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Plenary 2: Inter-professional Collaboration Between Medicine and Nursing This session will examine key issues and critical success factors for inter-professional collaboration between medicine and nursing through key learning from policy and theory, and at the coalface of education and practice. - PowerPoint PPT Presentation

Text of Maurene McQuestion John Waldron

  • Plenary 2: Inter-professional Collaboration Between Medicine and Nursing

    This session will examine key issues and critical success factors for inter-professional collaboration between medicine and nursing through key learning from policy and theory, and at the coalface of education and practice

    Maurene McQuestion John Waldron

  • SummaryInter-professional collaboration between Medicine and Nursing in the Management of Patients Undergoing Radiation Therapy for Head and Neck Cancers

    Radiation OncologyManagement of H&N Cancer With RadiationPatients Journey and Inter-professional Collaboration Along This Journey

    Inter-professional collaboration between Nursing and Medicine: literature and implementation of roles

  • Radiation OncologyApproximately 50% of patients with cancer require radiation treatment

    Radiation treatment requires a considerable technical infrastructure (linear accelerators, simulators) and human resources (therapists, physicists, nurses, oncologists)

    Radiation delivery centralized 38 cancer centers across Canada

  • Radiation Oncology330 Radiation Oncologists in Canada

    200-300 new patients seen per Oncologist/year

    80,000 Canadians per year

  • Head and Neck Cancer5000 cases per year in Canada2000 in OntarioOral cavityOropharynxLarynx

    Managed with radiation, surgery and chemotherapy

    Most patients have radiation

  • Background PMH H&N Radiation Therapy Program

    600 patients treated per year at PMH80-100 on treatment at any one time8 pairings of Radiation Oncologists and Nurse Case Managers2 Advanced Practice Nurses Clinical Nurse SpecialistNurse Practitioner

    Speech Pathologist, Clinical Dietician, Social Worker

    20 Radiation Therapists10 Radiation Dosimetrists and Planners4 Medical Physicists

    Dentists, Surgeons, Medical Oncolgists, Radiologists, Pathologists

  • 5 to 7 weeks2 weeks5 10 Years

  • 5 to 7 weeks2 weeks5 10 Years

  • Radiation TreatmentOutpatient treatmentDaily fractions Monday to FridayOver 5 to 7 weeksPatient remains supine in an immobilization device during 20 minutes of treatmentExamined weeklyOncologistNurse Case MangerComplex casesReferred or self-referredTo APN

  • Acute Symptom Management ChallengesPainDysphagiaMalnutritionDehydrationAspirationNauseaFatiguePsychological DistressFear & anxietyInsomniaDepressionAltered body imageSocial & financial issuesInfectionPneumoniaOralSinusSoft tissues, febrile neutropenia

  • Radiation Nursing Clinicstaffed by Nurse Case Mangers and APNs regular and prn assessment of patients on treatment

  • Collaborative ApproachNurse Case ManagerWorks with the Oncologist in every clinicMeets new patients as they are initially seenProvides direct nursing care in the outpatient clinicsProvides education and critical navigation in the period leading up to treatmentFirst line for patient contacts and queriesAdvanced Practice NurseRun an independent clinic for patients on treatmentTriage their degree of involvementManages complex acute toxicity issues independently yet in collaboration with OncologistsDevelopment and dissemination of management expertiseAdvancement of symptom management and survivorship program

  • Increasing Treatment Complexity

  • Increasing Treatment ToxicityAddition of concurrent chemotherapy

    Introduction of molecular targets agents

    More intense radiation schedulesHyperfractionationAccelerated radiation

    Survival benefit but at a costIncreased acute side effectsIncreased late effects

  • Lessons Learned:Diversification, Specialization and CollaborationIncreasing both complexity and toxicity of treatments requires the diversification and specialization of patient care beyond traditional models

    Specialization permits the advancement of expertisePatient careResearchEducation

    Advancement of expertise with associated inter-professional collaboration improves the patient experience and outcomes

  • Collaboration

    Collaborative practice is an inter-professional process for communication and decision making that enables the separate and shared knowledge and skills of care providers to synergistically influence the client / patient care provided

    Way, Jones & Busing, 2000

  • Navigating the SystemH&N CancerLiving with uncertainty- Wanting to return to normal Creating a new normalDiagnosis in communityReferral to Cancer or Treatment CentreConsultations & Further Tests - CT, MRI, PET, medical oncology, dental, Treatment 4 - 7 weeks Daily visits Mon FriAmbulatory +/- Hospital Admission1 3 months acute recovery, intermediate recovery 6 months +Treatment DecisionLong term follow up

  • Collaborative PracticeInterprofessionalStaff physicians, residents, clinical fellowsRadiation, medicine, surgery, psychiatryFamily physiciansAllied health SW, RD, SLP, MRT, OT, PT, RT, Chaplain

    IntraprofessionalRegistered NursesInpatient, ambulatory, communityAdvanced Practice NursesClinical Nurse Specialists (CNS)Nurse Practitioners (Adult NP / Child NP / RNEC)CNS/NPPrimary NP (PHCNP)

  • Continuum of APN RolesClinical Practice RoleIntegrated Role DomainsCNS NP Professional development Organizational leadershipResearchEducationAdvanced Nursing PracticeExpanded clinical functions requiring Extended Class (EC) License(Bryant-Lukosius, 2004)

  • APN Roles in Cancer Care

    Site based roles with high volume, high risk populations

    Rapid Diagnostic Clinic

    Community liaison clinics

    Urgent care clinic

    Symptom management & supportive care

    Palliative Radiation Oncology Program / Rapid Referral Program

    Pain & palliative care

    Home Care / CCAC

    Infectious diseases

    Wound care

  • Outcomes of APN Roles

    Improve access, coordination & continuity of careImprove patient and provider satisfactionPrevent or reduce side effects and complicationsImprove health, functional capacity, QOL and survival for high risk patient populationsLower acute care costs - LOS, ER visits and readmissionsImprove uptake of

  • Concepts / Essential Elements of Collaboration

    SharingPartnershipInterdependencyPowerProcessPatient centred

    Responsibility and accountabilityCoordinationCommunicationCooperationAssertivenessAutonomyMutual trust and respect

    DAmour, et. al., 1999, 2005

  • APN-Physician CollaborationExperience of

    Mutual trust and respect

    Defined practice role

    Maintains a nursing perspective

    Lives a positive experience

    Establishes collegial relationships

  • Critical Success Factors for Interprofessional Collaboration

    Collaborative skillsRole clarity & understandingClearly defined goalsSupport structures & resourcesGeneration and culture

  • Outcomes of CollaborationGood

    EngagementComplementary practiceImproved patient outcomes and quality of careStaff satisfactionFewer errorsImproved patient safetyImproved access to careReduced costs


    Power dynamicsPoor communication patternsLack of role understandingConflicts due to varied approaches to careFragmentation in carePatient & staff dissatisfactionDelays in implementation of interventionserrors

  • Challenges to Interprofessional Collaboration


    Lack of understanding or role and scope of practiceDiscipline based socialization, language & communicationIntergenerational & cross cultural professional workforce Perceptions of powerPerceived competition

    OrganizationOrganizational structures & complexitiesWorkloadDocumentation systems

    EducationUndergraduate programsAccess to IPE and mentorship

    PolicyLegislation & provider resistance to roles

    Stolee, et. al., 2008; Way, et. al., 2000

  • Examples of CollaborationPMH & H&N Site Group


    RN Case Manager / Physician clinicsAPN / Physician Symptom Management Urgent care clinic (REACH)Radiation Nursing ClinicSmoking Cessation Program / SHL referralsAmbulatory Redesign

  • Examples of CollaborationPMH & H&N Site Group


    Feeding tube program SDA-NDD-outpatient programNursing & resident education Organizational Guidelines for the management of H&N cancerAcademic research & publications

    Retreat implementation of NP role

  • The PEPPA Framework(Bryant-Lukosius & DiCenso, 2004)

  • Recommendations

    Inter-professional Education undergraduate & graduateIP mentorshipReduce barriers to practice, open opportunities for collaborationImplement APN roles across the health care system based on assessment of gaps and health care needsImprove collaboration between tertiary care centres & community

    Oxman (2008) over 40 definitions of colalboration

    Defined and shaped by the dynamics of a changing healthcare delivery system and various provider scopes of practice

    Joint communicating and decision-making process with the goal of satisfying the patients well being and illness needs while respecting the unique abilities of each professional (Oandasan, et. al., 2006) Canadian Health Services Research FoundationThe collaborative relationship works best when both parties have a thorough understanding of the scope of practice

    PEPPA Framework or a Participatory Evidence-based Patient-focused Process for APN Role Development

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