The role of advanced nursing in lung cancdevelopment

A. Serena a, b, c, *, P. Castellani b, 1, N. Fucina b, 1, A.-C. GS. Peters b, 3, M. Eicher a, c, 4

rn Switzerland, School of Health Fribourg, Switzerland

a r t i c l e i n f o

Article history:Received 21 February 2015Received in revised form13 May 2015Accepted 15 May 2015

' health needs, thee (APLCN) is well-veral North Euro-een developed inNursing has been

introduced relatively recently in Switzerland (since 2000 in theGerman-speaking part and since 2009 in the French-speaking partof Switzerland). Considering epidemiologic trends in lung cancerand the psychosocial and physical burden of these patients, it isimperative to develop the APLCN role in the Swiss context.

Globally lung cancer is the most common cancer, both in termsof new cases and deaths (Ferlay et al., 2014). Common physicalcomplaints reported by lung cancer patients include dyspnea, fa-tigue, pain, anorexia, cough, and insomnia (Cooley, 2000; Iyer et al.,

(P. Castellani), nadia.fucina@chuv.ch (N. Fucina), anne-claude.griesser@chuv.ch(A.-C. Griesser), jacqueline.jeanmonod@chuv.ch (J. Jeanmonod), solange.peters@chuv.ch (S. Peters), manuela.eicher@hefr.ch (M. Eicher).

1 Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 21, 1011 Lausanne,Switzerland.

2 Centre Hospitalier Universitaire Vaudois, Avenue Pierre-Decker 2, 1011 Lau-sanne, Switzerland.

3 Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne,Switzerland.

4 Haute ecole de sante Fribourg HES-SO, Route des Cliniques 15, 1700 Fribourg,

Contents lists availab

European Journal of

journal homepage: www.e

European Journal of Oncology Nursing xxx (2015) 1e7Switzerland.1. Introduction

In order tomeet complex lung cancer patientsrole of the Advanced Practice Lung Cancer Nursestablished in North America, Australia and sepean countries. Yet to date, no such role has bSwitzerland. Indeed, the Master of Science in

* Corresponding author. Centre Hospitalier Universitaire Vaudois, Avenue PierreDecker 2, 1011 Lausanne, Switzerland.

E-mail addresses: andrea.serena@unil.ch (A. Serena), pascale.castellani@chuv.ch 2015 Elsevier Ltd. All rights reserved.Keywords:Lung cancer nurseAdvanced practice nursingLung neoplasmSupportive carehttp://dx.doi.org/10.1016/j.ejon.2015.05.0091462-3889/ 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Serena, AJournal of Oncology Nursing (2015), http://da b s t r a c t

Purpose: Advanced Practice Lung Cancer Nurses (APLCN) are well-established in several countries buttheir role has yet to be established in Switzerland. Developing an innovative nursing role requires astructured approach to guide successful implementation and to meet the overarching goal of improvednursing sensitive patient outcomes. The Participatory, Evidence-based, Patient-focused process, forguiding the development, implementation, and evaluation of advanced practice nursing (PEPPAframework) is one approach that was developed in the context of the Canadian health system. Thepurpose of this article is to describe the development of an APLCN model at a Swiss Academic MedicalCenter as part of a specialized Thoracic Cancer Center and to evaluate the applicability of PEPPAframework in this process.Method: In order to develop and implement the APLCN role, we applied the rst seven phases of thePEPPA framework.Results: This article spreads the applicability of the PEPPA framework for an APLCN development. Thisframework allowed us to i) identify key components of an APLCN model responsive to lung cancer pa-tients' health needs, ii) identify role facilitators and barriers, iii) implement the APLCN role and iv) designa feasibility study of this new role.Conclusions: The PEPPA framework provides a structured process for implementing novel AdvancedPractice Nursing roles in a local context, particularly where such roles are in their infancy. Two key pointsin the process include assessing patients' health needs and involving key stakeholders.University Hospital Center of Lausanne, Switzc University of Applied Arts and Sciences Westea Institute of Higher Education and Research in Health Care, University of Lausanne, Switzerlandb erland., et al., The role of advancedx.doi.org/10.1016/j.ejon.2015er: A framework based

riesser b, 1, J. Jeanmonod b, 2,

le at ScienceDirect

Oncology Nursing

lsevier .com/locate/ejonnursing in lung cancer: A framework based development, European.05.009

l of O2013). Importantly, the physical symptoms resulting from the dis-ease and its treatment can cause signicant psychological distress,including depression and anxiety (Brintzenhofe-Szoc et al., 2009;Carlsen et al., 2005; Cooley et al., 2003). In addition, lung cancercarries a high disease burden and patients report high levels ofunmet supportive care needs related to psychological and physicalaspects of daily life (Li and Girgis, 2006; Sanders et al., 2010).

In recognition of the needs of cancer patients, the EuropeanPartnership for Action Against Cancer (EPAAC) recommends aspecialized Multidisciplinary Team (MDT) that includes an expertnurse to provide expert clinical advice to patients, exchange keypatient information and care recommendations with the MDT(Borras et al., 2014). The APLCN supports and counsels patients andfamilies during all stages of the disease providing emotional,informational and behavioral support. These activities focus on: i)developing patient self-management of symptoms, ii) improvingcommunicationwithin the care team and iii) ensuring continuity ofcare (Moore, 2002). To date, there are limited data on the effec-tiveness of such specialized nursing roles for improving outcomesor continuity of care (Aubin et al., 2012). Two initial studies on theclinical effect of specialist nurses (Bredin et al., 1999) and the role ofAPLCNs (Moore et al., 2002) point to positive outcomes on lungcancer patients, with decreased self-reported breathlessness,enhanced performance status, as well as improved emotional stateand patient satisfaction.

In line with the EPAAC recommendations, the University Hos-pital of Lausanne (CHUV) has launched a Thoracic Cancer Centerand we undertook a structured process to develop, implement andevaluate a novel APLCN role as key component of a MDTwithin thisThoracic Cancer Center. The APLCN focuses on delivering andcoordinating care for patients complex care needs and thus the roleincludes expanded autonomy beyond the traditional scope ofnursing practice. Accordingly, this role can be considered withinthe domain of Advanced Practice Nursing (APN) (Bryant-Lukosiuset al., 2004).

Introducing a new APN role is a complex and dynamic processthat must overcome a number of barriers including: i) lack ofclearly dened role and goals/expectations, ii) stakeholders'confusion related to describing the APN role, iii) difculty inidentifying and addressing obstacles to role implementation and iv)lack of evidence-based strategies guiding role development,implementation and evaluation (Bryant-Lukosius et al., 2004).Some have posited that using a systematic approach is an effectivemeans to overcome these barriers. One such approach is theParticipatory, Evidence-based, Patient-focused process, for guid-ing the development, implementation, and evaluation of advancedpractice nursing (PEPPA framework) (Bryant-Lukosius andDiCenso, 2004). The PEPPA framework was developed in thecontext of the Canadian health system for APN role development.However, to our knowledge, this framework has not been testedoutside of North American context (McNamara et al., 2009).Therefore, we aim to describe the development of an APLCN modelat a Swiss AcademicMedical Center as part of a specialized ThoracicCancer Center and to evaluate the applicability of the PEPPAframework in this process.

2. Method

The PEPPA framework was developed to address implementa-tion challenges for APN roles (Bryant-Lukosius and DiCenso, 2004)and is designed to: i) use the best available evidence and relevantsources of data to identify needs and establish goals and clearlydene the role, ii) support the development of patient-centerednursing practice, iii) use APN skills/knowledge in all role di-

A. Serena et al. / European Journa2mensions, iv) engage key stakeholders in the development and

Please cite this article in press as: Serena, A., et al., The role of advancedJournal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015implementation process, and v) dene outcomes and promoteongoing role development through monitoring and evaluation.

The framework comprises nine-phases: 1) dene the patientpopulation and describe current model of care; 2) identify stake-holders and recruit participants; 3) determine the need for a newmodel of care; 4) identify priority problems and goals to improvethe model of care; 5) dene the new model of care and the APNrole; 6) plan implementation strategies; 7) initiate the imple-mentation plan; 8) evaluate the APN role/newmodel of care; and 9)conduct long-term monitoring of the APN role/model of care. Forthe introduction of the APLCN role, we applied the rst sevenphases of the framework.

2.1. Phase 1: dene the patient population and describe currentmodel of care

The rst phase intends to dene the clinical pathway of a spe-cic patient population and map how care providers interact withpatients and families (Bryant-Lukosius and DiCenso, 2004). Wedened the patient population as those undergoing treatment forlung cancer at the tertiary academic medical center. To describe thecurrent model of care, we used a middle-range nursing theory, theNursing Role Effectiveness Model (NREM) (Irvine et al., 1998) toguide the new model of care (see Method phase 5). This model isuseful to depict a complex system of interrelated factors within apractice setting that impact role effectiveness (Sidani and Irvine,1999). The NREM is based on the structure-process-outcome in-dicators of Donabedian's (1980) that has long been used to describethe relationship between patient characteristic variables, nursinginterventions, and patient outcomes (Irvine et al., 1998).

The current model of care has been described by existingguidelines used in the hospital medical oncology and thoracicsurgery departments. In addition, between January and May 2013,22 exploratory, semi-structured interviews were conducted, with aconvenience sample of expert-providers. Participants for explor-atory interviews were purposefully selected from the departmentsof oncology, thoracic surgery (malignancies), pneumology, and ra-diation oncology. Health care professionals included head physi-cians and nurses of the respective services, clinical providers(physicians and nurses) stafng the inpatient and outpatientswards as well as datamanagers who help to coordinate patient owthrough their services. The aim was to describe the current illnesstrajectory of lung cancer patients and existing supportive care in-frastructures from the time of diagnosis through the end ofoncology treatment or to the palliative phase and to determine theneed for a new model of care. All interviews followed a self-developed interview guide (Supplemental Material 1, online only)and were conducted in the center by the Clinical Nurse Specialist(CNS) responsible for the APLCN role development project andlasted on average 45min. The CNS took notes during the interviewsthat were coded by the CNS and clustered based on thematicanalysis following an inductive approach to the data (Braun andClarke, 2006; Sim, 1998). Thematic analysis followed the six pha-ses proposed by Braun and Clarke (2006): 1) familiarizing withdata, 2) generating initial codes, 3) searching for themes, 4)reviewing themes, 5) dening and naming themes, and 6) pro-ducing the report.

2.2. Phase 2: identify stakeholders and recruit participants

Role acceptance and the support of key stakeholders arefundamental for successful implementation of a new role. Further,stakeholder participation at the onset of the project is critical forensuring commitment to the project, providing support for plan-

ncology Nursing xxx (2015) 1e7ned change and establishing a culture of shared values and beliefs

nursing in lung cancer: A framework based development, European.05.009

l of Onecessary to operationalize the role (Bryant-Lukosius and DiCenso,2004). When identifying key stakeholders for APLCN role devel-opment and implementation, we sought professionals involved inthe lung cancer clinical pathway such as, clinical nurse specialist,oncologists, thoracic surgeons, radiologists, radiation oncologists,pathologists, pneumologists, and project coordinator for thedevelopment of the Thoracic Cancer Center.

2.3. Phase 3: determine the need for a new model of care

This phase includes analyzing relative strengths and limitationsof the current model of care from the perspective of both patientsand care providers. To accomplish this, we conducted a descriptive,cross-sectional study to describe the unmet supportive care needsof lung cancer patients during the early systemic treatment phase(Serena et al., 2012). Patients (18 years and older) diagnosed withlung cancer (within the past 4 months) who were undergoingsystemic treatment were invited to participate in the needsassessment. Patients were recruited from both inpatient and out-patients settings over a 13 month period following a non-probability consecutive sampling method. Unmet supportive careneeds were measured by the validated French version of the Sup-portive Care Needs Survey Short Form comprising 34 items (SCNS-SF 34) (Bonevski et al., 2000; Bredart et al., 2012).

Additionally, the series of qualitative interviewswith health careproviders (see phase 1 above) were also focused on assessingstructure, process and outcome. Specically we aimed to identifyhealth care system factors (i.e. NREM structure indicators)contributing to unmet patient needs and shortfalls of currentpractice (i.e. NREM process indicators) impacting outcomes (i.e.NREM nursing-sensitive patient outcomes). Open ended questions(Supplemental Material 1, online only) centered on: i) habits andtools for assessing physical/psychological symptoms, ii) currentinterventions implemented in response to detected physical/psy-chological symptoms, iii) satisfaction with interdisciplinarycollaborationwithin the care team, iv) translational blocks betweentheory and practice, and v) perspectives and attitudes towards theAPLCN role. Data were collected and analyzed as described above(phase 1).

2.4. Phase 4: identify priority problems and goals to improve themodel of care

This phase is intended to reach consensus on the core challengesto be addressed in order to better meet patient care needs anddelineate related goals and objectives (Bryant-Lukosius andDiCenso, 2004). This consensus process was achieved via a seriesof strategic meetings with engaged stakeholders. The meetingswere used to present the data and analysis of the previous stepsand included iterative discussions to create priority lists that wererened until consensus was reached. The result of this phasecomprised a list of priority goals to achieve the maximum qualityimprovement of the clinical pathway through the implementationof an APLCN role.

2.5. Phase 5: dene the new model of care and the APLCN role

Broadly, this phase aims tomap priority goals identied in phase4 into the new model of care and new nursing role (Bryant-Lukosius and DiCenso, 2004). The priority goals serve to focus thedesign of the new model of care and the APN role, in this case theAPLCN role. Central to this step is identifying a guiding theoreticalframework for the APLCN clinical interventions, identify the bestavailable evidence on effectiveness of interventions to improve

A. Serena et al. / European Journapatient outcomes, dening how the role will be involved in new

Please cite this article in press as: Serena, A., et al., The role of advancedJournal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015care practices and goal-related strategies, identifying the skills andknowledge needed for the APLCN and outlining the scope ofpractice for the APLCN.

As the goals for this new role (i.e. NREM e nursing-patientsensitive outcomes) focus on improving unmet care needs of lungcancer patients, we selected the Theory of Symptom Self-management (TSSM) (Hoffman, 2013) as a guiding theoreticalframework for designing the APLCN clinical interventions andgauging expected patients' outcomes. This middle-range nursingtheory was formulated by Hoffman (2013) and maps Bandura'snotion of self-efcacy (Bandura, 1997) onto the Theory of Un-pleasant Symptoms (Lenz et al., 1997). The TSSM is used to guideoncology nursing via perceived self-efcacy-enhancing symptomself-management interventions to reduce patients' symptomburden associated with cancer and its treatment and thus enhancequality of life (Hoffman, 2013).

To identify the best available evidence on nursing interventionsrelated to the APLCN role relevant to the clinical context of CHUV,we conducted a selective literature review. The aim was to identifynon-pharmacologic interventions addressing physical and psy-chosocial burden and improving self-management in lung canceror oncology populations with similar physical and psychosocialsymptoms. A selective literature review of CINAHL and PubMed,was conducted with the search strings lung cancer AND self-management, lung cancer AND non-pharmacological interven-tion, fatigue AND non-pharmacological intervention, lungcancer AND nursing, supportive care AND lung cancer andsupportive care AND oncology. Selection criteria were: i) relevantstudies published in peer-reviewed journals between 1999 andAugust 2014, ii) in English language, iii) guidelines, randomizedcontrolled trials (RCTs), systematic reviews and meta-analysisfocused on non-pharmacological interventions concerning psy-chological and physical symptoms and concerning lung cancerpatients or patients with similar symptom burden, iv) articles thatwere focused on model of cancer nursing specialized or specializednursing, v) studies that describe non-pharmacological interventionthat can be carried out by nurses (in the context of the Swiss law)evaluated as feasible in the CHUV setting by expert stakeholders ofAPLCN project's working group. Following the evidence hierarchyapproach of Evidence-Based-Nursing process (DiCenso et al., 2005),selective literature review included best available guidelines(Summaries), followed by meta-analysis (Synopses of Syntheses),systematic reviews (Syntheses) and RCTs (Studies).

2.6. Phase 6: plan implementation strategies

This phase identies barriers and facilitators of implementationand denes outcomes for the evaluation phase (Bryant-Lukosiusand DiCenso, 2004). This step is fundamental to minimize bar-riers and prepare the clinical setting to receive and accept the newAPLCN role. This was accomplished in a stakeholder brainstormingsession identifying barriers and potential facilitators of role intro-duction. Moreover, two strategic planning meetings were held toidentify the metrics and nursing-sensitive outcomes (milestones)for evaluating the feasibility of the APLCN role in the multidisci-plinary team (see results).

2.7. Phase 7: initiate the implementation plan

According to the developers of the PEPPA framework, it is rarelypossible to have all implementation strategies in place at the timewhen the role is introduced (Bryant-Lukosius and DiCenso, 2004).Thus, there is a exible back and forth between steps 6 and 7 tostructure a stable, long-termmonitoring of the APN role and model

ncology Nursing xxx (2015) 1e7 3of care (Bryant-Lukosius and DiCenso, 2004). To implement the

nursing in lung cancer: A framework based development, European.05.009

APLCN role, we maintained a continuous quality appraisal processwherein the stakeholders provided ongoing feedback in monthlyprogress report meetings, and this is identied as a process ratherthan a singular event.

3. Results

The process of developing and implementing an APLCN role in amultidisciplinary team began in January 2012. The proximal goalwas to delineate and implement the APLCN role into a health caresetting in Switzerland that has yet to dene APN roles. The ultimategoal being to enhance the effectiveness of multidisciplinary carewith the inclusion of nursing interventions targeting the unmetself-management needs of lung cancer patients. The results of eachphase of the PEPPA framework process is described in the contextof dening the patient population (structure) and the model of care(process) in order to enhance care (outcome).

3.1. Phase 1: dening the patient population and describing currentmodel of care

A. Serena et al. / European Journal of O4The current model was delineated via semi-structured in-terviews (see method, phase 1 and phase 3) and by analyzing theexisting guidelines used in the medical oncology and thoracicsurgery departments. This process revealed that most patients withlung cancer are treated in three different disease trajectoriesinvolving systemic therapy combined (or not) with radiotherapyand receiving (or not) surgical intervention before/after systemictherapy. Less frequently, patients receive surgery only or radio-therapy only. The diagnostic process and medical managementwere guided by national/international guidelines built on the bestavailable evidence. However, interviewees reported a paucity ofguidelines/evidence concerning supportive care and nursing in-terventions. They conrmed that this resulted in inconsistentsupportive care based on individual preferences of nurses or otherhealth care professionals.

The systemic therapy is nearly always proposed to lung cancerpatients. Further, as lung cancer is often detected in advancedstages, these patients often need high levels of supportive care(Joyce et al., 2008; Temel et al., 2006). Therefore, we focused ondeveloping an APLCN clinical pathway for lung cancer patientsreceiving systemic therapy combined (or not) with radiotherapy.The initial steps for clearly identifying the patient population (Fig.1,Fig. 1. Dening the role of Advanced Practice Lung Cancer Nurse (Framework adaptedfrom Irvine et al., 1998).

Please cite this article in press as: Serena, A., et al., The role of advancedJournal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015A, Patient) and the current model of care was a critical and rationalrst step for dening the APLCN role.

3.2. Phase 2: identifying stakeholders and recruiting participants

We leveraged the existing working group of stakeholdersbrought together to guide the implementation of specializedThoracic Cancer Center. Thus we were not forced to identify par-ticipants as separate and distinct process. Enlisting these stake-holders in a working group enabled multiple viewpoints to beconsidered and buy-in across the care team. This groupmet weeklythroughout the project period, validated the project plan and theachieved milestones. It supported the process of role clarication,role acceptance, and the identication and discussion of strategiesto deal with potential barriers and facilitators to role imple-mentation. For feasibility reasons we could not include patients,families and nurse managers in this group of participants, but weincluded their viewpoints during the development process(described below).

3.3. Phase 3: determining the need for a new model of care

As noted previously we conducted supportive care needs as-sessments. Of 220 eligible patients, 106 were approached by phy-sicians and 37 patients agreed to participate (response rate 34.9%).Across the ve domains of the SCNS-SF 34, participants reportedthe highest levels of unmet needs in the psychological (Mean. 46.3),physical (Mean. 41.2), and informational (Mean. 39.1) domains(Serena et al., 2012). Lower levels of unmet needs were identied inpatient care and support and sexuality domains (mean 33.2 and22.8 respectively). This small study highlighted the difculty inrecruiting patients and the high levels of psychological and physicalunmet supportive care needs among lung cancer patients.Although the sample size was limited, results were in line withprior reports of physical and psychological symptom burden insimilar patient populations (Li and Girgis, 2006; Sanders et al.,2010). Importantly, our needs assessment also underscored theimportance of improving personalized information and patienteducation. Notably, more than half of patients desired more infor-mation on self-care management which could be done at home. Infact, 65% of patients expressed dissatisfaction concerning beinginformed about things you can do to help yourself to get well and60% concerning being given information (written, diagrams,drawings) about aspects of managing your illness and side-effectsat home (Serena et al., 2012).

In the present study, we conducted semi-structured interviewswith nurses (n 10), physicians (n 10) and data-mangers (n 2)who work with lung cancer patients (radiotherapy, pneumology,thoracic surgery and inpatient/outpatient oncology wards). The-matic analysis revealed four main emergent themes. Theseincluded: i) coordination/communication among health pro-fessionals, ii) information and symptom management education,iii) psychological assessment, iv) using evidence based nursingguidelines and support nursing staff sharing specic nursingknowledge. These topics were used as core elements of the newrole/model of care for responding to patient's needs and addressingthe shortfalls of current practice.

3.4. Phase 4: identifying priority problems and goals

During 2013, two strategic meetings with key stakeholders wereheld to nd consensus on the priority problems in meeting patientsupportive care needs and how the APLCN role would be intro-duced to meet these needs. Results of the needs assessment and

ncology Nursing xxx (2015) 1e7emergent themes of interviews were presented and discussed.

nursing in lung cancer: A framework based development, European.05.009

Stakeholders agreed that APLCN implementation could be anappropriate response concerning priority goals to improve the newmodel of care providing i) patient psychosocial support, ii) patientsself-management education, iii) ensure a continuity of care and iv)support nursing staff sharing specic nursing knowledge.

3.5. Phase 5: dening the model of care and the APLCN role

To meet the priority goals dened by key stakeholders, wedesigned an APLCN interventions based on the principles of theTSSM as well as a selective literature review and synthesis ofavailable evidence concerning care for lung cancer patients. Twelvestudies/guidelines were included (see owchart, Fig. 2). The se-lective literature review allowed us to identify i) instruments toassess physical and psychological needs of lung cancer population(or oncology populations with similar needs), ii) non-pharmacologic interventions addressing the physical and psycho-logical needs of patients, and iii) descriptions of existing APLCNroles (Supplemental Material 2, online only).

The APLCN role involves both independent functions (autono-

A. Serena et al. / European Journal of Omous actions initiated by nurse in response to patient's needs) andinterdependent aspects (activities shared with other members ofhealth-care team) across 5 key practice domains (Fig. 1B, Process).The APLCN's independent role comprises: i) providing psycholog-ical support to patients and families, ii) monitoring and managingphysical symptoms and providing symptom-management educa-tion and iii) providing timely patient information regarding diseaseand symptoms (Table 1). The interdependent role centers on: i)coordination and continuity of care, ii) supporting the nursing staffby sharing specic nursing knowledge related to the specic pa-tient population and symptom-management (Table 1).

The model of care incorporating the APLCN role (Fig. 3) isdesigned to meet the priority goals identied in the structuredprocess. APLCN-led interventions were targeted for the patientpopulation dened in Phase 1 (lung cancer patients receivingsystemic therapy combined (or not) with radiotherapy. Specically,the APLCN-led intervention includes four systematic, alternateface-to-face/telephone consultations. Information exchange be-tween the APLCN independent role (psychological support; moni-toring and manage physical symptoms and self-managementeducation; patient information-giving) and the MDT is funda-mental for fostering a collaborative approach across specializedFig. 2. Flow diagram of selective literature review.

Please cite this article in press as: Serena, A., et al., The role of advancedJournal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015health care providers and for facilitating continuity of care (Fig. 3).The APLCN role and intervention model of care were accepted bykey stakeholders in December 2013 setting the stage forimplementation.

3.6. Phase 6: planning implementation

An integral step in the implementation planning phase involvesidentifying: i) goal-related outcomes which are expected after theintroduction of APLCN role (outcomes), and ii) degree of educationand training for the new nurse (structure). Based on TSSM clinicaltheoretical foundation we dened clinical outcomes (lung cancersymptoms, self-efcacy for managing symptoms and, unmet sup-portive care needs) (Fig. 1C) to prepare the feasibility study. In linewith international recommendations, the APLCN model of care ofCHUV and the Swiss nursing education context we dened that theAPLCN had: i) a Clinical Nurse Specialist degree, ii) at least 2 years ofexperience in oncology care, and iii) successfully completed theeducation program oncology communication skills delivered bythe Swiss Cancer League (Fig. 1A, Nurse).

Planning emphasizes minimizing role barriers and maximizingacceptance of the new APLCN role. This includes addressing chal-lenges regarding APLCN role ambiguity and resistance from bothphysicians and nurses. To overcome this we employed severalcommunication strategies over a 3-month pre-launch period: i)meeting with implicated oncology nursing staff to share ways thatsupportive care for lung cancer patients could be improved, ii) keystakeholders consensus regarding priority goals were presented tothe nurse's managers across the oncology department and thoracicsurgery ward, and iii) the project was presented to all nurse teamsof the oncology, thoracic surgery and radiotherapy departments.Six months post introduction of the APLCN role, a clinical casereport concerning the APLCN contribution to the care pathway waspresented to the stakeholders to tangibly demonstrate the valueand impact of the role using a real-world example. The overall aimof this multilevel communication strategy was to present thecontribution of the APLCN to the goals dened in phase 4 tostrengthen the support of key stakeholders for the APLCN role. Asturnover is regular in academic training hospitals, the role isintroduced to new oncology and radiotherapy fellows/traineesevery 6-months.

3.7. Phase 7: initiating the APLCN role implementation plan

The APLCN role was implemented in January 2014, and policies(i.e. Delegate medical autonomy) and clinical protocols are under-going ongoing renement as part of a continuous qualityimprovement process (Fig. 1A, Organizational). As this APLCN role(and APN roles in general) is new to the Swiss health care system,assessing their acceptability by professionals (e.g. role tension) andfeasibility of the APLCN-led intervention (process) is critical forsuccess.

4. Discussion

Herein we described the development process of the newAPLCN role within a Swiss Thoracic Cancer Center enter. Weemployed the PEPPA framework to dene the APLCN role (Fig. 1),and the APLCN-led intervention plan (Fig. 3). This framework wasdeveloped and implemented in the context of the Canadian healthsystem (Bryant-Lukosius and DiCenso, 2004). In the present proj-ect, we introduced an APN role (APLCN) in a Swiss Thoracic CancerCenter. As the initial empirical demonstration of the applicability ofthe PEPPA framework in Europe, we have expanded the theoretical

ncology Nursing xxx (2015) 1e7 5utility of this model. This process could be used by clinicians,

nursing in lung cancer: A framework based development, European.05.009

holoppo

cernsicalo idnitoatmep dto m

A. Serena et al. / European Journal of Oncology Nursing xxx (2015) 1e76Table 1Independent and interdependent role of Advanced Practice Lung Cancer Nurse.

Responsibilities Process (tasks)

Psychosocial support Assess patient's psyc Provide emotional subody image).

Provide support conMonitoring and managing physical symptoms and

providing symptom-management education Assess patient's phy Work with patient tapproach for self-mo

Discuss potential trefatigue; anorexia, sle

Providing patient/family information regarding Adjusting languageresearcher and administrator to develop, implement and plan theevaluation of an introduced APN role, particularly in the oncologydomain. The PEPPA was particularly useful as the APN role is yet inits infancy in Switzerland. Two key points of PEPPA framework thatappear to be fundamental for successfully introducing a new APNrole implementation include the patient need assessment andinvolving key stakeholders into the process (Bryant-Lukosius andDiCenso, 2004).

In developing the novel APLCN role, the NREM and TSSM werecomplementary theoretical foundations for dening the APLCNrole. The NREM focused development on how the structure factorsinteract with process factors affecting nursing sensitive outcomes

disease and symptoms procedures and treatme Provide information andmanagement and extern

Coordination and Continuity of care Refer patient and familieaccording to the severity

Attend weekly multidisctherapy and disease evo

Organize multidisciplintherapeutic and enable p

Supporting the nursing staff Support the staff workinformation, advice andresults.

Collaborate in research pof nursing and secondar

Fig. 3. Advanced Practice Lung Cancer Nurse model of the University Hospital ofLausanne.

Please cite this article in press as: Serena, A., et al., The role of advancedJournal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015for the APLCN role (Fig. 1). The TSSM has been useful for describingthe interrelationship between nurse assessment of patient phys-ical/psychological needs and APLCN interventions for developingpatient self-care and symptom-management and with the goal ofimproving their performance outcomes.

The APLCN is both an expert resource and bridge for commu-nication and continuity of care through the care pathway. Twostudies have assessed the APLCN role in relation with patients whohad completed rst-line treatment (Bredin et al., 1999) and duringthe follow-up phase (Moore et al., 2002) observing positive impacton patient physical and psychological outcomes.

The APLCN model described in this article was designed spe-cically for the Swiss health system context and the local context of

gical distress using Distress Thermometer (Lynch et al., 2010).rt to patients and family (i.e reduce stress, anxiety, adjustment to illness, change in

ing practical problems (i.e. transportation, nancial problems).symptoms using the Lung Cancer Symptom Scale (Hollen et al., 1999).entify uncomfortable disease related symptoms applying a therapeutic educationring and self-management at home.ent side-effects and provide instruction for self-management (i.e. breathlessness;isturbances).eet the patient's emotional state and using lay language to explain the disease,nts.written reference materials regarding the disease, treatments, symptoms self-al support possibilities (i.e. patient association).s to specialist professionals (i.e. social worker, nutritionist, and psycho-oncology)of the assessed psychological or physical problem.iplinary tumor-board meetings to provide ongoing clinical overview on patients'lution.ary meetings with patients/family to share viewpoints, develop coherentatients to take an active role in therapeutic decision-making.ing with lung cancer patients (particularly other nurses), providing expertorganizing time for dissemination about nursing or supportive cares research

rojects and in developing evidence-based nursing guidelines (primarily in the eldily in medical or other health sciences).a Thoracic Cancer Center of CHUV. While our APLCN role mirrorsboth British APLCN model (Leary et al., 2014; Moore, 2002; Mooreet al., 2006; White, 2013) and the oncology nurse navigators in theUnited States (Horner et al., 2013), novel oncology role develop-ment process needs to be adapted to the local context. Indeed, thedevelopers of PEPPA underscore the importance of considering thelocal context (i.e. current model of care and patients' needsassessment).

Future work will include the ongoing feasibility and accept-ability study (ClinicalTrials.gov, Number: NCT02362204). This ex-amination will assess the APLCN role using the structure-process-outcomes framework to move optimize APLCN role's effectivenessand setting milestones for long-term monitoring of the APLCN roleand model of care (i.e. phase 8 and 9 of the PEPPA frameworkrespectively). In parallel, ongoing work will emphasize maintainingconsensus regarding scope of practice to ensure long-term sus-tainability of the APLCN role. In this way, the APLCN role may ableto provide ongoing, high-quality services meeting the needs ofpeople affected by lung cancer and this could include expandingthe role into initial diagnosis phase, post-surgical and follow-upphases.

In summary, we present a structured approach for developingand implementing a new APLCN role into a health system contextthat has yet to widely establish APN roles. The PEPPA frameworkprovides a systematic process using a health-oriented, patient-focused, participatory and stakeholder-driven process as a strategy

nursing in lung cancer: A framework based development, European.05.009

for overcoming barriers in the development and introduction of theAPLCN role. While a development APN role in Switzerland is still itsinfancy, this project represents a nurse-led response to meet theunmet needs of lung cancer patients.

Acknowledgements

This work was supported by key professionals of ThoracicCancer Canter of the University Hospital of Lausanne: Prof. Dr.Hans-Beat Ris, Dr. Alban Lovis, Prof. Dr. Laurent Nicod, Dr. HasnaBouchaab, Dr. Mahmut Ozsahin, Dr. Nicolas Peguret, Dr. Igor Leto-

Cooley, M.E., Short, T.H., Moriarty, H.J., 2003. Symptom prevalence, distress, andchange over time in adults receiving treatment for lung cancer. Psycho-Oncology 12 (7), 694e708. http://dx.doi.org/10.1002/pon.694.

DiCenso, A., Guyatt, G., Ciliska, D., 2005. Evidence-based Nursing: a Guide to ClinicalPractice. Elsevier Mosby, St. Louis, MO.

Donabedian, A., 1980. Explorations in Quality Assessment and Monitoring: theDenition of Quality and Approaches to its Assessment. Health AdministrationPress, Ann Arbor, Mich.

Ferlay, J., Soerjomataram, I.I., Dikshit, R., Eser, S., Mathers, C., Rebelo, M., et al., 2014.Cancer incidence and mortality worldwide: sources, methods and major pat-terns in GLOBOCAN 2012. Int. J. Cancer. http://dx.doi.org/10.1002/ijc.29210.

Hoffman, A.J., 2013. Enhancing self-efcacy for optimized patient outcomes throughthe theory of symptom self-management. Cancer Nurs. 36 (1), E16eE26. http://dx.doi.org/10.1097/NCC.0b013e31824a730a.

A. Serena et al. / European Journal of Oncology Nursing xxx (2015) 1e7 7vanec, Dr. Catherine Beigelman-Aubry, Claire Zurkinden, JacquelineBulliard and Marie-Rosalie Melanjoie-Petite. Scientic consultationwas provided by Prof. KateWhite, Prof. Diane Morin and Prof. SergeLeyvraz. Dr. Andrew Dwyer and Dr. Franois Mooser providedediting assistance.

Appendix A. Supplementary data

Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.ejon.2015.05.009

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The role of advanced nursing in lung cancer: A framework based development1. Introduction2. Method2.1. Phase 1: define the patient population and describe current model of care2.2. Phase 2: identify stakeholders and recruit participants2.3. Phase 3: determine the need for a new model of care2.4. Phase 4: identify priority problems and goals to improve the model of care2.5. Phase 5: define the new model of care and the APLCN role2.6. Phase 6: plan implementation strategies2.7. Phase 7: initiate the implementation plan

3. Results3.1. Phase 1: defining the patient population and describing current model of care3.2. Phase 2: identifying stakeholders and recruiting participants3.3. Phase 3: determining the need for a new model of care3.4. Phase 4: identifying priority problems and goals3.5. Phase 5: defining the model of care and the APLCN role3.6. Phase 6: planning implementation3.7. Phase 7: initiating the APLCN role implementation plan

4. DiscussionAcknowledgementsAppendix A. Supplementary dataReferences