Challenges involved in establishing the fortnightly MBC MDT

• Ineffective collection method of relevant statistics

• Establishing nurse led clinics and appropriate funding – currently exploring type C admissions (s/c medications)

Recommended credentials

• Role can be developed as a NP or CNC role: refer to SMICS report for CNC guidelines or MH MOC/ job description for NP guidelines

• Oncology experience and knowledge mandatory

• BCN / palliative care experience and knowledge desirable

• Knowledge of MBC treatments – safe administration, monitoring, management of side effects

• Symptom management knowledge

• Knowledge of early identification and management of oncological emergencies

• Established collaborative relationships with breast oncology and palliative care medical / nursing staff

• Effective communication/counselling skills

Conclusion / keys to

• Use MOC guidelines to develop a NP/CNC role at your organisation - adapt to meet local needs and available resources

• Consider job sharing a full time role (to provide optimum supportive care to all patients and each other; cover leave; work across different sites/settings)

• Develop KPI’s and data base to collect useful statistics and measure effectiveness of role

• Explore a variety of funding sources

• Involve key stakeholders when developing the role (nursing executive, medical/nursing staff, consumers)

• Establish collaborative relationships (medical and nursing staff) to establish referral pathways and ensure ongoing effectiveness of the role

• Credentials: oncology experience and knowledge of MBC treatments/ symptom management essential; breast care/palliative care nursing experience desirable.