Specialist nurses have an established role in the management of breast cancer in helping patients to understand their disease and treatment options, and in offering counselling and emotional support1,2; they are not usually involved in diagnosis.
In 1987 two clinical nurse specialists were appointed to the breast care clinic at our hospital; they were given responsibility for running outpatient clinics for symptomatic patients, including new referrals. The nurses take histories, examine the women, request imaging, and perform fine needle aspirations when appropriate. Test results are given by the nurses to both the patients and their general practitioners. The specialist surgeon sees patients who have been newly diagnosed with cancer and any patients for whom the evidence is equivocal. This paper describes patient satisfaction with a nurse led clinic screening for breast diseases in London and assesses the clinical expertise of the nurses.
Subjects, methods, and results
A specifically designed patient satisfaction questionnaire was distributed to 150 consecutive new referrals seen by the nurses during six weeks in June and July 1996. Altogether 119 questionnaires (79%) were returned after a postal reminder.
Women were asked to rank their opinion of eight features of the clinic on a four point scale which ranged from very satisfied to very disappointed. Forty out of 118 (34%) women were very satisfied with the amount of time it took to obtain an appointment. Altogether 47 out of 117 (40%) women were very satisfied with the amount of time they spent waiting at the hospital, 39 out of 113 (35%) were very satisfied with the facilities in the clinic, and 75 out of 113 (66%) were very satisfied with the way the clinic was run. A total of 88 out of 117 (75%) women rated themselves as very satisfied with the speed of diagnosis or reassurance, 67 out of 115 (58%) were very satisfied with the amount of time taken for consultation, and 83 out of 118 (70%) were very satisfied with the standard of care provided. Twenty six of 93 women (28%) were very satisfied with car parking, public transportation, or other access to the hospital.
Only five women had expected to see a nurse. All women were satisfied or very satisfied with the clinical care they received, and 19 out of 118 (16%) added specific praise to their questionnaires. Evaluation of clinical care and hospital services overall showed that the women were significantly more satisfied with the nurses (χ2 with Yates’s correction=22.5, 1 df, P<0.0001) than with other aspects of hospital care.
A postal questionnaire was sent to each woman’s general practitioner; 102 out of 150 (68%) questionnaires were returned. Altogether 99 questionnaires were analysed. Sixty four out of 91 (70%) of general practitioners always or regularly referring patients to the clinic were aware of the nurses’ role but only 8 out of 91 (9%) had informed their patients that the clinic was run by nurses. The most common reasons for referral to the clinic were the high standard of care and convenient location; however, some referrals were the result of a request by the patient to attend our clinic. There were no complaints about patients being misdiagnosed.
To measure the nurses’ technical expertise the results of fine needle aspirations of breast lesions were audited by type of clinician who did the aspiration and classification of disease. Pathologists had the lowest percentage of inadequate samples; their samples tended to be from gross lesions detected by other team members, as indicated by the high proportion of malignancies identified (table). A lower percentage of inadequate samples were aspirated by the specialist nurses compared with other team members across the range presenting symptoms.
Comment
Both patients and purchasers of health care expect patients referred for outpatient care to be seen by specialists. Historically this has meant patients were seen by consultants. Clinical guidelines on the management of symptomatic breast disease3 require that referrals occur rapidly. According to the same guidelines, breast care clinics should treat 100 to 150 new cases of cancer annually; this is equivalent to 1000 to 1500 new referrals. A single consultant cannot see this many patients in an outpatient clinic. Our study suggests that clinical nurse specialists can provide outpatient care in the absence of a second consultant.
In this study, being seen by specialist nurses was acceptable to patients and general practitioners; the nurses’ clinical expertise compared favourably with that of other clinicians. Other studies have found that pathologists may be less likely to classify their own samples as inadequate4 but it seems that variations in the rate of inadequate samples partially reflect the skill of the clinician doing the aspiration.
In another study patients were randomly allocated to be seen either by a nurse practitioner or a junior doctor.5 Patients who saw the nurse practitioner expressed more satisfaction and had less anxiety than those who saw either male or female junior doctors. No difference was found in adherence to protocols between the nurse practitioners and the junior doctors. Further trials are required to determine whether any cost-benefit results from nurse led clinics.
Table.
Cytological results of fine needle aspirations for all breast lesions by clinician doing the aspiration and classification of sample. Values are number of aspirations done by each type of clinician (percentage; 95% confidence interval)
| Classification | Clinician doing aspiration
|
Total | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Consultant surgeon | Pathologist | Radiologist | Senior registrar* | Registrar* | Research registrar* | Clinical assistant | Clinical nurse specialist* | ||
| C1 (inadequate sample) | 38 (58; 46 to 70) | 0 | 6 (11; 3 to 19) | 16 (55; 37 to 73) | 39 (41; 31 to 51) | 32 (42; 31 to 53) | 31 (24; 16 to 31) | 114 (31; 27 to 36) | 276 |
| C2 (benign) | 15 (23) | 4 (50) | 28 (50) | 12 (41) | 42 (44) | 34 (44) | 73 (55) | 206 (57) | 414 |
| C3 (probably benign) | 2 (3) | 1 (13) | 4 (7) | 0 | 6 (6) | 1 (1) | 9 (7) | 5 (1) | 28 |
| C4 (probably malignant) | 2 (3) | 0 | 8 (14) | 1 (3) | 0 | 0 | 4 (3) | 11 (3) | 26 |
| C5 (malignant) | 9 (14) | 3 (38) | 10 (18) | 0 | 8 (8) | 10 (13) | 15 (11) | 26 (7) | 81 |
| Total number of aspirates | 66 | 8 | 56 | 29 | 95 | 77 | 132 | 362 | 825 |
| Ratio of benign: malignant samples | 0.6 | 1.3 | 2.8 | NA | 5.3 | 3.4 | 4.9 | 7.9 | 5.1 |
NA=not applicable.
Combined results of two clinicians at each grade.
Acknowledgments
We thank Dr Janet Peacock for statistical advice.
Footnotes
Funding: The Health Care Evaluation Unit is funded by the Research and Development Directorate of the NHS Executive South Thames.
Conflict of interest: None.
References
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