Nruse's Perspective

From A Nurse's Perspective

Collaborative Practice: Partners in Caring

Nurses and Physicians working together to deliver care to patients with sarcomas.

Denise Reinke, APRN, BC, AOCN

Oncology Nurse Practitioner, Sarcoma Program

University of Michigan

A guiding principle for optimal sarcoma care is consultation with a sarcoma center that ascribes to a multidisciplinary team approach to care (Ref. 1). Commonly, multidisciplinary care means bringing together various perspectives to determine the best diagnostic and treatment approach for a given patient (Ref. 2). In the care of people with sarcoma, a central component of multidisciplinary care involves meeting face to face or via tele- or video-conference by a core group of specialists with medical, pediatric, surgical, orthopedic, radiation, radiology, and pathology expertise to provide an opportunity for a broad range of input and opinions about diagnosis and treatment. Guidelines that outline principles for care of people with bone or soft tissue sarcoma, such as those developed by the National Comprehensive Cancer Network (NCCN), ascribe to the multidisciplinary approach as a fundamental tenet of care (Ref. 3). While not directly mentioned within these NCCN guidelines, nursing expertise arguably is an important component of quality care for people with sarcoma. Oncology nurses collaborate with their physician colleagues in a variety of roles as part of the sarcoma team to optimize care and outcomes for patients and families who are dealing with the diagnosis and treatment of sarcoma.

The term nurse in today’s healthcare arena encompasses a number of different roles. Nurses help patients and families through their role as clinic nurses, infusion nurses, inpatient nurses, research nurses and advanced practice roles such as nurse practitioners or clinical nurse specialists. All are nurses but each with different skills and expertise that can provide help in providing care to people with cancer. In most sarcoma centers registered nurses interact with patients in various settings. The outpatient clinic nurse can be a key link to the entire care team for patients who are at home and have a problem or concern. When in the hospital, the inpatient nurse is the person who is there at the bedside to provide care and management of the acute needs of patients during their hospital stay. Many treatments are given in an outpatient arena and infusion nurses with expertise in safe delivery of treatment, educate and support patients during this time of care. Sarcoma care can frequently involve receiving care as part of a clinical trial and there are frequently research nurses who have in-depth knowledge of the clinical trial protocol that ensure proper delivery and management of patients is completed within the guidelines outlined in the study. Several inpatient and outpatient cancer centers have clinical nurse specialists who are masters’ prepared nurses who work primarily with nursing staff to provide education and develop standards of care and policy and procedures to enhance patient care outcomes (ref. 4). Nurse practitioners who are also masters’ prepared nurses generally work collaboratively with physician colleagues to guide the care and treatment of patients with sarcoma (Ref. 5).

My role is as a nurse practitioner in the sarcoma program at a university medical center. I work with a medical oncologist and together we share a practice. We strive to compliment each other’s skill set respecting that there are areas of overlap, however recognizing that we may have different strengths. We together discuss options with patients and families recognizing that the ultimate decision for which option will be best for any given patient is decided by that individual. Patients can be empowered to make the best decision for themselves when provided with accurate information in a manner that is understandable. As physician and nurse practitioner, we can articulate information using different words and approaches to ensure that information is as clear as possible, reinforcing and complementing each others approach.

Another important aspect of care that requires physicians and nurse collaboration is in assisting with the management of symptoms. Nurses and physicians strive to deliver optimal treatment. Unfortunately, optimal treatment can have associated untoward effects. The challenge is finding strategies to manage symptoms in a way that an individual can continue to do the things that bring meaning and pleasure to their day. Oncology nurses, nurse practitioners and registered nurses in clinical roles are frequently experts in this arena. Nursing research provides a rich body of information to support strategies that will likely relieve symptoms. It is the skillful application of that knowledge which nurses bring to the people for whom they care. Having an understanding of the individual, their health condition, their values and social situation, a nurse can select options and make recommendations that are most likely to be effective.

Two Additional Viewpoints

A Perspective as a Current Cancer Patient

By Jessica Frailey RN, MS

As a recent graduate of the Ohio State University’s psychiatric nurse practitioner program, I know much about the unique skill set of an advanced practice nurse. I am often asked what the difference is between a nurse practitioner (NP) and a doctor or between a NP and a physician’s assistant. Well meaning people who learn that I received a four year BA in psychology before going on to complete four years in a master’s nursing program often ask, “Why didn’t you just go to medical school?” I proudly reply that the art and science of nursing—and how it differs from the physician’s role in the medical field—is why I want to be a nurse.

But I also have another perspective on the medical community. As a current cancer patient, I know first-hand about the working relationship between a doctor and a NP. Four years ago—about two quarters into nursing school—I was diagnosed with a rare type of cancer called alveolar soft part sarcoma. The primary site was a large left thigh tumor which when discovered had already spread to my lungs. After traditional chemotherapy in my own hometown proved ineffective, I was referred to the sarcoma clinic at a major medical center. Here my thigh tumor was removed, I began a series of clinical trials, and an on-going relationship was established with an oncologist and his NP.

I see the oncologist and his NP working together at most every appointment. I have found that they brilliantly reflect my own assumptions and understanding of their professional roles. My oncologist is the typical clinician—smart, knowledgeable, and concise. His NP reflects all those qualities that often sets nurses apart and makes them loved by patients. She is caring, considerate, compassionate, insightful, and always accessible. She seems to be the hands and feet of the oncologist—she performs the physical exams, writes the needed scripts, relays cancer research and clinical trial information, and carries out many daily duties that keep the clinic running smoothly. His NP can also be the mouthpiece of the oncologist. Often she clarifies his statements or rewords his orders in a more understandable way. She is a true patient advocate—a go-between between my issues and the doctor’s treatment ideas. I know she will explain my concerns to the oncologist when I am too intimidated or unsure about what to say.

His NP has been a personal source of emotional and psychological support in addition to providing for my physical care. His NP takes time at every visit to ask how I am really doing knowing that cancer takes a toll on all aspects of life. This holistic perspective of patient care is a hallmark of advanced practice nursing. His NP often takes the time to alleviate my fears and is willing to address my questions and concerns at all times, even outside office hours. Most importantly she has built a relationship with me—an invaluable component in the team fight against cancer.

Academics and clinical knowledge can contribute greatly to becoming an advanced practice nurse, but in my case, my own personal situation has helped to shape my career in a more profound way. I see from my own needs, fears, and struggles what makes an excellent health care provider and what makes nursing special. Now when people ask me the difference between a NP and a doctor I smile and say, “Let me tell you about my NP.” She has not only provided excellent patient care but has inspired me to give this same level of care and attention to patients in my own field.

Collaborative Role of Nursing in Medical Oncology

Tammara Barnes, RN, MSN, CNS, AOCN

In Sarcoma Clinical Practice at MDAnderson Cancer Center our clinic uses the concept of a primary care team. The medical oncology team consists of a triad; the medical oncologist, clinic nurse and advanced practice nurse. This primary team assumes responsibility for the patients care from diagnosis through long term follow up care.

The physicians at a large research facility have many responsibilities outside of daily patient care such as research, publishing, teaching and administrative duties. Often their responsibilities result in traveling and therefore, the daily management of the patient and treatment side effects is the responsibility of the advanced practice nurse (APN) and the clinic nurse. The nurses assess and treat patients in the clinic urgent care, triage phone calls, call in prescriptions, review lab results, and diagnostic tests. We coordinate care within the institution as well as with outside treating physicians since many of our patients come from a distance. The APN may also assume the role of assessing patient readiness for continued chemotherapy and may review results of imaging studies with the patient if the primary physician is out of town.

The primary team collaborates on all aspects of care for our patients. We evaluate the patient’s lab trends, side effects and overall ability to tolerate the prescribed treatment. The team discusses the case and everyone has input on optimal management of each patient’s needs. We discuss continued treatment and any needed modifications to the treatment plan so that we can achieve the best possible results. This is a very collaborative team approach to care. The physician relies heavily on the input of the nurses because of their knowledge of the patient’s day to day management and tolerance of the therapy. Because of this close collaborative team, patients can feel secure that the information they are given is consistent with the overall plan and goal of care no matter what team member is communicating the information. Additionally, the patient also knows that the information they convey to any team member will be communicated to the entire primary team. We are committed to providing the best of care which is accomplished through effective and continual collaboration.

It is within a collaborative, multidisciplinary environment that healthcare professionals can bring to bear all of their expertise to care for patients with sarcomas. Nurses and physicians alike share a commitment to improving outcomes and finding better treatments. It is within the strength of these collaborations that we can make a difference.

This article deals with diagnosis and treatment phase of care. Nurses and physicians collaborate also in providing palliative or end of life care as well. This collaborative approach will be addressed in a separate article.

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References

Clasby, R., Tiling K, Smith, MA, et al. Variable management of soft tissue sarcoma: Regional audit with implications for specialist care. Br J Surg 1997: 84:1692-1696.
Zorbas et al, Multidisciplinary care for women with early breast cancer in the Australian context: what does it mean? MJA 2003; 179: 528-531.
National Comprehensive Cancer Network: Soft Tissue Sarcoma Panel. NCCN Clinical Practice Guidelines in Oncology: Soft Tissue Sarcoma. Version 1, 2007.
Bruce, S. Clinical nurse specialist role continues to evolve, Oncology Nursing Society News, November 2006, 21:11: 1-4.
Young, T., Utilizing oncology nurse practitioners: a model strategy, Community Oncology2005, 2:3: 218-24.