Since the birth of the NHS in 1948 the health needs of the UK population have continued to become increasingly complex, partly due to an ageing population (Barnett et al, 2012), higher healthcare costs and, more recently, increased pressures due to the COVID-19 pandemic (Hooks and Walker, 2020). Consequently, and in response to population needs, over the past few decades the NHS has seen the introduction of new roles, such as that of advanced nurse practitioners (ANPs), to improve standards of care and optimise service delivery (NHS England/NHS Improvement, 2019).
Advanced practice is recognised by the Royal College of Nursing (RCN) as a distinctive level of practice encompassing direct care provision, education, research and leadership – seen as the four pillars of advanced practice (RCN, 2018a). Practising at advanced clinical level involves autonomy and decision-making against a background of complexity, uncertainty and unpredictable risk, while taking accountability for actions undertaken (Health Education England, 2017; International Council of Nurses, 2020).
In 2011, due to increased demand for cancer care and in response to growing pressure on the workforce in the authors' tertiary cancer centre, ANPs were progressively introduced to support patients with various diagnoses. Since then, the ANP workforce at The Royal Marsden Hospital NHS Foundation Trust has grown and expanded into various specialties, working across professional and organisational boundaries to challenge and improve cancer services. This article explores how these specialist ANP roles are positioned within the Trust and describes their impact, scope of practice, the challenges experienced, and future directions of care. The ANP roles discussed in this article are found across the following specialties:
- Children and young people
- Colorectal surgery
- Vascular access
- Acute oncology service
- Haematology
- Gynaecology medical oncology
- Head and neck
- Systemic anticancer therapy
- Urology
- Breast
- Mental health
- Upper gastrointestinal and hepatobiliary surgery.
Children and young people
There are five paediatric ANPs working with children and young people (CYP) and two adult ANPs working with teenage and young adults (TYA) at the Trust. The remit of roles includes:
- Running end-of-treatment clinics for oncology paediatric patients, with focus on recovery and rehabilitation post treatment
- Running the paediatric transplant service on both a day-care and inpatient basis, which includes planning and running follow-up services
The clinical component of the paediatric roles has been embedded in a day-care unit and expanded to involve specialist ANPs for oncology and haemato-oncology. The team has largely led on service improvements through the development of treatment review clinics within the day-care setting, providing continuity of care and helping to reduce waiting times, while streamlining workflow.
The TYA ANPs provide continuity of care for the inpatient service, supporting its holistic care component, which is crucial due to the challenging nature of TYA care. The care of this patient group requires the involvement of specialists across both adult and paediatric teams, as well as medical, surgical and tumour-specific specialties. Having a ward-based ANP who can liaise with multiple teams ensures the provision of best-practice care, while supporting staff, and has brought significant benefits. More recently, an additional TYA ANP role was created to offer support specifically to day-care patients.
Over the past few years we have introduced a number of innovation to the CYP/TYA service in order to optimise service delivery, while retaining the focus on providing comprehensive holistic care, and improving patient experience and standards of care. This has included:
- Setting up a multidisciplinary team (MDT) clinic, run by the TYA ANPs, designed to review all newly diagnosed patients, evaluate their holistic needs and, more broadly, improving access to services by developing clearer pathways for referral and access to, for example, fertility preservation
- Establishing a parent involvement group, to improve the experiences of children, young people and their families under the care of the service.
Colorectal surgery
The colorectal surgery (CRS) ANP role involves supporting patients with complex and advanced colorectal cancers. Most of the patients are postoperative or being worked up to procedures such as total pelvic exenteration, which is associated with substantial morbidity risk.
The CRS ANP's daily tasks include:
- Leading ward rounds, clerking and discharge, assessing patients, making clinical decisions and drawing up management plans. The ANP operates autonomously, applying advanced clinical assessment and diagnostic skills; the role also involves obtaining consent for surgery, supporting patients to make informed decisions about treatment
- Reviewing outpatients in a day-care ward when clinical concerns such as bowel obstruction arise, to ensure that specialist comprehensive and streamlined care is provided
- Working alongside the clinical education team to train staff, and provide clinical expertise and support.
The CRS ANP has a crucial role in the careful planning and case selection at the pre-operative stage, ensuring a well-thought-out and coordinated team approach involving the input from different surgical specialities, anaesthetists, physiotherapists, dieticians, amongst others; so that short and long-term morbidities are minimised.
In 2020, to continue to meet patient needs during the pandemic, the service was expanded, with the CRS ANP playing a key role in setting up and running a COVID-19 cancer hub spanning a number of organisations that manage patients with colorectal cancer awaiting surgery. Of hundreds of the colorectal cancer patients referred to the hub from these multiple organisations, more than 200 were then able to undergo surgery at two COVID-free hospital sites.
It is envisaged that future developments will see the role focusing on formulating innovative best-practice guidelines centred on this patient group, which will feed into improving standards nationally. In particular, the aim is to focus on patients requiring exenterative procedures, and improving the patient pathway and postoperative outcomes.
Research findings will also be used to enhance practice and identify areas of improvement, facilitating implementation of a series of key ‘survivorship interventions’, which aim to improve outcomes for people living with and beyond cancer.
Vascular access
The insertion and post-care maintenance of vascular access devices are complex and ongoing procedures, requiring specialist knowledge and skills. Vascular access (VA) is a relatively young clinical specialty within health care and the Trust currently has two VA clinical nurse specialists (CNSs), two VA associate practitioners and one combined role of VA ANP and lead nurse. The remit of these specialist roles includes:
- Patient assessment and device insertion, including care and maintenance
- Reviewing and developing VA and intravenous (IV) therapy policies, standard operating procedures and patient group directives, as necessary
- Assisting consultant anaesthetists with the insertion of skin-tunnelled catheters and implanted chest ports.
The VA ANP/lead nurse provides clinical expertise and leads on the development of a comprehensive nurse-led service, managing the VA nursing team and delivery of new initiatives. In addition to being a clinical teacher and facilitator involved in workshops, study days and/or practice supervision to enable colleagues to develop their skills, the VA ANP works alongside clinical teams such as infection control and prevention. The role involves following up patients and troubleshooting VAD problems or issues, such as patency or dislodgement, as well as providing specialist clinical advice and guidance to clinical teams, with a unique focus on education and clinical governance, to ensure the delivery of high-quality care and improve service provision.
Between April 2021 and March 2022 the team had the capacity to:
- Undertake 973 peripherally inserted central catheter (PICC) insertions across two hospital sites
- Action 2269 referrals, an average of 10 per day
- Insert 100 implanted arm ports in the nurse-led clinic.
In future, the challenge is to continue to develop and demonstrate how VA specialist teams can improve clinical outcomes, enhance patient safety and educate stakeholders.
Acute oncology service
Nationwide, acute oncology services (AOSs) employ different models of care, which are dependent on the type of organisation. However, at their core, they all aim to provide prompt specialist assessment and management of patients presenting with an acute cancer-related complication and/or toxicities from systemic anti-cancer therapy (SACT).
The role of the five specialist ANPs at the Marsden, who work across two sites, includes:
- Focusing on non-elective patients and ambulatory care, to avoid unnecessary admissions and reduce length of hospital stay
- Taking referrals from the Macmillan hotline or directly from primary care teams
- Seeing patients in an assessment unit, which operates between 8am and 8pm
The AOS ANPs' scope of practice also covers advanced life support, knowledge of SACT, diagnostics, non-medical prescribing and paracentesis for malignant ascites.
The ANPs' responsibilities also include undertaking comprehensive health assessments, and using advanced assessment and clinical decision-making skills, to inform treatment plans and make referrals, where required. In addition, the AOS ANPs are key stakeholders in service development and improvement of local pathways and protocols, which are regularly audited, that specifically relate to neutropenic sepsis and metastatic spinal cord compression.
The AOS ANPs were also involved in developing and implementing an internal COVID-19 cancer hub for oncology patients across the Marsden sites suspected of having, or known to have, COVID. Throughout the peak of the pandemic, patients on active anti-cancer treatment were assessed in the hub, enabling the most vulnerable to be kept away from emergency departments, averting unnecessary interruptions to their anti-cancer treatment.
Further plans include expanding the AOS to a 7-day service, to cover weekends, and ensuring the delivery of consistent, continuous high-quality care. In response to rapid advances in oncology, such as immunotherapy, the service continues to evolve – this is what makes this subspeciality unpredictable, but also very interesting and rewarding.
Haematology
The role of haematology ANP was initially introduced to provide continuity of care in the inpatient setting. However, following the introduction of autologous and allogeneic transplants and chimeric antigen receptor (CAR)-T-cell therapy, the service has expanded. There are now eight ANPs for adult patients, who work across two sites.
Tasks regularly undertaken by the ANPs include ward rounds, clinical decision-making, clerking and discharge of inpatients, and clinical review of patients in the outpatient clinic (eg patients on active surveillance) or in the medical day unit (MDU). The ANP's skill set includes advanced assessment skills, prescribing, ordering and interpreting investigations, bone marrow biopsies, PICC insertion and removal of tunnelled lines.
Treatments for haematological cancers can result in many complications, and the establishment of haematology ANPs has been fundamental in identifying issues for individual patients, as well as providing continuity of care, with many patients receiving treatment over many years.
Recent initiatives implemented by the haematology team include the introduction of:
- Weekend cover, which has reduced waiting times for patients needing review and assessment and improved the patient experience
- A nurse-led ambulatory care unit, to assess unwell patients and treat chemotherapy and transplant complications.
The expansion of the haematology ANP team will hopefully lead to opportunities to further develop nurse-led services, particularly in outpatient clinics, to better manage patients on long-term follow-up.
Gynaecology medical oncology
The role of the gynaecology medical oncology ANP has expanded significantly since its introduction in the inpatient setting 8 years ago. Most clinical time is now spent within specialist oncology treatment clinics, which see both patients requiring assessment prior to receiving SACTs and those attending for follow-up care. The remit of these two specialist ANPs includes:
- Ensuring that the patient journey is streamlined, to enable smooth transition between teams. The treatment pathway frequently includes both surgery and SACT
- Managing dose adjustments and treatment breaks, where needed, and managing the side effects caused by treatment and/or disease using pharmacological and/or non-pharmacological approaches
- Guaranteeing that all tests are undertaken, for example genetic testing (both germline and tumour testing), imaging, and supportive measures such as ascitic drainage.
Cancer treatments are constantly evolving and, within ovarian cancer, there are now more maintenance therapies that have a positive impact on patient outcomes. The immediate future for the ANP role is to navigate the complex genetic testing required to guide our clinical decision-making and accessing therapies appropriately.
Other deployments have included the implementation of a joint-led nurse and pharmacist clinic for patients with ovarian, fallopian tube or peritoneal cancer on maintenance bevacizumab or PARP inhibitor, which has reduced waiting times and streamlined the patient pathway.
Our hope is to lead advanced nursing care in the field nationally and internationally, disseminating our experience and research to help the wider ovarian cancer community understand all that is available and proven to benefit outcomes.
Head and neck
The head and neck (H&N) and thyroid surgery ANP provides robust clinical leadership for ward nursing teams and is accessible to the wider MDT.
The daily tasks of the ANP include taking comprehensive patient histories, carrying out physical examinations, using knowledge and clinical judgment to identify potential diagnoses, referring patients for investigations, and actioning treatment plans. A vital part of the role is to provide teaching and training sessions on the management of altered airways. The way staff are trained has been streamlined: training is now done via a national online training platform, the National Tracheostomy Safety Project.
The H&N ANP has been commended through the ‘Getting It Right First Time’ initiative (https://www.gettingitrightfirsttime.co.uk) for the excellent management of theatre capacity via both elective and non-elective pathways, and focusing on meeting cancer targets – the Trust has much lower average waiting times for H&N cancers than the average for England.
In addition, the ANP was instrumental in the operation of an H&N surgical hub during COVID-19 and in co-ordinating theatre lists for five NHS trusts. Measured successes include no scheduled surgeries being cancelled, no COVID-19-related deaths or positive cases, and the service being able to clear its own elective waiting list for non-cancer procedures.
The ANP was also involved in creating patient information material and electronic consent forms, which has helped prevent delays to surgeries.
Following a National Confidential Enquiry into Patient Outcome and Death (Wilkinson et al, 2015), which stressed the need to improve the care of tracheostomy patients nationwide, the ANP developed a ‘tracheostomy passport’. This is now used for tracheostomy patients, along with associated nursing documentation, not only at the Marsden, but has also been adopted by other NHS trusts.
An altered airway MDT ward round has also been introduced as a patient safety initiative to ensure compliance with national intensive care standards and the recommendations from the UK National Tracheostomy Safety Project (McGrath et al, 2018). An audit that measured the outcomes was subsequently undertaken and published. As a result, the H&N MDT was privileged and honoured to win the 2019 Laing Buisson Nursing Award for this work.
Systemic anticancer therapy
Three SACT ANPs are based at a private patient MDU, delivering clinical support and providing continuous care and expert knowledge to patients undergoing SACT. Patients can be of any oncological specialty, with solid tumours being the most common. These can be gastrointestinal (upper and lower), breast, gynaecology and neuro-oncology, the least common being lung and urology.
The routine duties of the SACT ANPs include:
- Obtaining informed consent prior to the start of therapy,
- Prescribing SACT regimens and supportive medicines, including blood components
- Reviewing patients
- Assessing toxicities
- Requesting investigations, including restaging imaging
- Managing oncological emergencies.
Our aim for the future is to develop a nurse-led service with comprehensive holistic patient care embedded within our practice. With this in mind, we are building bridges with other departments so we can have the required medical support, if we were to face a clinical issue that we would lack the appropriate skills and knowledge to deal with (eg acute illness, non-cancer treatment related). Having the support of a medical professional with a broader scope of practice present in these specific situations could potentially translate into better patient care and outcomes.
Urology
There are five specialist urology ANPs working across three sites. Over time, the role has evolved, with the nurses developing additional skills, depending on the scope of their specific role within the team. Since the introduction of the urology ANP role 10 years ago, a role that is primarily focused on bladder and prostate cancers, its remit has expanded across the treatment pathways and cancer types, with the five ANPs now working in diagnostics, surgery, SACT and the consequences of cancer treatment.
The roles encompass the following:
- Postoperative care, the co-ordination of ward rounds, patient admission and discharge, as well as supporting and managing urgent care through the on-site assessment unit
- Essential skills, which include advanced physical assessment and independent prescribing.
The ANP team is continuously identifying gaps in care in existing pathways and actioning development measures, including teaching. For example, in patients who have had complex urinary diversions, improvements in patient education and streamlined discharge was established, with a focus on empowering patients through education about self-management and the provision of better quality discharge information.
The team also successfully introduced an enhanced recovery programme for radical cystectomy and retroperitoneal lymph node dissection, two procedures that necessitated longer inpatient stays. The team has also developed:
- Long-term follow-up clinics for patients having cystectomy, alongside nurse-led flexible cystoscopy clinics for those having bladder preservation or non-muscle-invasive disease
- A diagnostic service and ANP-led transperineal biopsy for prostate cancer.
The ANP model has shown to be valuable and a safe and effective approach to care, which is constantly evolving. Currently, a greater emphasis is being placed on long-term follow-up, and adapting and responding to patient needs.
Breast
The team consists of seven breast ANPs. The role is predominantly focused on diagnostics and based at the breast one-stop clinics; routine tasks undertaken include clinical examination, such as breast assessment, review of imaging and execution of biopsies where required. The ANP role ensures that patients can be reassured or given a provisional diagnosis on the day of attending the clinic, with the necessary follow-up care arranged.
Although many ANPs train under the supervision of a designated breast consultant, they can additional achieve competencies through designated training, which is usually delivered though breast screening centres. There is an expectation that ANPs will retain a large knowledge base of benign breast conditions and breast cancer, to enable them to diagnose and educate patients.
In 2020/2021, the team implemented a triage system to streamline GP referrals, and developed a breast health clinic for those referred with a low risk of cancer. Over this period, the ANP team received and actioned 8000 referrals.
They also developed an open access follow-up programme – a service specifically designed to support patients on completion of their breast cancer treatment – that offers clinical support and comprehensive educational sessions to support patients living beyond cancer. A recent patient satisfaction survey found that 99% of respondents agreed that the sessions had been beneficial.
To ensure the constant provision of effective, high-quality care, several innovations are planned. These include enhancing the open access follow-up service with a new web page for patients that will be user friendly and interactive, and include functions such as a chat bot, along with video information, news, and FAQs.
Mental health
Studies have indicated that patients with both severe mental illness and cancer have a considerably lower survival after a cancer diagnosis (Chang et al, 2014). Therefore, meeting the mental health needs of people being treated for cancer can have an impact on both mortality and post-treatment recovery (Chang et al, 2014).
At the Marsden, the ANP liaison psychiatry team consists of two nurses, with one based at each site. The duties of the team include providing a liaison psychiatry service and delivering a range of psychotherapeutic interventions, such as nursing care plans, personal support plans, prescribing and advocacy.
The team has a caseload of around 30 outpatients or day cases with mental health diagnoses, in addition to inpatients and pre-surgical assessments. These are spread across specialties such as haematology, breast and neuro-oncology, with patients being at different stages of their cancer treatment, ranging from the newly diagnosed to those undergoing treatment and individuals in the early phases of post-treatment recovery.
The nature of patients' mental health problems vary and include, among others, schizophrenia, psychosis, dissociative disorder, depression, anxiety disorder, dementia and post-partum depression. From a psychiatry perspective every case is complex, with interactions between conditions, such as leukaemia and dissociative disorder, between treatments such as tamoxifen and sertraline, and between treatment and other life stresses such as having to find alternative housing.
The team has recently been involved in developing and delivering a healthcare support workers' course on therapeutic specialling (one-to-one nursing), facilitating appropriate and valid training.
Upcoming service developments include a ‘prehabilitation’ clinic for patients with mental health problems scheduled for cancer surgery to allow them to be involved in developing their care plans in advance.
Upper gastrointestinal and hepatobiliary surgery
The upper gastrointestinal (UGI) ANP role, with a remit that covers oesophagogastric and hepatobiliary surgery, encompasses all aspects of the patient pathway, from pre-operative assessment and postoperative care to discharge management and outpatient follow-up. The ANP's daily tasks include:
- The execution of care plans and decisions discussed on ward rounds
- Undertaking advanced physical assessments, including history-taking and clinical examination
- Carrying out clinical procedures
- Prescribing medications
- Arranging investigations, such as imaging, interventional radiology and endoscopy
- Reviewing outpatients in day-care areas, either as a planned review following discharge (eg patients who had complicated postoperative recoveries and/or who have long-term treatment effects) or as an emergency, acting autonomously in clinical decision-making, regarding the management plan in place
- Developing surgical pathways and protocols, ensuring seamless patient care and that the MDT is supported in their actions.
Over the past 5 years the service has become more streamlined in terms of pre-operative assessment, with the implementation of regular summit meetings to discuss the suitability of surgical candidates. This has proven to be exceptionally valuable because the cohort of patients in UGI is often complex in terms of co-morbidities, due to the nature of the disease, and in relation to treatment modalities associated mortality and morbidity.
During the COVID-19 pandemic, the ANP, aided by her skills and knowledge related to cardiothoracic surgery, was instrumental in setting up a new service for the specialty of cardiothoracic surgery based at a different trust, because it was not possible for surgery to take place at the original site. The initiative encompassed the movement of an entire surgical department to a new hospital, ordering specific equipment and taking overall responsibility for its daily operational management, including patient care, clinical support and education of the MDT in the care requirements of this new patient cohort.
UGI surgery is constantly advancing, and the task now is to continue to improve the standards of patient care, not just at a local level, but on a national scale, and even globally, by contributing to the establishment and maintenance of relationships with other trusts and working collaboratively to shape the care delivered, and achieve high standards of clinical practice through support and education.
The challenges
One of the challenges experienced by the ANP group relates to the points at which their role was initially introduced within the specialist cancer team. There was limited insight, from the MDT, of the skills and knowledge that the ANP would bring and the likely benefit to the service and patient care; this was possibly related to the fact that these were new roles and blurred the line between the ANP and medical role. Thompson and McNamara (2022) stated that confusion and vagueness are often present in discussions about the role of the ANP. It is therefore important to establish clear definitions, and define role boundaries, to ensure that the full potential of the ANP is recognised, to avoid ANPs being underused and unable to fulfil their roles. This is extremely important, particularly in cancer care, because it will not only add identity to the ANP cancer workforce, but also help patients and relatives, who have the most to gain, to understand the ANP role.
A further challenge relates to being able to practise across the RCN's four pillars of advanced practice, principally the pillar of research. This is associated with ANPs having to prioritise clinical duties, due to the demanding nature of their roles and being unable to allocate the time to contribute to the research and innovation that could help improve standards of care. Fothergill et al (2022) found that research was a neglected advanced practice pillar and stated that greater diligence is needed to support and encourage ANPs to participate in research, sharing best practice and contributing to their professional development.
Implications for practice
The gradual introduction of ANPs nationwide over the past few decades, in response to increasing pressures on the NHS, has contributed to better meeting the ever-changing needs of patients. The application of advanced practice and clinical skills such as independent assessment, diagnosis and decision-making, and ensuring the delivery of holistic care has helped improve patient care, including the patient pathway and treatment outcomes (RCN, 2018b). A study undertaken across 579 hospitals in the USA confirmed the value of ANPs, observing higher patient satisfaction, lower surgical mortality and lower costs of care in hospitals that had more inpatient nurse practitioners (Aiken et al, 2021). This indicates that advanced nursing practice has a positive effect on patient care.
Although some of the advanced practice roles described in this article may be specialist in nature, most practitioners undertake comprehensive and detailed physical assessments of patients with complex cancer needs, while working independently or as part of an MDT, while practising values-based leadership. However, although recognised by the RCN as a distinctive level of practice (RCN, 2018c), advanced nursing practice varies considerably in roles and specialities within and between trusts.
Conclusion
The ANP role in cancer care is an important and necessary addition to the NHS, not solely from a financial perspective but also for the unique value it adds to the patient experience and patient outcomes. The NHS gains from having ANPs in place, in that the nursing contribution to care is optimised and other professionals in the MDT are encouraged to use their skills appropriately.
KEY POINTS
- The introduction of an ANP workforce in a tertiary centre has facilitated a transformative approach to leadership and practice, with ANPs vital to the changes, while remaining strongly aligned with their nursing specialties
- The ANPs provide support and leadership to the multidisciplinary team and junior staff, and provide training and education, often to a nationwide audience. They are also involved in projects to drive up standards, through the implementation of evidence-based practice, improving patient care and optimal clinical outcomes
- It is vital that cancer care ANPs are encouraged and supported to have their own identity, so that a shared understanding of the role – and how it can benefit the patient and other health professionals – can be attained
CPD reflective questions
- What are the essential or core clinical skills that cancer care ANPs should obtain?
- Should there be a standard competency framework for ANPs that is applicable across cancer specialities?
- What measures would ensure that ANPs engage in, and receive support for, their proposed research projects, to help expedite the implementation of new evidence-based knowledge in clinical practice?