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Mary Murray R'G'N' Onc' Cert' MSc


Attend and actively take part in meetings where decisions are to be made ... care is a new initiative within the afore mentioned clinical career pathway ... – PowerPoint PPT presentation

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Title: Mary Murray R'G'N' Onc' Cert' MSc

NCNM Masterclass 2006
  • Mary Murray R.G.N. Onc. Cert. MSc
  • Advanced Nurse Practitioner
  • Breast Care
  • St. Vincents University Hospital

(No Transcript)
  • Be prepared to challenge
  • To be challenged and speak out
  • Not afraid of articulating a nursing voice
  • Attend and actively take part in meetings where
    decisions are to be made
  • Dont be afraid to criticise policy where changes
    need to be made

The development and integration of the Advanced
Nurse Practitioner into a practice setting has
implications for
  • Patients
  • Nursing profession
  • Other health care providers

ANPs in the oncology setting play a pivotal role
in assisting patients across the cancer trajectory
  • From time of diagnosis through to rehabilitative
    phase of cancer care.
  • The skills and knowledge of CNS and ANPs are
    essential to patient receiving high quality,
    comprehensive cancer care.

  • Patients with breast cancer are now living longer
    with their disease.
  • Clinicians are also faced with managing other
    chronic diseases that affect the adult population.

  • Given there changing demographics the role of the
    ANP in breast care needs to be developed.
  • To meet the increasing healthcare needs of our
    surviving chronically ill population.

  • Oncology nursing practitioners work differently
    to physicians by bringing a nursing perspective
    and nursing skills to patient encounters

  • Breast care ANPs provide holistic care to
    patients either collaboratively or independently.

Role of ANP in Breast Care includes
  • Holistic assessment.
  • Screening and monitoring.
  • Facilitating compliance.
  • Co-ordinating the care pathway.
  • Ensuring consistency of contact with health care
  • Communication, health promotion.
  • Health education activities.
  • Commitment to ensuring post registration nursing
    programmes are developed to meet the challenge of
    Advanced Nursing Practice.

  • Advanced practice in oncology nursing has
    developed internationally and nationally.
  • Commission on nursing (1998) recommended a
    clinical career pathway leading from
  • Registration
  • ?
  • Clinical Specialisation
  • ?
  • Advanced Practice

The position of ANP breast care is a new
initiative within the afore mentioned clinical
career pathway
  • It aims to enhance the care of people with breast
    problems benign and malignant.
  • Develop and expand the role of oncology/breast
    care nurses.

The cancer strategy in Ireland proposed that care
  • Must be planned and led by nurses with post
    registration education in oncology.
  • That nursing services must be structured to
    ensure patients access to specialist nurses

WHO document Europe Health 21
  • Nurses are singled out as having a key role to
    play throughout the continuum of care.

In particular nurses are seen as working with
  • Individuals, families and communities to promote
    health and prevent ill health.
  • As well as
  • To care for people when they have disease
  • Supporting those in the terminal stages of
    disease as well as family and friends.
  • Ensuring a peaceful, dignified death are also
    perceived as crucial oncology nursing functions.
  • Oncology Advanced Nurse Practitioner are
    attributed with quickly and interviewing
    skilfully to prevent serious complications
    (Whittey 1992).
  • Practitioners, their enormous background of
    patient care experience.
  • Enhanced with post graduate education
  • Quickly able to assess a clinical situation.
  • Accurately target problems.

ANPs (oncology) play a critical role in leading
efforts to improve
  • Healtcare access.
  • Promot clinical excellence and quality of life.
  • Increase cost effectiveness.

Breast care ANP fucntion primarily in the
  • Medical domain using a nursing framework as
    clinical experts in oncology by providing direct,
    epiosodic health care to prevent and meet the
    acute asymptomatic or palliative care needs of
    patients with cancer.

ANPs scope of practice includes
  • Comprehensive health assessments.
  • Differential diagnosis.
  • Ordering, supervising and interpreting diagnostic
  • Developing a therapeutic plan in collaboration
    with a physician partner.
  • Screening to prevent illness and promote

Breast care ANP manages the care of patients with
complex needs
  • Instructs other nurses about the care of these
  • Is responsible for the quality of patient care.
  • (Gift 1998)

  • Comprehensive individualised and holistic care is
    not new to oncology nursing in Ireland.
  • Specialist breast care nurses have been at the
    forefront of inter disciplinary care.
  • Having in many instances established true
    partnerships' with physicians.

National Cancer Strategy identified the following
objectives that apply to Advanced Practice
Oncology Nursing
  • To take all steps possible to reduce rates of
    illness and death from cancer.
  • To ensure that those who develop cancer receive
    the most effective care and treatment.
  • To ensure the patients quality of life is
    enhanced to the greatest possible extent.

Recent decades breast cancer detection and
management strategies have changed dramatically
  • Implementation of National Breast Screening
  • Identification of BRCA1 and BCCA2 genes.
  • More breast conserving surgery and breast
    reconstructive procedures.
  • Increased use of adjuvant therapies.

  • Early detection Long term follow up
  • Age of population Complexity of
  • Long term
  • survival
  • Health Promotion Holistic Care
    Survivorship issues

The majority of persons with breast cancer are
now treated in the ambulatory setting Treatments
and surgery administered as day cases Nurse Led
Clinical practice associated with Advanced Care
  • Promoting breast awareness.
  • Family history and genetics.
  • Benign breast disease.
  • Breast screening.
  • Patients newly diagnosed with cancer.
  • Breast surgery and breast reconstruction.
  • Chemotherapy (and related side effects).
  • Radiotherapy (and related side effects).
  • Endocrine therapy (and related side effects).

  • Prosthesis fitting.
  • Management of menopausal symptoms.
  • Management of disease related symptoms e.g.
    lymphoedema, fatigue.
  • Management of fungating wounds.
  • Metastatic disease.
  • Recovery, rehabilitation and follow-up.

Expanded roles undertaken by ANP (Breast care)
  • Nurse led follow-up and consultation.
  • Family history screening and surveillance.
  • Diagnostic examination, Punch bx, FNAC.
  • Seroma drainage.
  • Tissue expander, inflation/deflation.
  • Micropigmentaion (tattooing).
  • Accepting direct referrals fatigue, fungating
  • Risk assessment and counselling about the risk of
    developing breast cancer.

Reported numbers of breast cancer has increased
over the past 20 years
  • Better statistical reporting.
  • Better screening methods.
  • Increased life expectancy.
  • Increased exposure to carcinogens.
  • Changes in lifestyle.

  • Age remains the greatest risk/action, with most
    breast cancers occurring in the post-menopausal
    age group.
  • 2002 before 2348 women diagnosed with breast
  • Many years we can truly reflect on the evidence
    and real benefits of breast screening or overall

Services needs addressed by post
  • Increased pressure on breast clinics to see
    patients more quickly.
  • Part due to breast awareness campaigns.
  • More women being screened.
  • Referrals from family planning clinics are
  • Results
  • Higher numbers of patients need to be seen
    efficiently with individualised treatment plans
    devised to suit their needs.

Pilot study of 24 patients seen at Nurse led.
  • 22 stated they would prefer to received part of
    their follow-up in the future at NFU.
  • Other benefits cited
  • Continuity of care same person at each visit.
  • Appointments runs to time less hurried.
  • Improved co-ordination and timing of visit.
  • Improved adherence to protocol on frequency of

Services needs
  • Patients who develop lymphoedema should be
    offered assessment.
  • Assessment of patients complaining of breast
    lumps, pain, discharge.
  • Seroma management.
  • Follow-up of patients with breast cancer/family
  • Micropigmentation.

  • 2 Nurse Led Clinics per week
  • Symptomatic /TAC Clinic
  • 1 session with plastics
  • Patient caseload average per week
  • Lymphoedema assessment 2-3 (inpatient and
  • Fatigue assessment 2
  • Areola micropigmentations 4-6
  • Tissue expansion/deflation 4-5
  • New patients complaining of
  • breast lumps, nipple discharge,
  • mastalgia and infection 17-20
  • Seroma aspiration/wound review 9
  • Follow up patients with breast cancer 26-30
  • Follow up patients with positive family
    history 2-4

  • Aim of nurse led breast care clinic is to ensure
    that patient receive consistent review by a named
    member of the team with appropriate specialist
    knowledge, ensuring continuity of a high quality
    standard of care.

Work across role boundaries
  • Communication.
  • Liaise with multidisciplinary teams
  • Intercede as patient advocate.
  • Make transparent the role of ANP.

  • Strengthen team cohesiveness.
  • Mentor newer staff members.
  • Getting involved and staying involved
  • Create opportunities for others to develop their
    maximum potential
  • Balancing professional and private life
  • Team building is an essential skill

  • Work independently.
  • Physical and psychosocial assessment.
  • Early recognition of complications.

Referral process to ANP
  • Surgeons, Medical Oncologists, Plastic
    Reconstructive surgeons, specialist nurses breast
  • Key members of multidisciplinary team, physio,
    social worker.
  • Patient/family referral for education and support

Autonomy in breast care nursing
  • Diagnosis and treatment of breast disorders
    within specific clinical guidelines.
  • Devising an individual care plan includes both
    nursing and medical management of care.
  • Comprehensive health assessments.

Services provided
  • Promoting breast awareness breast screening.
  • Early identification of breast problems.
  • Management of breast conditions.
  • Rehabilitation, follow-up, supportive care.

Expert Practitioner
  • Specific clinical expertise, in depth knowledge
    and understanding of breast disease/cancer.
  • Chooses interventions based on sound rational and
    accepted practice.
  • Make decisions where precedents do not exist.
  • Develops, implements and improves standards of
    breast care nursing.
  • Creates a culture of reflective practice
  • Initiates practice development initiatives

Clinical Leadership
  • Communication skills desire to hear and
    understand another point of view.
  • Commitment giving of self personally and
  • Getting involved and staying involved.
  • Developing ones own style.
  • Willingness to collaborate.

  • Is integral to Advanced Practice.
  • Identifies organisational learning needs.
  • Planning delivery of education nationally and
  • Develops teaching skills in others.
  • Develops relevant education materials for
    patients and staff.
  • Credible to teach all members of MDT.
  • Partnership with Higher Education Establishments

  • Competency/Collaborative Research
  • Evaluating practice.
  • Conducting research.
  • Audit.
  • Priority index on effectiveness of Nurse Led
  • (Murphy, Cowman 2006)

  • ANP works collaboratively within a
    multidisciplinary health team
  • Responsible for providing comprehensive and age
    appropriate care to both well or ill patients
    under the direction of a consultant.

  • Clinical Support
  • Management Support
  • Administration Support

  • Medical records
  • Scheduling
  • Registration
  • Pulling/filing back

Management Support
  • Business plan
  • Financial plan funding
  • Site visit

Clinical Support
  • Supervised hours
  • Support network
  • Professional tensions - ? Nursing
  • Position within nursing organisation

Personal Specification
  • Registered nurse.
  • MSc.
  • 7 years or more post registration and 5 years
    experience in specialist area.

Professional Regulations
  • An Bord Altranais.
  • Code of Professional Conduct.
  • Scope of Practice.
  • Dont forget safe administration of cytotoxic
    medical preps.

  • Vicarious liability.
  • Guidelines for good practice.

Benefits for patients from ANP service
  • ? number of patients receiving ambulatory care.
  • ? number older patients.
  • Model of care which is mainly ambulatory care
    following surgery directly mainly by ANPs.
  • Preventive care, screening, secondary care,
    active treatment control of side effects.

Breast Clinic Numbers 2005
  • Total Number of patients 7339

Future ANP in breast care will play a crucial
role in
  • Breast diagnostic centres via nurse led clinics
  • Community in a supportive/educative role.

Benefits of Nurse Led Clinics
  • Holistic assessment.
  • Facilitating compliance.
  • Improving liaison with other services e.g.
  • Patients understood their treatment better.
  • More likely to comply with treatments.
  • Improved co-ordination of care due to continuity
    of contact.
  • (Mackie 1996)
  • (Murray 2006)

  • Reduced waiting times at clinics from 2 hours to
    less than 10 minutes
  • Increasing, easier and more efficient access to
    care for patients
  • Operating an outpatient ambulatory facility
    dedicated to specific population of cancer
    patients i.e. breast
  • Delivering expert care in accordance with
    protocol/guidelines that are accurate, safe,
    comprehensive and effective
  • Co-ordinating plans to establish a speciality
    Breast Clinic Unit within the context of the new
    Ambulatory Day Care Centre (unit opened 25.08.06)
  • Recruit suitable post Graduate H.Dip Breast Care
  • Developing a programme of professional
    development for all Breast Care Nurses who staff
    the clinic
  • ANP is perceived to be approachable, available
    and accessible by the great majority of patients

  • Elderly people have difficulty advocating for
    themselves when confronted with life-threatening
    illness. Find it difficult to demand equality of
    access to optimal cancer care

Breast care ANP can do much to
  • Promote rights of elderly breast cancer patients.
  • Ageist and fatalistic attitudes can be challenged
    through public and professional education.

  • Development of nursing roles such as ANP can only
  • In a higher quality of care for patients.
  • Take action now. Do not wait standing still is
    not an option

Development of ANP service will enhanced the care
provided by
  • Developing an outcome oriented care plan that is
    individualised, holistic, culturally sensitive,
    cost effective and based on nursing diagnosis and
    incorporated cancer prevention, detection,
    treatment, rehabilitation and supportive care.
  • Increasing access to care and patient education.
  • Developing a clinical career pathway for
    experienced nurses in oncology.
  • Applying research to oncology/breast care nursing

  • Its all about Teamwork
  • Complementing the service

Consistency of services with unit philosophy
  • Mission of the unit
  • To lead in the provision of easily accessible
    high quality care for women with breast
    complaints through information, education,
    diagnosis, screening treatment and research.

Driving force for ANP role
  • Hanly Report
  • EU directives regarding reducing junior doctors
  • National health strategy QF.
  • Primary Health Care strategy.
  • Commission on nursing.
  • Cancer strategy.
  • Plan for womens health.

ANP in breast care demonstrated many of the
principles of QF (document).
  • Role provides a
  • People centred service that demonstrates clear
    accountability where quality is to the fore.

A service underpinned by equality and fairness
  • ANP led services must be population focused and
    of benefit to the people they serve.
  • (Cassidy 2002)

We must become the change we want to see
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