Tactics for Implementation of Nurse-Led Survivorship Care
There has been an increasing interest internationally in the development of nurse-led survivorship clinics or nurse-led care models of survivorship whereby advanced practice nurses particularly nurse practitioners are responsible for delivering survivorship care (92). Although the nurse is the health care provider common to this model, the services range from active responsibility for the medical follow up to providing counseling and education about late effects in preparation for transition to primary care; and physician assistants or physician associates have also been deployed in these follow-up models of survivorship care. This interest in nurse-led models of survivorship follow-up care is not surprising given that an earlier Cochrane review (2019) found that general practitioners (GP) or nurse-led care (compared to oncology specialist) made little or no difference to time to detection of recurrence, quality of life, anxiety or depression (93). The benefits are summarized in a recent commentary (94). Additionally, a more recent overview of systematic reviews identified 11 systematic reviews that reported on outcomes of models of survivorship care that also examined benefits of nurse-led models of care on satisfaction for patients and for healthcare providers (71):
Significantly higher patient satisfaction was found with nurse-led models of care relative to specialist-led care (n = 6 Systematic reviews; n = 9 primary studies)
Caregiver satisfaction of care reported was also significantly higher with nurse-led care compared to specialist-led models of care (n = 1 Systematic review).
In the United States, nurse practitioner (NP) led survivorship care is common and has been developed as either an independent provider of the post-treatment care or as an individual who provides a one-time consultation visit to prepare patients for discharge from cancer care including completion of a survivorship care plan (95). In the independent model, the survivor transitions from the oncologist to the NP who is then responsible for all core elements of survivorship care (surveillance, health promotion/prevention, interventions, coordination) and provides the patient and PCP with the treatment summary and survivorship care plan. In contrast, the consultation visit allows the oncologist to continue providing follow-up care, but the NP provides psychosocial and supportive care to enhance medical care. Development and adoption of NP-led survivorship clinics has the potential to improve follow-up care of cancer survivors by providing the following services: surveillance for disease recurrence, identification and management of treatment consequences (including symptoms, side effects, complications, and assistance with physical, emotional, spiritual, and practical concerns) (94).
A recent literature review and environmental scan noted barriers to implementation of nurse-led survivorship care (defined as NP or APN) led care at three levels (96) that will require systematic implementation strategies to assess and overcome these barriers:
- Individual-Level Determinants:
- Trust and Acceptance: Building trust among oncology specialists and patients is crucial. Strategies include establishing eligibility criteria, developing standard practice guidelines, and early discussions about transitioning care.
- Survivorship Care Plan: A mutually agreed-upon care plan should be documented and communicated to ensure patients are well-informed and can share responsibility for their care.
- Healthcare System-Level Determinants:
- Formal Transition Process: Establishing a formal referral procedure for transferring care from oncology specialists to NPs is essential.
- Role Clarity: Clear definition of roles and responsibilities within the care team to avoid confusion and enhance collaboration.
- Centralization of Resources: Integrating hospital-based services to reduce fragmentation and improve access, especially in underserved areas.
- Information Systems: Utilizing secure digital health information systems to ensure timely access to patient records and to promote continuity of care.
- Policy-Level Determinants:
- Funding and Compensation: Addressing inequalities in NP compensation and ensuring fair remuneration to improve retention and satisfaction.
- Payment Models: Considering government-funded salary models over fee-for-service to allow NPs to focus on holistic care without time constraints.
- Regulatory and Legislative Support: Enabling NPs to work to their full scope of practice, including ordering diagnostic tests and completing legal forms.
The expert panel for this guideline identified that the success of nurse-led models of survivorship care is dependent on clear communication pathways (between the NP and other key stakeholders [the patient hematologists, oncologists, primary care providers, other specialists/healthcare providers]). Clearly defining roles/responsibilities of those in the cancer clinic as well as expectations of the nurse is essential. The expert panel recommended that the nurses in these models of care be oncology nurses and ideally nurse practitioners (NP). Future directions include engaging stakeholders and public health agencies for funding advocacy, incorporating feedback from cancer survivors and multidisciplinary providers, and using data from monitoring and evaluation to evaluate effectiveness that could influence broader adoption of NP-led survivorship clinics.