Centre for Palliative Care Research and Education, Royal Brisbane and Women’s Hospital and Queensland University of Technology
Over the past few decades, cancer nursing services have developed in response to major scientific and technological advances in the treatment and support for people with cancer. Cancer nursing services today are widely regarded as an essential component of a safe, quality cancer care system, with nurses making a vital contribution to the prevention and reduction of physical and psychological morbidity associated with a cancer diagnosis and the process of cancer treatment.
Like most health professions, the way in which nursing services contribute to improving the cancer experience and optimising the outcomes of cancer care is undergoing significant change. This change is being driven by many factors. In particular, the imperative to reform cancer services to create a system that is more person-centred is requiring that all health professions, including nurses, re-consider their practices and systems of care, as well as the nature of the relationships between the various cancer care professionals and with their patients, family members and community members. With its strong foundation in traditions of holistic person-centred care, its pivotal location in the system and the sheer size of its workforce, nursing services are set to play a critical role in the more responsive cancer care models of the future. There are, however, a number of challenges to realising the potential that exists for improving the experiences of people diagnosed with cancer.
The series of papers in this edition of Cancer Forum has been compiled with three objectives in mind: to provide examples of how a skilled nursing workforce can contribute to achieving a safe, high quality cancer care system that is centred around the needs of the person; to discuss some of the challenges and risks associated with realising the potential for nursing services in achieving such goals; and to consider possible solutions for addressing these challenges.
A growing body of evidence suggests that gaps exist in physical, psychological, social and practical support provided for people with cancer1. This is despite the publication of evidence-based guidelines that provide clear guidance on practices such as providing information, discussing prognosis, facilitating choices, preparing patients for threatening procedures and for transitions in care, done with other forms of practical, emotional and social support2. All health professionals have a role in supportive cancer care as such core concerns experienced by the person with cancer are complex and require responses drawn from a range of disciplines. The medical profession, for example, is uniquely placed to provide information about disease and treatment options in ways that reduce uncertainty and promote patient and family well-being. Allied health professionals are uniquely placed to respond to the many functional, practical, psychological and social needs that fall within their scope of practice.
Similarly, nurses’ contribution to the supportive care dimensions of the cancer care service has features that can be both unique and complementary to that of other health professionals. In collaboration with other health professionals, nursing services are concerned with understanding and responding to diverse patient and family experiences of cancer, for example, distress, fear, fatigue, nausea, mucositis or neutropaenia. What is especially unique about the nursing contribution to patient support, however, is that nursing care draws from a broad knowledge base from clinical, social and psychological sciences. Moreover, compared to other health professionals, the nurse often has longer and more frequent interactions with the patient during their experience of the cancer care system, at least during much of the treatment phase.
In this edition of Cancer Forum, Piggott and colleagues emphasise how these more unique features of nursing practice enable nurses to be a focal point for assessment of support needs and a linkage with other parts of the health system. Similarly, Kristjanson’s paper highlights the scope of family caregiver needs and several important supportive interventions for addressing these needs. This pivotal role that nurses play in supportive care has been highlighted in the recent report of the National Breast Cancer Centre’s Multidisciplinary Care Demonstration Project, where the presence of a breast care nurse in a multidisciplinary team was seen to be beneficial to both women and clinicians3. The scope of nursing practice and their location in the system means that nurses are integral to identifying an individual’s supportive care needs and engaging an appropriate team response to address these needs.
Furthermore, the Optimising Cancer Care1 report emphasised that there are many places for patients to get lost in our current health system. A core feature of service models of the future will therefore be a greater emphasis on coordination of care to overcome such gaps. As such, this edition of Cancer Forum includes a timely review paper highlighting some of the issues associated with designing and implementing Cancer Care Coordinators roles. A key message to be taken from this review is that achieving continuity of care from the patient’s perspective will most likely require multifaceted system responses.
Gardner’s paper also highlights the potential contribution that may be afforded by development of advanced practice models of nursing. Using the nurse practitioner model as her example, Gardner argues that nurses working with a scope of practice that incorporates extended practice activities that can include both medical and nursing activities can be very effective when the nurse practitioner’s service fills a gap in access, efficiency or quality of service for the patient population in a specific field of health care. Such advanced practice roles, clearly situated within a team approach to health service delivery, present some important opportunities for cancer care. Recent UK studies4 of nurse-led clinics in cancer care demonstrate that such models achieve good patient outcomes.
While the papers in this edition of Cancer Forum highlight some important ways in which cancer nursing is responding to the pressure for system reform, Barrett’s paper reminds us of some of the challenges that exist in achieving significant gains. Barrett’s article presents quite sobering data that illustrate the workforce challenges nursing faces. Indeed, these workforce challenges are not unique to nursing. The National Health Workforce Strategic Framework5 published recently by the Australian Health Minister’s Council notes that in Australia today, the health workforce grows at an annual rate of around 170,000 per year. However, in the year 2020, this number is predicted to be just 12,500 per year. The health system overall is facing increasing and unprecedented pressure as a result of such workforce challenges. Barrett’s article is a timely reminder of the scope of the problem for cancer nursing in Australia and more importantly highlights the many factors contributing to the problem so that potential solutions can be identified.
The National Health Workforce Strategic Framework5 provides a vision for the health workforce over the next decade, and sets out a blueprint for action to achieve a sustainable health workforce. Two major government reports published in the last two years The Patient Profession6 and National Review of Nursing Education in Australia7clearly place the spotlight on nursing as a key component of the health system that requires attention if Australia is to maintain its high quality health service. The National Nursing and Education Taskforce has subsequently been established to implement recommendations from the National Review of Nursing Educations and a number of prohects are already underway looking at workforce planning, undergraduate and postgraduate education and nursing research and research training. At the same time, the establishment of the Cancer Nurses Society of Australia in 1998 has seen the professional organisation of cancer nurses in Australia develop rapidly, providing increased opportunities for developing and disseminating resources for cancer nursing practice, facilitating research and education in cancer nursing, promoting cancer nurses’ contribution to national cancer control activities and for professional networking. The success of these types of policy initiatives and professional support programs will be critical for continued improvements to be made to cancer care services in this country.
The Commonwealth Government national review of nursing education report concludes that Australian nurses should be proud of the contribution they have made, often with limited acknowledgement other than the community’s trust7. The report notes that many of the current problems experienced by nurses are brought about by the fragmentation of different policy and funding responsibilities. The report also concludes that considering the size of the nursing profession, it has received relatively little attention, being largely invisible in the policy debate and research priority agendas. We have a growing body of evidence about what patients need and want from our cancer system and about the models of care that might best address these needs. Such evidence continues to suggest that nurses will be integral to achieving a more patient-centred service. Realising this potential for service improvement through the contribution of nursing will, however, present some unprecedented challenges.
1. Clinical Oncological Society of Australia, The Cancer Council Australia and the National Cancer Control Initiative. Optimising cancer care in Australia. Melbourne: National Cancer Control Initiative, 2003.
3. National Breast Cancer Centre. National Multidisciplinary Care Demonstration Project. National Profile study of Multidisciplinary Care and Observational Study of Multidisciplinary Care, NSW National Breast Cancer Centre.