A quality improvement pilot to initiate treatment summaries and survivorship care plans in oncology services in South Australia

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Nadia Corsini
Chantelle C Hislop
Tracey N Doherty
Marion C Eckert
Kate Cameron
Michael K Fitzgerald
Taryn Bessen
Chris Christensen
Nicole Loft
Kate H Turpin
Dagmara M Poprawski
Bogda Koczwara


Survivorship, care plans, treatment summary, implementation, medical oncology, South Australia


To review, test and refine standardised tools for nurses to initiate treatment summaries and care plans, and identify barriers and enablers to providing them. Background:
This paper reports on a pilot study informed by the development of a Survivorship Framework in South Australia.

Expression of interest was sought for adult medical oncology services to pilot standardised tools within existing services and resources. A quality improvement approach was used over three months with nurse practitioners and nurse practitioner candidates to obtain feedback, refine tools and resources, and identify barriers and enablers. Quantitative and qualitative data was recorded at each site using spreadsheets, at fortnightly meetings, and at a final debriefing. Content analysis was used to identify key themes in the context of barriers and enablers.

Four medical oncology clinics in South Australia participated (three metropolitan, one regional). Forty-three consultations were delivered at three sites. Barriers included time to complete documentation, perceived knowledge and skills, re-orientation of clinics and referral pathways, competing service priorities and lack of administrative support. Enablers included interrelationships within and between pilot teams, supporting resources, and increased familiarity with tools.

Discussion and conclusion:
There is potential for nurses to initiate treatment summaries and care plans in the treatment setting with the use of standardised tools. Further refinements are needed to make the process less time burdensome, additional specialised training is needed to improve confidence of nurses to work in a wellness model, and numerous system challenges need to be overcome to improve overall feasibility of using standardised tools to provide survivorship support to patients. Lack of systems to populate information, and lack of referral processes to support survivorship discussions with patients are likely to limit the initiation of survivorship care in treatment settings in South Australia. Further nurse-led development of tools for treatment summaries and care plans should occur in parallel with translational research designed to address system challenges.

What is already known about this topic?
– Structured survivorship care is recommended to facilitate the individual follow-up needs, health and wellness of people treated for cancer. Many health services are grappling with the challenge of delivering survivorship care in a sustainable way. It is clear that embedding survivorship care routinely and at scale presents a significant implementation challenge for oncology services.

What this paper adds.
– Nurses are well placed to lead the initiation of treatment summaries and care plans, however, this pilot provides real-world insight into the system and practical challenges that need to be addressed to provide essential components of survivorship care in South Australia


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