Maurene McQuestion John Waldron

1. Plenary 2: Inter-professional Collaboration Between Medicine and NursingThis 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

2. Summary • 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

3. Radiation 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

4. Radiation Oncology • 330 Radiation Oncologists in Canada • 200-300 new patients seen per Oncologist/year • 80,000 Canadians per year

5. Head 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

6. Background – PMH H&N Radiation Therapy 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

7. Consultation • Radiation Oncologist • Nurse Case Manager Admission • Chemotherapy • Feeding tube • Supportive care • Follow-Up • Radiation Oncologist • Nurse Case Manager • APN** Daily • Radiation Therapists Weekly • Radiation Oncologist • Nurse Case Manager • Advanced Practice Nurse (CNS/NP) PRN • RD, Social work • Preparation • Nurse Case Manager • Radiation Therapists • Dentistry • Radiation Oncologist • Medical Oncologist 2 weeks 5 to 7 weeks 5 – 10 Years

8. Admission • Chemotherapy • Feeding tube • Supportive care Daily • Radiation Therapists Weekly • Radiation Oncologist • Nurse Case Manager • Advanced Practice Nurse (CNS/NP) PRN • RD, Social work 2 weeks 5 to 7 weeks 5 – 10 Years

9. Radiation 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

10. Acute Symptom Management Challenges • 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

11. Radiation Nursing Clinic • staffed by Nurse Case Mangers and APNs • regular and prn assessment of patients on treatment

12. Collaborative 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

13. Increasing Treatment Complexity

14. Increasing 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

15. Lessons Learned:Diversification, Specialization and Collaboration • 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

17. 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

18. Navigating the SystemH&N Cancer Diagnosis in community Referral to Cancer or Treatment Centre Consultations & Further Tests - CT, MRI, PET, medical oncology, dental, …… Treatment Decision Treatment 4 - 7 weeks Daily visits Mon – Fri Ambulatory +/- Hospital Admission 1 – 3 months acute recovery, intermediate recovery 6 months + • Living with uncertainty • - Wanting to return to normal • Creating a new normal Long term follow up

19. Collaborative 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)

20. Continuum of APN Roles CNS NP Integrated Role Domains Advanced NursingPractice Expanded clinical functions requiring Extended Class (EC) License Professional development Organizational leadership Research Education Clinical Practice Role (Bryant-Lukosius, 2004)

21. 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

22. Outcomes 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

23. Concepts / Essential Elements of Collaboration Sharing Partnership Interdependency Power Process Patient centred Responsibility and accountability Coordination Communication Cooperation Assertiveness Autonomy Mutual trust and respect D’Amour, et. al., 1999, 2005

24. APN-Physician Collaboration Experience of • Mutual trust and respect • Defined practice role • Maintains a nursing perspective • Lives a positive experience • Establishes collegial relationships

25. Critical Success Factors for Interprofessional Collaboration • Collaborative skills • Role clarity & understanding • Clearly defined goals • Support structures & resources • Generation and culture

26. Outcomes 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

27. Challenges to Interprofessional Collaboration 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 roles Stolee, et. al., 2008; Way, et. al., 2000

28. Examples of CollaborationPMH & 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

29. Examples of CollaborationPMH & 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

30. The PEPPA Framework 3. Determine Need for a New Model of Care 1. Define Patient Population & Describe Model of Care 2. Identify Stakeholders & Recruit Participants 4. Identify Priority Problems & Goals to Improve Model of Care 9. Determine Future Needs ROLE OF NURSING PROFESSION & APN COMMUNITY 5.Define New Model of Care & APN Role 8.Evaluate APN Role & Model of Care 6. Plan Implementation 7. Initiate APN Role Evaluation Plan Begin Role Development & Implementation Develop APN Role Policies & Protocols Provide Education, Resources & Supports (Bryant-Lukosius & DiCenso, 2004)

31. Recommendations • 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