When nurses embrace opportunities to optimise patient pathways, their own professional development benefits

As a nurse consultant in urology at United Lincolnshire Hospitals (UHL) NHS Trust, service development and improvement is a fundamental part of my role.

My aim is to provide a high-quality service to our patients, ensuring any initiatives that could improve our pathways are considered, developed and, where viable, applied.

After taking up my post in 2015, I was heavily involved in the development of our emergency urology and local cancer guidelines. I oversee the professional development of our urology team too, especially that of nurses.

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These two main components of my role – professional development and service improvement – go hand-in-hand; not only can pathway redesign improve the patient experience, it presents great development opportunities for staff.

The patient experience was poor and we needed to do something about it

In February 2018, UHL began exploring the possibility of introducing a nurse-led telephone triage system to the prostate cancer service, prompted by a cancer alliance call for ideas to improve the pathway.

The rationale for telephone triage seemed obvious; our existing pathway was protracted, often requiring two-week-wait (TWW) patients to go back and forth to the hospital for investigations while we determined the right course of action. The patient experience could be poor at times and we needed to improve it.

Suggest the idea, build the business case, embed in practice

After suggesting the concept of nurse-led triage, I worked closely with our business unit, the trust’s cancer department and the cancer alliance to map the project and build a business case to show it could transform the pathway.

The business case was approved by the trust. The system, in which our triage nurse is proactive in arranging all the required investigations for TWW patients, is now part of standard practice, with a long-term triage nurse funded by our cancer alliance.

‘My experience clearly demonstrates how nursing innovation can lead change and transform patient care – all that is required is a clear need, a good business case and plenty of determination’

The triage system ensures patients have undergone all their investigations – such as additional prostate-specific antigen (PSA) test, MRI, CT, bone scan or prostate biopsy – before their first appointment with a consultant, who by now has all the results they need to make timely clinical decisions.

Nursing innovation transforms patient care

The approach has made a huge difference to patient care, accelerating the referral pathway and removing avoidable delays. In most cases, the pathway has been shortened by a good two weeks, and in the immediate aftermath of the system’s introduction, we saw improvements in our 62-day cancer pathway for three consecutive months.

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My experience in helping redesign the prostate cancer pathway clearly demonstrates how nursing innovation can lead change and transform patient care. All that is required is a clear need, a good business case and plenty of determination.

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By adopting a novel technique we reduced inefficiency and patient distress

Having made good gains with the telephone triage system, we shifted our focus to improving the pathway for patients requiring transperineal (TP) biopsy.

Our approach was again driven by a pinch point identified when auditing the pathway; as TP biopsies were being conducted in theatre, there was often a six-week wait for the procedure.

The hospital was also doing many trans rectal ultrasound (TRUS) biopsies that were coming back negative, with most of these patients then going to theatre for a template biopsy to give clinicians the reassurance to discharge or step them down from the pathway. The whole process was slow, inefficient and distressing for patients.

‘Stakeholders immediately saw the transformative potential and supported me in driving the change through’

After presenting my findings at one of our audit meetings, a trust partner told me about a new technique that was helping hospitals conduct TP biopsies under local anaesthetic in outpatient settings.

In many of these trusts, the procedure – known as LATP (local anaesthetic transperineal biopsy) – is carried out by trained nurses, relieving the burden on urology consultants and freeing them to focus on diagnosed patients.

Shortening the care pathway saved us money and theatre time

The benefits of LATP were evident; efficiencies in the pathway would save us time and money, while moving the procedure to an outpatient setting would help the urology team maximise precious theatre time.

Evidence indicates that LATP is a good alternative to traditional TRUS biopsies, which can increase the risk of infection and yield inaccuracies in identifying cancer cells. Although LATP isn’t a practical option for everyone, it seemed like a good idea to shift to it where possible.

I again worked with key stakeholders in the trust to build the business case, and they immediately saw the transformative potential and supported me in driving it through.

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Developing my practice brought measurable service improvements

In November 2018, I began learning how to use PrecisionPoint, the pioneering freehand technology that is opening the door to LATP. The training was supported by the South East London Cancer Network, and I travelled to Guy’s and St Thomas’ NHS Foundation Trust in London once a week for three months to observe, learn and practise under the tutelage of the network’s advanced nurse practitioner Jonah Rusere.

‘Change isn’t easy. It requires perseverance to overcome potential resistance and hard work to develop the evidence-base to persuade others of the need for change’

One of our urology consultants subsequently gave me his patient list, enabling me to carry out the procedure in theatre under supervision. I then graduated to the outpatient setting, performing the procedure under local anaesthetic with the supervision of expert practitioners.

I am now fully authorised to conduct LATP on my own, running four lists a week in outpatients.

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The outcomes to date have been encouraging; an audit of patients undergoing prostate biopsy between May and August 2019 showed that targeted and systematic LATP biopsies picked up more clinically significant disease than TRUS.

The approach also allowed us to discharge almost 60% of patients with negative biopsies, and enhanced the patient experience – patients are no longer stuck in a repeat cycle of invasive biopsies before they are diagnosed or discharged, so it’s a win-win for everyone.

Evidence for why nurses’ ability to optimise care pathways should be recognised

The triage and LATP projects at UHL are great examples of nurse-led service transformation. Although they are specific to the NHS, they are a vindication of any approach internationally that advocates nurses playing a greater role in optimising patient pathways.

With the World Health Organization estimating that the world will be short of 18 million health workers by 2030 – a fifth of the workforce needed to keep healthcare systems going – it is important healthcare systems make the most of the valuable resources available.

Challenging processes and ingrained thinking is hard – but it’s worth it

Changing existing processes and ingrained ways of thinking isn’t easy, neither is achieving success. It requires perseverance to overcome potential resistance and hard work to develop the evidence-base to persuade others of the need for change.

But with a sound business case, a good understanding of your service and patient needs, and support from stakeholders, it is possible to make a huge difference for patients.

As nurses, this is what we are all here to do.

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Milica Zina Bojin is nurse consultant, urology, at United Lincolnshire Hospitals NHS Trust