Nurse-led telephone service proves effective in endometrial cancer follow-up
Kinta Beaver leads the Endometrial Cancer Telephone (ENDCAT) trial team. Here, she explains the benefit of having specialist nurses provide a telephone follow-up service for patients.
Kinta Beaver leads the Endometrial Cancer Telephone (ENDCAT) trial team. Here, she explains the benefit of having specialist nurses provide a telephone follow-up service for patients
More than 7,200 British women are diagnosed with endometrial cancer every year. It is a figure that is rising markedly, with the cancer being linked to problems with obesity on an international scale. Although an early diagnosis leads to a good prognosis, after treatment has been completed patients are asked to attend regular outpatient clinic appointments for three to five years.
The appointments usually include a clinical examination and consultation, but, as patients tend to report symptoms between visits, this routine review has shown little benefit in terms of survival rates or detection of recurrent disease.
While hospital consultations can be reassuring, clinics are busy, patients are often anxious, and the environment is not always conducive to expressing concerns. Patients often see different junior doctors at each visit, with little continuity of care. There are limited opportunities to provide patients with the information and support they need to live well following diagnosis and treatment.
If recurrences are not detected at hospital consultations, why bring patients into costly clinics? We decided to test an alternative strategy and harness the skills and expertise of specialist nurses to provide a service addressing the needs of women being treated for endometrial cancer. The service was focused on providing women with the information they needed to live well beyond the cancer diagnosis.
Once funding had been secured, I led the team in the ENDCAT trial, a randomised controlled trial comparing hospital-based follow-up with nurse-led telephone follow-ups for early stage endometrial cancer patients. As a nurse and a strong advocate for specialist nursing roles, I had led previous studies evaluating nurse-led telephone follow-up for breast and colorectal cancer patients.
We designed a structured telephone intervention, delivered by eight gynaecology oncology clinical nurse specialists (CNS) at five NHS trusts in England: Preston, Blackpool, Lancaster, Burnley and Wigan. These nurses had the specialist knowledge and expertise to meet the physical and psycho-social needs of patients and make appropriate referrals if required.
We had already researched the information needs of patients with different types of cancer and had used the findings from these studies to develop the nurse-led telephone intervention. For the ENDCAT trial we worked closely with gynaecology oncology nurse specialists to adapt the telephone intervention to ensure it was suited to women treated for endometrial cancer.
For example, we added questions about the specific signs and symptoms of recurrence (see box below). We held a series of meetings and training sessions where we discussed the rationale for the initiative, and the way in which telephone follow-up would be delivered. We had detailed discussions on how to answer patient questions, sharing our expertise.
We also discussed practical issues in relation to setting up telephone clinics, such as liaisons with medical records staff and hospital information systems. Medical colleagues were positive about the initiative, so it was implemented in a supportive environment.
The nurses telephoned patients at home, or wherever was convenient for the patient, which enabled them to address patient concerns in a more relaxed environment. They could give patients time to express their concerns, and in turn, the initiative provided nurses with the opportunity to extend their communication and listening skills to meet the needs of patients.
We faced a number of challenges. There were concerns that something would be missed and that patients would be anxious if they did not have a clinical examination and see a doctor. There were also concerns about discussing cancer over the phone.
The intervention involves questions focused on the physical, psychological and social aspects of care. Getting communication right was demanding at first, as no visual cues were available to nurses.
They had to hone their listening skills and make judgements as to whether an expressed concern warranted a referral to other services. However, these skills developed quickly.
If the nurse specialists who delivered the intervention were on sick leave, this raised challenges in terms of cancelling clinics and re-scheduling patients. However, it was acknowledged that the same situation would occur if a doctor was unavailable to attend a hospital clinic. There were also some administrative difficulties in replacing hospital appointments with telephone clinic appointments.
The initiative has been formally evaluated by the ENDCAT trial. The study was funded by the National Institute of Health Research’s Research for Patient Benefit Scheme.
Patients were randomised to receive either hospital or nurse-led telephone follow-up. Patients in the telephone section of the study did not receive a consultation with a doctor or a physical examination. We examined anxiety, quality of life, patient satisfaction with information and service, time to detection of recurrent disease and cost-effectiveness. We recruited 259 women who were asked to complete questionnaires at different points and we collected information from hospital clinic visits and telephone appointments to examine the outcomes of all follow-up appointments. We also interviewed 26 patients in the telephone arm of the study and six nurses who provided telephone follow-up to explore views in more detail.
We found that women in the telephone group were not more anxious, and were highly satisfied with the information and the service they had received. During the study, 10 women developed further disease (five in each group). The average time to detection of recurrence was nine days in the hospital group and seven days in the telephone group.
Patients valued the convenience of the telephone appointments as well as the continuity of care and felt they built a trusting relationship with their nurse and were not starting over again with a new clinician at each appointment. They reported feeling more comfortable and relaxed and referred to their nurse as a friend. Patients said they enjoyed their consultation.
The telephone service was not more expensive than the hospital service, even though patients had longer appointments over the telephone (an average of 20 minutes) than in hospital clinics. Interviews showed that patients valued the convenience and continuity of telephone follow-up, as the same nurse would usually phone on each occasion.
The study would not have been possible without the commitment of eight gynaecology oncology clinical nurse specialists, who delivered telephone follow-up over a period of three years while the study took place.
They have continued as clinical champions for the initiative since the study ended over a year ago. Telephone follow-up continues to be implemented at the five NHS hospitals involved in the study. Two other senior nurses assisted in coordinating the programme of work.
Our work demonstrates that specialist nurses can provide a quality telephone follow-up service for patients, without the need for them to attend busy hospital clinics and deal with car parking difficulties and long waiting times, all for a brief appointment. The telephone service provides continuity of care and the opportunity for patients to build a trusting relationship with their specialist nurse. For nurses, it provides the opportunity to enhance their clinical and communication skills.
We are delighted it has been a success for the patients involved.
Structured telephone intervention template (20 minutes):
- What were the previous issues?
- Have there been any changes?
- Does the patient have bleeding, unusual discharge and/or unusual aches and pains?
- Provide information about: the operation, cancer diagnosis, other treatments and side effects (if applicable), any genetic risk and impact on sexual image/sexual function.
- Does the patient have any concerns about how their family are coping?
- Does the patient have any other questions?
- When would they like their next appointment?
Kinta Beaver is University of Central Lancashire professor of cancer care and a finalist in the Cancer Nursing category of the RCNi Nurse Awards 2016. She leads the ENDCAT (Endometrial Cancer Telephone follow up trial) project team