Advanced Nursing Practice and Nurse-led Clinics in Oncology

Carole Farrell

• Publisher: Routledge
• Year: 2015
• Print ISBN:
  9780415746496
• eBook ISBN:
  9781317753735
• Topic: Medicine
• Subtopic: Health Care Delivery

Over the past ten years there has been a dramatic increase in new nursing roles and nurse-led clinics within oncology. This unique handbook is a comprehensive companion for nurses studying and practising at an advanced level in this emerging field.

This text outlines and discusses roles, responsibilities and skills related to advanced practice in oncology nursing – including leadership, communication skills and prescribing – linking throughout to the implications for clinical practice. It then provides a step-by-step guide to setting up and developing nurse-led clinics, looking in more detail at clinics focusing on surgery, chemotherapy, radiotherapy, clinical trials and follow ups, and providing an in-depth case example of a clinic set up for adjuvant Herceptin use.

Practical, relevant and underpinned by current legislation, Advanced Nursing Practice and Nurse-led Clinics in Oncology is an invaluable resource for oncology nurses.

Chapter 1

Nursing developments and policy influences

Carole Farrell

This chapter provides a timeline for professional developments in nursing, including a brief discussion on nursing models, alongside discussions of influential government policies. Emphasis will be placed on developments in oncology nursing and cancer policies. This will provide a historical summary of developments, outlining the major factors to impact on nursing roles. Implications for service provision and the impact of government targets and quality measures will be discussed to show how this has influenced nurses’ roles and responsibilities.

However, in order to understand nurses’ roles it seems crucial to consider current operational definitions for nursing, specialist and advanced nursing practice, and nurse-led clinics. This seems particularly important given the confusion created by the plethora of nurses’ titles and clinical roles.

Defining nursing

What is a nurse? It seems such a simple question, but when you actually focus on it there are differences in meaning and imprecise definitions. In some ways, when you look at the history of nursing and how it has evolved, the lack of precision seems understandable, particularly since the main component of nursing is ‘caring’, which is rather vague and lacking in scientific rigour. This makes it difficult to quantify and measure what nurses do within their roles; as a result, determining outcomes from nursing becomes complex and often requires qualitative analysis. To ensure clarity it seems crucial to peel back the layers of nursing and discuss basic definitions and meanings within nursing.

The International Council of Nurses (ICN) states that the title of ‘nurse’ should be protected by law and applied to and used only by those legally authorised to represent themselves as nurses and to practice nursing (ICN, 2012, 2013). However, in the UK there is no legal definition of nursing, although a legislative definition for ‘registered nursing care’ is in place to distinguish between other types of care, such as social care (RCN, 2003). In contrast, most countries have a legal definition of the title ‘nurse’ and some have a legal definition of ‘nursing’, although the definitions and scope of practice vary from country to country. It seems difficult to comprehend the lack of consensus in defining nursing at its most basic level; however from this basis it seems unsurprising that we are struggling nationally to define advanced nursing practice.

However the following broad definition of nursing is provided by the ICN (2014):

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.

Nursing care usually refers to the tasks and activities of the nurse, and often reflects everything a nurse does for a patient (DalPezzo, 2009). Although there are many attributes of nursing care, there appear to be three main categories:

• The tasks or procedures
• The nature of nursing care (for example skilled, compassionate, holistic)
• The functions of nursing care (for example, listening, assessing, monitoring) (DalPezzo, 2009)

These categories reflect different aspects of nurses’ roles and are important factors to consider when exploring what nurses do within clinical practice.

Nursing models

Nursing models were developed in order to define nursing and to provide a framework to guide practice and education (Murphy et al., 2010). A nursing model is a collection of interrelated concepts or components that can be taken apart and understood, and all nursing models involve assessing patients’ needs and implementing appropriate care. However the components of nursing are complex and difficult to define; therefore several models were created, each offering a different way of thinking to guide nursing practice (Murphy et al., 2010). (See Table 1.1.) However it is crucial to include goals that can be measured or evaluated to determine future improvements. The majority of nursing models utilise care plans that can be evaluated daily to record each patient’s progress; however there are a range of different theories within nursing models, and most are no longer used within current nursing practice.

The original nursing role incorporated a biomedical model of care, which was prescribed by a physician and focused on physical aspects of care and the treatment of disease. Before the development of nursing models nurses used the medical model, which focuses on diagnosis and treatment of specific illnesses or conditions (Murphy et al., 2010). Alternatively nurses relied on their intuition and experience. However, the biomedical model does not take into account individual characteristics such as ethnicity, culture, and religion. This contrasts with a social model of health care which emphasises potential changes within society or lifestyle factors that may improve health.

Table 1.1 Nursing theorists and nursing models

Nurse theorist	Name of model	Main concepts
Florence Nightingale (1859)	Environmental theory	• Unsanitary conditions pose a health hazard. • Nursing can provide fresh air, warmth, cleanliness, good diet, quiet to facilitate reparative process. • External influences can prevent or contribute to disease or death.
Hildegard Peplau (1952)	Interpersonal relations model	• The person is a developing organism, tries to reduce anxiety caused by needs, lives in a stable equilibrium. • Based on psychodynamic nursing. • Uses an understanding of one’s own behaviour to help others identify their difficulties. • Nursing is a significant, therapeutic, interpersonal process that functions cooperatively with others to make health possible, and involves problem-solving.
Ida Orlando (1961)	Deliberative nursing process	• The deliberative nursing process is set in motion by the patient’s behaviour. • All behaviour may represent a cry for help. Patient’s behaviour can be verbal or nonverbal. • The nurse reacts to patient’s behaviour and forms basis for determining nurse’s acts. • Nurses’ actions should be deliberative, rather than automatic. • Deliberative actions explore the meaning and relevance of an action.
Dorothy Johnson (1980)	Behavioural systems model	• The person is a behavioural system comprised of subsystems constantly trying to maintain a steady state. • Constancy is maintained through biological, psychological, and sociological factors. • A steady state is maintained through adjusting and adapting to internal and external forces. • Nursing is an external regulatory force that is indicated only when there is instability.
Dorothea Orem (1991)	Self-care model	• Self-care comprises those activities performed independently by an individual to promote and maintain person well-being. • Self-care deficit occurs when the person cannot carry out self-care. • The nurse then meets the self-care needs by acting or doing for; guiding, teaching, supporting, or providing the environment to promote patient’s ability. • Wholly compensatory nursing system – patient dependent. • Partially compensatory – patient can meet some needs but needs nursing assistance. • Supportive educative – patient can meet self-care requisites, but needs assistance with decision making or knowledge.
Betty Neuman (1982)	Health care systems model	• The person is a complete system, with interrelated parts. • Maintains balance and harmony between internal and external environment by adjusting to stress and defending against tension-producing stimuli. • Nursing interventions strengthen flexible lines of defence, strengthen resistance to stressors, and maintain adaptation.
Sister Calista Roy (1980)	Adaptation model	• The person is an open adaptive system with input (stimuli), who adapts by processes or control mechanisms (throughput). • The output can be either adaptive responses or ineffective responses.
Roper, Logan, Tierney (1980)	Activities of daily living model	• The patient is assessed on their ability to perform the 12 activities of daily living. • The goals of the care plan are agreed between patient and nurse, then evaluated. • 5 dimensions: physiological, psychological, socio-cultural, politico-economical, environmental.
Maslow (1970)	Hierarchy of needs model	• A 5-stage model based on a person’s needs, placed in a hierarchy. • Stages go from basic (physiological) needs to safety needs, social needs, and esteem needs, with self-actualisation being the highest level. • Later expanded to an 8-stage model to include cognitive and aesthetic needs, with transcendence needs (helping others to achieve) at the top.
Patricia Benner (1984)	From novice to expert model	• Describes 5 levels of nursing experience and developed exemplars and paradigm cases to illustrate each level. • Levels reflect movement from reliance on past abstract principles to the use of past concrete experience as paradigms, and change in perception of situation as a complete whole in which certain parts are relevant.

The emergence of nursing models aimed to develop a broader focus based on human needs and developing therapeutic relationships with patients (McCrae, 2012). However, nursing theorists have struggled to provide precise definitions for nursing and achieve consensus regarding theoretical nursing models.

All models have four elements: the person, their environment, their health, and nursing (Fawcett, 1995); and nursing models have three key components:

• A set of beliefs and values
• A statement of the intended goal
• The knowledge and skills required (Pearson et al., 1996)

Although all models have a different emphasis, they are influenced by the following continuums:

• Optimum health Ill health
• Independence Dependence
• Adaptation Maladaptation
• Self-care Reliance on others

Nursing models/theories emphasise a more holistic approach to disease, although the term ‘holistic’ is often misused and open to interpretation (Farrell, 2014). However, models are not facts; rather they emerge and evolve, informing thinking and imply different nursing processes.

In the 1970s, the concept of the nursing process was introduced in the UK, which was a four-stage model incorporating assessment, planning, implementation, and evaluation (MacFarlane and Castledine, 1982). However, the introduction of patient pathways and standardised multidisciplinary approaches became the gold standard from the 1990s to emphasise quality in health-care provision (Currie and Harvey, 2000).

Nursing models have been criticised for their frequent use of jargon and complex concepts, which led to problems in understanding (Hodgson, 1992; Kenny, 1993). In addition, some of the models developed in the USA appeared inappropriate for health systems in the UK (Murphy et al., 2010), or appeared to have narrow perspectives that failed to capture the meaning of nursing (Hardy, 1982). Despite seeking to articulate the nature of nursing as a discipline, the models seemed idealistic and increased the gap between theory and practice (Hardy, 1982). Models also lacked research underpinning the relationship between the concepts and impact on patient care (Fraser, 1996; Dickoff and James, 1968), and the application of nursing theories (Draper, 1990).

The emergence of nursing models aimed to develop a broader focus based on human needs and developing therapeutic relationships with patients (McCrae, 2012). However, nursing theorists have struggled to provide precise definitions for nursing...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Table of contents
• List of tables and figures
• Preface
• List of contributors
• Introduction
• 1 Nursing developments and policy influences
• 2 The changing face of oncology nursing
• 3 Advanced nursing practice and clinical leadership
• 4 Autonomy: implications for oncology nursing
• 5 Non-medical prescribing
• 6 Compassionate and effective communication: key skills and principles
• 7 Developing and evaluating nurse-led clinics
• 8 The nature of nurse-led clinics in oncology
• 9 Nurse-led pathway for patients with HER2 positive breast cancer receiving Trastuzumab (Herceptin)
• Index