Together we are better: Establishing a community oncology nursing programme to improve cancer care through shared working

1. Background and introduction

One in three people in Ireland will develop cancer during their lifetime, and over 29,000 new cases of cancer are diagnosed each year [1]. Due to an aging population and improved screening/detection of cancer, the incidence is expected to rise exponentially to over 40,000 per year by 2020 [1] with an estimated 100% increase in cancer incidence over the next 20 years [2].

Many, if not all, of these people will require nursing care during their cancer experience. Currently, 42% of the men and 50% of the women diagnosed with cancer survive for 5 years and longer [1,2] and require ongoing follow-up, support and/or treatment(s). The increasing number of individuals with cancer receiving potentially life-threatening treatments which have significant side-effects causes a considerable challenge for acute hospital services.

2. Community care

Most individuals receiving treatment for cancer attend a treating cancer unit for therapies and are then discharged home; thus most side-effects are experienced within the community setting. This model of cancer care has the aim of retaining the patient in their own environment, yet oncology health professionals are cognisant of the requirement to provide continuous, safe and efficient cancer care.

3. Development of a training programme

The National Cancer Strategy (2006) for Ireland recognised the need for improved integration between specialist and primary health-care services. Since 2007, specialist oncology personnel in a district general hospital in a rural county in Ireland (County Donegal) have collaborated with community nursing colleagues to provide specific procedures in the community to patients undergoing systemic therapy.

Following discussions between the national department for cancer care in Ireland (National Cancer Control Programme), the local oncology hospital and community nursing staff, it was agreed that this initiative could be formalised and developed to provide a more holistic shared care approach. This programme could then be accredited by educational authorities to make it available nationally.

4. Delivery of the community training programme

In 2010, the National Cancer Control Programme developed the Community Oncology Nursing Programme. Its aim was to build capacity, confidence and competence in community professionals to provide integrated seamless care throughout the patient journey. The course was delivered over a 6-month period and involved local staff delivering appropriate education on cancer care relevant to community nurses. The training was theoretical and skill-based and was approved by the Irish Nursing Board (An Bord Altranais).

National and local governance structures and processes were established through a local implementation group. Ethical approval was sought and obtained through the local hospital ethics committee. Project design, implementation, data collection, analysis and evaluation involved collaboration with relevant nursing, medical and management representatives from community, hospital and nurse education.

A key safety feature built into the programme included assessment of community nurses’ knowledge, skills and competence upon completion of training. A designated referral form and a Community Oncology Nursing Resource Book [3] were developed to support the Community nurses’ extended roles.

A full evaluation of this educational initiative was performed by the National Cancer Control Programme and is currently in press [4]. The evaluation involved patient interviews, focus groups with community and hospital staff and analysis of longitudinal data obtained from patient interventions in both hospital and community.

5. Evaluation of patient outcomes

This programme reduced the patient’s burden of travel and the additional pressures on their family of having to make repeated journeys to the hospital. For the majority of patients in the study, the return hospital trip was 1½–2 h. Patients appreciated not having to travel for all of their care, particularly at times when they were weak and unwell. Patients valued having aspects of their care delivered at home, and they reported that it improved their quality of life. Most importantly the patients expressed confidence in the community nursing service and no adverse patient events occurred throughout the evaluation period.

6. Evaluation of nursing outcomes

A benefit for nursing included an increased scope of practice for the community nurses involved, but the additional workload, particularly within an already stretched service, was identified as a challenge. By its nature, the timelines and immediacy of some cancer interventions resulted in rescheduling of other non-cancer patient visits and clinics. There was a dramatic decrease in hospital attendances for defined clinical procedures that were then performed in the community. Consequently hospital capacity was improved and no adverse patient events occurred.

7. Future plans

The collaborative approach offered by local hospital oncology specialists, community nurses and educational leaders helped to develop the required skills and attitudes to provide innovative and safe patient care. University accreditation is currently being sought for this educational programme, and once this is obtained it will then be expanded nationally. In addition, the service is a good example of patient-centred integrated care and could be further developed as a model for other chronic diseases.

To ensure continued safety, auditable systems and formalised policies/standard operational procedures are vital for shared care between the hospital and the community. It is hoped that these will be developed in the future.

The evaluation highlighted that for community nurses there is great variability in the interventions performed since they have been trained. Consequently ongoing training continues to be made available locally (up to four times a year) in a theoretical and skills-based workshop format to ensure maintenance of competence.

8. Conclusion

This programme has been successful in terms of quality of life for patients. By taking an integrated approach to patient care and delivering appropriate care in the community, the potential exists to meet the growing demands of oncology care. The community nursing service has adapted and expanded to embrace this new initiative, has increased its scope of practice and has increased its partnership with hospital staff in the care of individuals with a cancer diagnosis.

This programme demonstrates that safe, seamless and efficient nursing care can be delivered so long as there is prior and extensive planning, detailed collaboration and efficient leadership. Shifting oncology care to the community can have a positive impact on the patient’s quality of life and can improve hospital capacity through shared working.

In line with the national cancer nursing strategy [5], this programme will be offered again and extended nationally once third-level educational accreditation is obtained. It will require ongoing evaluation and local planning and development with clinical leaders who are cognisant of appropriate utilisation of resources. The potential for improvement for cancer care in Ireland through shared working between hospital and community staff will continue to be promoted and maximised in the future.

9. Conflict of interest statement

The author is an employee of the Health Service Executive (Ireland).