Nurse led ultrasound assessment clinics

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Nurse led ultrasound assessment clinics

• Using Evidencing Work Based Learning to support
  the development of competencies for specialist
  cancer nurses

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Background to the projectThe UK national picture

• Continuing rise in incidence of breast cancer in
  the UK upwards of 37,000 p.a.(www.statistics.gov
  .uk)
• Increase in survival rates 5 year survival now
  80
• Only 20-30 of referrals (urgent and routine) are
  subsequently diagnosed as breast cancer positive
• Increased pressure to reduce waiting times to 18
  weeks from referral to first treatment by Dec.
  2008
• Further reduction in waiting times to 13 weeks
  introduced with the Cancer Reform Strategy
  December 2007.

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The collaborators

• Cancer Services Collaborative Improvement
  Partnership (CSCIP)
• Jill Turner, Associate Director
• The Breast Care Centre North Bristol NHS Trust
• Simon Cawthorne, National Lead Clinician,
  Breast Cancer
• Jane Barker, Breast Care Specialist Nurse
• University of the West of England
• Pat Turton Principal lecturer in Cancer Care

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The clinical picture

• Great increase in workload as more people
  diagnosed and more treatment options to consider
  (Cancer Action Team 2007)
• Initial patient assessment typically delivered
  through rapid access one stop shop clinics
• Increased number of patients needing assessment
  of response to hormonal therapy and surgical
  follow-up, and eventually initial diagnosis could
  be managed by nurse-led assessment clinics
  supported by consultants.

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Opportunities

• To improve patient experience through reduced
  waiting times, and contact with one healthcare
  professional
• To release consultant time for surgery and
  management of complex cases
• To extend of nursing roles to include the
  necessary appropriate skills taking into account
  Professional and Clinical Governance issues
• BUT.
• No nationally agreed course
• although..
• Some national competences developed by Skills for
  Health

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Educational and collaboration opportunities via
work-based learning

• Evidencing Work-based Learning (EWBL) module
  developed by Lesley Moore, Principal Lecturer ,
  Health and Social Care the University of the West
  of England (UWE) to meet this type of problem.
• EWBL is
• Flexible learning based around an individual
  learning contract allows students to identify,
  plan and evaluate their personal learning
  requirements
• A tri-partite arrangement between the individual
  student, the clinical mentor and/or manager, and
  the academic mentor
• A process whereby competencies are assessed at
  work-place level with support from appropriate
  academics to meet clinical governance needs

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The initial process

• Initial Steering group developed, comprising
  CSCIP representatives, Clinical and management
  colleagues from North Bristol Trust (NBT) and
  colleagues from School of Radiography at UWE,
  and Skills for Health,
• Learning set of 7 specialist nurses recruited to
  participate
• Funding initially agreed from CSCIP for a single
  module lasting 6 months
• Module taken at Masters level, or level 3
  standard 20 credits
• Students meet monthly for technical input
  regarding ultrasound and breast palpation skills
  and discussion of progress
• Assessment format agreed between student,
  clinical mentor and academic tutor with
  competences agreed at Trust level.

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Interim evaluation 1

• Opportunities for service development and
  extension of nursing roles
• Each nurse identified ways of significantly
  improving patient experiences and smoothing the
  patient pathway.
• (information from assignments)
• For example-
• Specifically in the follow-up care of older
  women with breast cancer being maintained on
  hormonal therapy
• Patients no longer have to wait for an available
  doctor through the nurse being able to undertake
  Fine Needle Aspiration for the aspiration of
  seroma.

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Interim Evaluation 2.

• Emerging Professional Issues
• Professional boundaries are challenged some
  doctors and radiographers and/or
  ultrasonographers unhappy with nurses extending
  their roles in this way
• Who is going to support the nurse clinically to
  develop new skills?
• Some nurses dont want to be doctors! want to
  retain traditional support roles, and see the new
  tasks as eroding these
• Extending roles in this way is a big move towards
  autonomous practice e.g.
• I have participated in ultrasound consultations
  for about 10 years, but I have never looked at
  the screen properly before!

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Interim Evaluation 3.

• Emerging organisational issues
• Clinics not usually set up to allow nurses to run
  own clinic as nurse-led clinics this leads to
  problems of access to sufficient patients to gain
  experience in ultrasound practice
• Need to ensure safe practice for clinical
  governance need for research to establish
  safety issues
• Job descriptions require revising and clinic
  protocols need to be reviewed and/or developed
• Resource issues e.g. back-filling of existing
  roles, additional radiographer/ultrasonographer
  time for teaching and clinical supervision, more
  ultrasound machines, not enough rooms etc
• Forward planning for staff undertaking this and
  time for adequate learning and training is a big
  issue.

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The added-value of an EWBL university accredited
module

• Provided a simple structure and framework to
  support nurses whilst they were both undergoing
  training to become competent, and implementing
  the necessary organisational change
• Supported professional development, and gave
  permission to negotiate change within their
  participating organisations
• Encouraged participants to become responsible for
  their own learning, rather than receive a
  previously developed package
• Is enabling the project to be fully evaluated

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The evolving process!

• EWBL is an excellent tool for getting the show
  on the road and encouraging and supporting
  students to develop their individual practice and
  skills
• Six months was not enough! - a further 6 months
  and an additional EWBL module was negotiated for
  the participants and completed in October 2007
• Students now undertake a 12 month double module
  action learning set with parallel action learning
  and assessed ultrasound component Negotiated
  Specialist Practice in Medical Ultrasound.
  Currently being undertaken by a further 5
  students

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Formal Evaluation plans..

• Ongoing (funded by grant from Department of
  Health..)
• Qualitative interviews with students, managers
  and clinicians with analysis of resulting data
  for themes relating to -
• organisational changes and impact on service
  development
• personal and professional development of
  participating students and staff
• Proposed
• Comparative RCT between medical and nursing
  ultrasound assessment to determine safety and
  effectiveness
• Qualitative project to determine patient attitude
  to non-medical follow-up

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On-going collaboration with the current project

• Cross-faculty working Nursing and Radiography
• Expanded Steering group North Bristol Trust,
  NHS Improvement Partnership, Department of
  Health, Breakthrough Breast Cancer (user input),
  Skills for Health, Avon Somerset and Wiltshire
  Cancer Services Network

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Future collaboration and knowledge exchange
projects..

• Watch this space!!
• Workshop to kick start Faculty Cancer
  Collaborative in the new Faculty of Health and
  Life Sciences
• Identified potential to establish a role for the
  University in the wider cancer field, especially
  in applied and developmental work

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• For further information, please get in touch!
• Pat2.Turton_at_uwe.ac.uk
• 0117.3288848