CCO Medical Oncology Staffing, Caseload and Requirements using Recommended Provincial Staffing Standards

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1 Appendix Fb CCO Medical Oncology Staffing, Caseload and Requirements using Recommended Provincial Staffing Standards RCC Caseload Current FTE Caseload per FTE MOPAC Requirements Alberta Requirements BC Requirements Levin/Bersage l Requirements Yr Cases/FT E HRCC KRCC LRCC *NEORCC *NWORCC ORCC TSRCC *WRCC TOTAL ** Staffing Standards MOPAC 160/FTE teaching *175/FTE non-teaching Alberta 150/FTE BC 130/FTE Levin/Bergsagel 138/FTE ** 258 teaching, 261 non-teaching -Current FTE does not include hematology consultants -10 funded vacancies have not been subtracted from future requirements 1

2 Appendix G Clinical Associates Roles Introduction The clinical associate is a physician who fulfills a number of valuable roles within the regional cancer centres and at the Princess Margaret Hospital. These roles include provision of inpatient and outpatient acute care, supportive and palliative care and community liaison. The clinical associate is an important member of the cancer centre team providing a significant component of medical care. Developing the role and expanding the numbers of those general practitioners or internists, who have decided on a permanent oncology career, can assist considerably in addressing the shortage of medical oncologists, while at the same time maintaining a high level of patient care. Maximizing the clinical associate role requires that the position be formally recognized within CCO and PMH and that the roles and responsibilities be more clearly defined. Current Role The clinical associate is a physician, most often trained in family medicine, although some have completed internal medicine training. In the past, the clinical associate frequently has been viewed as a term position, rather than a permanent career path. As a result, the position has been structured to provide a supportive rather than primary role in the delivery of medical care. This view has contributed to a lack of consistency in the role of the clinical associate across the system, with cancer centres developing the position to meet gaps in service specific to individual centres. Current roles include: inpatient care in the host hospital supportive and palliative care outpatient care including new patient assessments, implementation of treatment plans and well follow-up triage of unscheduled/emergency patients maintenance of patients chemotherapy schedules including provision of coverage when medical oncologists are not available communication with family physicians teaching medical students and residents The perception of the position being a transient one is not, however, in keeping with the experience of many current CCO/PMH clinical associates who have worked in the cancer centres for a number of years and who have both the expertise and the desire to pursue a career in oncology. The current shortage of medical oncologists makes it imperative that CCO maximize the contribution of clinical associates in the delivery of systemic therapy. The recommendations contained in this report are intended to accomplish this objective by: formally defining and acknowledging the role of clinical associates within the structure of CCO/PMH; 2

3 expanding the clinical associate role incrementally, so that scope of practice is commensurate with the clinical associate's level of oncologic expertise; offering competitive remuneration and incentives to facilitate recruitment and retention of clinical associates. Expansion of the Role of the Clinical Associate The clinical associate offers value both from the patient care perspective and from the medical oncology staffing perspective. There are a number of opportunities to maximize the role of the clinical associate. Overtime, the clinical associate develops a significant level of oncologic expertise. Therefore, the role needs to be structured such that the clinical associate's scope of practice broadens as his or her level of expertise increases. Outpatient care Experienced clinical associates working in conjunction with oncologists and primary care nurses are capable of assuming responsibility for the assessment of new patients, and the treatment and management of routine systemic therapy cases and their follow-up. This in turn can reduce systemic therapy waiting times and allow medical oncologists to concentrate their specialized skills on complex cases. Clinical associates also provide coverage for medical oncologists necessitated by vacation, illness and academic and administrative responsibilities. Inpatient Care At many cancer centres, the clinical associate provides a significant amount of the day to day inpatient care. Clinical associates are particularly needed for, and skilled at, the provision of pain and symptom control for inpatients who have advanced terminal cancers. Such patients require recurrent visits for medication adjustments and patients and their families require frequent medical contact for communication and supportive care. This care by clinical associates is valued by medical oncologists because it allows them to concentrate on consultations, ambulatory care of systemic therapy patients, research and other non-clinical responsibilities. Communication with Family Physicians It has long been recognized that there needs to be improved communication between the cancer centres and family physicians. Family physicians find it difficult to reach oncologists and to obtain information that is meaningful and relevant to their practice. Time constraints make it difficult for medical oncologists to regularly communicate with family physicians. The clinical associate's family medicine training and oncology experience makes the position ideal for bridging this gap. Recommendations: 1. Organization of Clinical Associate Work by Disease Site To facilitate the development of clinical associate expertise, it is recommended that to the extent possible, clinical associates work as part of a disease site team in association with several oncologists. 3

4 2. Independent Clinics Clinical associates with more than 2 years of oncology experience and following appropriate training/mentoring should be given responsibility for running adjuvant chemotherapy clinics and well follow-up clinics 3. Palliative Care Specialization Appropriately trained and experienced clinical associates could undertake a specialized role in palliative care. The clinical associate could then be an inpatient and/or a regional palliative care resource to the cancer centre and community. 4. Family Physician Resource The clinical associate should be formally identified as a resource to family physicians in the community and be a major link between the cancer centre and family physicians, particularly in the areas of triage and palliative care. Defining the Role 1. Formal recognition within CCO The clinical associate position should be formally recognized within the structure of CCO. This could be accomplished through the following initiatives: Developing a standardized job description; Adopting a standardized job title; Developing a Clinical Associate Professional Advisory Committee and/or securing representation on the Systemic Therapy Advisory Committee. 2. Training i) CCO's Education Division should work with the clinical associates to develop a formal orientation and educational program for new clinical associates. ii) CCO should work with the College of Family Medicine to develop an oncology specialty certification and appropriate designation for clinical associates. Retention The perception of the clinical associate as a term position has meant that clinical associate retention has not figured prominently in CCO s human resource planning. The recommendations set out below recognize and support the position as a career path. Salary, benefits and professional development comparable to other medical professionals, in addition to formal recognition within CCO, will improve job satisfaction, help retain existing clinical associates and attract new ones to the position. Recommendations: 1. Improved remuneration Remuneration for clinical associates should be increased to be competitive with the remuneration of private practice general practitioners, taking into account the expenses of office practice. Fixed fees including CMPA, OMA, CPSO should be taken into account when setting salary levels. On-call remuneration should be enhanced. 4

5 2. Improved vacation benefits Vacation time for clinical associates should be similar to that of medical oncologists considering the fact that they are exposed to the same work-life stresses. 3. Retention of independent practice status CCO should explore mechanisms that would allow clinical associates to retain independent practice status while working at the cancer centre. 4. Continuing Medical Education The Canadian College of Family Physicians now has mandatory requirements for CME. Hospitals also are requiring CME to retain privileges. Clinical associates working within the cancer system, therefore, should be provided with annual education days annually (minimum of 5 days per annum), and funding for attendance at these CME activities. Recruitment In order to realize the benefits of the clinical associate, the role needs to become one that will continue to attract family physicians and other physicians as a career choice. Recommendations: 1. Adopt retention recommendations, particularly retention of independent practice status. 2. In academic health science centres, work with Family Medicine Program Directors to increase family practice residency rotations in the cancer centres. 3. Undertake a centrally coordinated recruitment initiative targeted at specific groups including new graduates, FPs with young families and other FPs who want to work part-time/job-share. 4. Ask the Ontario College of Family Physicians to consider time spent in RCCs towards CME credits. 5

6 Clinical Associate Staffing Standard The medical oncology staffing standards recommended by CCO's Medical Oncology Professional Advisory Committee (MOPAC) is one medical oncologist for every 158 new cases in teaching centres and 1 to 173 in non-teaching centres. The formula for the MOPAC standard does not factor in clinical associates. However, because clinical associates were working in the system when the medical oncology workload data were collected, it can be assumed that the work performed by the clinical associates is in addition to the work of the medical oncologists. This is particularly true for inpatient care, where clinical associates carry the large burden of supportive/palliative care, as well as the day to day management of the patient. As such, the recommended staffing standard for clinical associates is based on a ratio of clinical associates to medical oncologists. Current Clinical Associate/Medical Oncology Staffing Ratio Currently, the number of FTE clinical associates (CA) to FTE medical oncologists (MO) at the RCCs is as follows: RCC CA (FTE vacancy) MO (FTE vacancy) TSRCC (1) HRCC (2 ) LRCC 1.7 (4.9) 9.2 (3) KRCC NEORCC (1) NWORCC (1) ORCC WRCC (1) Total 19.3 (24.2) 55.1 (64.1) Current ratio 1 (1) 2.85 (2.65) It should be noted that some centres have no clinical associates and others have vacancies, as there is a general shortage of family medicine practitioners, which is particularly acute in some areas of the province. It should also be noted that the centre with the greatest number of clinical associates (Ottawa) is the centre with the greatest deficit in number of medical oncologists and no primary care nursing. This underscores the fact that there is regional variability in the availability of human resources and that individual centres attempt to meet patient needs through different combinations of healthcare providers. Ratio of Clinical Associates to Medical Oncologists in other Jurisdictions Alberta recommends 1 clinical associate for every 5 medical oncologists, but also recommends a lower caseload for medical oncologists (150 new cases per medical oncologist) and this ratio excludes inpatient clinical associates. British Columbia does not have an established ratio, but includes clinical associates as a 0.4 FTE in their formula for calculating medical oncologist staffing levels. As British Columbia recommends a medical oncologist for 130 new cases, it is apparent that clinical assistants 6

7 have become the means by which the Ontario system has been able to provide care to its cancer patient population. Recommended Staffing Ratio It is recommended that CCO adopt a staffing ratio of one clinical associate for every 2.5 FTE medical oncologists. As the system is currently under resourced for medical oncologists by 16, then there is a need for 12 additional clinical associates positions. Individual centres will have to make best use of available human resources, including medical oncologists, primary care and advanced practice nurses and pharmacists functioning in expanded roles. Therefore, there will be an ongoing need to assess the appropriate numbers and mix of healthcare providers based on caseload and the availability of different types of health professionals. This might result in a different medical oncologists to clinical associate ratio in some centres. 7

8 Appendix H Family Physician Roles Family Physicians The family physician is a community-based physician with responsibilities for patients with a wide range of clinical problems, one of which may be cancer. Family physicians could assume three distinct roles which would address the need to provide: a) continuity of care between the cancer treatment system and the community and b) high quality care as close to home as possible. These roles are: Follow-up for: a) supportive care, b) disease monitoring Palliative care Delivery of systemic therapy 1. Follow-up care Family physician involvement with patients diagnosed with cancer has diminished as more and more of their care is provided in cancer centres. This has not always been to the satisfaction of patients or their family physicians and is not necessarily in the best interest of either. There have been multiple reasons for this shift of care which can be attributed to both cancer centres and family physicians. Increasing the involvement of family physicians in the ongoing care of cancer patients would be expected to: a) provide care closer to home, b) improve the level of supportive care provided to patients, c) improve the commitment of the family physician to provide palliative care, and d) increase patient satisfaction with care. Family physician involvement in the follow-up of cancer patients after treatment would be the ideal point at which to reconnect patients with their family physicians. There are two broad purposes for family physician follow-up: a) provision of supportive care and b) disease-specific follow-up. Family physicians are in a position to provide a great deal of supportive care. By virtue of their knowledge of their patients, they are able to provide supportive care which is tailored to patient and family needs. This support may include review of diagnosis and treatment plan, assistance with emotional, social or family issues, and transition from treatment to long-term follow-up or palliation. The evidence would suggest that a large percentage of family physicians are willing to provide components of follow-up care. If provided with appropriate guidelines, many family physicians have indicated a willingness to provide disease-specific follow-up for recurrence. At least one study has shown that patient outcomes with family physician follow-up of treated breast cancer patients is equivalent to cancer centre follow-up. Patient satisfaction was higher with family physician follow-up. There was a suggestion of increased system cost, but lower patient cost with family physician follow-up. At the present, time there is a provincewide study ongoing in Ontario to examine follow-up of treated breast cancer patients by their own family physicians. This study will hopefully provide the evidence to guide a province-wide approach to this issue. 8

9 There are, however, a number of significant barriers to improving the amount and quality of family physician follow-up: Poor quality communication between cancer centres and family physicians Heterogeneity among family physicians with regards to willingness to provide supportive and well follow-up care Differences in beliefs between oncologists, family physicians and patients about where follow-up care should occur The economic impact on family physicians, oncologists, and cancer centres of where follow-up occurs The negative impact on the quality of work life of oncologists of not seeing successfully treated patients The lack of well patient patients in Cancer Centres to demonstrate to medical students and other trainees that positive outcomes can be achieved in cancer patients Problems in communication have been a major barrier to family physician involvement in cancer patient care. Some of the specific problems in communication have been: Information about patients is frequently slow to reach the family physician s office. This could be enhanced by the use of newer technologies, such as fax out programs as is being done now from several regional cancer centres The content and language of the information ( eg practice guidelines) is often not suited to the needs of family physicians Family physicians and oncologists experience great difficulty in trying to make direct personal contact with one another (eg voice mail systems are a significant barrier to communication) There is a lack of generic cancer information and family physician oriented practice guidelines, and information resources are not accessible when family physicians need them To move forward with increasing the family physician s involvement, solutions will need to be found to these problems. Recommendations 1. CCO and the CCORs, through the Family Physician Initiative, should develop a communication strategy to enhance the relationship between cancer centres and family physicians. 2. CCO and the CCORs, through the Family Physician Initiative, should develop a strategy to increase the supportive care and well follow-up of cancer patients by their family physicians. 3. CCO should continue to support the Primary Care Oncology Group in the development of guidelines for family physicians. 4. CCO should be prepared to implement disease-specific follow-up of treated patients by 9

10 family physicians, particularly if the outcome of a current trial in breast cancer supports this approach. 2. Palliative Care At the present time 40 50% of all cancer patients in Ontario will die of their disease. That means that palliative care is a core service to cancer patients and their families. At the current time in Ontario, there is no reliable system of palliative care. This is particularly true of the physician component of palliative care. The availability of physicians to provide palliative care, especially in the home environment is woefully inadequate. It has long been assumed that family physicians would provide this component of care but, there is substantial opinion in the palliative care community that this is not occurring. While there are a number of family physicians who have the motivation and skills to provide excellent palliative care, there is another group who, although committed, have inadequate training or experience to manage common palliative care problems. There is a third group who simply will not provide this care. It must also be acknowledged that the individual family physician will only see on average about 4 patients per year requiring palliative care. This small number is probably inadequate to maintain a high level of competency in the pain and symptom management of cancer patients There are a number of ideas about the barriers which prevent family physicians from providing this service. These include: 1) a lack of adequate training and experience in family medicine training programs, 2) a perception that palliative care is not part of the primary care role, 3) a loss of contact with (and possibly commitment to patients during the course of active cancer treatment, 4) inadequate consultative support, and 5) lifestyle and remuneration considerations. The lack of systemic support for education, consultative expertise, and remuneration can be profoundly de-motivating for family physicians. Addressing these issues is vital to improving the performance of family physicians in this role. The Palliative Care Initiatives for Ontario (1992) was an attempt to develop a system of care which included pain and symptom management teams and educational opportunities for physicians. Unfortunately this initiative was inadequately funded and inconsistently applied across the province. There are also models in other provinces which make use of subgroups of family physicians who are motivated to provide palliative care. These physicians are supported by a system of consultants, hospices, and regular educational opportunities. To be successful in Ontario, it will be necessary to accept that not all family physicians will provide palliative care. Rather, it will be necessary to recruit a subgroup who will commit to providing this care and these physicians will need to be supported adequately with consultative expertise, access to hospice/hospital beds when needed, adequate remuneration, and ongoing education. 10

11 Recommendations 1. Cancer Care Ontario should accept a leadership role in advocating for, planning, and implementing a palliative care strategy for cancer patients in Ontario. 2. Cancer Care Ontario should develop a working relationship with the Ministry of Health, Ontario Palliative Care Association, the OMA section of Palliative Care, and the Ontario College of Family Physicians to develop a palliative care strategy for Ontario. 3. The palliative care strategy for Ontario should focus on identifying a subgroup of committed family physicians, who, with appropriate training, could meet the needs of the majority of patients requiring palliative care in the community. These family physicians would need to be supported by appropriate levels of consultative expertise, human and physical resources, education, and adequate remuneration. 3.. Delivery of systemic therapy Currently there are two models of care delivery in which family physicians deliver systemic therapy in communities at a distance from cancer centres. One model has been used in northern communities where populations are dispersed. The other is a model developed in Eastern Ontario best exemplified by the Renfrew Satellite Oncology Unit of the Ottawa Regional Cancer Centre. This model is appropriate for modest sized communities at a distance from a specialized centre. These programs have demonstrated that it is possible to deliver chemotherapy of low acuity, and with experience even high acuity therapy, with outcomes which are equivalent to those achieved in a regional centre. This is achieved with high satisfaction to care providers, patients and their families. The key components of these programs are: Designated family physicians who are trained to provide systemic therapy and who receive ongoing education in cancer treatment A formal agreement between physicians, the community hospital, and the cancer centre Appropriately trained nursing and pharmacy personnel Sufficient caseload to maintain competency Oncological consultation High quality communication linkages with just-in-time delivery of consultation information, disease summaries and family physician oriented practice guidelines Clearly described treatment and follow-up guidelines There is potential to apply these models to a larger number of communities in Ontario which achieves the goal of providing high quality care close to home and which improves the utilization of physician resources. Several key issues need to be addressed in order to move forward: 11

12 A set of criteria need to be developed which would identify a community as being a candidate for such a program. These criteria would likely define: a) distance from a cancer centre, b) population base, c) presence of a community hospital, d) availability of willing family physicians. Educational programs would need to be developed for initial and ongoing training for the designated family physicians, nurses, pharmacists and other health care personnel who would be involved in such a program. The financial issues for both family physicians and the community hospitals will need to be examined and clarified. Recommendation: 1. CCO and the CCORs should continue to expand those models best suited to their regions which utilize designated family physicians to delivery systemic therapy in communities at a distance from cancer centres. 12

13 Family Physician Roles Role Action Plan Implementation strategies Systemic Therapy Designated family physicians deliver systemic therapy in the community with consultation and support from a cancer centre Work with the CCOR s, regional cancer centres, community hospitals and University Departments of Family Medicine to expand the designated physician model. Use current programs providing chemotherapy to patients at a distance through designated family physicians, as models for further expansion of systemic therapy delivery across the province. Develop criteria for communities that can utilize these models. Develop and implement a recruitment strategy for designated family physicians and community hospitals. Develop and implement an educational program for designated family physicians, nurses, pharmacists and other health care personnel who are involved in care delivery. Identify and address remuneration issues and financial issues for community hospitals. Develop policies and procedures modeled after the programs currently operating in northern communities. Follow-up Deliver follow-up supportive care to treated cancer patients and monitor for disease recurrence according to standard follow-up protocols Work with the CCORs, the regional cancer centres, community oncologists, the Ontario College of Family Physicians to increase the involvement of family physicians in follow-up care. Provincial DSGs to develop standard protocols for well follow-up. Through the CCO Family Physician Initiative: i) develop and implement a communication strategy to improve the relationship between cancer centres and family physicians. ii) develop and implement a strategy to increase the supportive care / well follow-up of 13

14 Palliative Care Delivered by a core group of family physicians in their offices, the patient's home, in hospice or in hospital CCO should take a leadership role in advocating for, planning, and implementing a palliative care strategy for cancer patients in Ontario. cancer patients by family physicians. Continue CCO support for the development of guidelines for family physicians through the Primary Care Oncology Group. Develop mechanisms to provide timely, relevant cancer information to family physicians. Implement well followup of treated patients by family physicians as evidence emerges to support this. Establish a relationship with the Ontario Palliative Care Association, the OMA Palliative Care section, the Ontario College of Family Physicians, and the Ministry of Health and Long Term Care to develop a palliative care strategy for cancer patients in Ontario. Inventory the palliative care services available in each CCOR. Develop and implement a strategy to deliver palliative care at each cancer centre with integration of these services with regional services through CCOR. 14

15 Appendix I CANCER NURSING IN ONTARIO Position Paper December 1999 Written by M. Fitch, RN, PhD & D.Mings, RN, MHSc, OCN For the CCO Nursing Professional Advisory Committee and the Nursing Sub-Committee of the Systemic Treatment Task Force 15

16 EXECUTIVE SUMMARY The delivery of cancer care in Ontario is facing unprecedented challenges. Shortages in nursing, as in all professional disciplines are having an impact on the delivery of cancer care. Oncology nurses have a major role to play in the delivery of optimum cancer care. Oncology nursing, when adequately defined and supported, can benefit the cancer delivery system, patients and families. A primary nursing model is seen as being key to the delivery of optimum cancer care. Primary nursing as a philosophy facilitates continuity of care, coordination of a patients care plan and a meaningful ongoing relationship with the patient and their family. Primary nursing, when delivered in the collaboration of a nursephysician team allows for medical resources to be used appropriately. According to Marram, Barrett & Bevis (1979) Primary Nursing "can best be defined as each patient has one accountable nurse who plans and modifies his/her care, and this nurse is the patient's primary point of contact in accessing the health care team." Defined roles enable nurses to manage patients within their scope of practice in collaboration with physicians. Enacting other nursing roles such as nurse practitioners and advanced practice nurses can also enable the health care system to manage a broader number of patients with more complex needs. Recommendations are made for recruiting and retaining nurses as an essential strategy to ensuring the supply of oncology nurses. Other issues are also raised in regards to standardizing aspects of the nursing role, so it is clearly defined. Providing ongoing education and areas of advancement is also seen as important issues to be addressed. Nursing currently contributes in a positive manner to patient care delivery in Cancer Care Ontario. There is opportunity to maximize the impact of nursing on patient care and the cancer system by ensuring the role of nursing is understood and used efficiently. 16

17 NURSING IN CANCER CARE ONTARIO INTRODUCTION The delivery of cancer care in the Province of Ontario is facing unprecedented challenges. Escalating patient numbers and needs for service combined with increasing complexity in treatment protocols have created spiraling demands which cancer care professionals are struggling to meet. Patients too, are struggling to navigate the cancer care system and receive timely and appropriate care. Oncology nurses are an integral component in cancer care delivery. They play key roles in assessment, coordination and patient and family education and support. At a time when the health care system requires experienced and educated nurses to meet the growing demands for cancer care, nursing in Ontario is experiencing an impending crisis. This document highlights the current situation in cancer nursing in Ontario and offers some recommendations for action to Cancer Care Ontario. The paper outlines new and innovative models for nursing within C.C.O. and describes how various nursing roles can work collaboratively to ensure that nursing is being used to it's fullest benefit for patient care. Current Reality - Nursing in Ontario and Canada A 1998 study by the Canadian Institute of Health reveals that Ontario has fewer Registered Nurses per capita than other Provinces (6.9 per 100,000 vs the national average of 7.6 per 100,000). A recent study by the Canadian Nurses' Association points to an impending shortage of nurses, as many as 113,000 Registered Nurses across Canada by the year The supply of Registered Nurses per 100,000 population has been declining while Ontario's population has increased by almost 25% between 1981 and The number of RNs in the same period increased by only 12%. Since 1994 there has been only a 4% increase in the supply of RNs, and on average close to 81% of professional nurses eligible to work in Ontario currently do so. This figure has been relatively stable since the early 1990s. Clearly, a shortage of nurses is apparent and projected to last for many years. Factors contributing to this shortage are complex and are not easily fixed (O Brien-Pallas, personal communication 1999). 17

18 Concern has also been expressed over the fact that the largest age cohort in the nursing profession is between 45 and 49 years of age, with almost half of this group over 45. Nurses under 30 years of age are increasingly employed in casual and part-time positions. At present, half of the work force in nursing report part-time employment. Both nurses and patients report frustration with the lack of continuity caused by the reliance on casual workers. Patients in particular have identified their concern with seeing a new face each shift during the course of their nursing care. Of further concern is the fact that there has been a significant and steady decrease in the number of students enrolling in professional nursing programs. In the same period ( ) there was a decline of almost 8% in RN graduates from both university and college programs. Based on the average retirement age of 56 (and not accounting for recruitment into the profession) half of Ontario's nurses could be retired by the year (All statistics taken from the report: Good Nursing, Good Health: An Investment for the 21 st Century, Ministry of Health an Long Term Care, October 1999) 18

19 Oncology Nursing in Cancer Care Ontario The current status of nursing within Cancer Care Ontario mirrors the situation with Nursing in the Province of Ontario. The C.C.O. nursing workforce is proportionately older with nurses who have been in oncology nursing for much of their career. Many have had extensive nursing experience prior to their employment in current cancer programs. The advantage to CCO is an experienced workforce with many collective years of oncology experience. The potential impact of large numbers of older nurses includes increased use of sick time and a desire to work more part time hours. Increasing patient numbers and patient acuity/complexity in cancer centers without a concomitant increase in nursing FTEs has had significant impact on quality of work life for current staff members. Recruitment of qualified and/or experienced nurses with oncology background is becoming increasingly difficult. Less qualified nursing staff in cancer care necessitates an increased investment of time and resources for training and orientation to ensure competency for safe patient care. Because of the increasing complexity of treatment protocols and patient needs, nursing roles have, of necessity, become more complex. Not only must nurses work with patients face to face in clinic situations, they are required to coordinate patient care "behind the scenes" and conduct a growing amount of their practice over the telephone. The complexity of care has also led to the development of subspecialties within oncology nursing. Nurses are currently employed in each of the cancer programs across Ontario. However, the roles of these nurses vary tremendously and the models of nursing care delivery can differ from program to program. The roles range from clinic based nursing where the nurses work with patients in a clinic environment in which the nurse is geographically based; to team based nursing where the nurse works with a variety of disease site based physicians; to a primary nursing role in which the nurse and physician(s) work together to manage the care of patients within a specific practice. This role can include not only clinic-based interactions but also follow up interaction and telephone exchange. There are also nurses who perform specific duties and responsibilities within the systemic program ie. the delivery of chemotherapy and in some clinic 19

20 settings, program-specific responsibilities (apheresis, genetic counseling, pain and symptom management, supportive care, bone marrow transplant coordinator and stem cell coordinator). The pattern across the Regional Cancer Centers for nursing has been for each center to enact its own model based on their identified needs and gaps. As yet, no coordinated effort has been made within C.C.O. to define core values and role responsibilities for its nursing staff, nor is there an identified Provincial infrastructure to support the growth and development of the specialty of oncology nursing. Information is collected inconsistently between cancer centers and this makes comparing staffing levels and FTE s precarious. The enactment of differing roles and models makes it difficult to determine optimal staffing levels. No long term human resource planning has occurred. Oncology Nursing as a Specialty Since 1997, the Canadian Nurses Association through their certification examination process has recognized Oncology Nursing as a specialty. The Oncology Nursing Society (U.S.A.) has recognized the specialty status for 20 years. Throughout the United States there are educational programs offered to prepare nurses at Basic, Specialty and Advanced levels in Oncology Nursing. However, in Canada, the situation is dramatically different. There are only a very limited number of educational programs focused on oncology nursing. The Cross Cancer Institute has developed an oncology educational program and the University of Alberta recognizes this program through credits toward Bachelor of Science in Nursing. McMaster University (Hamilton, Ontario) has developed a distance education program in both Pediatric and Adult Oncology. The courses in the McMaster program provide credit towards the third year of a bachelor degree. Other than these two programs, special preparation for oncology is often undertaken at the initiative of the individual nurse, through a series of continuing education programs and events that can lead to a diploma or certificate. Such an approach can take a significant commitment of time and resources from the student. Presently the only consistent credential for the specialty of Oncology Nursing in Canada is the C.N.A. Certification examination. This credential allows a nurse to use the designation C.O.N.(C) (Certified Oncology Nurse, Canada) following their name. 20

21 Preparation for this Position Paper In May 1999, the Nursing Advisory Committee of Cancer Care Ontario took steps to examine the roles of nursing in cancer care. The Systemic Task Force commissioned this activity. In order to ensure consensus and involvement in the process of developing the concepts for this position paper, a group of oncology nursing leaders met in August to discuss nursing roles and workload measurement. Consensus was achieved regarding four key concepts: - Oncology nursing is a specialty requiring additional knowledge and skill for competency in practice - A nurse moves through a continuum from novice to expert as an oncology nurse; the movement requires experience, knowledge and specialized skills. The expert level allows the nurse to enact a broad range of nursing roles - Primary nursing as a philosophy facilitates continuity of care, coordination of a patient's care plan and a meaningful, ongoing relationship with the patient and family - There is a role for nurse practitioners and advanced practice nurses within C.C.O. settings. An advanced practice role requires Masters preparation Describing Nursing Roles Before innovative models for nursing can be constructed, a basic level of understanding about nursing roles is critical. The qualifications and primary responsibilities of each key nursing role are described in detail below. General descriptions for each of the following roles are provided below: - Oncology Primary Nurse - Nurse Practitioner - Advanced Practice Nurse Standards exist that outline expectations for practice from the Oncology Nursing Society (USA) and the Canadian Association of Nurses in Oncology. 21

22 ONCOLOGY PRIMARY CARE NURSE Qualifications: - diploma or BScN prepared (BScN prepared by 2005 as entry to practice) - specialty certification in oncology nursing i.e. CON(C) or ONC - specialty diploma, post basic education Entry to Practice Competencies for Registered Nurses in Ontario as of January 1, Each nurse provides, facilitates and promotes the best possible professional service. The nurse responds to the needs of consumers in a way that fosters trust, respect, collaboration and innovation. 2. Each nurse possesses and continually acquires knowledge relevant to the professional service she or he possesses. 3. Each nurse continually strives to improve the application of professional knowledge. 4. Each nurse understands, upholds and promotes the ethical standards of the profession. 5. Each nurse maintains competence while striving to improve the quality of her or his dimension of practice. 6. Each nurse is accountable to the public and responsible for ensuring that her/his practice meets legislative requirements and the standards of the profession. (College of Nurses of Ontario, 1999) The nurse is expected to work within and maintain the standards of the College of Nurses as outlined. In addition, the role of the nurse in enacting a primary nursing focus includes the following aspects: - works with a physician or a group of physicians to provide care to patients within a specific population or disease site group - acts as a liaison between patient/family and physician - works collaboratively with the physician to ensure patient/family needs are met - accountability for coordinating a comprehensive plan of care that is consistent, is reassessed and is modified based on patient and family needs - front line worker providing direct care to patients and families - provides support to a specific group of patients - establishes supportive/therapeutic relationship with patient/family - has knowledge and skill to adequately assess a patient/family on a physical, psychosocial and spiritual basis and is able to determine when medical intervention is necessary 22

23 - consults and refers to other health care providers as necessary - able to coordinate the needs of the patients along the continuum of care and communicates and documents as appropriate - able to integrate research findings into practice, suggest topics for potential research, participate in data gathering - works collaboratively with the physician, patient and family and other members of the health care team - meets and maintains College of Nurses and Oncology Nursing standards With additional knowledge, experience and training the role may expand to take on a more specialized component with specific populations of patients. A specialty diploma and/or additional training and the use of medical directives facilitate the development of this role. Examples of Roles with additional training: Apheresis Nurse Bone Marrow Transplant Nurse Pediatric Liaison Nurse Chemotherapy Nurse NOTE: Marram, Barrett & Bevis (1979) summarizes the role of the primary nurse: "each patient has one accountable nurse who pans and modifies her/her care, and this nurse is the patient's primary point of contact in accessing the health care team" Primary Nursing: A model for Individualized Care. Mosby Company,

24 NURSE PRACTITIONER - PRIMARY HEALTH CARE Qualifications: "Generalist nurse practitioner" stream primary care nurse practitioner Diploma + 24 months training BScN prepared + 12 months training College of Nurses extended class license (EC). Role Statement The primary health care nurse practitioner (PHCNP) is a registered nurse with advanced education in nursing knowledge and other sciences beyond the basic level. Credentials for the PHCNP may be acquired through university courses and/or prior learning assessment and recognition. Nurse practitioners are generalists who provide primary health care and continuous care to clients across the health continuum and throughout the life span to enable clients to increase control over their health. The PHCNP is a RN with advanced knowledge and decision-making skills in assessment, diagnosis, and health care management. The primary health care nurse practitioner is a community-based practitioner whose scope of practice includes providing services to individuals of all developmental stages, and to families and communities. (Ontario Primary Health Care Nurse Practitioner Education Program, August 1998.) Competence Statements for Registered Nurses in the Extended Class (PHCNP) Registration in the Extended Class is based on demonstration in each of six competency areas: 1. Health Assessment and Diagnosis 2. Therapeutics (including pharmacological, complementary, and counseling interventions) 3. Role and Responsibility 4. Health Promotion and Disease Prevention 5. Family Health 6. Community Development and Planning Primary Role Focus: Works with a defined, stable group of patients-refers/consults physician when patient problem outside scope of practice 24

25 Focus is on health and wellness able to provide the public with services in all five components of comprehensive health services: - health promotion - disease prevention - cure - rehabilitation - support services emphasis on patient care delivery able to communicate a diagnosis within a primary care setting able to prescribe/dispense drugs and order therapeutic and diagnostic interventions as set out in the regulations within a primary care setting able to integrate research findings into practice, suggest topics for potential research, participates in data collection A generalist class nurse practitioner focuses on giving people the information, care, advice and support they need to be healthier and prevent illness and injury. manages treatment of clients with chronic stable disease or disorders diagnosed by a physician it is expected the PHCNP will consult with members of the health professions as appropriate in order to ensure that overall health care needs of their patients are met Examples of Roles: Currently none in C.C.O. potential - outpatient new patient clinic providing comprehensive assessment, patient care and team membership - specific clinics (bone mets, colposcopy, genetics) - high risk clinics (familial gyne/breast) - inpatient role with patients needing monitoring and discharge planning NOTE: The training and focus of this role is on primary care. Additional training and education would be required for this role to be enacted in a tertiary care setting. Also, Extended Class licensing is only valid in the primary care setting. The PHCNP would have to work under medical directives vs. Privileges that are a part of the extended class license i.e. prescriptive/diagnostic/laboratory mandates in the primary care setting. 25

26 ADVANCED PRACTICE NURSE (includes clinical nurse specialist & acute care nurse practitioner) Clinical Nurse Specialist Qualifications: Masters prepared College of Nurses, regular class Practices within the domains of organization leadership, clinical practice, education, research and consultation. Emphasis in this position is placed on clinical, interpersonal and leadership skills used to enhance the role of nursing and promote organizational goals. Change agent, role modeling, mentorship are all-important components of this role. Advanced Practice Nurse/Acute Care Nurse Practitioner (ACNP) Qualifications: Masters prepared Certificate in Acute Care Nurse Practitioner Program (ACNP) College of Nurses, regular class Primary Role Focus: Works in a tertiary health care institution to deliver an advanced level of nursing care to a specific population in collaboration with physicians, nurses or other health professionals Works within medical directives Emphasis on a combination of patient care delivery to the individual and the population as well as leadership in the organization Oncology nurses practicing at the advanced level must be able to assess, conceptualize, diagnose and analyze clinically complex and non-clinical problems related to an actual or potential diagnosis of cancer and is best defined as expert competency and leadership in the provision of care. The nurse must have advanced physical and clinical assessment skills, advanced clinical decision-making abilities and the knowledge and skills to manage patients pharmacologically and therapeutically. Clinical Competencies at an Advanced Level: clinical expertise/experience critical thinking and analytical skills 26

27 clinical judgement decision making ability leadership and management abilities communication skills problem solving abilities the ability to collaborate and consult where appropriate participation in the mentoring and development of colleagues ability to participate/collaboration/conduct research and integrate it into clinical practice program development plan strategies to improve outcomes and quality of care evaluation of practice for continuous improvement Examples of Roles: currently none in C.C.O.; many in university affiliated centers ie. Princess Margaret Hospital Outpatient - symptom management clinic - new patient clinic for high risk or complex disease site groups - wound management (complex) - follow up for complex patients (bone marrow transplant, chemotherapy, neutropenia) Inpatient - patients with complex care needs NOTE: An advanced practice nurse is more than an expert nurse. Both have special knowledge, skills and experience related to the care of a specific client population. But, in addition, the advanced practice nurse has: A pre-established minimum level of post-basic education required for the advanced level (ie. Masters degree) the ability to integrate concepts, research, and theories and apply this knowledge and skill in practice (Nursing Regulation and Advanced Practice Nursing, College of Nurses of Ontario, Sept 1995) 27

28 Figure 1. Direct Care Component of Advanced Nursing/Nurse Practitioner Roles Clinical Nurse Specialist 0% 30% 100% Nurse Practitioner 0% 80% 100% Advanced Practice Nurse 0% 50%-60% 100% All nursing roles have various components including direct patient care, education and research. The amount of time devoted to direct patient care varies from role to role. Health care agencies need to determine the amount of direct clinical practice required in order to decide the role that is most appropriate for their institution. The leadership component needs to be evaluated and the amount of time required to participate in organization needs to be addressed. Determining these two factors will help determine which role is most appropriate for the organization. 28

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