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An exploration of oncology specialist nurses’ roles in nurse-led chemotherapy clinics
[Thesis]. Manchester, UK: The University of Manchester; 2014.
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Abstract
The purpose of this study was to investigate nurses’ roles within nurse-led chemotherapy clinics. There has been a rapid expansion and development of nursing roles and responsibilities in oncology, but little understanding of how roles are enacted and their impact on patient experiences and outcomes. This was a two stage approach comprising a survey of UK oncology specialist nurses followed by an ethnographic study of nurses’ roles in nurse led chemotherapy clinics. Ethics approval was obtained prior to each study; research and development approval was obtained from each hospital site prior to Study 2. Study 1 used a questionnaire survey to explore the scope of nurses’ roles. A purposive sample of oncology specialist nurses perceived to be undertaking nurse-led clinics was obtained using snowball methods. Data analysis included descriptive and inferential statistics. Study 2 used ethnographic methods to explore nurses’ roles in nurse-led chemotherapy clinics, which included clinical observations, interviews with nurse participants and studying documentation (protocols0 for nurse-led chemotherapy clinics. Findings were coded and thematic analysis undertaken. In study 1, 103 completed questionnaires were received with a response rate of 64%, however analysis identified 79 (76.7%) nurses undertaking nurse-led clinics, therefore statistical analysis was limited to this sample of 79 nurses. An additional 12 (11.7%) nurses wanted to undertake nurse-led clinics, therefore findings from this group were analysed separately. There was little congruence between nurses’ titles and clinical roles, with significant differences in practice between different groups of nurses, in relation to history-taking (p=.036), assessing response to treatment (p=.033). Although there was no difference in the number of nurses undertaking clinical examinations (p=.065), there were differences in the nature of examinations undertaken, including respiratory (p= .002). There were also significant differences between groups of nurses in relation to nurse prescribing (p<.0001). Study 2 included observations (61 consultations by 13 nurses) and interviews (n=11). There was variability in patient numbers within nurse-led clinics, identifying implications for service delivery and sustainability. Disparities in nurses’ roles and responsibilities revealed four different levels of nurse-led chemotherapy clinics, from chemotherapy administration to totally nurse-led clinics. The identification of four levels of nurse-led chemotherapy is a new finding, and suggests a framework for nurse-led chemotherapy clinics that could link with nurse competencies and training. Five main themes were identified in study 2; a central theme of autonomy linked with themes of knowledge, skills, power and beliefs. A key finding was the reduced emphasis on compassionate care with greater medical (clinical) responsibilities within nurses’ roles, and poor communication skills by some nurses. Despite a great diversity in oncology specialist nurses’ roles, the lack of clarity in roles and responsibilities is creating confusion. Similarly the rapid increase in nurse-led chemotherapy clinics has been ad hoc with no formal evaluations. Although nurses in study 2 perceived they were providing holistic care there was no evidence of this in observations, and nurses appear to use a medical model care based on doctor-nurse substitution, which may have led to reduced emphasis on nursing skills and compassionate care.
Layman's Abstract
The purpose of this study was to investigate nurses’ roles within nurse-led chemotherapy clinics. There has been a rapid expansion and development of nursing roles and responsibilities in oncology, but little understanding of how roles are enacted and their impact on patient experiences and outcomes. This was a two stage approach comprising a survey of UK oncology specialist nurses followed by an ethnographic study of nurses’ roles in nurse led chemotherapy clinics. Ethics approval was obtained prior to each study; research and development approval was obtained from each hospital site prior to Study 2. Study 1 used a questionnaire survey to explore the scope of nurses’ roles. A purposive sample of oncology specialist nurses perceived to be undertaking nurse-led clinics was obtained using snowball methods. Data analysis included descriptive and inferential statistics. Study 2 used ethnographic methods to explore nurses’ roles in nurse-led chemotherapy clinics, which included clinical observations, interviews with nurse participants and studying documentation (protocols0 for nurse-led chemotherapy clinics. Findings were coded and thematic analysis undertaken. In study 1, 103 completed questionnaires were received with a response rate of 64%, however analysis identified 79 (76.7%) nurses undertaking nurse-led clinics, therefore statistical analysis was limited to this sample of 79 nurses. An additional 12 (11.7%) nurses wanted to undertake nurse-led clinics, therefore findings from this group were analysed separately. There was little congruence between nurses’ titles and clinical roles, with significant differences in practice between different groups of nurses, in relation to history-taking (p=.036), assessing response to treatment (p=.033). Although there was no difference in the number of nurses undertaking clinical examinations (p=.065), there were differences in the nature of examinations undertaken, including respiratory (p= .002). There were also significant differences between groups of nurses in relation to nurse prescribing (p<.0001). Study 2 included observations (61 consultations by 13 nurses) and interviews (n=11). There was variability in patient numbers within nurse-led clinics, identifying implications for service delivery and sustainability. Disparities in nurses’ roles and responsibilities revealed four different levels of nurse-led chemotherapy clinics, from chemotherapy administration to totally nurse-led clinics. The identification of four levels of nurse-led chemotherapy is a new finding, and suggests a framework for nurse-led chemotherapy clinics that could link with nurse competencies and training. Five main themes were identified in study 2; a central theme of autonomy linked with themes of knowledge, skills, power and beliefs. A key finding was the reduced emphasis on compassionate care with greater medical (clinical) responsibilities within nurses’ roles, and poor communication skills by some nurses. Despite a great diversity in oncology specialist nurses’ roles, the lack of clarity in roles and responsibilities is creating confusion. Similarly the rapid increase in nurse-led chemotherapy clinics has been ad hoc with no formal evaluations. Although nurses in study 2 perceived they were providing holistic care there was no evidence of this in observations, and nurses appear to use a medical model care based on doctor-nurse substitution, which may have led to reduced emphasis on nursing skills and compassionate care.