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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
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Plenary 2: Inter-professional Plenary 2: Inter-professional Collaboration Between Medicine and Collaboration Between Medicine and NursingNursing
This session will examine key issues and critical success factors for This session will examine key issues and critical success factors for inter-professional collaboration between medicine and nursing inter-professional collaboration between medicine and nursing through key learning from policy and theory, and at the coalface of through key learning from policy and theory, and at the coalface of education and practice education and practice
Maurene McQuestion John Waldron
SummarySummarySummarySummary• Inter-professional collaboration between
Medicine and Nursing in the Management of Patients Undergoing Radiation Therapy for Head and Neck Cancers
• Radiation Oncology• Management of H&N Cancer With Radiation• Patients Journey and Inter-professional
Collaboration Along This Journey
• Inter-professional collaboration between Nursing and Medicine: literature and implementation of roles
Radiation OncologyRadiation OncologyRadiation OncologyRadiation Oncology
• Approximately 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 OncologyRadiation OncologyRadiation OncologyRadiation Oncology
• 330 Radiation Oncologists in Canada
• 200-300 new patients seen per Oncologist/year
• 80,000 Canadians per year
Head and Neck CancerHead and Neck Cancer
•5000 cases per year in Canada•2000 in Ontario•Oral cavity•Oropharynx•Larynx
•Managed with radiation, surgery and chemotherapy
•Most patients have radiation
Background – PMH H&N Radiation Background – PMH H&N Radiation Therapy ProgramTherapy Program
• 600 patients treated per year at PMH• 80-100 on treatment at any one time• 8 pairings of Radiation Oncologists and Nurse Case Managers• 2 Advanced Practice Nurses
– Clinical Nurse Specialist– Nurse Practitioner
• Speech Pathologist, Clinical Dietician, Social Worker
• 20 Radiation Therapists• 10 Radiation Dosimetrists and Planners• 4 Medical Physicists
• Dentists, Surgeons, Medical Oncolgists, Radiologists, Pathologists
5 to 7 weeks2 weeks 5 – 10 Years
Daily
Radiation TherapistsWeekly
Radiation Oncologist Nurse Case Manager Advanced Practice Nurse (CNS/NP)
PRN RD, Social work
Admission Chemotherapy Feeding tube Supportive care
Follow-Up Radiation Oncologist Nurse Case Manager APN**
Consultation Radiation Oncologist Nurse Case Manager
Preparation Nurse Case Manager Radiation Therapists Dentistry Radiation Oncologist Medical Oncologist
5 to 7 weeks2 weeks 5 – 10 Years
Daily
Radiation TherapistsWeekly
Radiation Oncologist Nurse Case Manager Advanced Practice Nurse (CNS/NP)
PRN RD, Social work
Admission Chemotherapy Feeding tube Supportive care
Radiation TreatmentRadiation Treatment
• Outpatient treatment• Daily fractions Monday to Friday• Over 5 to 7 weeks• Patient remains supine in an immobilization
device during 20 minutes of treatment• Examined weekly
– Oncologist– Nurse Case Manger
• Complex cases– Referred or self-referred
To APN
Acute Symptom Management Acute Symptom Management ChallengesChallenges
– Pain– Dysphagia
• Malnutrition• Dehydration• Aspiration
– Nausea– Fatigue– Psychological Distress
• Fear & anxiety• Insomnia• Depression• Altered body image• Social & financial issues
– Infection• Pneumonia• Oral• Sinus• Soft tissues, febrile neutropenia
Radiation Nursing ClinicRadiation Nursing Clinic
•staffed by Nurse Case Mangers and APNs• regular and prn assessment of patients on treatment
Collaborative ApproachCollaborative Approach• Nurse Case Manager
– Works with the Oncologist in every clinic
– Meets new patients as they are initially seen
– Provides direct nursing care in the outpatient clinics
– Provides education and critical navigation in the period leading up to treatment
– First line for patient contacts and queries
• Advanced Practice Nurse– Run an independent clinic for patients on treatment
– Triage their degree of involvement
– Manages complex acute toxicity issues independently yet in collaboration with Oncologists
– Development and dissemination of management expertise
– Advancement of symptom management and survivorship program
Increasing Treatment ComplexityIncreasing Treatment Complexity
Increasing Treatment ToxicityIncreasing Treatment Toxicity
• Addition of concurrent chemotherapy
• Introduction of molecular targets agents
• More intense radiation schedules– Hyperfractionation– Accelerated radiation
• Survival benefit but at a cost– Increased acute side effects– Increased late effects
Lessons Learned:Lessons Learned:Diversification, Specialization and Diversification, Specialization and
CollaborationCollaboration• Increasing both complexity and toxicity of
treatments requires the diversification and specialization of patient care beyond traditional models
• Specialization permits the advancement of expertise– Patient care– Research– Education
• Advancement of expertise with associated inter-professional collaboration improves the patient experience and outcomes
CollaborationCollaboration
“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 SystemNavigating the SystemH&N CancerH&N Cancer
Living with uncertainty
- Wanting to return to normal- Creating a new normal
Diagnosis in community
Referral to Cancer or Treatment Centre
Consultations & Further Tests
- CT, MRI, PET, medical oncology, dental, ……
Treatment 4 - 7 weeks
Daily visits Mon – Fri
Ambulatory +/- Hospital Admission
1 – 3 months acute recovery, intermediate recovery 6 months +
Treatment Decision
Long term follow up
Collaborative PracticeCollaborative Practice
• Interprofessional– Staff physicians, residents, clinical fellows
• Radiation, medicine, surgery, psychiatry
– Family physicians– Allied health – SW, RD, SLP, MRT, OT, PT, RT, Chaplain
• Intraprofessional– Registered Nurses
• Inpatient, ambulatory, community
– Advanced Practice Nurses• Clinical Nurse Specialists (CNS)
• Nurse Practitioners (Adult NP / Child NP / RNEC)
• CNS/NP
• Primary NP (PHCNP)
Continuum of APN Roles
Clinical Practice Role
Integrated Role Domains
CNS NP
Professional development
Organizational leadership
Research
Education
Advanced Nursing Practice
Expanded clinical functions requiring Extended Class (EC) License
(Bryant-Lukosius, 2004)
APN Roles in Cancer CareAPN 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 RolesOutcomes of APN Roles
• Improve access, coordination & continuity of care
• Improve patient and provider satisfaction• Prevent or reduce side effects and
complications• Improve health, functional capacity, QOL and
survival for high risk patient populations• Lower acute care costs - LOS, ER visits and
readmissions• Improve uptake of EBP
www.oapn.ca
Concepts / Essential ElementsConcepts / Essential Elements of Collaboration of Collaboration
• Sharing
• Partnership
• Interdependency
• Power
• Process
• Patient centred
• Responsibility and
accountability
• Coordination
• Communication
• Cooperation
• Assertiveness
• Autonomy
• Mutual trust and respectD’Amour, et. al., 1999, 2005
APN-Physician CollaborationAPN-Physician Collaboration
Experience of
• Mutual trust and respect
• Defined practice role
• Maintains a nursing perspective
• Lives a positive experience
• Establishes collegial relationships
Critical Success Factors for Critical Success Factors for Interprofessional CollaborationInterprofessional Collaboration
• Collaborative skills• Role clarity & understanding• Clearly defined goals• Support structures & resources• Generation and culture
Outcomes of CollaborationOutcomes of Collaboration
Good
• Engagement• Complementary practice• Improved patient
outcomes and quality of care
• Staff satisfaction• Fewer errors• Improved patient safety• Improved access to care• Reduced costs
Poor
• Power dynamics• Poor communication
patterns• Lack of role understanding• Conflicts due to varied
approaches to care• Fragmentation in care• Patient & staff
dissatisfaction• Delays in implementation of
interventions• errors
Challenges to Interprofessional Challenges to Interprofessional CollaborationCollaboration
Discipline
• Lack of understanding or role and scope of practice
• Discipline based socialization, language & communication
• Intergenerational & cross cultural professional workforce
• Perceptions of power• Perceived competition
Organization• Organizational structures
& complexities• Workload• Documentation systems
Education• Undergraduate programs• Access to IPE and
mentorship
Policy• Legislation & provider
resistance to rolesStolee, et. al., 2008; Way, et. al., 2000
Examples of CollaborationExamples of CollaborationPMH & H&N Site GroupPMH & H&N Site Group
• PMH
– RN Case Manager / Physician clinics– APN / Physician – Symptom Management – Urgent care clinic (REACH)– Radiation Nursing Clinic– Smoking Cessation Program / SHL referrals– Ambulatory Redesign
Examples of CollaborationExamples of CollaborationPMH & H&N Site GroupPMH & H&N Site Group
• H&N
– Feeding tube program – SDA-NDD-outpatient program– Nursing & resident education – Organizational Guidelines for the management of H&N
cancer– Academic – research & publications
– Retreat – implementation of NP role
The PEPPA Framework
1. Define Patient Population & Describe Model of Care
9. Determine Future Needs
8. Evaluate APN Role & Model of Care
2. Identify Stakeholders & Recruit Participants
3. Determine Need for a New Model of Care
4. Identify Priority Problems & Goals to Improve Model of Care
5. Define New Model of Care & APN Role
6. Plan Implementation
Provide Education, Resources & Supports
Develop APN Role Policies & Protocols
Begin Role Development & Implementation
ROLE OF NURSING PROFESSION
& APN COMMUNITY
7. Initiate APN Role Evaluation Plan
(Bryant-Lukosius & DiCenso, 2004)
RecommendationsRecommendations
• Inter-professional Education – undergraduate & graduate
• IP mentorship• Reduce barriers to practice, open opportunities
for collaboration• Implement APN roles across the health care
system based on assessment of gaps and health care needs
• Improve collaboration between tertiary care centres & community