Registed Nurses' Association of Ontario

After Cancer Treatment Transition: Strengthening Advanced Nursing Practice in Cancer Survivorship Care

Aronela Benea, RN, BScN, MScN
Women’s College Hospital After Cancer Treatment Transition Clinic

This Advanced Clinical Practice Fellowship took place at Women’s College Hospital and Princess Margaret Cancer Centre. The overall purpose of the fellowship was to enhance the care provided to patients and their families attending the After Cancer Treatment Transition (ACTT) clinic at Women’s College Hospital. Specifically, the fellowship was aimed at strengthening the advanced nursing practice role in the context of ACTT clinic.

Every day, approximately 542 Canadians are diagnosed with cancer and two-thirds of them can expect to live 5 years or more post diagnosis (Canadian Cancer Society, 2015). In the context of longer survival rates, many cancers are considered chronic diseases as patients may experience late and persisting side effects from cancer treatment and require long term surveillance. The post-treatment phase of cancer survivorship has its own challenges for the cancer survivors and the health care system. Cancer survivors may feel reluctant to leave the cancer care settings due to concerns over effective screening, long term effects from cancer treatment, and gaps in coordination and transition of care. In addition, primary care practitioners may be less familiar with the cancer survivorship guidelines and the management of late and persisting effects (Chapman & Wiernikowski, 2010). To address this gap, the ACTT clinic has been established at Women’s College Hospital in collaboration with Princess Margaret Cancer Centre to transition cancer survivors back to their primary care practitioners with a supportive structure in place. More than 2500 recurrence free patients who completed active treatment for melanoma, breast, gynaecological, thyroid, testis, and colorectal cancer have been transitioned from Princess Margaret Cancer Centre to ACTT. Patients are followed up at ACTT for a variable period of time, in average 2.5 years in order to be transitioned back to their primary care practitioners safely and effectively. The model of care for cancer survivorship follow up employed at ACTT is very innovative and involves shared assessments by an Advanced Practice Nurse and a General Practitioner in Oncology. Nurses in advanced nursing practice roles enhance the provision of timely and accessible quality care (Canadian Nurses’ Association [CNA], 2006). The expertise in a specialized area of practice represents the cornerstone of advanced nursing practice (CNA, 2008). My overall learning goal for this Fellowship was to strengthen my advanced nursing practice skills in cancer survivorship and to find resources for the update of the ACTT cancer survivorship care plan.

Fellowship Experience
The RNAO Advanced Clinical Practice Fellowship was an excellent opportunity for me to refine my expertise in oncology advanced practice nursing by enhancing my clinical skills and increasing my awareness of resources and services available to ACTT patient population. My learning activities included training and certification in MammaCare clinical breast examination, shadowing numerous clinicians at Women’s College Hospital and Princess Margaret Cancer Centre, completing physical assessments, presenting the ACTT model at the International Conference in Cancer Nursing, attending the Canadian Association of Nurses in Oncology Conference, reviewing the literature on cancer survivorship care plans and patients’ needs, engaging in focused self-directed learning, attending multidisciplinary rounds, and identifying resources for patients and health care providers. Many of these activities were very inspiring and rewarding. The time spent in various clinics at Princess Margaret Cancer Center and Women’s College Hospital was invaluable in regard to fostering trust and collaboration. One major challenge that may need to be taken into consideration by future applicants interested in the clinical stream of the Advanced Clinical Practice Fellowship is related to organizational policies regarding direct clinical care activities at a different organization than the fellow’s employer. Based on my experience, there is gap in addressing the learning needs of APNs who would like to enhance their clinical practice skills including targeted physical assessment proficiency under the guidance and supervision of established clinicians from other health care institutions. The inter-organizational barriers that prevent nurses from building and developing their specialty expertise in the practical aspects of nursing outside of an accredited education program need to be given significant consideration, specifically by APNs who are seeking opportunities for clinical specialization and not lastly by nursing organizations involved in fostering the professional development of nurses and the advancement of nursing practice.

Fellowship Outcomes and Sustainability
The short, medium, and long term outcomes of this Fellowship consist of (1) the fellow’s enhanced APN competencies and expertise in cancer survivorship, (2) high quality of nursing care and an updated cancer survivorship care plan for over 1500 patients, and (3) greater capacity at Women’s College Hospital to foster the professional development of health care professionals in oncology and evidenced based practice in cancer survivorship. At the end of this fellowship, I was able to meet my learning objectives and capitalize on the collaboration established with various clinicians who mentored and supervised me for the duration of this fellowship. Sustainability activities will be aimed at achieving the aforementioned medium and long term goals. Some examples include the update of the survivorship care plans provided to ACTT patients, the development of a resource package for ACTT trainees, and my engagement in knowledge dissemination, survivorship care teaching, and continued professional development activities. This fellowship had positive results at the individual level for me as the fellow, at the program level for ACTT, and at the organization level for Women’s College Hospital. The knowledge dissemination sustainability activities will promote a system level benefit for cancer survivors and health care professionals interested in cancer survivorship.

I would like to express my gratitude to Shari Moura, RN, MN, CON (C), CHPCN (C), Dr. Carol Townsley, ACTT Medical Director, Jane Mosley, MScN, WCH Chief Nursing & Health Disciplines Executive, and Catharine Fox, MSW, RSW, MBA, Clinical Manager for the guidance and support they offered me during this fellowship. My special thanks are also addressed to RNAO, MOHLTC, Women’s College Hospital, and Princess Margaret Cancer Centre for supporting this exciting learning opportunity.