Letterkenny General Hospital, Co.Donegal

1. Letterkenny General Hospital, Co.Donegal The development of an Advanced Nurse Practitioner Post Oncology Dr Janice Richmond

2. JaniceP.Richmond@mailb.hse.ie m.murray@st-vincents.ie

3. Structure Local context and pre-site facilitation work Site preparation-working to site accreditation Working as an ANP site-facilitator Job components ANP accreditation working to submit portfolio Working as an ANP candidate Conclusion

4. Local context and pre-site facilitation work

5. LGH context 2006 Regional General 300 nurses 300 beds 1 Haem/Onc DSU 1 Haem/Onc ward 1 Cons Onc 1 Cons Haem

6. Service history up to 2006 1990s-Staff nurses in oncology commenced service 2001/2002-Consultant Oncologist and Haematologist appointed 2002 CNM2 Haem/Onc DSU appointed 2002 CNS Haematology appointed 2002 CNS Oncology appointed 2002 OPD clinics commenced 2003 CNS Oncology Liaison appointed 2005 ANP Site-facilitator Oncology appointed 2005 CNM1 Oncology DSU appointed 2005 CNM2 Haem/Onc In-patient ward appointed 2006 ANP appointed and nurse-led clinics commenced

7. Oncology/Haematology Service up to 2006 1 Day services Unit I In-patient ward (11 beds) opened 03/2006 1 OPD Oncology Clinic Monday pm 1 OPD Haematology Clinic Monday am 3 satellite St Luke's clinics/month Visiting radiation oncologist 2 nurse-led Oncology Clinics/week & 1 walk-in clinic per week

8. Pre-site facilitation work DoN had a vision for ANP Oncology in 2002 ANP posts must be service-led Behind in review clinics Psychological support at clinics minimal Delay in reviewing consults Delays in Haem/Onc Day Services for review patients

9. The route taken CNS Oncology given the job of leading out on development of ANP job description Key stakeholders group set up to lead/develop this role CNS oncology, CNS haematology, CNM2 oncology, DoN, A/DoN, CNM3, PD person. Medical staff & NCNM not included at this stage

10. The route taken-4 meetings Brainstorming sessions surrounding job components of ANP role Analyse National Council requirements for ANP Analyse existing ANP roles/job descriptions and other job descriptions Analyse job components documented by nursing literature Advantages/disadvantages of ANP role Vision for ANP role within LGH Developed complex job description Needed reduced and redefined

12. Taking this forward Consult wider group (medical board) NCNM involved Funding sought (? NCNM, ? Health board) Funding obtained (NCNM) Job advertised Summer 2004 Interviews 16.07.04 Successful applicant informed 23.07.04 Site-prep commenced 21.02.05

13. Site preparation-working to site accreditation Working as an ANP site-facilitator

14. Successful applicant RN, BSc(Hons) 1996 PGDip Advanced Nursing-1998 Doctorate in Nursing Science-2002 N.Ireland Kenya Ireland

15. Successful applicant Oncology experience Radiation-inpatients and hostel setting Chemotherapy-in-patient and day services care Palliative care Teaching at QUB/UUC Research-clinical trials and nursing research Oncology mainly since 1997 Staff Nurse Nurse Manager Practice Development Nurse Clinical Nurse Specialist

16. Site preparation stage Site document prepared Also undertook: Physical examination module (UCD) Psycho-Oncology Module (DCU)

17. Site-preparation Job description already written Site-preparation had unofficially been ongoing in ideas and conversations only Nothing had been documented Released full-time for site prep

18. The site-preparation file Part 1: Application form (download) Part 2: Job description Part 3: ANP preparation Part 4: Financial approval form (download) Appendices Reference list

19. The site-preparation file Part 2: Job description (pg 30 NCNM 2004) Job title Grade WTE hours Reporting relationships Location Background to post Includes historical documents Oncology Department information National Developments Service Need Purpose of the post

20. The site-preparation file Part 2: Role responsibilities (pg 31 NCNM 2004) Clinical practice Autonomy Expert clinical practice Pioneering professional and clinical leadership Researcher (Identify priorities for nursing research) Descriptive Talk through job description

21. The site-preparation file Part 2: Person specification (pg 32 NCNM 2004) Qualifications outlined Experience specified Competencies Autonomy in clinical practice Expert practitioner Professional and clinical leadership Researcher Make description in previous section (role responsibilities) into competencies

22. The site-preparation file Part 3: ANP Oncology Site Prep (pg 33 NCNM 2004) Took the 11 criteria and made them into 11 sections & 1 conclusion

23. The site-preparation file Part 3: Health service need (pg 33) Background to post (description of route taken) Results of audits Service review, evaluation and case load analysis (service plan) Review of relevant literature and documents Epidemiological and demographical data (HSE and NWHB documents) National and international developments Conclusion

24. The site-preparation file Part 3: Relevant legislation, rules, regulations and guidelines Relevant documents (ABA) Areas of expansion in relation to ANP Oncology Laws, rules, regulations and guidelines Conclusion

25. The site-preparation file Part 3: Service insurance arrangements Liaise with Clinical risk manager Vicarious liability

26. The site-preparation file Part 3: 4. Guideline development Outlined generic process Identify caseloads Consider scope of practice Write guidelines (#19)

27. The site-preparation file Part 3: 5. Patient/client benefits (pg 34 NCNM 2004) Introduction Projected level of service to be provided Current service provision Identification of key projected outcomes in service Audit of service provided Potential value of ANP to pt/client

28. The site-preparation file Part 3: 6. Consistency with service philosophy Statement of service Philosophy of care Role of ANP ANP links with philosophy of care

29. The site-preparation file Part 3: 7. Facilitation of service plan Described how ANP would complement and expand current service provision

30. The site-preparation file Part 3: 8. Location of service 1 paragraph outlining where the ANP should function

31. The site-preparation file Part 3: 9. Integration of the role to the MDT Identified key stakeholders and methods of communication Relationship of the role to other MDT members Areas of role development that required negotiation Effect of the role upon other health professionals

32. The site-preparation file Part 3: 10. Role context within nursing framework Areas of responsibility Levels of authority Channels of accountability

33. The site-preparation file Part 3: 11. Resource implications Rostering Staff Equipment and facilities Research facilities CPD Audit facilities Liaison arrangement with 3rd level institutions

34. The site-preparation file Part 3: 12. Conclusion Reiterated job purpose

35. The site-preparation file Part 4: Financial approval form (download)

36. The site-preparation file Appendices Audit tables/diagrams Guidelines #19 Audit form(s) & documents References

37. Site preparation Commenced 21.02.05 to 04.04.05 Site visit by NCNM June 2006 Site accredited August 2006 by NCNM ANP candidate job advertised Feb 2006 ANP candidate appointed May 2006 Only when achieved �candidate� status can ANP portfolio be submitted

38. ANP job components

39. Clinical work of ANP Oncology Caseload management of all patients with a breast cancer and colorectal diagnoses following an 18 month disease free period. Caseload management of all patients with a testicular cancer diagnosis not on active treatment. Shared caseload management of review patients attending the multi-disciplinary oncology clinics. Initial assessment and examination of �new� patients referred to the Oncology team. Shared caseload management of in-patients where the skills of ANP specifically requested

40. Clinical job components Advanced holistic psychosocial and physical assessment To include family members/significant others Plan Oncology care and communicate this to patient/family Education Advocate Initiate care/work-up/investigations and treatment modalities

41. Clinical job components Identify and implement health promotion strategies Refer to to other health professionals Plan for and state when discharge appropriate Initiate follow-up Provide contact details

43. Education LYIT Undergraduate programme LYIT Postgraduate Oncology Diploma UUC Undergraduate programme CNME Study days & short courses CNME Foundations in Oncology & Haematology Nursing LGH workshops LGH study days 1 annual Haem/Onc study day 2 Conferences per annum 2 publications per annum

44. Research and Audit Neutropenia research ? Study on Port-a-Caths in 2007 Continually record/audit ANP workload

45. Other work Initiate and lead Haem/Onc nurses meetings Haem/Onc Board member Policy Review committee member Chairperson for accreditation process Support group

46. Other work contd� Senior nurse-pulled into management Mid-line catheters Clinical Trial PICC service

47. External to LGH Cancer Nursing Practice Editorial Board IANO committee member NW IANO chairperson NCI All-Ireland Nurses Working Group External reviewer to RCN publishing External reviewer to UCF Editorial board member

48. ANP Oncology Overview

49. ANP audits (per annum) ANP clinics (n=251) Walk-in clinics (commenced July 2006, n=23) OPD clinics (n=319 or 46% of review workload) RIP letters (n=50 approx) Thank you�s (n=52) Education (53.5 hours and 94.5 hours mentor) Staff support (Commenced July 2006, n=10.5 hours) Consults (n=50) Ward work (n=42) Mid-line catheters (Commenced June 2006, n=15)

50. ANP accreditation Re-accredited every 5 years

51. Portfolio. Page 37, NCNM 2004 Application form (download) Job description (as per site-prep document) Detailed Portfolio Competencies required and attained Evidence and certificates References

52. Portfolio, part 3 Personal details General Education Professional education Registerable qualifications Other professional qualifications Meaningful achievements Professional nursing posts held

53. Portfolio, part 3 5. CPD Study activities (small courses) Research audit and project work Documents produced/developed Publications (list) Professional awards obtained (list & date) Lectures &seminars presented Courses organised Study days organised Papers presented Posters presented Clinical supervision involvement In service training obtained

54. Portfolio, part 3 Conferences and seminars attended Study days attended Professional and work-based activities

55. Portfolio Part 4: competencies required and obtained Table format

56. Portfolio Reference list Evidence in order as to which it was referred to in the list of competencies

57. Conclusion

58. Value of ANP Oncology Initial assessment by ANP provides patient/family with immediate plan for Oncology Tx and/or palliative care Reduces patient/family anxieties Can have graded approach to breaking bad news Ensures faster & appropriate work-up Improved referral mechanisms Enables speedier and more seamless discharge for in-patients Reduces in-patient bed requirements

59. Value of ANP Oncology Continuous link in patient�s care (at diagnosis, as in-patient, review clinics etc) Available by telephone and have admission rights Have referral mechanisms in place for community staff to have ANP review patients

60. Value of ANP Oncology ANP-led clincs enables more time to be spent with patients Focus on quality of life issues & health promotion ANP clinics reduce pressure on multi-disciplinary clinic times Can bring sicker patients back to this clinic ANP at OPD clinics increases numbers of patients reviewed Zeroed waiting times for review patients

61. Achievements to date Reduced review patient waiting times to be scheduled for review-now on target Release consultant time to deal with complex cases at clinic-no additional �new patient clinics� have been needed prior to commencing service All consults reviewed within 24 hours Senior nurses meeting No complaints to date Better able to lead/develop service Launch patient support group November 2006

62. Improvements required Prescribing rights Radiology rights Need good nursing leader Hand over clinical trial Set up but then hand over PICC placement

63. Lessons to be learnt Get site-prep done ASAP! Go to all meetings relevant to the job. Don�t let others describe it for you Don�t be too ambitious Consider impact on porters, secretaries, medical records, phlebotomy etc Contact cards Am I doing it right? Am I doing enough? Encouragement: New South Wales UK MSKCC-USA

64. Value of ANP Oncology Specialised team member Professional and clinical leader Initiates/leads/participates in educational programmes (internal/external to hospital) Researcher Participates in audit and uses results to change practice Have national/international links Promotes hospital/nursing through journal publications/conference presentations

65. The ANP is a senior member of nursing staff able to function as an autonomous practitioner responsible for leading a comprehensive oncology nursing service for cancer patients and their families in Letterkenny General Hospital. The ANP, as an expert practitioner, is an integral member of the multidisciplinary team, linking hospital care with the community, and is a recognised leader within oncology nursing practice and research .