1. Nursing and Technology

In the UK during the first wave of the pandemic, most hospitals almost immediately moved as many outpatient appointments as possible to either to telephone or to ‘virtual’ video-linked appointments. Between different waves of the pandemic some groups of patients (for example new patients) have moved, at least in part, back to face-to-face or  in person appointments  but large numbers of more routine visits are still carried out ‘virtually’.

This has been a massive paradigm shift in the way oncology functions, and a particular challenge to specialist cancer nursing. Some clinicians and patients have welcomed this change, as it offers greater flexibility and it seems likely that the increased reliance on ‘non face-to-face’ appointments will continue.

The question is, however does this really work for nursing? Cancer nursing relies on forming relationships with patients and the building of a therapeutic relationships. This method of working will radically change the way patients are referred to nursing services such as the Clinical Nurse Specialists.  Nurses themselves need to develop their own clinics to assess and liaise with patients virtually but the evidence for doing this in terms of patient benefit and nursing effectiveness has not been developed. Because of this an important element of nursing work post-pandemic is to build this evidence via focussed nursing research
 

2. Maintaining Safe Cancer Services in the COVID-19 Era

It seems inevitable that oncology services will have to manage the presence of the COVID-19 virus in the general community for some time to come. This might well be achieved via a balanced strategy containing these elements-:

•            Identifying groups most at risk

•            Staff and patient testing

•            Encouraging up-to-date vaccination

We are now aware that patients with solid tumours do not necessarily have increased risk factors outside of those of the general population but patients with haematological malignancy have a higher mortality when they contact COVID-19. For older patients this can rise to between 47%, in patients under 60 years old the mortality is still high at 34%.  We are therefore likely to need different strategies for this group of patients than with the general oncology population. As risks change over time cancer clinicians will need to assess clinical risk of treatments, in terms of developing COVID-19 and becoming very unwell versus the potential benefits. Discussing these risks with patients is good practice and the involvement of skilled oncology nurses is vital.

One of the risks encountered by patients attending for appointments or treatment is from the staff they meet in hospitals or health environments. All hospitals in the UK have already developed thorough staff testing regimes with patient-facing staff testing, once or twice per week and this is likely to continue either via PCR testing, lateral flow testing or a mix of both. Because of the increased risks to cancer patients, particularly those with a haematological malignancy oncology and haematology are likely to want to continue this testing, possibly even after other areas are more secure in not doing this.

All hospitals test patients prior to surgery or other procedures. Cancer Centres currently test patients prior to starting radiotherapy and before chemotherapy. The logistics of this are challenging but systems are already in place for this.

Vaccinations against COVID-19 are the main weapon in the armoury to protect the general population against COVID-19 infection. UK NHS guidance tells us that cancer patients on treatment , and those who continue to be at higher risk should be encouraged to be vaccinated as with the general population and, indeed, should be prioritised. Current guidance indicates that the best time to administer vaccinations to patients on SACT is around the time of treatment, but not on the same day. This might change as different vaccines enter the arena or as knowledge develops.
 

Reducing Patient Isolation and Improving Community Support

The majority of people with a cancer diagnosis live their lives in the community, many with physical and psychological challenges relating to their cancer diagnosis. Many of these will also be older people, some providing care for others.  The pandemic has further reduced the numbers of options people living with cancer have for obtaining support and advice and many require ongoing cancer rehabilitation in a format that they can access. Both hospital visits and face to face appointments with GPs have been reduced and social services are stretched. This has led to increased isolation in the community for people with a cancer diagnosis and this who care for them. Looking forwards,   Cancer Rehabilitation services will need to be developed to meet these needs, alongside a raft of other resources, such as social prescribing which encourage people to improve their self-care where possible and assist them in accessing help where it is not.
 

Building and Maintaining the Cancer Nursing Workforce

The cancer nursing workforce has been placed under considerable strain by the pandemic. It was already a specialist field struggling to maintain adequate numbers to meet clinical need. The effects of the pandemic on an aging workforce, redeployment and wholescale changes to services will take their toll in numbers leaving oncology nursing, as well as a likely backlog of patients needing treatment due to diagnostic delays and late presentations.  Cancer care providers will need to both retain existing staff and recruit new cancer nurses.

Retention of existing staff will need to concentrate on incentivising staff to stay in cancer nursing.  These incentives may take the form of financial incentives, which are more difficult to achieve across a national pay scale or, more likely, other incentives. Examples of these might be

• Better access to training and development. There should be a clear pathway for all cancer nurses to develop in their careers without the need to leave a particular employer.
• Improved work/life balance. Improved shift patterns and family-friendly working.
• Nurses wishing to retire should be offered more flexible hours or negotiate a ‘phased’ approach to retirement which might allow knowledge to be passed onto to new or junior staff.

The pandemic has undoubtedly caused stress to nurses and oncology nurses are no exception. The full psychological impact on staff is unlikely to be fully realised until after the pandemic has fully stabilised. Healthcare providers have put support mechanisms into place to try and help staff deal with stress including improved access to psychological support, free access to stress–reducing apps and rest and recuperation areas.  There will need to be a longer-term commitment to supporting nurses who have suffered stress because of the pandemic, even after the current situation eases.

Recruitment of cancer nurses relies largely on the recruitment of nurses into the profession generally. Nurses specialise once training has completed, and without access to newly qualified or early career nurses all specialities will suffer poor recruitment. Many of the measures used to retain staff will also serve to improve recruitment and make Cancer Nursing more attractive. The pandemic has also greatly improved interest in nursing as a career when many other professions are struggling to employ people due to financial pressures. These should be favourable conditions to recruit more nurses but the NHS needs to drive this forward via policy and fair pay for student nurses and nurses who wish to return to the profession after a period away.
 

Summary

The pandemic has challenged cancer nursing in the way we deliver care, the effect on our patients (psychologically and socially), and in how we maintain a specialist workforce. The pandemic has also illustrated the real value of nursing, improved the international profile of the profession and forced us to adapt quickly and positively to a rapidly changing situation.
 

Cancer nursing can grow and adapt as a result of the pandemic and it is important that these positive aspects can be brought to the fore as we move into a post-pandemic world.