Plenary 2: Inter-professional
Collaboration Between Medicine and
Nursing
This session will examine key issues and critical success factors for
inter-professional collaboration between medicine and nursing
through key learning from policy and theory, and at the coalface of
education and practice
Maurene McQuestion
John Waldron
Summary
• Inter-professional collaboration between
Medicine and Nursing in the Management of
Patients Undergoing Radiation Therapy for Head
and Neck Cancers
• Radiation Oncology
• Management of H&N Cancer With Radiation
• Patients Journey and Inter-professional
Collaboration Along This Journey
• Inter-professional collaboration between Nursing
and Medicine: literature and implementation of
roles
Radiation Oncology
• Approximately 50% of patients with cancer
require radiation treatment
• Radiation treatment requires a considerable
technical infrastructure (linear accelerators,
simulators) and human resources (therapists,
physicists, nurses, oncologists)
• Radiation delivery centralized 38 cancer centers
across Canada
Radiation Oncology
• 330 Radiation Oncologists in Canada
• 200-300 new patients seen per Oncologist/year
• 80,000 Canadians per year
Head and Neck Cancer
•5000 cases per year in Canada
•2000 in Ontario
•Oral cavity
•Oropharynx
•Larynx
•Managed with radiation, surgery
and chemotherapy
•Most patients have radiation
Background – PMH H&N Radiation
Therapy Program
•
•
•
•
600 patients treated per year at PMH
80-100 on treatment at any one time
8 pairings of Radiation Oncologists and Nurse Case Managers
2 Advanced Practice Nurses
–
–
Clinical Nurse Specialist
Nurse Practitioner
•
Speech Pathologist, Clinical Dietician, Social Worker
•
•
•
20 Radiation Therapists
10 Radiation Dosimetrists and Planners
4 Medical Physicists
•
Dentists, Surgeons, Medical Oncolgists, Radiologists,
Pathologists
Consultation

Radiation Oncologist

Nurse Case Manager
2 weeks
Preparation

Nurse Case Manager

Radiation Therapists

Dentistry

Radiation Oncologist

Medical Oncologist
Admission

Chemotherapy

Feeding tube

Supportive care
5 to 7 weeks
Follow-Up

Radiation Oncologist

Nurse Case Manager
 APN**
5 – 10 Years
Daily
Radiation Therapists
Weekly

Radiation Oncologist

Nurse Case Manager

Advanced Practice Nurse (CNS/NP)
PRN

RD, Social work

Admission

Chemotherapy

Feeding tube

Supportive care
2 weeks
5 to 7 weeks
5 – 10 Years
Daily
Radiation Therapists
Weekly

Radiation Oncologist

Nurse Case Manager

Advanced Practice Nurse (CNS/NP)
PRN

RD, Social work

Radiation Treatment
•
•
•
•
Outpatient treatment
Daily fractions Monday to Friday
Over 5 to 7 weeks
Patient remains supine in an immobilization
device during 20 minutes of treatment
• Examined weekly
– Oncologist
– Nurse Case Manger
• Complex cases
– Referred or self-referred
To APN
Acute Symptom Management
Challenges
– Pain
– Dysphagia
• Malnutrition
• Dehydration
• Aspiration
– Nausea
– Fatigue
– Psychological Distress
•
•
•
•
•
Fear & anxiety
Insomnia
Depression
Altered body image
Social & financial issues
– Infection
•
•
•
•
Pneumonia
Oral
Sinus
Soft tissues, febrile neutropenia
Radiation Nursing Clinic
•staffed by Nurse Case Mangers and APNs
• regular and prn assessment of patients on treatment
Collaborative Approach
• Nurse Case Manager
–
–
–
–
Works with the Oncologist in every clinic
Meets new patients as they are initially seen
Provides direct nursing care in the outpatient clinics
Provides education and critical navigation in the period
leading up to treatment
– First line for patient contacts and queries
• Advanced Practice Nurse
– Run an independent clinic for patients on treatment
– Triage their degree of involvement
– Manages complex acute toxicity issues independently yet
in collaboration with Oncologists
– Development and dissemination of management expertise
– Advancement of symptom management and survivorship
program
Increasing Treatment Complexity
Increasing Treatment Toxicity
• Addition of concurrent chemotherapy
• Introduction of molecular targets agents
• More intense radiation schedules
– Hyperfractionation
– Accelerated radiation
• Survival benefit but at a cost
– Increased acute side effects
– Increased late effects
Lessons Learned:
Diversification, Specialization and
Collaboration
• Increasing both complexity and toxicity of
treatments requires the diversification and
specialization of patient care beyond traditional
models
• Specialization permits the advancement of
expertise
– Patient care
– Research
– Education
• Advancement of expertise with associated
inter-professional collaboration improves the
patient experience and outcomes
Collaboration
“Collaborative practice is an inter-professional
process for communication and decision
making that enables the separate and shared
knowledge and skills of care providers to
synergistically influence the client / patient
care provided”
Way, Jones & Busing, 2000
Navigating the System
H&N Cancer
Diagnosis in
community
Referral to Cancer
or Treatment
Centre
Consultations & Further Tests
- CT, MRI, PET, medical oncology,
dental, ……
Treatment Decision
1 – 3 months acute recovery,
intermediate recovery 6 months +
Treatment 4 - 7 weeks
Daily visits Mon – Fri
Ambulatory +/- Hospital Admission
Living with uncertainty
- Wanting to return to normal
- Creating a new normal
Long term follow up
Collaborative Practice
• Interprofessional
– Staff physicians, residents, clinical fellows
• Radiation, medicine, surgery, psychiatry
– Family physicians
– Allied health – SW, RD, SLP, MRT, OT, PT, RT, Chaplain
• Intraprofessional
– Registered Nurses
• Inpatient, ambulatory, community
– Advanced Practice Nurses
•
•
•
•
Clinical Nurse Specialists (CNS)
Nurse Practitioners (Adult NP / Child NP / RNEC)
CNS/NP
Primary NP (PHCNP)
Continuum of APN Roles
CNS
NP
Integrated Role Domains
Advanced
Nursing
Practice
Professional development
Organizational leadership
Research
Education
Clinical Practice Role
(Bryant-Lukosius, 2004)
Expanded
clinical
functions
requiring
Extended
Class (EC)
License
APN Roles in Cancer Care
• Site based roles with
high volume, high risk
populations
• Palliative Radiation
Oncology Program /
Rapid Referral Program
• Rapid Diagnostic Clinic
• Pain & palliative care
• Community liaison
clinics
• Home Care / CCAC
• Infectious diseases
• Urgent care clinic
• Wound care
• Symptom management &
supportive care
Outcomes of APN Roles
• Improve access, coordination & continuity of
care
• Improve patient and provider satisfaction
• Prevent or reduce side effects and
complications
• Improve health, functional capacity, QOL and
survival for high risk patient populations
• Lower acute care costs -  LOS,  ER visits and
readmissions
• Improve uptake of EBP
www.oapn.ca
Concepts / Essential Elements
of Collaboration
• Sharing
• Partnership
• Responsibility and
accountability
• Interdependency
• Coordination
• Power
• Communication
• Process
• Cooperation
• Patient centred
• Assertiveness
• Autonomy
• Mutual trust and respect
D’Amour, et. al., 1999, 2005
APN-Physician Collaboration
Experience of
• Mutual trust and respect
• Defined practice role
• Maintains a nursing perspective
• Lives a positive experience
• Establishes collegial relationships
Critical Success Factors for
Interprofessional Collaboration
•
•
•
•
•
Collaborative skills
Role clarity & understanding
Clearly defined goals
Support structures & resources
Generation and culture
Outcomes of Collaboration
Good
Poor
• Engagement
• Complementary practice
• Improved patient
outcomes and quality of
care
• Staff satisfaction
• Fewer errors
• Improved patient safety
• Improved access to care
• Reduced costs
• Power dynamics
• Poor communication
patterns
• Lack of role understanding
• Conflicts due to varied
approaches to care
• Fragmentation in care
• Patient & staff
dissatisfaction
• Delays in implementation of
interventions
• errors
Challenges to Interprofessional
Collaboration
Discipline
• Lack of understanding or
role and scope of practice
• Discipline based
socialization, language &
communication
• Intergenerational & cross
cultural professional
workforce
• Perceptions of power
• Perceived competition
Stolee, et. al., 2008;
Way, et. al., 2000
Organization
• Organizational structures
& complexities
• Workload
• Documentation systems
Education
• Undergraduate programs
• Access to IPE and
mentorship
Policy
• Legislation & provider
resistance to roles
Examples of Collaboration
PMH & H&N Site Group
• PMH
–
–
–
–
–
–
RN Case Manager / Physician clinics
APN / Physician – Symptom Management
Urgent care clinic (REACH)
Radiation Nursing Clinic
Smoking Cessation Program / SHL referrals
Ambulatory Redesign
Examples of Collaboration
PMH & H&N Site Group
• H&N
– Feeding tube program – SDA-NDD-outpatient program
– Nursing & resident education
– Organizational Guidelines for the management of H&N
cancer
– Academic – research & publications
– Retreat – implementation of NP role
The PEPPA Framework
9. Determine
Future Needs
3. Determine
Need for a New
Model of Care
2. Identify Stakeholders &
Recruit Participants
1. Define Patient
Population & Describe
Model of Care
4. Identify Priority
Problems & Goals to
Improve Model of Care
ROLE OF
NURSING PROFESSION
& APN COMMUNITY
5. Define New Model
of Care & APN Role
8. Evaluate APN
Role & Model of Care
6. Plan Implementation
7. Initiate APN Role Evaluation Plan
Begin Role
Development &
Implementation
Develop APN Role
Policies & Protocols
(Bryant-Lukosius & DiCenso, 2004)
Provide Education,
Resources & Supports
Recommendations
• Inter-professional Education – undergraduate &
graduate
• IP mentorship
• Reduce barriers to practice, open opportunities
for collaboration
• Implement APN roles across the health care
system based on assessment of gaps and
health care needs
• Improve collaboration between tertiary care
centres & community