1. My first year as an Oncology Nurse Practitioner
Non-Medical Prescribing
Sarah McCauley
South Eastern Trust

2. Background 2006: RN Haematology/Oncology day unit
2008: PICC nurse led service
2017: Deputy Ward Sister
2017: Acting Ward Sister
2018: Oncology Nurse Practitioner

3. Qualifications 2006: BSC Hons Nursing Sciences (Adult Nursing) QUB
2007/08: Chemotherapy Administration and Principles of Radiotherapy QUB
2009/10: Cert Haematology and Bone Marrow Transplant QUB
2010/12: Specialist Practice – Cancer Nursing (Oncology) QUB
2016/17: Non-Medical Prescribing QUB

4. Reforms in Cancer Services
Due to a discrepancy between the medical workforce and the increased demand for chemotherapy, a need for Non-Medical Prescribers within the field of Oncology was identified (National Chemotherapy Advisory Group, 2009).
The volume of patients who need chemotherapy is growing (Lennan et. al., 2010) placing greater strain on already stretched services.
Fears about patient safety during chemotherapy treatment were stressed in a report produced by the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD, 2008).

5. Reforms in Cancer Services
This enquiry examined the care of patients who died within 30 days of receiving SACT, and found that care was felt to be good in only 35% of cases.
The enquiry identified that there was scope for improvement in 49% of cases and that care was unsatisfactory in 8% of cases.
Subsequent to this, the National Chemotherapy Advisory Group (NCAG) was established, with an aim to improve the quality and safety of chemotherapy service delivery.

6. Reforms in Cancer Services
The report encouraged the development of nurse-led chemotherapy services to improve both quality and safety in addition to meeting the escalating need for treatment (NCAG, 2009).
The United Kingdom Oncology Nursing Society (UKONS) encourage that healthcare trusts should develop nurse-led chemotherapy clinics when considering service development as they categorise nurse prescribing within the nurse-led chemotherapy clinic as the gold standard (Lennan et. al., 2012).

7. Induction Robust induction. Building and maintaining relationships
Locally – SETrust MDT, visiting Oncologists
Regionally – NICC, Other Trusts, NICaN
Nationally – UKONS, NMPs

8. Induction Clinical Champion for each tumour site Prostate Breast
Enhancing clinical knowledge
Developing protocols and guidelines for SETrust
(IR(ME)R) Training

9. Competencies Worked from NICaN competency framework
Level 1 Prescribers are able to prescribe SACT from the 2nd and subsequent cycles, but all prescriptions will require a countersignature from a Consultant or SACT competent registrar. All incoming registrars (StR3 and above) and non-medical prescribers will begin at Level 1. Evidence from Level 1 can be used to prove level 2 competencies.
Level 2 Prescribers are able to prescribe SACT from the 2nd and subsequent cycles and do not require a countersignature. Prescribers at Level 2 may not initiate SACT.

10. Competencies Clinical Champion for each tumour site – Consultant.
Level 1 – completed 20+ prescriptions with countersignature.
Level 2 – Mini CEX for each tumour site and Level 2 competencies.

11. Breast – List of Drugs Denosumab Docetaxel FEC Fulvestrant Goserelin
Palbociclib
Trastuzumab
Vinorelbine
Zoledronic Acid

12. Virtual oral vinorelbine clinic
Once established on vinorelbine patient attends clinic (week 1).
Assessed and prescribed 3 weeks supply of vinorelbine.
Week 2 and 3 patient gets bloods checked day prior to phone call.
Check blood results.
Phone patient – telephone assessment based on UKONS telephone triage call sheet.
Authorise or defer treatment accordingly.
Document.

13. Prostate – List of Drugs
Abiraterone
Upfront Docetaxel
Enzalutamide
Zoledronic Acid
Also assess for Radium 223 review

14. Having rights to request
CT CAP
CT Brain
Abdominal X-Ray
Chest X-Ray
DEXA
Ionising Radiation(Medical Exposure) Regulations
(IR(ME)R) Training

15. Change is inevitable
Change will be resisted unless the resistor believes the changes are
Long term
Will not be abandoned
Will make a powerful, positive difference to patient care
Will help others to do their jobs better
Help maintain key working relationships

16. Facing Challenges Shared vision – Medical team, patients
Communication - essential
Visibility – maintain a presence
Sustained contact – reliable, constant, build confidence

17. Solutions
Establishing and promoting an overarching shared vision that NMP will
Improve the delivery of high-quality care
Improve patient experience
Outcomes focused on patient care

18. In the beginning……
Select suitable patients (treatment types) – agree with Consultant
Preparation – identifying suitable patients
Consent of Consultant
Consent of patient
Discuss prior to clinic with Consultant each patient I aim to see
Same clinic space

19. Currently….. Breast Continue to see from the general chemotherapy list
Discuss with Consultant prior to clinic
Prostate
This clinic leant itself to dedicated NMP appointment slots
Discuss with Consultant prior to clinic

20. Proformas
Developed Proformas
Tumour/Drug specific
Gives structure

21. Proforma

22. Current issues 6-8 patients per chemotherapy clinic
Numbers vary week to week
Start date, deferrals
Succession planning

23. Prostate Review Clinic
Nurse led review of patients post radiotherapy treatment
Hormones
PSA tracking
Face to face appointments
Keen to implement telephone reviews in the future

24. Other Projects Antibiotic PGD For nursing staff in MacDermott
Antibiotic PGD (Tazocin and Ciprofloxacin)
Questionnaire for RISOH
Flow chart for guidance
TKI Project
Day 5 phone call – early intervention of side effects
Bespoke telephone call sheet
Patient information leaflet

25. Database Maintain database Record all patients seen
Record all drugs prescribed
Record outcomes – prescribed/deferred
Demonstrate my progress

26. Going forward Breast review clinic Competencies Updating knowledge
Professional development
User feedback

27. Finally…. Enjoying this new and exciting role.
Excited to be a part of something new.
Developed strong working relationships with Consultants, Medics, Ward Sister MacDermott, Nursing Staff, Pharmacy, fellow ONPs.
Stressful at times – change, lack of confidence, learning constantly.
Feel very supported by the team.
Looking forward to see how NMP progresses.

28. Questions? Any questions? Sarah McCauley Oncology Nurse Practitioner
SETrust
Ulster Hospital

29. References
Lennan, E, Roe, H., Young, A. and Crowe, M. (2010). National Chemotherapy Advisory Group report: implications for nurses. Nursing Standard, 24(36) pp
Lennan, E., Vidall, C., Roe, H., Jones, P., Smith, J., and Farrell, C. (2012). Best practice in nurse-led chemotherapy review: a position statement from UKONS. ecancer, 6(263) pp 1-11.
National Chemotherapy Advisory Group (NCAG) (2009). Chemotherapy Services in England: Ensuring quality and safety. Available from:
National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2008). For better, for worse? A review of the care of patients who died within 30 days of receiving systemic anti-cancer therapy. Available from: (Internet) (Accessed 03/01/19).