Back to face-to-face care for our bowel cancer patients
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Back to face-to-face care for our bowel cancer patients

Stephanie Jones-Berry @StephJonesBerry Features editor

As COVID pressures continue and NHS services tackle huge waiting lists, three colorectal oncology nurses share the highs and lows of a typical day

Around 43,000 people are diagnosed with bowel cancer in the UK each year and it is the country’s fourth most common cancer.

Nursing Standard. 37, 5, 67-69. doi: 10.7748/ns.37.5.67.s21

Published: 04 May 2022

As pandemic pressures continue to affect NHS services, three nurses working in colorectal oncology services share their accounts of a typical day two years after COVID-19 changed everything.

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Picture credit: iStock

A chance to reconnect with our patients

Joanna Thomson (pictured right), a lower gastrointestinal oncology clinical nurse specialist (CNS) at Guy’s and St Thomas’ NHS Foundation Trust in London

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7am I start early to try to avoid morning rush on the tube. As I’m one of the few people on the tube wearing a mask, I’m conscious of the risks to our patients of travelling when it’s busy.

9am I join the virtual board round, a discussion of patients’ journeys. We discuss existing gastrointestinal (GI) oncology inpatients and those admitted overnight, to check whether our team can offer support on the wards. There is a mix of patients to see: a new admission, an acutely unwell patient, some exhibiting challenging behaviours and one with a discharge complication. I go up to the ward to see if we can help.

10am Once finished, I tackle our ever-growing inbox with my colleague. How it reaccumulates so fast overnight always fascinates me. I’m grateful every day that there are two of us in the colorectal cancer team. Our tasks to respond to include new referrals, patients with treatment questions and symptom concerns, missing medications, appointment queries, and the current favourite – a positive COVID-19 test result. We divide and conquer as many of these as we can.

12pm I head to the oncology ward, instantly reminded of the daily challenges there in balancing complex patients with ongoing staff shortages. Speaking to the nurse in charge, I sense relief that they can hand over responsibility of some of the patients to us for a short time. After a quick handover, I don the personal protective equipment (PPE) and head into the bay. I spend some time with each patient and make a to-do list of follow-ups.

1.30pm Time for a quick pre-clinic meeting between the CNSs, consultants and clinical fellows to highlight any concerns, plan who will see who, and discuss our six new patients.

2pm Clinic starts. There aren’t enough rooms in the department for all the doctors to start at once, so we decide who will see the first few patients face to face and who will get on with calls. While these patients are being seen, it’s a great opportunity for me to inhale some lunch.

New patients have their initial consultation with the consultant, where they go over their diagnosis, staging, prognosis (should they want to know) and the treatment plan. A GI oncology CNS then meets them in a separate room to offer them time to breathe, digest and ask questions. We explain the support services available and practical things such as hospital transport and, importantly for them – as it is difficult at this stage for people to really take in information – we give them a contact sheet with our details.

Today I am with a patient who has come to his appointment alone, and has been told his only options for treatment are palliative. He is not expecting this news. Unfortunately, in our world this is a fairly common scenario, though not one that ever gets easier to witness. He wanted to know his prognosis but it comes as a huge shock. The consultation is stopped there and I take him into a quiet room accompanied by another CNS who he knows well. Instead of giving him all the usual information, we just give him our contact details and agree to speak again tomorrow.

‘COVID has taken away so much of our ability to communicate with patients on a more sensitive level. Virtual calls and emails don’t have the same empathetic effect as sitting face to face’

Joanna Thomson

7pm Although I finish late, clinic is the part of the job I love the most – where we get to see the patients, reassure them and try to solve problems. COVID has taken away so much of our ability to communicate with patients on a more sensitive level. Virtual calls and emails don’t have the same empathetic effect as sitting face to face. Clinic gives us this time to be able to reconnect and provide the support we went into this job to provide.

I feel I’ve made a difference in one of the best jobs there is

Nicola Tonks, colorectal consultant nurse at the Royal Wolverhampton NHS Trust

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7.30am Monday morning. I check whether any patients were added to the clinic late on Friday, then review our colorectal clinics, inpatient list and the list of patients who will be admitted for theatre this week. Then I check our phone support line for any messages left over the weekend and reply to urgent emails. I’m hoping the phone doesn’t ring just yet; if it does, there’s a chance it will be one of the team unable to come to work because of a positive lateral flow test. Everything feels precarious with COVID-19 cases on the rise.

9am Thankfully the whole team is in today, and we finish our handover. This is an important hour as we can draw on each other’s expertise and experience and discuss any patient care issues. It’s going to be a busy week. Increasing numbers of patients are being referred to the colorectal cancer fast-track triage clinic with bowel cancer symptoms, or receiving a colorectal cancer diagnosis at a more advanced stage, compared with before the pandemic.

‘I think about how difficult it has been during the past two years for patients who have had to attend appointments alone, or have been unable to see their family while in hospital’

Nicola Tonks

9.30am There are more messages from the support line. One recently discharged patient has concerns about leakage from his rectum and redness around his parastomal skin area. I listen to his concerns and hear how he and his wife are coping since he returned home, then arrange a virtual clinic appointment for him at midday. Video consultations have been one of the positive changes in care since the pandemic, helping us to respond quickly to problems.

10am I have two patients to see in clinic. The first has been through the bowel cancer screening service and diagnosed with rectal cancer. I’m glad to see that he is accompanied by his wife at the appointment. His surgeon and I discuss his diagnosis, treatment options and next steps with them. I never underestimate the potential psychological impact of a cancer diagnosis. I arrange to phone him to provide ongoing support.

My next patient has completed her chemoradiotherapy course and is ready for surgery. She needs an abdominoperineal resection, which will mean a permanent colostomy, and she is aware of this from earlier discussions. Although keen to get on with the surgery, she’s worried about the psychosexual aspect of living with a stoma. We arrange a further counselling session.

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Virtual meetings have got teams through the pandemic, but don’t allow the same level of communication as face-to-face interactions

Picture credit: iStock

12.20pm I go to the ward to see a patient who underwent a reversal of his stoma on Friday and is going home today. We discuss his bowel function and management, and continued support. Our support worker updates me on other patients’ progress towards managing their stoma independently.

1pm I take a sandwich back to the office ready for a Teams meeting about identifying any potential psychological harm caused by delays in treatment.

2pm I check on the team, answer queries about referrals and schedule some appointments for patients with symptoms of low anterior resection syndrome.

3pm I prepare for our patient support group meeting and think about how difficult it has been during the past two years for patients who have had to attend appointments alone, or have been unable to see their family while in hospital. I’ll be glad to recommence face-to-face support group meetings, but for now we have video calls.

5pm The end of another rewarding day, which leaves me feeling that I’ve made a difference and have one of the best jobs there is. Time to head to the gym for a swim.

It’s great to have critical care provision back

Claire Taylor, Macmillan nurse consultant in colorectal cancer at St Mark’s Hospital, part of London North West University Healthcare NHS Trust

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7.30am The day starts with listening to a grand round presentation online, where conditions and treatments are presented to clinicians and students for learning purposes. This is an important part of our in-house education, which covers a wide range of colorectal research. St Mark’s is the only hospital in the world to specialise entirely in intestinal and colorectal medicine, so we talk a lot about bowels here.

8.15am Quick catch up with the Macmillan colorectal CNS team. We carry our own caseload but share some patients with this team.

9am I return calls to people who left messages on our helpline, seeking updates on their care, pathway support and symptom advice. I primarily look after patients with locally advanced and recurrent disease who are referred to our complex cancer clinic. This is a specialist service, and most patients live out of area, so we rely on email, phone and video to keep in touch.

11am Ward meeting to discuss discharging a young woman who has had palliative surgery for an extensive colonic cancer with peritoneal metastases. She needs a lot of support from the palliative care team, the stoma care nurses, the rehabilitation unit, the Macmillan clinical psychologist and the physiotherapist and occupational therapist. I value working in a team with a strong multidisciplinary approach to patient care. It’s vital we combine our expertise and skills if we are to get her home.

‘I value working in a team with a strong multidisciplinary approach to patient care’

Claire Taylor

12pm We start our complex cancer clinic. I’ve booked in five patients who each receive a 45-minute multidisciplinary consultation, either via video or in person. The first patient is a man in his forties shocked to hear the extent of the surgery being offered to achieve curative treatment of his rectal cancer. He will need a lot of support to help prepare him emotionally and physically, if he chooses to go ahead and I will be a key contact person for him. On average, we have 40 interventions with each patient, often over many months, if not years. The next patient, a woman in her late seventies, swims every day and takes no medication, so feels she will cope well with major surgery. I refer her to our prehabilitation service.

I am responsible for organising the three complex cancer clinic surgical lists we have each week, which involves considerable coordination. Two of the lists allow for extended theatre operating, with intensive care unit provision, so it’s essential we use these resources effectively. During the pandemic we had months without critical care provision on site, and the whole team is grateful to have this back. I just hope further COVID-19 surges don’t affect patients accessing timely cancer surgery.

4pm Late lunch on my own in the office to reflect and recharge.

4.30pm I work through some of the many emails that come in each day. The email workload can feel onerous, so efficient management is required.

6pm My final job for the day is to try to find some more participants for two studies that I am recruiting to. I never finish all that I plan to do each day, so several activities get added to tomorrow’s ‘to-do’ list.

Giving bad news and picking up the pieces rcni.com/giving-bad-news

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