It has been recognized that there is a steady growth in oncology patients receiving palliative chemotherapy and radiotherapy, nationally and internationally, with no increase in nursing resources.
In developing formal collaboration and partnerships with other healthcare providers, my aim is to improve supportive care towards oncology clients with advanced disease across the acute, sub-acute, and community settings.
In developing my ONP role, I met with stakeholders to identify service delivery gaps. A major issue in regional Australia is the shortage of general practitioners (GPs) and the high number of GPs migrating from developing countries into regional or remote areas. The transient GP nature makes it difficult for GPs to engage with patients in addressing supportive care needs. Patients experience difficulties obtaining an appointment with GPs and oncologists or there are long waiting times for clinic appointments. I also see a number of patients presenting to ED inappropriately because of deteriorating illness. Lack of after-hour support contributes to this problem.
Impaired health literacy also has an impact on supportive care delivery, especially by the older oncology patients and indigenous population. Besides this, community district nurses are not always skilled in dealing with complex oncology issues. Being endorsed as an NP in palliative care, I often notice that medical professionals are not recognizing when a patient moves towards the terminal stage of their illness. This is causing delay in appropriate symptom management and increased burden on the patient due to invasive, futile treatment.
The oncology nurse practitioner model of care brought into practice
The environment I work in is quite unique. The catchment area is spread over two states -- New South Wales and Victoria -- with the hospital positioned on the New South Wales side of the border. I work as a member in an ambulatory team with four medical oncologists who have private practices in Victoria and who provide consultation at the hospital in NSW. I work alongside rotating oncology registrars and medical residents in the hospital. Inpatient demand is managed through admission to the general medical ward.
Patients entering and exiting my care
I do proactive follow-up of new chemotherapy patients, within 24 hours after their initial chemotherapy, including new patients commenced on oral chemotherapy trials.
The oncologists refer patients with complex supportive care needs (complex social issues, advanced diseases, or complex treatment regimens) to my service to enhance the patient's quality of life. I work in collaboration with the registrar, triaging new patients in the ED, and I attend most multidisciplinary meetings.
Patients exiting my care tend to be in stable condition post-treatment. I discharge patients from my care when they are referred to palliative care services, other inpatient services, or when patients move towards residential accommodation.
Barriers of the ONP role
In Australia, Medicare NP remuneration is based on time frame of consultation, promoting "six-minute medicine" rather than remunerating on the level of the patient's care needs. This is a major barrier in developing the NP role in Australia. For an NP to be in sustainable practice, a high number of consultations need to be achieved every day.
Medical professionals are apprehensive regarding the role and its blurring professional boundaries, and I had to advocate for legislative and organization adjustments, which was required to enable my scope of practice. An example of this is the documentation of all my outpatient contacts and geographic data of patients to generate state-based funding.
Enablers of ONP development
A clear role definition and differentiation from that of other providers is important in maintaining professional boundaries. Collaborative agreements with the medical oncologists inform my practice and future role development.
More than a year into this position, I raise the question: How would I be able to evaluate the effectiveness of my role? With no pre-existing data, I can't compare or assess the influence on the service since the development of my role. Besides documented and evidenced patient satisfaction, I would like to know how other ONPs evaluate their practice and outcomes with their clients.
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