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

29 Enacting Nursing Roles/Working with Physicians The concepts of patient needs and stages of illness are developed from the Provincial Supportive Care framework (see Figure 2). Figure 2. Cancer Care Spectrum of Experience: PRE- D IA G N O S IS D IA L O G U E R E F E R R A L R E H A B IL IT A T IO N R E C U R R E N T D IS E A S E B E R E A V E - M E N T D IA G N O S IS TREATMENT S U R V IV O R S H IP N O N - C U R A T IV E D IS E A S E Continuum of events experienced by cancer patients and their families. Building on the roles illustrated, further details were developed to illustrate how the various nursing roles could contribute to patient care at different points along the cancer continuum. Additionally, how oncology physicians relate to these nursing roles is also defined. These descriptions are presented in Table 1 7. Please note the ideas represented in these tables are not exhaustive and are included for discussion and to generate discussion. 29

30 Table 1. Early Diagnosis: Nursing Role Clinic Nurse (nurse examiners in OBSP) Contribution to Cancer Patient/Family Care Basic Assessment of patient (history) Report issues of concern Support to client Patient education regarding selfexamination, behaviors and monitoring of potential signs of disease Counseling re: life style factors Physician Responsibility to Clinic Nurse Review History Perform physical assessment Reinforce patient education and counseling issues Nursing Role Contribution to Cancer Patient/Family Care Nurse Practitioner Comprehensive Assessment Monitoring of high risk men or women who have genetic predisposition to cancer Support and reassurance of client Patient education regarding selfexamination, behaviors and monitoring of potential signs of disease Counseling re: life style factors Physician Responsibility to Nurse Practitioner Confirm abnormal findings Discuss treatment options Reinforce education and counseling issues

31 Table 2. Diagnosis/New Patients Nursing Role Contribution to Cancer Patient/Family Care Primary Nurse Basic Assessment oriented to disease site and history Patient education re: cancer diagnosis, treatment side effects and resources for coping, plan Support of and interaction with patient and family Focuses on the individual and family Suggests and initiates referrals to appropriate resources Develops nursing plan of care Clarifies and reinforces treatment plan Nursing Role Contribution to Cancer Patient/Family Care Nurse Practitioner Comprehensive Assessment, oriented to site Capable of ordering appropriate lab tests, diagnostic tests Patient education re: cancer diagnosis, treatment side effects and resources for patient and family Support and interaction for patient and family Focuses on the individual and family Physician Responsibility to Primary Nurse Confirms history and performs general physical exam Orders tests Interprets test results Makes diagnosis and discusses diagnosis and treatment options with family Develops medical plan of care Physician Responsibility to Nurse Practitioner Participates in development of medical directives appropriate for disease site Confirms abnormal findings Makes diagnosis and treatment plan

32 Table 2. Diagnosis/New Patients - cont. Nursing Role Advanced Practice Nurse Contribution to Cancer Patient/Family Care Comprehensive Assessment, oriented to site Patient education re: cancer diagnosis, treatment side effects and resources for coping Support and interaction for patient and family Crisis intervention/counseli ng Focuses on the individual, family or groups Capable of arranging appropriate lab/diagnostic tests (under medical directives) Physician Responsibility to Advanced Practice Nurse Participates in development of medical directives appropriate for disease site Confirms abnormal findings Makes diagnosis and treatment plan

33 Table 3. On Treatment Nursing Role Contribution to Cancer Patient/Family Care Primary Nurse Ongoing assessment related to therapy and pain and symptoms related to site Telephone contact and response to patient queries; triage urgent vs nonurgent patient situations Patient education regarding management of side effects, psychosocial reactions and community resources Support and interaction for patient and family Suggests and initiates referrals to appropriate resources Nursing Role Chemotherapy Nurse Contribution to Cancer Patient/Family Care Ongoing assessment, specific to toxicities Delivery of chemotherapy drugs Support patient during chemotherapy administration Patient teaching regarding chemotherapy and management of side effects Referral to primary care nurse as appropriate Physician Responsibility to Primary Nurse Responds to nurse regarding patient problems related to disease and treatment (ie. vomiting on treatment) Decision-making re: treatment plan, admission etc. Participates in development of patient education materials Refers to other specialists and/or disciplines Physician Responsibility to Chemotherapy Nurse Responds to nurse regarding urgent/emergency issues in patient treatment area (Taxol reaction, toxicity assessment, out-of-range blood counts etc.)

34 Table 3. On Treatment - cont. Nursing Role Contribution to Cancer Patient/Family Care Physician Responsibility to

35 Advanced Practice Nurse Assessment of complex patient and family situations (hypercalcemia, acute confusion, febrile neutropenia) Provide appropriate interventions to manage identified symptoms Monitor and identify precursors to oncologic emergencies Completes comprehensive history and physical examination Initiates medical directives and, after consultation, admits patient Provide support and counseling using a theoretical framework to patients with complex needs (psychosocial, symptom complexes) on an individual or group basis Counseling related to adjustments to disease progression/living with cancer Development of programs/materials for patient education Involvement in focus groups (with other data gathering techniques) to identify patient needs and areas for improvement in care delivery for the site group Advanced Practice Nurse Participates in the development and ongoing monitoring of medical directives outlining scope of responsibilities for A.P.N. Confirms abnormal results, and Confirms appropriate course of action

36 Table 4. Well Follow Up/Stable Disease Nursing Role Contribution to Cancer Patient/Family Care Primary Nurse Basic assessment, tumour site specific (i.e. breast exam) Referral of abnormal findings to oncologist Support and interaction with patient and family Patient teaching regarding possible symptoms, investigative approaches Referral to nurse practitioner and/or oncologist for difficulties regarding life-style factors Referral to appropriate resources for adjustment disorders Nursing Role Nurse Practitioner Contribution to Cancer Patient/Family Care Comprehensive assessment, site specific Orders lab and diagnostic tests Referral to oncologist for confirmation of diagnosis and treatment plan Patient teaching re: health promotion strategies and lifestyle factors Referral to appropriate resources for adjustment disorders (i.e. psychiatry/psycholog y/social work) Physician Responsibility to Primary Nurse Sign prescription/orders Confirm recurrence/disease progression/patient disease free state Determine plan of treatment for patients with recurrent/advancing disease Physician Responsibility to Nurse Practitioner Sign prescription/orders Confirm recurrence/disease progression/patient disease free state Determine plan of treatment for patients with recurrent/advancing disease

37 Table 5. Advanced Disease/Palliative Nursing Role Contribution to Cancer Patient/Family Care Primary Nurse On-going assessment, specific to site Telephone contact and response to patient queries; triage urgent and non-urgent patient situations Support and interaction for patient and family members Suggests and initiates referral to appropriate resources Patient teaching regarding symptom management, adjustment and coping issues, disease progression, end of life issues Physician Responsibility to Primary Nurse Responds to nurse regarding patient problems related to disease and treatment (ie. vomiting on treatment) Decision-making re: treatment plan, admission etc Participates in development of patient education materials Refers to other specialists and/or disciplines

38 Table 5. Advanced Disease/Palliative - cont. Nursing Role Advanced Practice Nurse Contribution to Cancer Patient/Family Care Comprehensive assessment of patients with complex symptom management issues Provide appropriate interventions to manage identified symptoms (pain, nausea, vomiting, fatigue, metastatic chest wall lesions) Monitor and identify precursors to oncologic emergencies Completes comprehensive history and physical examination Initiates standing orders and, after consultation, admits patient Provide support and counseling, using a theoretical framework, to patients with complex needs (physical, psychosocial) on an individual or group basis Counseling related to adjustments to disease progression/confront ing impending death Physician Responsibility to Advanced Practice Nurse Participates in the development and ongoing monitoring of medical directives outlining scope of responsibilities for A.P.N. within a practice or disease site group Confirms abnormal results, and Confirms appropriate course of action, determines change in medical plan of care

39 Table 6. Palliative/End of Life (Primarily community based) Nursing Role Contribution to Cancer Patient/Family Care Primary Nurse Responds to patient need for admission to hospital through telephone support and triaging, manages patient/family symptoms and distress Nursing Role Advanced Practice Nurse Contribution to Cancer Patient/Family Care Coordinates care of patient/family case management including physical care Physician Responsibility to Primary Nurse Admits patient to hospital Confirms need to admit (depends on model) Physician Responsibility to Advanced Practice Nurse Primary care physician/responds to patient and families needs, symptom management OTHER TEAM MEMBERS Social Worker Provides appropriate psychosocial intervention for patient/family May be involved in bereavement follow up Spiritual Expert Provides appropriate spiritual/existential intervention for patient/family May be involved in bereavement follow up Palliative Care Physician Consultation as needed in patients needing pharmacological or anesthesia management

40 Table 7. IN-PATIENT NURSING CARE Nursing Role Staff Nurse (Primary Care Nurse) Nursing Role Contribution to Cancer Patient/Family Care Basic nursing assessment Provision of bedside nursing care Patient education regarding management of side effects, psychosocial reactions and community resources Support and interaction for patient and family Suggests and initiates referrals to appropriate care providers Identifies precursors of oncologic emergencies Contribution to Cancer Patient/Family Care Physician Responsibility to Staff Nurse (Primary Care Nurse) Responds to nurse regarding patient problems related to disease and treatment (i.e. vomiting on treatment) Orders medications, laboratory tests and interventions as appropriate Refers to other specialists and/or disciplines Physician Responsibility to

41 Nurse Practitioner Comprehensive assessment including history and performs a thorough physical examination Order lab work, radiological tests, appropriate consultation with other health professionals Provide counseling, teaching, clarify expectations about anticipated course of recovery and position on the disease trajectory Identify social support and evaluate home discharge needs Monitor daily progress Work with inpatient nurses to provide clinical expertise and leadership Monitor and manage pain and other symptoms Monitor nutritional status Nursing Role Contribution to Cancer Patient/Family Care Nurse Practitioner Participates in the development and ongoing monitoring of medical directives outlining scope of responsibility for A.P.N./N.P Confirms abnormal results and Confirms appropriate course of action; determines change in treatment plan Physician Responsibility to

42 Advanced Practice Nurse Works in a health care institution to deliver an advanced level of nursing care to a specialized population in collaboration with physicians, nurses or other health professionals Works within medical directives/standing orders Implements research findings in practice and assists staff nurses to do likewise Conducts own research project or work with interdisciplinary research team Engages in processes to achieve quality improvement Mentors staff nurses Develops and offers educational programs for staff and patients Advanced Practice Nurse Participates in the development and ongoing monitoring of medical directives outlining scope of responsibility for A.P.N./N.P. Confirms abnormal results and Confirms appropriate course of action; determines change in treatment plan

43 Further defining nursing roles: How do they work with physicians? Having described the nursing roles and the ways in which various roles can contribute to patient care, it is important to illustrate how these roles interact with the roles of medical practitioners. The physician provides the medical care for cancer patients and contributes to the provision of their supportive care. A nurse, working collaboratively with a physician, ensures care is coordinated, distress regarding symptoms is identified and managed, and patient and family education is provided. Additionally, nurses provide access to on-going care and support as patient status changes via their telephone practice. In ambulatory settings, telephone interactions can constitute a significant portion of the nurse s practice. Nurses working in a Primary Nurse model are able to provide continuity of care and establish a long-term relationship with patients and families. The resulting knowledge about the patient and family coupled with the skill and clinical judgement of the nurse facilitates efficient assessment and response when patient status changes. The nurse is a conduit to the physician and to the cancer care system, thus enabling the patient to access those resources more easily and appropriately than might otherwise occur. When a physician and primary care nurse are working within a trusting and collaborative relationship, many of the patients needs can be addressed by the nurse. Only when the complexity or acuity of a patient need is beyond the scope of nursing practice does the physician need to become reinvolved or consulted. The majority of the patient needs can be met by the nurse, thus allowing the physician to concentrate on issues requiring medical expertise (e.g., decision to admit, treatment related decisions and options, communication about diagnosis and prognosis, etc.). The patient experiences a team approach with each discipline using their expertise to its fullest potential. Other members of the team are consulted (e.g., social work, pharmacy, nutrition, etc) when specific needs are identified which necessitate their expertise. The benefits to patients of a primary nurse model lies in the provision of consistent care and the long term relationship that patients desire when they are trying to navigate through the cancer care system. Thus primary care nurses can form the backbone of a patient-centered care delivery system. Additional nursing roles Additional nursing roles (e.g., NP, APN, CNS) also contribute to innovations in patient care delivery and maximizing the use of resources. NPs and APNs can serve as role models and facilitate the continued development of primary care nurses. They can act as resources and mentors in areas such as physical assessment and the assessment of complex patient needs. They can provide leadership to the organization in terms of research and research utilization and can be involved in projects and issues related to quality patient care.

44 NP and APNs can contribute in the clinical setting by providing comprehensive patient assessment. An experienced NP/APN can increase the number of patients seen in a clinic. These roles can work in concert with physician roles. With new patients, NP and APNs are able to carry out the majority of the assessment with the physician verifying abnormal findings and communicating specific issues (e.g., treatment options) with the patient and the family. Depending upon the practice setting and the area of need, both APNs and NP s can provide clinical support in an organization and work with primary teams or within a disease site group. For example, APNs are able to assume responsibility for patients with complex needs, who would ordinarily require lengthy clinic visits. This allows the primary team to see other patients and address their needs thus providing sufficient care for all patients in a practice. NPs can assume responsibility for well follow-up patients. Working in concert with a physician, more follow-up patients could be seen or an identified group of patients with specific needs could be seen. For example, high-risk patients with breast cancer could be followed up with a physician and a NP. The primary nurse/physician team could follow lower risk patients with more stable disease. In these cases, the physicians responsibility is to be available for consultation, confirm abnormal findings, discuss treatment options and facilitate decision-making with patients and families. Medical Directives All nursing roles can make use of medical directives that have been developed and authorized by the appropriate medical advisory board within the institution. Medical directives allow the nurse to work within a set of parameters when specific patient situations have been identified. For example, a patient with vomiting post chemotherapy will require specific laboratory tests and an assessment to determine the degree of dehydration. Nurses can work within the parameters of the medical directive to ensure the appropriate triaging is done, tests ordered and results obtained. When determining the specific course of action required for the individual patient, the nurse can review the findings with the physician and act on a course of action i.e. admission, rehydration, home care etc. Advanced Practice Nursing Finally, the APN provides care not only to the individual patient but also determines population needs through coordinated research efforts and provides leadership within the organization. The preparation at the Masters level facilitates the ability of the APN to be used within the organization at a more advanced level, i.e. working on quality initiatives, organizational goals and population based educational initiatives etc. as well as within the clinical setting. Conclusions:

45 Organizations need to assess their individual environments to determine their requirements for these additional nursing roles. The decision to introduce such roles must be made based on clinical need and the nature of organizational leadership required. This requires an understanding of primary nursing, nurse practitioner and advanced practice nursing roles. Clarification across CCO will be an important component to the implementation of these roles. Clear job descriptions outlining roles, competencies and qualifications are an important first step. Also, understanding the scope and limitations of each role will be essential to the proper enactment and utilization of registered nurses within CCO. For example, there are many nursing models in the regional cancer centers of CCO. Standardizing components of the nursing role i.e. physical/psychosocial assessment, telephone triaging skills, team functioning, chemotherapy delivery and basic oncology knowledge ensures consistency in nursing. Centers can adapt the role to ensure the unique needs of the center are met, by core competencies should remain clear and definable. Another important issue involves clarifying the role of the primary care nurse practitioner within CCO. Primary care nurse practitioners (PCNP) have been trained to work within the primary care system to deliver care to stable populations of patients. Currently, there are few opportunities for primary care nurse practitioners within primary care. However, many tertiary care centers and under serviced northern centers are looking for help. If CCO is going to recruit PCNPs a consideration must be given to the additional training and development in a tertiary care specialty and an understanding of the scope of practice a primary care nurse practitioner brings. The nursing roles described in this document will allow for the establishment of innovative care delivery and practices. As noted, CCO has the advantage of having many experienced nurses who are practicing at the expert end of the primary nursing continuum. It is important to capitalize on the existence of an experienced and committed pool of oncology nurses who, through additional education and development opportunities could assume innovative or primary nursing roles. Identifying key individuals for further development to assume nurse practitioner or advanced practice roles, is another strategy that could assist the organization in maximizing resources. Additionally, active steps are needed to recruit existing nurses to the field of oncology and to provide the necessary education and skill development. Without these steps, and in view of the impending overall nursing shortage, there may be insufficient nurses to provide even basic cancer nursing care. Enhancing the attractiveness of entering and remaining in the oncology field, through training, education and potential for advancement could be an important step in the recruitment and retention of oncology nurses. Partnerships with universities in the development of curriculum can ensure consistency and quality in oncology education programs. There are opportunities to standardize some aspects of orientation across CCO. For example, the basics of chemotherapy delivery, education related to chemotherapy regimes and toxicities and the

46 basics of toxicity assessment are common themes in all regional cancer center orientation programs for new staff. Every center starts from scratch when developing orientation programs. A core curriculum could be developed for basic systemic issues, augmented with regional cancer center specific policies and procedures. Universities/colleges could also assist in the development of physical/psychosocial skill development programs that could provide the basis for a standardized nursing skill base across all regional cancer centers. Nursing care of cancer patients requires expertise, experience and competency. Used appropriately, nursing roles can support and enhance the care of cancer patients and their families. The need for experienced oncology nurses is escalating within a context of increasing demand for nurses in Ontario. To ensure the availability of experienced oncology nurses and thereby ensuring appropriate cancer care to patients, steps must be taken now. Cancer Care Ontario must show pro-active leadership in recruitment, retention and professional development of nurses for the specialty of oncology.

47 Recommendations: The following recommendations are made to Cancer Care Ontario to attend to the current and potential crisis in oncology nursing: 1. C.C.O. develop appropriate nursing infrastructure provincially i.e. Recruit a Chief Nursing Officer who will support the development of oncology nurses within cancer centers, provide a nursing presence at CCO and a link to stakeholder organizations. 2. C.C.O. acknowledge and recognize oncology nursing as a specialty. Specifically, C.C.O. attempt to recruit nurses with oncology expertise, experience or academic qualifications i.e. CON(C) (Certified Oncology Nurse (Canadian); ONC (Oncology Nursing Certification, American); A post basic certificate or Adult Oncology Program (McMaster) and/or ensure certification and post basic education is supported for current nursing staff. 3. C.C.O. initiate partnership activities and agreements with universities and colleges to offer training and development opportunities for the specialty of oncology nursing. 4. C.C.O. provide pro-active leadership in the recruitment and retention of nurses to the specialty of oncology. Specifically, determine manpower needs per center; mount an active recruitment campaign through universities and colleges; introduce appropriate orientation programs and continuing education programs through universities/colleges; financial support for continuing education; job sharing and part time opportunities; financial support for CON(C) designation i.e. $100 towards tuition. 5. All regional cancer programs adopt primary nursing as a philosophy. Specifically, define the core competencies for primary nursing at CCO through appropriate research initiatives; develop job descriptions and performance expectations and competencies for use by all registered nurses across CCO. 6. Each regional cancer center assess the need for additional nursing models/roles and determine how to integrate the Nurse Practitioner and Advance Practice Nurse roles within the center. Specifically, develop job descriptions, performance expectations and competencies for these roles to be used across all regional cancer programs.

48 Appendix 1 Sub-Committee Oncology Nursing Practice Terms of Reference Purpose: Scope and Tasks 1.0 Oncology Nursing Roles: The purpose of the Oncology Nursing Practice Sub-Committee is to advise the CCO Task Force on the Systemic Therapy Program regarding staffing guidelines for chemotherapy suites and workload standards as they relate to Professional Nursing Practice. Distinct recommendations will be identified for primary care nursing, including chemotherapy delivery and advanced nursing practice roles. 1.1 Define the roles and responsibilities of oncology nurses in Systemic Therapy including the delivery of chemotherapy, primary care nursing and the role of the advanced practice nurse. 1.2 Review current staffing patterns for nurses assigned to the Systemic Therapy Program and recommend workload standards and guidelines. 1.3 Identify strategies to ensure the recruitment and retention of oncology nurses. 2.0 Chemotherapy Delivery: 2.1 Evaluate current training programs for the administration of chemotherapy and make recommendations as appropriate for standardized educational curriculum consistent with College of Nurses (CNO), Canadian Association of Nurses in Oncology (CANO) standards to relevant stakeholders such as CNO and the Ministry of Colleges and Universities. 2.2 Conduct a workload measurement pilot in four Centres and three community chemotherapy clinics on activity level reporting of nursing activities. 2.3 Recommend an appropriate methodology for determining staffing levels and staffing patterns in a chemotherapy unit as it relates to workload volumes. 2.4 Identify continuing education and training needs for oncology nurses in the administration of chemotherapy. Accountability The Sub-Committee will be accountable to the Chair, Task Force on the Systemic Therapy Program of Cancer Care Ontario. Deliverables A report including: Results of the workload measurement pilot on activity level reporting.

49 A methodology for determining staffing levels/patterns for chemotherapy units. A position paper on the roles and responsibilities of oncology nurses in systemic therapy, including Advanced Practice Nurses and Nurse Practitioners.

50 Appendix Ia DEVELOPMENT OF A CHEMOTHERAPY SUITE NURSING WORKLOAD STANDARD FOR CANCER CARE ONTARIO Introduction: The CCO Provincial Systemic Therapy Task Force assigned the task of developing a workload indicator for Chemotherapy Nurses to the CCO Nursing Professional Advisory Committee. Three different indicators were evaluated: 1) Systemic Suite Antineoplastic and Parenteral Treated Cases (S23 on the Activity Level Reports, 2) Total Nursing Complexity in minutes, S16, or 3) Total Systemic Suite Visits, S15. 1) Systemic Treated Cases were not considered a reasonable indicator of workload for the chemotherapy suite, since the nurses see patients each treatment visit, and the number of visits per treated case varies widely by regimen, disease site group, and complexity varies with the type of drug(s) used. 2) Total Nursing Complexity, as measured through the ALR data, was analyzed to show total complexity and average complexity (min.) per visit, by disease site group, by year, and by Centre. The data did not show any significant changes in complexity over time. However, it was recognized that a number of the recently introduced drugs were not being recorded appropriately in OPIS for their complexity. This may explain why overall complexity of chemotherapy delivery appears not to be increasing when, in fact, many feel that it is. Based on the available ALR data, the average complexity, over all disease site groups and all centres, for 1998/1999 was 29.5 minutes (rounded to 30 minutes) per visit. Further work will be required to ensure the appropriate capture of levels of complexity in the systemic suite visits. 3) Total Systemic Suite Visits, which includes non-drug procedures performed by chemotherapy nurses, was chosen as the best indicator currently available for chemotherapy nursing workload. However, it was recognized that not all centres capture the non-drug component of the workload, and an attempt has been made in some cases to estimate what this component might be in the analysis that follows (see foot note to Table 1). Some work had already been done at the Hamilton Regional Cancer Centre using Total Systemic Suite Visits as an indicator for chemotherapy nursing. The analysis that follows is based on this work. Methodology: To determine an appropriate workload standard for nurses working in a systemic therapy suite (chemotherapy treatment unit) administering chemotherapy and other non-chemotherapy related procedures, the following methodology was used: Chemotherapy regimens were assigned a standard nursing complexity or workload value based on increments of 15 minutes. These workload values were based on measured nursing times: minute preparation time for each chemotherapy administration (includes checking doctor s orders and protocol requirements, blood work results, IV set up and IV start, checking chemotherapy drugs and documentation) minutes for anti-emetic administration 5-90 minutes of nursing time for chemotherapy delivery (dependent on the type of chemotherapy regimen: single vs multiple drugs; bolus vs infusion)

51 Using this workload measurement system (WMS), the average nursing time (in minutes) per systemic suite visit was determined for all Cancer Care Ontario centres for fiscal 1998/99. This average of 29.5 minutes was rounded to 30 minutes/visit. This may underestimate workload complexity, because the new agents recently funded through the New Drug Program have not been recorded with an appropriate complexity level. The time available to provide direct patient care during chemotherapy visits was calculated as follows. Staff are scheduled for 8-hour blocks of time. In that time, they get a ½ hour unpaid meal break and two 15 minute paid breaks. Therefore, in an 8- hour shift, there are 7.5 paid hours, of which 0.5 hours are breaks. With breaks and ¼ hour set-up time, there are theoretically 6.75 hours or 405 minutes available per FTE per day for chemotherapy delivery and related activities in the systemic therapy suite. In fact, empirical data from analyses of workload measurement systems (WMS) shows that even in the best of situations, a WMS reflects only 65-70% of the worked time being used for the clinical duties that the system is designed to capture. In part, this is due to the fact that there are non-clinical duties that are not measured, as well as variability in the flow of work, which is typical of systemic therapy treatment units. Based on direct observations of nursing availability/utilization at the Hamilton Regional Cancer Centre, estimates of the time actually available for direct patient care is in the range of 65-70%. This is largely due to the non-uniform flow of patients into the systemic suite for treatment over the course of the day, or over the course of the week. Therefore, based on the above analysis, the available nursing time is 65-70% of 405 minutes ( minutes) divided by 30 minutes per patients or patients per day. Difficulty is experienced when patients are spread unevenly throughout the day, or when too many long chemos are booked (the average complexity would then be significantly higher than 30 min. per visit). In addition, systemic suite visits are cancelled approximately 12% of the time due to factors such as intercurrent patient illnesses, disease progression, etc., and result in an observed number of systemic suite visits per nurse of 8. Based on 45 weeks per year per nurse (52 weeks x 5 days/week minus 13 statutory holidays, 20 vacation days and 8 sick days), the total treated cases per nurse is 45 x 5 x 8 = In many centres there are also 3 Education days and 2 float holidays assigned to each nurse, so the workload per FTE nurse would be less in these centres. Workload Standards Developed by the BC Cancer Agency Provincial Systemic Therapy Program: Through a separate initiative, the BC Cancer Agency has proposed that 1,700 Chemotherapy Appointments per Nurse be adopted as the standard for the BC Provincial Systemic Therapy Program. The methodology for developing this standard of 1700 visits/fte/nurse is not known. Of note, is the fact that the projected average workload for the four BC cancer centres is 1824/FTE/year for fiscal 1999/2000. If we used the standard of 1700 visits/fte/year as suggested in BC, this would equate to 6.88 visits/fte/day.

52 Annual FTE s for Direct Chemotherapy Administration and Associated Procedures: Using 1800 visits per nurse per year as a standard, we can calculate the number of chemotherapy nurses required at each centre, from the Total Systemic Suite Visits (S15) projected for 1999/00 (see table 2 below). Please note that this only calculates chemotherapy nurses required for the direct administration of chemotherapy and associated non-drug administration procedures, and the arrivals function; if the chemotherapy nurses in some centres perform other duties, these other duties, such as patient telephone calls, would need to be justified separately. In addition, in the smaller centres where the number of FTE s is less than 3.0, additional FTE s may be required for coverage. The nursing complexity can also vary from centre to centre based on the drug protocols, programs (i.e., stem cell) or use of different types of equipment (i.e., pumps). The non-drug procedures include such tasks as blood draws through devices, hydration, venous access device and line care procedures, transfusions, dressing changes, suture removal, lumbar punctures, additional patient education, etc. The arrivals function includes checking the scheduled appointments, checking for patient arrivals, checking for drugs mixed, troubleshooting patient problems, and other tasks Table 1 Estimates of the required number of FTE Systemic Suite Nurses required in CCO Centres Based on Proposed Workload Standard Total Systemic Suite Visits (S15 from Nov. ALR), projected for 12 mo of fiscal 99/00 FTEs required for a standard of 1800 HRCC* KRCC *** LRCC NEO RCC NWO RCC ORCC TSRCC ** WRCC 18,463 6,171 14,075 6,284 4,205 24,255 13,608 5, visits/fte/year Fiscal 99/00 FTE s (incl. coverage) The Total Systemic Suite Visits (S15 Core) for each centre were obtained from the November 1999 ALR data on the CCO Intranet and multiplying by 12/8 to project annual numbers. * The HRCC Systemic Suite visits have been adjusted to include an estimated number of non-drug procedures and the scheduled but not treated visits that are currently not being captured in OPIS. This

53 number was estimated by calculating the average percentage of non-drug visits compared to the S1=Antineoplastic and parenteral visits at London, Ottawa, and Toronto-Sunnybrook since 1996/97. ** The TSRCC Systemic Suite visits were calculated by adding 1980 projected annual pump visits to the ALR S15 visits. *** The KRCC Systemic Suite visits have been adjusted to include an estimate of missing non-drug procedure workload.

54 Primary Nurse Staffing Ratio Document Appendix I(b)

55 Appendix J THE EVOLVING ROLE OF THE ONCOLOGY PHARMACY IN ONTARIO Prepared by Larry Broadfield for the Pharmacy Committee of the Systemic Therapy Task Force I. Introduction The rapid growth in the availability of new systemic therapy treatments, the rising incidence of cancer and increased consumer demand for timely, state-of-the-art care have converged to create an unprecedented

56 demand on the systemic therapy program in Ontario. The demands have exceeded the capacity of the system to train and recruit sufficient numbers of health care professionals, and there is now good evidence that the system is under extreme stress. The Pharmacy Committee of the Systemic Therapy Task Force considered strategies that could be undertaken to address the growing need for care providers through the evolution of the role of the oncology pharmacy. A number of the initiatives described below have the potential to improve the quality of patient care while offloading other health care providers of tasks that could be competently provided by pharmacists and pharmacy technicians. Oncology as a Pharmacy Specialty Traditionally, the role of the pharmacist has been to manage the delivery of medications to patients. Pharmacists are licensed health care professionals who have a responsibility to ensure that medications ordered by physicians are provided safely to the patients for whom they are intended. In hospital-based practices, pharmacists have also assumed a role in clinical service provision by ensuring appropriate pharmacotherapy for patients. An oncology pharmacy service emerged in most cancer programs in the 1980s when concerns arose about the occupational safety of workers handling cytotoxic agents. This prompted the development of controlled central admixture programs for chemotherapy preparation, operated by pharmacy personnel. This central preparation of cytotoxic agents in specialized facilities containing biohazard hoods using standardized preparation techniques is now universally accepted in all developed countries. Because of these developments, it is not surprising that specialization in oncology pharmacy has been a recent development. Although practitioners have recognized oncology as a specialty within pharmacy for approximately two decades, it only received official recognition as a specialty in the United States in 1995 through the American Board of Pharmaceutical Specialties (BPS). Certificates are awarded to oncology pharmacists upon successful completion of a peer-reviewed examination, as well as the completion of other requirements. The BPS exam has been offered only twice since oncology was formally recognized as a specialty. Successful candidates may use the letter designation BCOP. In Canada, there is as yet no formal recognition of oncology pharmacy as a specialty. However, development of a specialty is often proceeded by the formation of a professional society. In 1994, the Canadian Association of Pharmacy in Oncology (CAPhO) was formed and now has members. The International Society of Oncology Pharmacy Practitioners (ISOPP), formed in 1993, and now has a membership of These societies are actively reviewing the role of oncology pharmacy in relation to other systemic therapy providers and how oncology pharmacists, in particular, can positively interact and integrate with other systemic therapy providers, including medical oncologists and nurses in the provision of care of high quality to cancer patients. Increasingly, the role of the pharmacist in oncology involves the provision of clinical services such as medication reviews, screening for drug drug interactions and adverse drug effects, patient teaching about medications, management of pharmacotherapy for symptoms resulting from cancer and its treatment and verification of systemic therapy orders to ensure maximum patient safety. Because cancer chemotherapy is universally toxic, and oncologists generally use these drugs at their highest-tolerated dosage, oncology pharmacists can play a key role in the provision of supportive care medications to reduce the toxic side effects of chemotherapy. III. Development of Pharmaceutical Care as the Practice Model for Pharmacy

57 In recent years, the model of pharmacy practice has evolved towards a new paradigm called pharmaceutical care. In this model, it is assumed that the pharmacist will be responsible to each patient for the pharmacotherapy received. This requires that the pharmacist understand and validate medication orders written by physicians and that the pharmacist communicates with each patient about this pharmacotherapy. Increasingly, this is a legal responsibility. With this enhanced responsibility, practicing pharmacists establish a caregiver-patient relationship, as opposed to the past reliance on indirect interactions with patients through others, such as physicians or nurses. As this new model is gradually embraced by pharmacists, the role of the pharmacist will change. It will require oncology pharmacists to participate to a much greater degree in patient medication teaching. This increased interaction with cancer patients will require adaptation by patient and care providers alike, as pharmacists integrate into care provider teams to enable patient education and treatment. Current Status of Oncology Pharmacy Practice in Ontario Virtually all injectible systemic therapy agents are prepared by central pharmacy admixture services located in regional cancer centres or hospitals which have oncology programs. All of these pharmacy facilities meet the standards established by Cancer Care Ontario for chemotherapy preparation. The number of oncology pharmacists in Ontario is small, as it is across Canada. Hospitals struggle to recruit and retain licensed pharmacists due to a national shortage. Recruitment of hospital-based pharmacists is more difficult as salaries are not competitive with retail positions. However, the opportunity for progressive professional practice and regular working hours does appeal to many pharmacists and there is continued interest by the pharmacy community in oncology practice. In community hospitals, oncology units are smaller and therefore must employ the services of a single pharmacist and technician on a part-time basis only. Advanced practice roles among practicing oncology pharmacists are rare largely due to current workloads. Most oncology pharmacies report significant workload increases in recent years and the workload itself is of higher acuity. These increases have not been matched by compensatory increases in pharmacy human resources. Currently there is no formal training program for oncology pharmacy and only a few Ontario oncology pharmacists have taken the BPS examination to date. However, oncology pharmacists are committed to continued professional development, to the development of their specialty and to greater patient-care responsibility. To this end, in the absence of a formal training program, most oncology pharmacists participate in multiple continuing education opportunities. For example, the National Oncology Pharmacy Symposium, which is held annually in conjunction with the NCIC meeting, is attended by about 150 oncology pharmacists annually. The development of specialized oncology training programs within pharmacy schools would be a logical next step in the evolution of the oncology pharmacist s role in the new model of pharmaceutical care. V. Opportunities for Oncology Pharmacy With the current human resource pressures and the increasing demand for service, it is essential that oncology pharmacy resources be used optimally. In this regard, the oncology pharmacy, working within the Systemic Therapy Program, must optimize the use of its various workers. Simply stated, clerical staff should undertake clerical tasks, technical tasks should be undertaken by pharmacy technicians and

58 professional staff (pharmacists) should undertake cognitive tasks. By optimizing the use of the oncology pharmacy, physicians should be able to devote a greater proportion of their time to diagnostic and direct medical tasks, while other health care professionals, including pharmacists, provide educational and supervisory activities formerly undertaken by nurses and physicians. In this situation, all health care providers must participate as full members of functional care provider teams, supporting each other in their collective activities. By so doing, each health professional should derive enhanced job satisfaction while each patient receives high quality care. Greater support of the medical oncologist in carrying their caseload should enable them greater time to see the growing number of patients. In order to achieve this goal, there must be: 1) adequate numbers of appropriate personnel, including clerical staff, pharmacy technicians and pharmacists. 2) adequate space in patient-care areas to enable the pharmacists to participate in patient teaching 3) appropriate training and ongoing staff development of pharmacists, technicians and support personnel. VI. Future Roles for Oncology Pharmacy Listed below are potential future roles for the oncology pharmacy. Some of these are in existence as "best practices" in various centres in Ontario now. These are summarized in Appendix 1 of this report. Efforts should be made to share the experience from these initiatives across the province. 1. Supervision and management of chemotherapy orders. Many chemotherapy regimens require repeated treatments over many months. In some cases, these treatments are quite routine (e.g. adjuvant breast cancer therapy). The oncologist could order part, or the entire course, of chemotherapy and initiate the first treatment. The pharmacist could review side effects and ensure the delivery of subsequent courses of treatment according to standardized orders making dose adjustments in the management of commonly-expected toxicities. The pharmacist would contact the oncologist for unexpected or severe problems. The advantage of this approach would be that physician time would be freed up as the oncologist would not be required to review the patient at each treatment visit. The pharmacist could provide close supervision of toxicities and ensure appropriate supportive care drugs and systemic therapy administration. At the same time, psychosocial support could be provided by the pharmacist and the nursing staff. 2. Advanced Directives If the oncology pharmacist is to undertake an expanded role, advanced directives will be required from physicians. These would consist of standardized orders for typical treatment situations, standard monitoring criteria for adverse events and rules for when physicians should be contacted. To be effective, advanced directives require that the oncologist and pharmacist truly work as a team, with the potential benefit to the oncologist being a major saving in time. 3. Patient Medication Reviews In the pharmaceutical care model of pharmacy practice, the oncology pharmacist would interact directly with patients during their initial and subsequent clinic visits to look for potential drug-interactions and the adverse effects of cancer chemotherapy on other medication. Again, the oncology pharmacist must be a true team member and participate within the oncology clinic in order to directly access the patient during initial consultation and subsequent assessments. Such timely access to the patient would avoid "downstream"

59 medication reviews, communication difficulties or drug-related problems, resulting in improved quality of patient care. 4. Delegated Prescribing for Symptom Control The oncology pharmacist could take on the responsibility of providing selected symptom control medications according to specific protocols. These might include anti-emetics, antibiotics for low-risk febrile neutropenics, anti-diarrheal medications, analgesic dose adjustment and supportive care drug administration, such as G-CSF and erythropoietin. The advantage to the oncologist of pharmacists prescribing for symptom control would include reduced time for the oncologist to manage supportive care drugs, provide greater job satisfaction for pharmacists and potentially improve the overall quality of care for patients. 5. Patient Medication Teaching This should be a major role of the oncology pharmacist. It would be important to clearly define this role in relation to nursing and the oncologist in order to avoid unnecessary duplication. It is an opportunity to reinforce patient knowledge and medication, increase the quality of care, reduce unnecessary telephone calls to oncologists or triage offices in busy cancer centres and to improve the professional job satisfaction of pharmacists. 6. Technician-Check-Technician for Chemotherapy Doses Once chemotherapy orders have been verified by an oncology pharmacist in a large chemotherapy in a treatment facility, the doses prepared by one technician are then checked by another technician. This will require a training program for technicians. The benefit of a such a tech-check-tech system is that it would free up pharmacist time for other duties and may increase the speed of chemotherapy preparation. 7. Clinical Trials - Technician Role For chemotherapy drug trials, the pharmacy technician could undertake drug management, inventory and accountability, participate in the initial clinical trials start-up and audit visits and develop standard pharmacy procedures for managing drugs and clinical trials. The advantage of this delegation of clinical trials related pharmacy activities to a technician is that it frees up pharmacists' time for other duties. 8. Assist with Drug-related Correspondence There is an increasing amount of burdensome correspondence associated with the acquisition of chemotherapy drugs. Currently much of this is done by oncologists. Clerical staff working within the oncology pharmacy could use standard forms to generate correspondence for government such as the completion of Section 8 - Requests or the provision of information for special drug access programs or insurers. The Cancer Care Ontario new drug forms could also be completed by clerical staff under the direction of the oncology pharmacist. The advantage of this approach would be to reduce by oncologists completing paperwork. In addition, insurance issues and timely feedback on prescription problems are efficiently undertaken by the pharmacy. IV. Summary An expanded role for oncology pharmacy will not, in and of itself, resolve the human resource shortages of the Systemic Therapy Program. However the changes in roles described above will enhance the efficiency of other care providers and result in improvements of patient-care quality. As indicated, most of these role changes have been tried in one or more oncology pharmacy practices in Ontario in one of its regional cancer centres, academic or community hospitals. Many of these role changes could be adopted more widely and evaluated for effectiveness. However, essential for the success of any of these strategies will be support for management and staff for a changed role for oncology pharmacy. Also essential for the success of an expanded role for the oncology pharmacist is the provision of adequate

60 support staff, space and technology (e.g. informatics). With many of the suggested role changes, it is expected that time efficiencies can be gained while simultaneously improving patient care.

61 Appendix J(a) RECOMMENDATIONS FOR WORKLOAD STANDARDS FOR THE ONCOLOGY PHARMACY To determine an appropriate workload for pharmacists, pharmacy technicians and clerical staff working in an oncology pharmacy, preparing and dispensing chemotherapy, as well as providing clinical and administrative support to patients, physicians and clinical trials initiatives, the following assumptions were made and analyses undertaken: Assumptions: Regional Cancer Centres and community oncology programs provide similar pharmacy services in the preparation of chemotherapy for patients. Appropriate indicators of human resource needs are treated systemic therapy cases, systemic suite visits or prescriptions filled. Human reource requirements for retail pharmacy services, should be planned and budgeted for separately from other pharmacy services. Workload related to inventory management, or educational services should be proportionate to chemotherapy workload and included with direct chemotherapy services when calculating human resource needs. Pharmacy administration includes a number of different components; however administrative workload should be proportionate to the number of staff supervised. (In some regional cancer centres, this supervision is provided by the host hospital pharmacy department, but for most RCCs, direct supervision is done at the Centre. Clinical patient services may also include a variety of activities for the pharmacist. As recommended in the Task Force report, Cancer Centres should plan for sufficient pharmacist numbers to provide at least a rudimentary clinical service. Data Sources: Systemic therapy visits (chemotherapy suite visits for systemic or supportive therapy), and new systemic cases were obtained ALR data posted on the CCO website (1999 data). Number of parenteral prescriptions was obtained from OPIS data. (Table 1.) Each RCC was surveyed to obtain the total pharmacy human resource complement and the distribution of FTEs according to categories of work in and (year to date). The survey data is summarized in Table 2. The work categories identified: Retail Pharmacy Chemotherapy Related Activities Inventory Management (adjusted for sites with retail pharmacies- 50% of posted inventory time reallocated to retail pharmacy) Clinical Trials Activities Patient Clinical Services Administration Activities Education Activities Other (some exceptional workload removed from analysis, e.g. time spent on CCO Formulary Project) Funded vacant positions Similar data was requested from selected non-cco sites, for comparative purposes. As data was only provided from one non- CCO site, it is not included in the analysis. Data Analysis: For each RCC, the number of systemic suite visits and prescriptions per pharmacist and pharmacy technician were determined using 1998 data (Table 3.) Two Models of Oncology Pharmacy were described: Model 1: This model includes all pharmacy functions in the calculation of the workload ratios for pharmacists and technicians, except the work related to the operation of a retail pharmacy.

62 Model 2: This model also excludes the work of the pharmacist and technician in relation to clinical trials, pharmacy management and clinical patient services, i.e. it includes only those activities which are directly related to chemotherapy preparation and dispensing For each model, an analysis was undertaken of the ratio of pharmacists to pharmacy technicians Data were compared with workload standards developed in British Columbia by the BC Cancer Agency Current Pharmacy Human Resources: From the data, the following observations were made: There is a wide variance in the numbers of visits per pharmacist or technician between RCCs Smaller RCCs tend to have more pharmacists relative to technicians (T:P range 0.6 to 1.0:1) while larger RCCS had more technicians (T:P range 1.1 to 1.8:1)- See Table 3 The retail pharmacy staffing was similar for each of the 3 RCCs with a retail pharmacy unit. Only one RCC currently has substantial resource committed to Clinical Patient Services (NEORCC) The workload ratios were remarkably different between the 2 ORCC sites; however, it was noted that visits and new cases were increasing at the General site and decreasing at the Civic site The Use of Current Best Practices to Benchmark Pharmacy Workload: Benchmarking of all RCCs pharmacy activities from one RCC produced confusing results that were not supportable. Therefore, it was decided to model pharmacy services against the current Best Practices identified in RCCs across CCO HRCC was identified as having the best practice as relates to technicians checking other technicians (Tech-Check-Tech; T-C- T) for chemotherapy dose preparation; TSRCC was felt to have an optimal number of pharmacists for their chemotherapy program and workload at TSRCC was used as Best Practice for pharmacists in the chemotherapy delivery role. NEORCC has the best developed pharmacy clinical patient services model and therefore was used as Best Practice for this activity HRCC Pharmacy is currently the only Centre with dedicated clerical support. This was used to benchmark clerical support for other RCCs Other RCCs have strengths, but these centre Best Practices were felt to be most useful for determining oncology pharmacy human resource needs. Choice of Indicators of Workload: Analysis of the data revealed that some indicators were better predictors for different functions. No single workload measure was appropriate to use for all pharmacy functions and human resource needs: Pharmacy technician workload is most directly related to the number of orders/prescriptions filled for patient care; therefore, the number of parenteral prescriptions was used as the workload measure to determine the appropriate number of pharmacy technicians (N.B. parenteral routes include IV, IM, IT, SC, etc. and all these non oral routes of chemotherapy administration should be included in the ALR reports for parenteral chemotherapy). Pharmacists workload in the chemotherapy program was felt to be best related to the amount of therapy review time, which in turn is directly related to the number of systemic suite visits. Pharmacist workload providing clinical patient services is analogous to the clinical services offered by oncologists and nurses and, therefore, new systemic treated cases were identified as the most relevant indicator of workload. The administrative responsibilities of pharmacists are attributable to a number of different activities. To account for the variance between sites with and without retail pharmacies, administration workload was related to the number of personnel being supervised. Clerical support is linked to the magnitude of the administration time. Recommended Workload Standards for the Oncology Pharmacy: Pharmacy technicians:

63 For the seven RCCs not using a Tech-Check-Tech model of chemotherapy preparation, the number of prescriptions per FTE ranged from 8,498 to 20,169 when analyzed according to Model 1, or 9,029 to 20,169 for Model 2. The mean value for Model 2 (including the significant outliers, KRCC and ORCC General) was 11,750. This was rounded to 11,500 prescriptions per FTE for workload measurement. The HRCC is the only RCC that has implemented the Tech-Check-Tech model proposed for CCO in Oncology Pharmacy document. The number of scripts per FTE was 9,380.8 or 10,468 when analyzed for each of the 2 models. The mean value was 9,500 scripts per FTE, which is below the mean of the prescriptions using current practice. As it should produce a more efficient throughput, it will not be used at this time to determine workload for the oncology pharmacy. Pharmacists- Chemotherapy Delivery: Model 2, which excludes retail pharmacy, clinical trials (justified independently from core services), clinical patient services (calculated separately) and pharmacy administration (also calculated separately) was used for comparison between RCCs. Using systemic treatment visits per FTE, the workload varied from 3,247 to 12,337. The mean number of visits per FTE was 6,770 (4,870 for smaller RCCs and 8,290 for larger RCCs) As TSRCC indicated that their pharmacist staffing appears optimal for their workload and there are 5,916 visits per pharmacist FTE, the workload for pharmacists for chemotherapy delivery was defined as 6,000 systemic suite visits/ FTE. Pharmacists- Clinical Services: Workload to provide clinical services has been minimal at most RCCs to date, as there have been insufficient human resources to devote to this area of practice in Pharmacy departments As an initial step, CCO should benchmark to the only oncology program, currently operative in the province, which is at NEORCC. The Oncology Pharmacist takes patient medication histories for each new systemic therapy patient. At NEORCC. 0.5 FTE pharmacist provided a basic service to 752 new systemic therapy patients in 1999, a ratio of 1,504 new cases per FTE. This was rounded to a workload ratio of 1,500 new systemic therapy treated cases per FTE. It should be noted that this clinical service only provides an average of minutes of pharmacy clinical service time per new patient. Therefore, this benchmark will need revision as clinical services expand across CCO in response to evolving role of oncology pharmacists Pharmacists- Administration Time: Administration includes many activities, of which supervision of personnel is the major component; RCCs with retail pharmacy units have a proportionately larger staff group to supervise. The amount of administration time varies widely across the province, especially when compared with the number of staff supervised (Table 4.) The average for all RCCs was FTEs supervised per FTE Administration time (12.19 for larger RCCs vs for smaller RCCs). The benchmark value chosen was 12 FTEs supervised staff per 1 FTE pharmacist for administration time. Comprehensive Model for Pharmacy Manpower in CCO: Using benchmarks, key indicator values, and actual resource utilization for non-calculated components, a comprehensive model is constructed as follows: Pharmacy Technicians: If Tech-Check-Tech is in place, 1 FTE Technician per 9,500 scripts If Tech-Check-Tech is NOT in place, 1 FTE Technician per 11,500 scripts Pharmacists:

64 For Clinical Services, 1 FTE Pharmacist per 1,500 Systemic Treated Cases For Chemotherapy Core Services and other activities, 1 FTE Pharmacist per 6,000 Systemic Treatment Visits For Administration (pharmacist only), 1FTE Pharmacist per 12 FTE supervised staff; if staff supervised by host hospital pharmacy administration, actual values are used For the purpose of calculating the total oncology pharmacy complement, the staffing for Retail Pharmacy and staffing for Clinical Trials (Pharmacists and Technicians) was the actual number of persons currently employed for these specific functions; any enhancements in these areas would have to be justified independently from the model Other Centre-specific activities must also be justified independently from the model (e.g. extra staffing levels to support community outreach systemic therapy delivery, special projects such as the CCO Formulary, etc.) These additional staffing needs are NOT included in the oncology pharmacy human resource model. The staffing levels required under this model are derived from data in Tables 5a, b and displayed in 5c & d. Summary of Human Resource Requirements for the Oncology Pharmacy for CCO Pharmacists: There is a conservatively projected need for an additional 7-8 FTE pharmacists across CCO. This would allow for a core service with minimal clinical patient services and adequate staff supervision. Only 1 Centre (NEORCC) is projected to have adequate pharmacist staffing, and this site has support for an extensive outreach systemic treatment program (these activities are NOT included in the model). Other RCCs need between 0.2 and 2.0 FTE pharmacists, just to meet current centre-related workload demands. Pharmacy Technician numbers need to increase by 3-4 FTEs across CCO for a Tech-Check-Tech program (exclusive of technician justifications beyond this model). Many pharmacies noted that much technician time is spent performing clerical duties, which may be shifted once clerical support becomes available for the Pharmacies. Clerical support is almost non-existent in CCO Pharmacies. A conservative estimate of need across CCO is for 1.75 FTEs (i.e. ½ to 1 day per week in most RCCs. Comparison with Staffing Standards from BCCA: The British Columbia Cancer Agency (BCCA) has a human resource plan, that includes Pharmacy staffing for their outpatient systemic therapy program. The BCCA plan bases human resource needs upon prescriptions as the only workload indicator. The BCCA plan anticipates a ratio of Pharmacists to Technicians of 1 to 0.65, in comparison to the range in CCO of 1 to (excluding retail pharmacy staffing levels). The planned workload in BCCA is 5,800 prescriptions per pharmacist. The current actuals for BCCA are documented in Table 6. The data available does not include prescription totals, only relative workloads, so only relative comparisons may be made CCO does not come close to equaling the BCCA Provincial Standard of 5,800 Scripts per Pharmacist. In BC, the range is 2,466 8,255, while in Ontario the range is 5,521 24,203 with a mean across CCO of 9,155 Given the difference in staffing patterns between BC and Ontario, a fairer comparison may be the number of scripts per Pharmacy FTE. In BC, the adjusted standard would be 3,515 scripts per FTE, with an actual range of 1,724 4,914. By comparison, in CCO the provincial mean is 4,147, with a range of 3,704 11,001. Not one RCC in Ontario achieves the BC standard, and the average CCO workload is 18% greater than the BC standard (range 5% to 213% above BC standard) Future Needs Once implemented, the staffing standards need to be revisited for their appropriateness every three years Staffing should be based on the recommended oncology pharmacy model with numbers and type of human resources determined annually on the basis of actual workload. Future human resource needs should be based on three-year caseload projections and estimates of systemic suite visits and numbers of prescriptions. Workload and human resource data should be collected from CCO sponsored community oncology programs and non-cco programs to ensure that these programs are appropriately resourced As more data becomes available and experience is acquired, this model may further refinement to adjust workload standards according to the size of the systemic therapy program )small vs large centre vs community-based satellite unit)

65 Summary: A model has been developed to project optimal pharmacy manpower needs to manage current workload levels. Most RCCs are deficient in human resources in varying degrees. This model is based on conservative estimates, and allows very little opportunity to evolve the role of the Oncology Pharmacy, as recommended by the Systemic Therapy Task Force. However, it provides a standardized methodology of determining the level of staffing for Pharmacy services according to growth in caseload. The model will need revision over time by the CCO Pharmacy PAC to accommodate changes in oncology pharmacy practice. Table 1. Key Indictor Values from ALR Data- Dec 1998-Nov 1999 Core Scripts Core Visits & Cases HRCC IV Chemotherapy Scripts* S1 Antineoplastic Parenteral Treatment Visits 15,083 Total Visits Other IV Scripts** S5 Supportive Agents (e.g. cytokines, ivigg, etc.) 1, Total IV Scripts 36,116 S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 1530 KRCC IV Chemotherapy Scripts* 9,162 S1 Antineoplastic Parenteral Treatment Visits 5,340 Total Visits Other IV Scripts** 4,647 S5 Supportive Agents (e.g. cytokines, ivigg, etc.) Total IV Scripts 13,809 S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 702 LRCC IV Chemotherapy Scripts* 19,239 S1 Antineoplastic Parenteral Treatment Visits 10,644 Total Visits Other IV Scripts** 16,012 S5 Supportive Agents (e.g. cytokines, ivigg, etc.) Total IV Scripts 35,251 S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 1316 NEORCC IV Chemotherapy Scripts* 9,690 S1 Antineoplastic Parenteral Treatment Visits 5,247 Total Visits Other IV Scripts** 4,756 S5 Supportive Agents (e.g. cytokines, ivigg, etc.) Total IV Scripts 14,446 S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 752 NWORCC IV Chemotherapy Scripts* 6,345 S1 Antineoplastic Parenteral Treatment Visits 3,546 Total Visits Other IV Scripts** 3,492 S5 Supportive Agents (e.g. cytokines, ivigg, etc.) Total IV Scripts 9,837 S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 469 ORCC BOTH DIVISIONS S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 2404 CIVIC DIVISION IV Chemotherapy Scripts* S1 Antineoplastic Parenteral Treatment Visits 8,632 Total Visits GENERAL DIVISION TSRCC WRCC Other IV Scripts** 6407 S5 Supportive Agents (e.g. cytokines, ivigg, etc.) Total IV Scripts 24,203 S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 1055 IV Chemotherapy Scripts* S1 Antineoplastic Parenteral Treatment Visits 11,035 Total Visits Other IV Scripts** S5 Supportive Agents (e.g. cytokines, ivigg, etc.) Total IV Scripts 31,323 S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 1349 IV Chemotherapy Scripts* 19,413 S1 Antineoplastic Parenteral Treatment Visits 9,554 Total Visits Other IV Scripts** 9,905 S5 Supportive Agents (e.g. cytokines, ivigg, etc.) Total IV Scripts 29,318 S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 1150 IV Chemotherapy Scripts* 9,474 S1 Antineoplastic Parenteral Treatment Visits 4,843 Total Visits Other IV Scripts** 149 S5 Supportive Agents (e.g. cytokines, ivigg, etc.) 4896 Total IV Scripts 9,623 S23 Systemic Suite, Antineoplastic Parenteral Treated Cases 608 * All chemotherapy drugs given by parenteral routes (IV, CIV, PIV, IT, SC, IP, IPL, IM, VES) ** All non-chemotherapy drugs given by parenteral routes (IV, CIV, PIV, IT, SC, IP, IPL, IM, VES) Numbers of Cases are estimates from previous 3 years data, inflated by average annual growth rate; for some clinics (KRCC, NWORCC, WRCC), actual numbers were increased by the CCO average for calculated RCCs Data N/A for separate ORCC Divisions- Cases assigned in proportion to S1 Visits

66 Pharmacists FTE Retail Table 2. Reported Actual Human Resources in RCCs- Nov 1999 Chemotherapy Inventory Clinical Trials Pt Clinical Services Admin Education Other TOTAL FTE Comments HRCC KRCC LRCC ORCC Civic ORCC General NEORCC NWORCC actual 1.1 FTE TSRCC WRCC only 1 FTE! Mt. Sinai Pharmacy technicians FTE Retail Chemotherapy Inventory Clinical Trials Admin Education Other TOTAL FTE Comments HRCC KRCC LRCC ORCC Civic ORCC General NEORCC NWORCC TSRCC WRCC only 1 FTE! Mt. Sinai Mt. Sinai Visits; 43.3% of scripts (workload) for Outpatients

67 Table 3. Systemic Suite Visits # and Parenteral Scripts per Pharmacist and Pharmacy Technician- 2 Models Visits/ Pharmacist MODEL 1* MODEL 2** Visits/ Tech Scripts/ Tech Visits/ Chemo Pharmacist Visits/ Chemo Tech Scripts/ Chemo Tech Scripts Visits HRCC 36, KRCC 13, LRCC 35, ORCC Civic 24, ORCC 31, General NEORCC 14, NWORCC 9, TSRCC~ 29, WRCC 9, Mt. Sinai 7, TOTAL 203, AVERAGE RANGE 8,498 to 3,247 to 12,337 3,297 to 7,760 9,029 to 20,1 20,169 Averages: Small RCCs Averages: Large RCCs # Includes totals of S1 & S5 from core RCC ALR reports, Dec 98-Nov 99, as surrogate for calendar 1999 * Excludes all pharmacists and techs assigned to retail pharmacy ** Excludes all retail, clinical trials resources plus management & clinical pharmacist resources ~ Removed 0.5 (Formulary Project) and 0.5 (Education- students)

68 Table 4. Ratio of Administration Time to FTEs Supervised Administration Optimal Admin Workload Ratios* 12FTE/Admin Variance Host Host Host * (Total FTEs-Admin time)/admin time Average (excluding Host administered RCCs) Large RCCs Small RCCs

69 Table 5a. CCO Pharmacy Manpower Model- Key Indicators and Actual Staffing Levels for Non-Modelled Activities KEY INDICATORS 1999 Actual Staffing Retail Pharmacy Clinical Tria Dec 98-Nov 99 Systemic Scripts/ Centre Scripts Visits Treated Cases Visit Techs Pharms Techs Pharms Techs Pharm HRCC KRCC LRCC ORCC Civic ORCC General NEORCC NWORCC* TSRCC~ WRCC* ~ Excludes 0.5FTE (Formulary Project) and 0.5FTE (Student Educator) * Adjusted to actual staffing levels proportionately Table 5b. CCO Pharmacy Manpower Model- Pharmacy Technician Staffing Levels Core Services Current TOTALS Actual # Va Centre With T-C-T No T-C-T Clinical Trials Retail With T-C-T No T-C-T With HRCC KRCC LRCC ORCC Civic ORCC General NEORCC NWORCC TSRCC~ WRCC TOTALS: T-C-T is Technician-Check-Technician model

70 Table 5c. CCO Pharmacy Manpower Model- Pharmacist Staffing Levels for Modelled Activities Core Services Current Clinical Services Administration Centre Current Planned Clinical Retail Current Planned Current With No Trials T-C-T T-C-T Actual # HRCC KRCC LRCC ORCC Civic ORCC General NEORCC NWORCC TSRCC~ WRCC TOTALS: 22 Table 5d. CCO Pharmacy Manpower Model- Pharmacy Clerical Staffing Levels for Modelled Activities Centre Current Planned Variance HRCC KRCC LRCC ORCC Civic ORCC General NEORCC NWORCC TSRCC~ WRCC TOTALS: 1.73

71 Staffing Table 6. Comparison of CCO Centres to BCCA Centres for Pharmacy 1999 Data Scripts/ Pharmacist* Technician: Pharmacist Scripts/ FTE BCCA Centres VCC VICC FVCC CCSI BC Provincial Standards CCO Centres HRCC KRCC LRCC ORCC Civic ORCC General NEORCC NWORCC TSRCC WRCC CCO Provincial Mean * For this analysis, retail time only is excluded from CCO staffing

72 Appendix J(b) Training Issues for Oncology Pharmacy A Report for the Systemic Therapy Task Force of Cancer Care Ontario Prepared by Larry Broadfield, on behalf of the Pharmacy Committee of the Task Force Introduction: The emergence of oncology as a pharmacy specialty is a recent trend, based upon growing demand for this specialized professional service. Pharmacists are trained at the baccalaureate level and graduate with a BSc degree in Pharmacy. To practice, pharmacists require licensure by the Ontario College of Pharmacists. Pharmacists may continue with post-graduate education in an academic stream towards a Master s degree or in a clinical practice stream towards a Pharm D. An advanced practical experience can be obtained in a Residency in a teaching hospital, which results in a certificate of completion. Practicing pharmacists may participate in continuing education (CE) opportunities, including in Oncology pharmacy. Some pharmacy technicians are trained at the Community College level. College diploma courses for Pharmacy Technicians have been developed over the past decade; many senior Pharmacy Technicians have not had the opportunity to take these college courses or to obtain a diploma. Recently, the Ontario College of Pharmacy has begun to offer semi-annual training courses for Pharmacy Technicians. Based upon experience, successful completion of training and a standard examination, a certificate is awarded. Some hospitals also offer formal technician training courses. Hospitals and cancer centres require, as a minimum, that pharmacists be licensed by the Ontario College of Pharmacy. Advanced qualifications are not required. Few health care facilities require pharmacy technicians to hold a diploma or certificate, although candidates with these credentials are preferred. Collective bargaining agreements often do not accept the college diploma as a minimum requirement for pharmacy technicians. The Current Status of Oncology Pharmacy Training in Ontario: The only undergraduate pharmacy program in Ontario has little oncology content in the curriculum. This lack of formal exposure to oncology topics during pharmacy training leaves many graduates fearful of this specialty and therefore unlikely to chose oncology pharmacy as a career path. Most practicing oncology pharmacists are self-taught, having learned about cancer care on the job. Without a formal training program, oncology pharmacist knowledge levels are variable. Continuing education opportunities are plentiful, but these do not ensure a solid base of core knowledge of oncology. An Oncology Specialty Certification process was started in the USA several years ago, but to date few practicing oncology pharmacists from Canada have taken the opportunity to write this certification examination. Pharmacy technicians receive technical training in chemotherapy preparation during Community College diploma courses. However, there is variability in the quality of this technical training. Some recent college graduates have entered positions in hospitals and cancer centres with unsatisfactory entry-level skills.

73 What are the Barriers to Training? For oncology pharmacists who have been practicing for several years, practice and personal commitments limit the time available to participate in formal education programs. The University of Toronto Faculty of Pharmacy has not yet developed an oncology focus in the undergraduate curriculum. Oncology rotations have generally not been fostered within the undergraduate program. Training Needs for Pharmacy Technicians The top priority for this group is to ensure that both new and current pharmacy technicians have received standardized training on the safe handling of cytotoxic drugs, and on aseptic drug preparation. As oncology pharmacy units evolve to a tech-check-tech role (where technicians check each other s work and dispense a final product without a final check by the pharmacist), additional training will be needed to ensure the quality of this advanced practice. Cancer Care Ontario should take the lead to ensure that all pharmacy technicians in cancer treatment sites achieve standardized training and certification. We recommend the following plan for standardized Pharmacy Technician training: Establish a set of program objectives and a standard course outline for the technical training of pharmacy technicians working in chemotherapy preparation facilities. Disseminate these objectives to the community college programs and to the coordinating body of the pharmacy technician programs, for incorporation into existing diploma courses. Maintain a registry of those training facilities that have incorporated these training objectives into their curriculum. Work with the Community Colleges to develop a standard course for pharmacy technicians currently in cancer treatment facilities, which will enable pharmacy technicians to upgrade their skills A working group from the CCO Pharmacy PAC (PPAC) should be struck to work with the Community Colleges to develop the program objectives and course outline. The working group should include representation from outside the CCO RCCs and PMH. Training Needs for Pharmacy Students As there is a growing shortage of pharmacists across Ontario, it is critical that oncology pharmacy be promoted as a challenging and rewarding career path to undergraduate and postgraduates using the following approaches: Pharmacy students need to be exposed to relevant oncology content in the undergraduate program. Enhanced knowledge of oncology will be advantageous to pharmacists and to the whole of the cancer care system. For postgraduates, there is a need to create oncology pharmacy specialty residencies and develop oncology specialists within the Pharm D program. Such oncology-specialty trained residents or Pharm D practitioners specializing in oncology will be of greatest benefit in tertiary care centres such the RCCs and Princess Margaret Hospital. To begin this process, we believe that CCO s PPAC should petition the Faculty of Pharmacy, University of Toronto to enhance oncology in the undergraduate curriculum. Members of the Pharmacy faculty have indicated that they would be willing to include an oncology rotation if the oncology pharmacy community were willing to develop it and participate in its teaching. The Pharmacy PAC should work to establish an Oncology Pharmacy Residency program. Such a program is currently under consideration at the PMH. The PPAC should promote

74 oncology rotations for residents in other programs, with predefined and uniform expectations for these rotations. The PPAC, in consultation with pharmacy residency directors, should develop a standard oncology rotation to be offered to general pharmacy residents. Oncology pharmacy programs for Pharm D students should be explored. Training Needs for Practicing Pharmacists The majority of pharmacists practicing in the oncology field are doing so without the benefit of formal training. It is generally acknowledged that the knowledge and skill levels of individual practitioners vary. Some oncology pharmacists are recognized as experts among their peers. Pharmacists in academic centres tend to have more opportunities for self-education, but all oncology pharmacists could benefit from a formalized training program and continuing education. Pharmacy practitioners are constrained in their ability to obtain additional education or training by commitments to work and family, or by financial barriers. In addition, employers have limited ability to replace staff, who are absent for continued training, especially if there is a significant time commitment. For example, extended leaves for training would not easily be sustained by many employers. Training costs to continue practicing at the same job would be a financial barrier to most pharmacists. Recommendations on the Training options for Oncology Pharmacists were considered for: i) Junior Oncology Pharmacists: Those pharmacists who are new practitioners or practitioners from smaller centres with less oncology exposure and fewer learning opportunities ii) Senior Oncology Pharmacists: Those pharmacists who are experienced practitioners with formal oncology training or long-standing practice in a tertiary centre) Junior Oncology Pharmacists are potential candidates for training in the basics of oncology practice. The PPAC should undertake a survey to determine what programs are presently available in Community Colleges, through correspondence courses, or at programs in teaching hospitals or oncology centres in support of such training. Some amount of hands-on practical training would still be needed, even with comprehensive local or correspondence learning options. For this practical experience, Senior Oncology Pharmacists are likely to be the trainers. Senior Oncology Pharmacists, may benefit from specific administrative training for the emerging Managed Systemic Therapy Program and other oncology programs, or as educators for a Train-the-Trainers level of educational session/seminar. These programs would be new initiatives requiring developmental work. Participation in Continuing Education should be documented in the pharmacist s learning portfolio (see recent regulations from OCP), and submitted to a designated administrative centre, to monitor oncology-specific learning by pharmacists. CCO could then track the amount of continuing education as a quality indicator of pharmacists activities in both RCCs and community oncology programs. Future Training Concepts for Practicing Oncology Pharmacy The Pharmacy Committee of the Task Force felt that formal programs of continued learning that did not require pharmacists to leave their own communities should be established. CCO or an external educational institution might offer correspondence courses and other distance learning options in the future. As well, supervised practical experience would need to be acquired at the tertiary sites. This latter experience could most readily be organized by CCOR region, using the RCC or PMH as a training site.

75 The training model for clinical physicists could serve as the template for an oncology pharmacy training model. This model includes academic learning, practical experience, placement with a mentor, and oral examinations by experts prior to completion and certification. The clinical physicist s model requires a full year commitment by each physicist, during which they provide service and are paid as employees. For oncology pharmacists, practical training could be conducted at an advanced practice pharmacy location for defined periods. The proposed training program could be submitted to the Pharmacy Residency Board (a national body) for advice and assistance with accreditation. Upon successful completion, each participating pharmacist should be awarded a Certificate of completion, with proper notarization by the sponsoring educational institution. Summary: To properly qualify oncology pharmacists and their support staff, several educational strategies must be implemented. Pharmacy Technicians across Ontario should be trained and certified according to standardized criteria to ensure a high quality of technical practice. Additional standardized training should be developed to support advanced practice for the technicians, such as tech-check-tech for final systemic therapy products. Pharmacy students should be provided with more oncology content in their undergraduate curriculum, to eliminate the barriers to oncology pharmacy as a future career option. Postgraduate and residency programs need to be developed. Practicing oncology pharmacists need educational support, both for professional practice quality assurance and for personal job satisfaction. The training and education of practitioners must be balanced against employment and personal commitments. However, a formal training program for current practitioners is recommended. Other educational initiatives, including a central registry of oncology-specific continuing education programs, mentorships, and BPS Certification for Expert Oncology Pharmacists should be encouraged and supported to the extent possible.

76 Oncology Pharmacy Training Action Plan: 1 Develop model(s) for oncology pharmacist training. Survey oncology pharmacists at Ontario practice sites to identify present level of formal and informal training/education in oncology. Determine perceived training needs of oncology pharmacists. Develop an inventory of local oncology training opportunities (e.g. rounds, community college courses, correspondence courses, other opportunities). Develop an inventory of self-learning opportunities for Ontario oncology pharmacists 2 Pharmacy Technicians Training Compile technician training materials for oncology drug preparation from RCCs, PMH, community colleges and other sources Develop a summary of key training elements and compile into standard training program. Submit program to each CCOR with recommendation to ensure training program available for pharmacy technicians in each region 3 Undergraduate Curriculum Develop learning objectives and content outline for an oncology rotation during undergraduate training to be submitted to the U of T Faculty of Pharmacy. Obtain support for proposal from the CCO Pharmacy PAC and CAPhO (Ontario group) 4 Develop standard oncology rotation(s) for hospital pharmacy residents Circulate standard expectations to RCCs, PMH and residency directors at teaching hospitals Action: Pharmacy PAC- Pharmacist Training Working Group* with CAPhO Education Committee Pharmacy PAC- Technician Training Working Group* Pharmacy PAC- Pharmacist Training Working Group* with CAPhO Education Committee Pharmacy PAC- Pharmacist Training Working Group* * The CCO Pharmacy PAC will create 2 Training Working Groups to conduct these activities. This group may need participants from outside CCO.

77 Future Training Concepts for Practicing Oncology Pharmacy: A Proposal A possible program for training current oncology pharmacy practitioners, as discussed in the position paper, is described below. To address the practical training needs of current practitioners, this proposal is a modular program, with didactic and hands-on practical components. The proposal is described as follows: About 4-6 modules to cover the spectrum of oncology pharmacy (may vary for individual pharmacists, based upon prior experience) Each student is assigned a mentor from among current senior oncology pharmacists Assigned reading and knowledge acquisition for each module, circulated in advance of practical session; student is expected to complete self-learning materials, assisted by personal mentor as needed Modules may be offered in 1 week blocks, about 4-8 weeks apart, possibly hosted at different locations Assessment examination after each module; Comprehensive oral examination upon completion of all modules A certificate would be awarded upon satisfactory completion Employers would continue the pharmacist s salary through the training period; training program administrators would try to locate inexpensive housing during the training, and to explore possible new funding opportunities to underwrite the delivery costs of the program. The roles of each participant in the proposed training program are described in the following table: Students Mentors Attend training site 1 week in 8 Assist students through program Didactic teaching by pharmacists & oncologists Responsible for co-ordination issues, progress reports Intense hands-on practical training Attend final exam with student Report progress to mentor Program Preceptors 12 students per year Organize didactic and practical training on site Final oral exam by 3 Senior Oncology One student every 4 weeks (12/year) Pharmacists Co-ordinate schedule with student Award certificate Administer standard examination, report to Solicit participants to blanket province over 3-4 mentor years

78

79 This model would require a high level of participation by senior oncology pharmacists, and support by CCO and the Pharmacy Residency Board. Funding could be requested from CCO or the Ministry of Health. The program could be run by the CCO Pharmacy PAC or the CAPhO Education Committee. This could become a national level program, if there is sufficient interest outside Ontario. 79

80 Appendix K TRAINING, RECRUITMENT AND RETENTION OF MEDICAL ONCOLOGISTS FOR CANCER CARE IN ONTARIO Prepared by Dr Jack Laidlaw, Director of Education, Cancer Care Ontario and the Postgraduate Training Committee For The Systemic Therapy Task Force January 4, 2000 Introduction: There is currently a deficit in the number of medical oncologists in the formal cancer system estimated at 34. There may be almost as large a deficit in the community and, certainly, as new cancer centres are established and adopt appropriate staffing standards, there will be a requirement for a substantial number of new medical oncologists. This deficit will increase and patient care will suffer, if actions are not taken promptly to increase the number of residents in medical oncology specialty training in Ontario. In addition, initiatives are urgently needed to retain the residents and attract back fellows who have been trained in Ontario. This paper will review the recent history of training in 80

81 medical oncology in Ontario, the fate of the trainees of the Ontario medical oncology training programs and the results of surveys of those who have taken positions outside of Ontario or who are taking fellowship training in Medical Oncology in Ontario and the United States. It will also describe strategies to attract medical students and internal medicine residents into the oncology field and the strategies necessary to recruit new medical oncologists from other jurisdictions and retain trainees from Ontario programs. Finally, it recommends the size of the medical oncology training program from now until the year 2010 and need for external recruitment of medical oncologists from elsewhere in Canada and from abroad in order to achieve the workload standard established by the Systemic Therapy Task Force Training Programs in Ontario: There are 4 Royal College accredited training programs for medical oncology in Ontario located at the Universities of Toronto, Ottawa, McMaster and Western Ontario. Since 1996, these 5 programs have graduated 28 medical oncologists or an average of 7 graduates per year. In 2000, only 4 trainees will take their fellowship examinations but a further 10 will be prepared to take their fellowship examination in One of these individuals is funded by the Nova Scotia government and is expected to return to Nova Scotia on completion of his training. As residency training slots have decreased in recent years secondary to the down sizing of medical schools and the specialty programs, it has been increasingly difficult for medical oncology to retain positions for training programs in most universities. Medical Oncology must compete against other subspecialties of Internal Medicine and General Internal Medicine itself for a diminishing number of residents. Residents are increasingly aware of the heavy caseload and stress of a career in oncology and not infrequently avoid oncology rotations during their internal medicine residency training. Generally, Internal Medicine residents do not see Medical Oncology as an attractive career option. They are further deterred by the perception that there are no vacant positions available Similarly, Family Medicine training programs usually do not mandate, or even offer, oncology as a rotation for those in Family Medicine because of a perception that the experience is not relevant to family medicine practice. As a result, few graduates of Family Medicine programs have any real competency in Oncology to enable them to play a significant role in the diagnosis, treatment, follow-up, or provision of supportive/palliative care to cancer patients. Because of the limited number of MOH funded postgraduate training positions and the serious need for medical oncologists, some Regional Cancer Centres have begun to fund residency training positions independently. Nonetheless, the enrollment for July 2000 is only a total of 6 in the province, distributed as follows: Hamilton 1 HRCC funded London 2 LRCC funded Ottawa 1 MOH funded Toronto 2 MOH funded Even if all the trainees currently in the Medical Oncology training program or entering it in July 2000 were to graduate and stay in the province of Ontario, the numbers would be insufficient to close the gap between the current needs in the formal cancer system (34), let alone meet the needs of the informal system. Nor would this number of graduates be able to address the growth in the need for medical oncologists due the growing number of patients requiring systemic therapy. In addition, this number does not address the issue of attrition from retirement, illness or career change or the recent trend by medical oncologists to reduced FTE status. Therefore, the numbers presented below are a conservative estimate of the number of training positions required. The recent history of the fate of graduates of Ontario Medical Oncology Programs is indicative of the need for strategies to retain graduates in the province of Ontario. Of the 28 graduates since 1996, 17 have entered practice. Only 9 (32%) have been retained in Ontario; 5 in CCO RCCs or the PMH and 4 have taken positions in the community. Eight (8) have taken positions outside of Ontario: 6 in other provinces in Canada (predominantly British Columbia) and 2 in the United States. There are also 11 fellows taking advanced training in Medical Oncology. Four of these fellows are currently in Ontario, but 7 are taking their fellowships in the United States and are at risk of being lost from the Ontario system. This risk is highlighted by the results of surveys of recent graduates and fellows 81

82 Survey Results of Medical Oncologists No Longer Practicing in Ontario To better understand the reasons that medical oncologist have not stayed in Ontario on completion of their training and to develop strategies to ensure the future retention of Ontario trainees, a survey was undertaken of those medical oncologists who are no longer practicing in Ontario. Six surveys were mailed and 4 responses were obtained. One individual indicated that they had been offered a position in British Columbia after completing a fellowship there, which offered them the opportunity to continue in the field of research interest. At that time, (1996) there were no academic positions available in Ontario due to a lack of funded vacancies. Two individuals indicated that it was a lack of jobs in Ontario that caused them to leave. The fourth was actively recruited by the BCCA, which provided research opportunities and facilitated obtaining a job for his spouse. The respondents to the survey were asked to indicate what factors could have influenced them to stay in Ontario to practice. The highest ranking given was family reasons, followed by research opportunities, the opportunity to teach, remuneration and other factors such as workload, academic position and the cohesiveness of the cancer system. Survey Results of Medical Oncology Fellows Eleven surveys were mailed to Medical Oncology fellows, but, unfortunately, replies were obtained from only 5 respondents. Four of these individuals will complete their fellowship in 2000 and the other finished in Three of the fellows were taking their fellowship in Ontario and 2 in other locations. Of the three taking their fellowship in Ontario, two indicated that they intended to remain in Ontario when their fellowship was completed and one was unsure. Those taking fellowships outside of Ontario expressed uncertainty about returning to Ontario. In one case, the exceptional opportunities to do research in the United States were a very strong inducement to stay in the USA. These individuals were also asked to comment on the factors that could potentially attract them to return to Ontario. They listed, in rank order, research, family factors, and remuneration and teaching opportunities. All the fellows indicated that they would want to continue to practice in a specialized cancer centre and stressed the desire to pursue academic activities. One even indicated that it would be too depressing to do oncology without research interests. Survey of Medical Oncology Residents Surveys were sent to 14 residents currently in training and 8 responded. Of the respondents, 4 indicated that they intended to stay in Ontario, 2 indicated that they would not stay in Ontario and 2 were unsure. Family reasons figured prominently in the decisions of the respondents. All planning to stay in Ontario cited the fact that their families are located here. Two who planned to leave were from other provinces originally and intended to return to where their families were. In rank ordering the factors that would determine a decision to practice in Ontario, family and research opportunities rated most highly, followed by remuneration, teaching and other factors, including standard of living, workload and finding employment for their spouse. Seven of the 8 respondents indicated that they intended to practice in a specialized cancer center and one was uncertain. Of the 7 indicating a desire to practice in a specialized cancer center, 6 cited interest in research and academic oncology and one indicated an interest in working in a multidisciplinary environment. Summary of Recent Recruitment and Survey Information Over the past 5 years, Ontario has done poorly in attracting residents to the field of oncology and has had a poor record of retaining the small number of specialists it has invested in. Only one third of those graduating from Ontario training programs are now practicing in the province. Including the fellows doing their fellowships in Ontario, still less than half (46%) are actually in Ontario. The largest factor contributing to the loss of Ontario postgraduates has been the lack of available positions within the formal cancer system to recruit individuals into. At the same time, other provinces have established workload standards and competitive salaries and a supportive working environment with opportunities for research and teaching. These latter factors appear to be very important to Medical Oncology graduates. The official position of the MOHLTC that it does not support research is a barrier to the recruitment of individuals into a system that now desperately needs specialist human resources. 82

83 Proposed Strategy to Train and Retain Medical Oncologists A multi-faceted plan is required to adequately provide for sufficient medical oncologists to meet current and future patient care needs for systemic therapy. These strategies must include the following: 1. Increased retention of Medical Oncology trainees in Ontario. The goal should be to increase retention to at least 60% of graduates from the current level of 33%. This could be accomplished by: a) Competitive compensation b) Standardized workload as per the recommendations of the STTF report, which would then match job availability to training program outputs c) Centralized mechanism to track residents and fellows and to maintain contact and interest in the Ontario cancer system d) Recognition and acceptance by CCO and the MOHLTC of the importance of research and other academic activities as a recruitment and retention strategy. e) Allocation and protection of time for academic activities to ensure that system attracts the best individuals to Ontario. 2. The Medical Oncology Training Program in Ontario should immediately be expanded to 10 new positions per year (i.e. a total of 20 positions; 10 positions for each of the two years of the program). As it is unlikely that there would be sufficient candidates to achieve this expansion of the training program for an Ontario-based solution, it will be necessary to engage in external recruitment from Canada, the United States and abroad (see below). 3. Recruitment should aim to attract as many of the current trainees and fellows who will be available over the next 3 years ( ). The maximum potentially available over the next 3 years is 30 (Table 3). Based on Ontario s past history, only a total of 10 are likely to return to Ontario. Concerted efforts, with attention to the items identified in #1 might be expected to increase this number to External recruitment from elsewhere in Canada, the United States and abroad should commence immediate with the minimum recruitment target being 36 medical oncologists over 3 years (Table 3) 5. From July 2003 to 2010 the Medical Oncology Training Program should be sized to match projected need. Based on estimates of the projected incident cases from the Ontario Cancer Registry (see attached Table 1), there will be a need for 4-6 medical oncologists per year based on the assumption that 50% of incident cases will be seen for systemic therapy. This number would meet the needs of both the formal and informal cancer systems assuming that there is no major change in medical practice. Based on an estimated retention of 60%, the requirement will be for 8-10 training positions. 6. To attract more internal medicine residents to the field of oncology, several initiatives need to be undertaken: a) Efforts to interest medical students in oncology must begin early in the undergraduate curriculum with relevant oncology content taught by oncologists. Undergraduate Associate Deans of the University Faculties of Medicine need to be encouraged to review their undergraduate curricula for relevant oncology content and ensure that oncologists are active in its teaching b) Medical Oncologists need to participate actively in the teaching of clinical skills (physical examination, patient interviews and communication skills) and to serve as role models to the medical students c) Associate Deans of Postgraduate Education need to be informed of the need for Medical Oncologists and encouraged to make training positions available d) The Royal College of Physicians and Surgeons needs to be lobbied to make oncology training mandatory for all Internal Medicine trainees e) Physicians re-entering training from practice or from other programs need to be encouraged to consider medical oncology as a career option 7. Because even an expanded training program cannot close the gap in the need for medical oncologists (Table 2), there is a need for a concerted medical oncology recruitment effort over the next three years to recruit an additional 44 medical oncologists from outside Ontario or Canada over the next 3 years (Table 3). 8. The needs for medical oncologists may be partially alleviated by knowledgeable and skilled family physicians. Family Medicine training programs must be persuaded of the need to provide their trainees 83

84 with relevant oncology training and skills in cancer diagnosis, screening, treatment, and follow-up and pain and symptom management. 84