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Patient Evaluation of Nurse-Led Oncology Review Clinics

Current National Health Service (NHS) policy in the United Kingdom recommends that services should be provided closer to the patient [1] as there are many anticipated benefits in shifting the balance of care away from a central hub to delivering services near to patients’ homes. In implementing this policy, ‘nurseled’ initiatives have often been adopted for a variety of reasons, such as the capability and capacity of the workforce, cost-benefit modeling, and assumed continuity of care. However, previous studies of several ‘nurse-led’ or ‘near-to-home’ services have provided mixed outcomes with regards to their impact on costeffectiveness, clinical effectiveness, perceived quality of life, and patient health outcomes.


Introduction
Current National Health Service (NHS) policy in the United Kingdom recommends that services should be provided closer to the patient [1] as there are many anticipated benefits in shifting the balance of care away from a central hub to delivering services near to patients' homes. In implementing this policy, 'nurseled' initiatives have often been adopted for a variety of reasons, such as the capability and capacity of the workforce, cost-benefit modeling, and assumed continuity of care. However, previous studies of several 'nurse-led' or 'near-to-home' services have provided mixed outcomes with regards to their impact on costeffectiveness, clinical effectiveness, perceived quality of life, and patient health outcomes.
In Wales a randomized trial by Moore et al. [2] found that a nurse-led service was acceptable to lung cancer patients and general practitioners (GPs), leading to positive health outcomes, including less severe dyspnea and better emotional functioning. Additionally it was identified that nurses recorded progression of symptoms sooner than doctors. Wattchow et al. [3] conducted an international trial comparing GP and surgeon follow up for patients with colon cancer and found that there was no significant difference at 12 and 24 months with regards to patient quality of life indicators. The main differences related to the nature of follow-up investigation, with surgeons requesting more ultrasounds and colonoscopies, and GPs requesting more faecal occult blood tests. An evaluation of a nurse-led telephone follow-up clinic for prostate cancer by Anderson [4] found that 39 (90%) patients stated that they were 'very satisfied' with the service provided. A modeling study carried out in the NHS Grampian region [5] aimed to explore the views of both potential recipients and their GPs regarding shared care of cancer follow-up care. It was found that many rural patients, and some urban patients, would appreciate follow-up being available nearer to home with the associated benefits of time saved, easier parking, and continuity of care. However there were concerns about how non-specialized GPs would attain and retain the necessary competencies to deliver such follow-up support.
In NHS Grampian a collaborative project commenced in 2007 between the acute and community care services to enable patients with colon cancer, and latterly those with prostate cancer, to be followed up in a local community hospital. The appropriate consultants from the medical and nursing professions, and strategic and operational management levels of the organization supported the project. Work-based education for nurses undertaking the enhanced role was devised, delivered and evaluated, and an implementation resource pack was developed and made available online.
This ongoing service consists of monthly nurse-led oncology review clinics at four community hospitals based at Inverurie, Banchory, Turriff and Fraserburgh.
The map in (Figure 1) shows how these hospitals cover a wide area of Aberdeen shire and are away from Aberdeen city, thus benefiting patients who would otherwise need to travel from outlying areas to the city (often making round trips of at least 50 miles, and in some cases exceeding 100 miles). As well as reducing patient travel time and carbon footprint, consultant time is also freed-up to deal with new patients and more complex ongoing patients who require consultant treatment interventions. The number of referred patients to the nurse-led oncology review clinics has steadily increased since its inception in 2007, so that by June 2010 there were sufficient patients attending these clinics to warrant an evaluation of patient experiences. The objective of this study was to appraise the findings of a survey of patients' experiences in these clinics.

Methods
This was a qualitative study using a structured questionnaire that was designed following consultations with health professionals involved in the service and a user group. Topics included focused on the following: basic demographic data; mode of transport; perceptions of parking, travel, continuity of care, timing of appointments; satisfaction with service attributes; any concerns; suggestions for improvement; and an overall rating score. Drafts of the questionnaire were circulated to health professionals involved in providing the service and suggestions to improve the questionnaire were subsequently acted upon. The final questionnaire comprised four sections: demography; a set of judgmental statements; patient concerns; and an overall judgment of service quality and identification of areas for improvement.
The judgmental statements were formed following discussion with health professionals, a user group and from previous questionnaires used to evaluate aspects of cancer services elsewhere in Scotland. By ascertaining whether someone agreed or disagreed with a statement we were able to obtain an indication of perceived or projected satisfaction and acceptability. Fourteen statements were created and the majority took a personal perspective using 'I', 'my', or 'me' in each statement.
An evaluation proposal and a questionnaire set (comprising the questionnaire itself along with a patient information letter and a return stamped addressed envelope) were scrutinized and approved by the local Research and Ethics Committee. The project was classified as service evaluation.
Prior to commencing the Main Study in August 2010 a short Pilot Study was carried out involving patients attending a clinic at Fraserburgh Hospital (chosen as it had been running the longest). All five patients attending the clinic in June 2010 participated in the pilot study. The outcomes of the pilot study showed that the administrative procedure worked and suggested that the goodwill and co-operation of the designated receptionist and nurses at the clinic were essential for facilitating a good response rate. Patients could complete the questionnaire with relative ease. The questionnaire was flexible and open to allow for additional comments and observations to be made, and everyone appreciated the option of telephone contact with the evaluator. The evaluator was able to set up a distribution and return database and also an SPSS (Statistical Package for the Social Sciences) database for questionnaire analysis.
The Main Study aimed to receive 100 returned patients' questionnaires. Packages containing questionnaire sets were dispatched to a designated receptionist at Inverurie, Banchory, Turriff and Fraserburgh Community Hospitals, requesting that they be given to each patient previously treated for colon or prostate cancer who would be attending the oncology review clinic.

Results
The Main Study ran from August 2010 to July 2011, during which time 216 questionnaires were sent out to the clinics. The number received back from consenting patients was 103 (48%), slightly more than the target of 100; all questionnaires received contained usable data. The breakdown of returns from the four community hospitals was: Inverurie 21 (44%); Banchory 26 (48%); Turriff 25 (45%); and Fraserburgh 31 (53%). Findings from the four community hospitals have been grouped together following an assessment by the evaluator who found a lack of inter-hospital variation in responses.

Patient profile
Patient demographics are shown in (Table 1). The majority of patients (75%) attending these clinics had been treated for colon cancer as the clinics were initially only set up to meet the followup needs of this cohort. Both men and women attended the clinic an average of three times. However, there were 19 respondents (15 men, 4 women) for whom this was their first appointment at the nurse-led clinic. Of these, all the women and eight of the men were attending for colon cancer follow-up with the remaining seven men attending for prostate cancer follow up.

Mode of transport
The majority of patients, 90 (87%), used a car to attend clinic; eight people walked; three caught a bus; and two used taxis. (Table  2) shows a representative sample of the positive comments made by patients in relation to the benefits of local travel, while (Table  3) shows the concerns of patients particularly in relation to public transport and the possibility of driving in bad weather.

Patient views of the service
Patients discussed various aspects of their own general health with the nurses and the majority also considered the timing of the next appointment. Three quarters of patients discussed results and/or tests that had been carried out or were coming up. Aspects of personal support were less frequently discussed, as was the support from family members or friends. (Table 4) summarises all topics discussed and the frequency of response to each theme.
The views expressed by patients when asked to rate the service against the fourteen judgmental criteria are shown in (Table 5). The overall quality of the service was judged to be: excellent by 62 (60%) patients; very good by 35 (34%); and good by 2 (2%). No patient judged the service as fair or poor; 4 (4%) did not complete this section. Comments made with regards to the quality of the service and about the nurses delivering the service are shown in (Table 6).
Respondents were asked to cite any concerns they had about attending the local follow-up clinic compared to the clinic at Aberdeen Royal Infirmary. The vast majority (90%) had no concerns at all. Four patients from Inverurie, three from Banchory, and one from Turriff stated that they had concerns; two patients failed to respond to this question. The concerns cited by these eight individuals are shown in (Table 7). 60 patients reported that they attended the appointment by themselves and 37 were accompanied; six patients did not answer this question. Of those who were accompanied, five companions commented on their perceptions of the benefits of attending the local clinic. (Table 8) summarises these responses. (Table 9) summarizes the statements five patients made about the service and the suggestions for improvement made by four others. (Table 9) also contains comments from four patients for what have been termed 'clinical realizations' about themselves.        Confusion over scan and clinic. I can't see my consultant and 3 weeks to wait for CT scan report is too long.
Slight concern that my appointments are on time and do not get lost in the system. Much, much better that going to Aberdeen, but slight worry that one may be lost to follow up system.
Had I had my appointment at ARI results of my scan would have been with consultant? Scan done 3 weeks ago. I was disappointed not to have received scan results as I was told when I had the scan the results would be available at my appointment, which I feel would be better than receiving results by letter.
Scan results did not get reported to the clinic, need better communication between ARI and clinic.
I would have liked to know what to expect on first visit please include this with the letter. I have a problem which I prefer to discuss with Mr K W, Urology nurse specialist.
ARI are familiar with my prostate history and I meet consultant who has handled my prostate problem.
Clinic location not indicated. Please advise name of person/doctor I will be seeing in covering letter.
I feel this level of nursing could be carried out by my experienced nurse at the surgery unfortunately not always available. Nurses should attempt to avoid duplication of blood testing less than 14 days apart. My surgery has taken positive steps. When leaving hospital, staff dealing with aftercare at ARI are a waste of time; even in hospital they have little or nothing to contribute. Unnecessary to have two nursing staff. We get a trip to Banchory together I receive first hand information from the nurses as my husband is slightly deaf I was accompanied by my wife -much closer to home for us at our age Nurse knew us from last time. Both nurses make you feel at ease and so you feel relaxed about asking any questions Nurses were very friendly and took time to discuss any concerns we had Table 9: Statements of affirmation, improvements and clinical realizations.

Affirmations (N = 5) Suggested Improvements (N = 4) Clinical Realisations (N = 4)
Keep up this standard Too early to comment If I am being referred here then I am probably not needing to be here

Discussion
This evaluation confirms very high levels of patient satisfaction with these nurse-led oncology review clinics for patients who have been treated for colon or prostate cancer, with over 90% of patients satisfied with the administration of the clinic and the quality of communication between the service and patients. These findings are consistent with other studies, particularly in terms of patient satisfaction and role transfer across health professionals. Grunfeld et al. [6] found that patients with breast cancer were more satisfied with follow-up in general practice than they were with that received in hospital outpatient departments. Similarly, the outcomes of Anderson et al [7] demonstrated that specialist nurses could effectively follow-up patients with prostate cancer and that this was cost-effective, especially in those without metastatic disease.
One particular comment from patients in our study is that they like the clinic being closer to their homes. Follow-up for these patients used to involve a round trip Aberdeen, which for some could be in excess of 100 miles, followed by stressful parking experiences on the main hospital site. One interesting observation was that only 36% of patients were accompanied by someone to their appointment. This may indicate that when attending a local clinic the patient needs less family or friend support than when attending an appointment further afield in Aberdeen, which has a bearing on reducing the indirect costs of providing a service near to the patient. Half of the respondents disagreed with the statement about being able to get to the clinic by bus. This is surprising given that patient transport services are unavailable and, while the clinic is closer to their homes, transport to the community hospitals is almost exclusively privatized.
Patients valued the quality of communication with the nurse, the personal service they received, and the continuity of care as they often saw the same person each time they attend the clinic. This encouraged almost all patients to discuss various aspects of their own general health with the nurses. One patient stated that, "I was made to feel welcomed and relaxed enough where I could talk about my concerns and worries -until now I have not had any [concerns]". Comments such as this indicate that patients had very positive healthcare experiences and had gained clinical realizations about themselves.
Patients also valued the collaborative working practices between the acute cancer centre and the outlying community hospitals with 89% feeling reassured with regard to the nurses being in close contact with the relevant medical consultant back at Aberdeen. The responses to the overall quality of the service were very impressive and indicate how much this type of local service is valued by patients, and also the high esteem in which the nurses are held. From the concerns expressed and suggestions for improvements received, some could be used to improve various aspects of the service; in particular, more information could be provided prior to the first follow-up appointment.
The limitations of the evaluation pertain to the number of questionnaire returns, as with more data it would be possible to explore variation between types of patients or between localities. In retrospect, enhancements could have been introduced including some questions about patients' willingness to recommend this type of service to other patients like themselves, or by asking them to rank the most important benefits of the service from their point of view. Further comparative evaluations could be conducted, which include the perspective of staff, and most importantly health outcomes and cost-effectiveness. Bearing this in mind it would be interesting to conduct and compare the results of surveys carried out at the Aberdeen Royal Infirmary to understand more about the benefits and limitations of both approaches.

Conclusion
This patient-focused evaluation of nurse-led oncology review clinics demonstrated very high levels of patient satisfaction with the quality of the service on many fronts. The evidence collected suggests that the service meets the needs of the cohort of patients receiving follow-up care for colon or prostate cancer, and there is strong patient demand for this type of service to continue. Patients particularly value the continuity of care and the professionalism of the nursing staff providing the service.
Our approach provides a framework for service development that is transferable to other patient types and to other city localities as well as further rural settings.
Similarly from a health services management perspective, utilizing non-specialist nurse-led oncology follow-up provides a template for service development locally and elsewhere in Scotland.