Renal cancer is the seventh most prevalent cancer in the UK (Cancer Research UK, 2023). It is estimated that 13 300 patients are diagnosed annually with renal cell carcinoma, which make up the majority of cases of kidney cancer (Cancer Research UK, 2023). For the cases of patients with organ-confined and locally advanced disease who meet oncological and functional criteria, current guidelines suggest curative surgical excision (European Association of Urology, 2023). Consequently, many patients undergo either a partial or radical nephrectomy.
Post-operatively patients are stratified by level of risk and, although there is no consensus on follow-up regimens, guidelines suggest surveillance for 5 years for disease recurrence and monitoring for cardiovascular and renal deterioration post-operatively (European Association of Urology, 2023).
Within the NHS, experienced specialist nurse roles have been well established within specific areas of clinical practice and the literature has a wealth of evidence supporting the use of specialist nurse-led follow-up within a range of settings, specifically in cancer (Mole et al, 2019; Moloney et al, 2019; Sharma et al, 2020; Fishburn and Fishburn, 2021). Within urology, specialist nurse-led follow-up has been well established for prostate cancer with several studies showing high levels of patient satisfaction (Shaida et al, 2007; Casey et al, 2017). In comparison, little evidence has been published to support the use of similar models of follow-up with renal cancer patients. The authors were able to find only one single-centre study of 89 patients demonstrating that nurse-led renal cancer follow-up was both a safe practice and satisfactory from the patient perspective (Sibbons et al, 2019).
In the authors' tertiary renal cancer centre at Lancashire Teaching Hospitals NHS Foundation Trust, nurse-led follow-up has been established for several years. It is run by a single specialist nurse, who reviews patients, who have had either a partial or radical nephrectomy, at appropriate intervals, according to risk stratification. The patients also have the contact details of the specialist nurse as their first point of contact for any queries outside of the clinic times during working days. The nurse-led clinic runs concurrently with the renal cancer specialist consultant clinic, which means that any clinical queries that cannot be answered by the specialist nurse can be escalated to the consultants in a timely manner.
Given the increasing population of patients who survive renal cell cancer, specialist nurse-led follow-up could be used to implement protocol-driven cancer surveillance while maintaining patient satisfaction. In turn, this could allow consultant clinic time to be used more efficiently.
Aims
The study aimed to assess patient satisfaction levels with specialist nurse-led renal cancer follow-up. It was hoped that this would help validate the use of the service in this centre and also provide data to add to the current evidence base, potentially supporting other centres to implement similar services.
Methods
The study was registered with the Research and Development Department of Lancashire Teaching Hospitals NHS Foundation Trust. A departmental database was used to identify 100 patients who had been followed up in the nurse-led renal cancer clinic between January 2020 and May 2021, who were then invited to take part in the study. Only patients who had had a partial or radical nephrectomy were deemed eligible.
A patient information leaflet was created, which was then approved by the research department. An information pack was posted to each of the 100 eligible patients informing them of a time slot for telephone interview. The pack included the leaflet and provided a dedicated telephone number that patients could call to leave a message if they wished to opt out or wanted to change the time slot. The subsequent telephone interviews were conducted by two doctors, who were not directly involved in the clinical care of the patients; they began each interview by obtaining standardised verbal consent. Interviews were conducted over a 3-week period.
The study used the validated Consultation Satisfaction Questionnaire (CSQ), which was developed in 1990 to measure patient satisfaction with consultations in primary care (Baker, 1990; Poulton, 1996). It was modified to make it relevant to measure satisfaction with the authors' service (Box 1). The CSQ evaluates four domains:
- General satisfaction with consultations
- Professional care
- Depth of relationship
- Length of consultation.
Box 1.Questions covered in the patient satisfaction surveyPlease choose strongly agree, agree, neutral, disagree, strongly disagree for the following statements:General satisfaction
- I am not completely satisfied with my appointment with the specialist nurse (SN)
- Some things about my consultation with the SN could be better
- I am totally satisfied with my visit/consultation to the nurse-led clinic
Professional care
- 4. There is good continuity of care with SN follow-up
- 5. The SN knows all about my diagnosis and treatment
- 6. I understand my illness much better after seeing the SN
- 7. There are some things relating to my health that this SN does not know about me
- 8. The SN told me everything about my treatment and follow-up plan
- 9. I will follow the SN's advice because I think they are absolutely right
Depth of relationship
- 10. I would find it difficult to tell the SN about some private things
- 11. I felt the SN really knew what I was worried about
- 12. The SN was interested in me as a person not just my illness
- 13. I thought the SN took notice of me as a person
- 14 I felt I was able to tell the SN about personal things relating to my diagnosis.
Perceived time of consultation
- 15. I wish it had been possible to spend a little longer with the SN
- 16. The time I was allowed to spend with the SN was not long enough to deal with everything I wanted
- 17. The time I was able to spend with the SN was a bit too short
Doctor versus nurse
- 18. I prefer seeing or speaking to a doctor for appointments, even if they are different every time
Telephone versus face-to-face consultation
- 19. I prefer traditional face to face appointments
- 20. I feel I can ask the SN what I want on the telephone
- 21. Telephone appointments are less personal
- 22. I think it is more convenient having telephone appointments
- 23. I prefer receiving scan results face to face regardless of the result and I feel anxious waiting for CT scan results
- 24. I am happy to monitor my own blood pressure at home
Cost of travel
- 25. I save money/time on parking when I have telephone appointments
- 26. I save money on travel when I have telephone appointments
Three more domains were added to gather further information for the specific cohort of patients. Additional feedback was elicited on the patients' views about:
- Doctor versus nurse consultations
- Telephone versus face-to-face consultations
- Cost of travel.
The questionnaire comprised 29 questions to which there were five possible responses: ‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ and ‘strongly disagree’. In addition, if they wished, the patients were invited to provide general comments/feedback regarding the service. The responses were transferred from the survey responses to an Excel spreadsheet. Qualitative data analysis was then carried out on the findings.
Results
Of the 100 patients who were invited to take part in the study, 69 accepted and took part in the questionnaire interview.
General satisfaction
In this category, 97.1% (67/69) patients responded ‘agree’/‘strongly agree’ to the statement ‘I am totally satisfied with my visit/consultation to the nurse-led clinic’, 1.4% (1/69) had a ‘neutral’ response on this, and 1.4% (1/69) ‘disagreed’ that they were completely satisfied (Figure 1). Most respondents (87.0%; 60/69) ‘disagreed’/‘strongly disagreed’ that any aspects of their consultation could have been better; 10.1% (7/69) agreed that the consultation with the specialist nurse could have been better, and 2.9% (2/69) had a ‘neutral’ response to this statement.
Professional care
Regarding statements on professional care, 94.2% (65/69) ‘agreed’/‘strongly agreed’ that they had good continuity of care with specialist nurse-led follow-up (Figure 2), 2.9% (2/69) ‘disagreed’ with this, and 2.9% responded ‘neutral’ (2/69). Regarding diagnosis and treatment, 98.6% (68/69) respondents felt that the specialist nurse was knowledgeable about their case and 75.4% (52/69) of patients responded that they understood their illness much better after seeing the specialist nurse.
A majority (98.6%, 68/69) ‘agreed’/‘strongly agreed’ that the specialist nurse had explained everything regarding their treatment and follow-up plan.
On questions regarding whether they thought that there were aspects of care that the specialist nurse did not know about, 78.3% (54/69) of respondents ‘disagreed’/‘strongly disagreed’ with this statement. Most patients (95.7%; 66/69) responded that they would follow the specialist nurse's advice.
Depth of relationship
When it comes to the depth of the relationship with the specialist nurse, 92.8% (64/69) of respondents felt that they were able to tell the specialist nurse about personal concerns (Figure 3). Furthermore, 97.1% (67/69) of respondents felt that the specialist nurse took notice of them as a person and 89.9% (62/69) of respondents felt that the specialist nurse was interested in them as a person and not just an illness. 87.0% (60/69) of respondents felt that the specialist nurse really knew what they were worried about and only 4.3% (3/69) of respondents found it difficult to tell the specialist nurse about private concerns.
Perceived time of consultation
When it came to the time of the consultation, 81.2% (56/69) of respondents felt that the time that they were able to spend with the specialist nurse was not too short; however, 14.5% (10/69) felt that they could spend a little longer with the specialist nurse. The rest of the respondents were neutral with regards to the time of the consultation (Figure 4).
Doctor versus nurse consultation
The respondents were asked about whether they prefer seeing or speaking to a doctor for appointments given that they may be contacted by a different doctor every time; 8.7% (6/69) agreed with this statement, 21.7% (15/69) were neutral towards this statement and 69.6% (48/69) ‘disagreed’/‘strongly disagreed’ with this statement (Figure 5).
Telephone versus face-to-face consultation
Regarding type of consultation, 52.2% (36/69) of patients preferred traditional face-to-face appointments rather than telephone appointments (Figure 6), 30.4% (21/69) did not have a preference (‘neutral’ response) and 17.4% (12/69) did not prefer face-to-face appointments (‘disagreed’). A total of 94.2% (65/69) of respondents felt that they could ask the specialist nurses what they wanted on the telephone.
Many 73.9% (51/69) of respondents ‘strongly agreed’/‘agreed’ that having telephone appointments was more convenient; however, 44.9% (31/69) responded that telephone appointments were less personal. Just under half (46.4%; 32/69) said they would prefer receiving scan results face-to-face regardless of the result. A majority (76.8%; 53/69) were happy to monitor their own blood pressure at home (Figure 6).
Cost of travel
On the question of travel costs, 60.9% (42/69) responded that having telephone appointment saved them money and time on both travel and parking (Figure 7).
Discussion
This study has demonstrated that patients are generally satisfied with having specialist nurse led follow-up after surgery for renal cell carcinoma. The findings corroborate other published data regarding specialist nurse follow-up for other cancer types and adds to the evidence base to support wider use of nurse follow-up. Specialist nurses provide a personalised, professional, and holistic approach to care, while upholding continuity of care. The service provided within the authors' Trust (Lancashire Teaching Hospitals NHS Foundation Trust) has the safety net of an adjacent consultant-led clinics, in cases when additional clinical advice may be necessary. The rotational training system of doctors within the UK can result in patients speaking to different clinicians over time, which does not allow for the same level of continuity of care as can be provided by specialist nurses. This was demonstrated by the fact that over two-thirds of patients who took part in the survey responded that they did not want to see different doctors at each appointment.
The findings also provide favourable data regarding patient satisfaction with telephone appointments. In the post-pandemic healthcare system, these continue to be used widely, particularly for follow-up, and patients were generally happy with this. Telephone appointments were also felt to save time and money. Most patients responded that the telephone format enabled them to ask relevant questions. With just over half of patients preferring face-to-face clinic appointments there was a relatively even split on this point. This demonstrates the value of tailoring care to individual preferences from the start of a patient's cancer care journey. This high standard of care has the potential to be implemented by specialist nurses who, as this study findings show, build meaningful relationships with patients over several years.
Limitations
One of the study's limitations is its small sample size of 69 patients. The authors could have used multiple methods to collect responses to increase the number of participants. Another limitation is that, within the authors' Trust there is one specialist nurse who sees all these patients: the responses could therefore be biased, because the survey only captures the experience of patients who interact with one nurse. Finally, the follow-up consultations over the telephone took place during the pandemic and the comments suggested that patients accepted these because they knew this was necessary. There is potential to conduct follow-up surveys to establish whether patient have changed their opinion now that there is no need for social distancing.
Conclusion
A growing number of allied health professionals are involved in the ongoing care of patients. NHS services are increasingly stretched and, where specialist nurse-led follow-up takes place within a standardised, protocol-driven framework, there are high levels of patient satisfaction. Expanding nurse-led services, as has been done in the authors' Trust, would enable care to be better streamlined, with patients who do not require specific input for doctors having consultations with a specialist nurse. This would both increase the number of clinic appointment available and free consultants, leaving with more time to see those patients who require their expertise.
The findings of this study show that more than 97% of patients were completely satisfied with their consultations with the nurse. The implementation of renal cancer nurse-led follow-up across more Trusts nationally could therefore help ease clinic appointment waiting times while ensuring patients have a high standard of care.
Moreover, the findings demonstrate that there not only is there objectively positive patient satisfaction with nurse-led follow-up, but also that patients find that the nurses have the knowledge and advice they need and are able to trust their advice. This demonstrates that this is a robust form of follow-up for patients that can be expanded to other specialties for cancer follow-up.
KEY POINTS
- Specialist nurse-led follow-up for renal cancer patients following surgery has high patient satisfaction in the authors' centre
- Patients reported excellent continuity of care, trust and comfort with specialist nurse-led follow-up
- Nurse-led follow-up for renal cell cancer is a safe and well-received service that could be implemented in other centres
CPD reflective questions
- In my clinical experience, does it improve patient care when the same clinician is following up the patient?
- How much training time would I need to be confident to facilitate this service and raise concerns to the consultant as and when needed?
- How do I find managing clinic follow-up over the telephone? Is it more difficult to deliver more bad news?
- Do I think this is a service that can set up in my practice for patients who are post-renal cancer surgery?