Modern healthcare in the United Kingdom and internationally is currently undergoing a difficult but a profound change process especially in the way it delivers healthcare.1–3 A number of government strategies are now in place to provide healthcare services through the expansion of traditional nursing roles, such as advanced specialist nurses.4,5 The role of the advanced specialist nurse has been defined as, “a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master’s degree is recommended for entry level.”5 Central to the development and expansion of such roles, which includes advanced cancer specialist nursing roles, encompasses a variety of advanced skills that might include nonmedical prescribing.6,7 The Department of Health defines a nonmedical prescriber as “independent prescribing is prescribing by a practitioner (e.g. doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing.”7 Therefore, central to safe and effective prescribing practice, nonmedical prescribers may need to formulate a differential diagnosis and evidence-based management plans during clinical consultations.
A clinical consultation has been described as an encounter that is a 2-way process of information exchange between a healthcare professional and a patient. Such a consultation maybe initiated by the patients when they are ill or by the healthcare professional to provide health promotional intervention or a screening intervention.8 There are various approaches to consultation, and over recent decades, there has been an evolution of various consultation models in the literature, but for the most part, consultation models have been developed for general practitioners (GPs) up until now,8 and not specifically for advanced nursing roles in cancer care. Collectively, the nursing profession has endured significant changes in role development that has resulted in more autonomous roles both in community and acute care settings. The term consultancy has only been applied within the medical context predominantly, whereas nowadays, consultancy has become an integral part of many advanced nursing roles in contemporary healthcare.9
The development of consultancy skills within the context of prostate cancer care is ever pressing, as highlighted in the Improving Outcomes Strategy for Cancer,2 which recognizes that not enough attention has been given to the long-term consequences of a cancer diagnosis, the need to maximize service delivery for the ever-increasing number of individuals surviving the disease, or how to enable individuals to return to active lives after the completion of initial cancer treatment. Thus, effective consultancy skills are paramount in delivery of supportive care for men affected by prostate cancer.10
Supportive care is a person-centered approach to the provision of the necessary services for those living with or affected by cancer to meet their informational, spiritual, emotional, social, or physical needs during diagnosis, treatment, or follow-up phases, including issues of health promotion and prevention, survivorship, palliation, and bereavement.11,12 The physical and psychological sequelae of prostate cancer and its associated treatments have been well documented (eg, urinary, bowel, and sexual dysfunction; pain; fatigue; spinal cord compression; hot flushes; and difficulties with self-image and masculinities), but little is known about men’s perceptions about the impact of these on their lives and the areas in which they most require assistance.10 One approach to quality of life evaluation that assesses supportive care requirements is needs assessment.13
Supportive care needs can be defined as requirements for care arising during treatment and illness to manage symptoms and side effects, enable adaption and coping, optimize understanding and informed decision making, and minimize decrements in functioning.14 Therefore, identifying and addressing such needs during clinical consultation with men with prostate cancer can prevent patient distress, improve quality of life, and improve overall satisfaction with care,12 while reducing healthcare utilisation and costs.15
This literature review aimed to critically appraise existing models of consultation and make recommendations for a model of consultation within the scope of clinical practice for prostate cancer care.
A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines published in 2009.16 The following electronic databases were searched: DARE, Cochrane, MEDLINE, BNI, and CINAHL, which used a wide range of keywords and free text items to increase the sensitivity and inclusiveness of the searches. Examples of search terms included consultation models, consultation, nurses, doctors, communication, interpersonal skills, prescriber, biomedical, psycho-social, holistic, person-centred, autonomous, prostate cancer, and assessment. Databases were searched from the earliest date available to 2015 using truncation, wildcards, and Boolean logic. Additional searches were performed in Index to Theses, Google Scholar, Google, and manual library searches. All of the publications were managed using the software package Endnote X4.
Inclusion and exclusion criteria were applied to all records identified. The electronic searches began in September 2015 and concluded on the December 2015. The following preselection criteria were applied to all records.
- Literature that detailed a theoretical model of consultation
- Qualitative and quantitative methods irrespective of research design that have tested consultation models in clinical practice
- Studies published in the English language
- Studies conducted with adults (≥18 years old)
- Studies published in peer-reviewed journals with no date parameters
- Literature that did not describe a model of consultation
- Studies that did not explicitly test consultation models in clinical practice
All literature sources were reviewed by members of the research team using a pro forma checklist to make decisions to include or not to include studies, based on the inclusion/exclusion criteria. All articles that met the inclusion criteria were retrieved in full-text. Any disagreements were resolved through discussion. One author extracted data from the final sample of literature sources.
This review used a narrative synthesis and tabulation of literature to generate broad findings and conclusions. Specifically, the narrative synthesis undertook the following steps: data reduction (subgroup classification based on the levels of evidence and the review questions), data comparison (iterative process of making comparisons and identifying relationships), and finally, conclusion and verification (checking primary data sources for accuracy and confirmability). This process has been applied to several systematic reviews including prostate cancer.17,18
The research steering group included a professor of surgical urooncology with a special interest in prostate cancer, a senior prostate cancer clinical specialist nurse, and service users to inform the appraisal of models of consultation.
Of the 1829 publications retrieved from the search, 1464 were excluded following the application of the inclusion/exclusion criteria (Figure 1).
This left 32 publications reviewed in full, of which 15 articles were excluded8,9,19–31 because they did not meet the inclusion criteria (see Figure 1). This left 17 papers that fully met the inclusion criteria. Noteworthy, there is a lack of empirical evidence to test the effectiveness of the included consultation models in routine clinical practice, underscored by the levels of evidence D (summary review articles and discussions of relevant literature and conference proceedings not otherwise classified)32–45 and C1 (descriptive and other research or evaluations, eg, convenience samples)34,46–52; see Table 1 for an overview of the included consultation models.
Most consultation models have been developed for GPs’ use in clinical practice, with only 3 models37,40,43 developed for specialist nurses and 1 consultation model for use in emergency care.47,48 The development of the early consultation models were predominately biomedical and do not address psychosocial factors, for example, Stott and Davis (1979)44 and Byrne and Long (1976),34 or focused entirely from the patients perspective and lacked guidance on the steps involved in the consultation process, such as Maslow (1954),41 Berne (1964),33 and Helman (1984).38,39 More recent models of consultation delineate specific steps in the consultation process, such as Pendleton et al (1984, 2003),49,50 Neighbour (1987),42 Calgary-Cambridge (1996),53 and Consultation Assessment (2006).37
Synthesis of Evidence to Inform Consultation Model for Prostate Cancer Care
There were 17 consultation models included in this review. There were a number of beneficial features that ranged across a number of models that included a person-centered consultation,35,39–41,43,52,53 development of shared management plans,50 and safety netting.40,42 However, one of the main limitations that featured across all of the reviewed models is the lack of standardized assessment of the patient’s problems or areas that are of most concern to the patient to guide the consultation, a feature particularly relevant in supported self-management for prostate cancer care.18
A recent systematic review has identified that men with prostate cancer can experience a range of supportive care needs as detailed in Table 2. The classification of the domains of prostate cancer survivorship care needs and has been informed by existing international clinical guidelines.54–60 Healthcare professionals have identified challenges in providing optimum supportive care and identification of unmet needs due to limited time and resource in the clinical setting.12 As a consequence, by asking men to complete patient-reported outcome measures before their clinical consultation, communication between the patient and the healthcare professional can be improved, patients can experience greater satisfaction with care, an opportunity for tailored self-management advice is enabled, and targeted and better management of side effects in line with patient need can be promoted.61,62Table 3 provides a summary of existing validated quality of life assessment tools for use within prostate cancer care. Evidence supports the use of patient reported outcomes in routine clinical practice,63 enabling a systematic and “real-time” assessment of person-centered supportive care needs, to enable interventions to be appropriately targeted within the consultation. Point-of-care quality of life assessment is not yet widespread in prostate survivorship care, but a recent study identified that patients’ quality of life and satisfaction with care were better compared with those of patients who did not complete point-of-care quality of life assessments in routine follow-up care.57 Therefore, using validated patient-reported outcome measures during consultations with patients can increases the specialist nurse’s/clinician’s awareness of the multifaceted factors that can negatively affect quality of life and can facilitate tailored self-management plans that are protocol driven at the individual level of need,10 as detailed in Table 2.
Based upon critical appraisal of existing models of consultation to date, none of the reviewed models are suitable for use in prostate cancer care for the following reasons: (1) no recognition of the cancer care continuum and its influence on consultation, (2) lack of supported self-management as a long-term condition, (3) no appreciation of the complex factors that influence consultation for each individual man affected by prostate cancer (demographic, self-efficacy, cultural, etc), and (4) very little acknowledgement of the evidence base to inform management plans within the consultation itself. Therefore, a new model of consultation has been informed from critical review of existing models of consultation, expert guidance from men affected by cancer, and expert clinicians in prostate cancer care (see Figure 2). The Prostate Cancer Model of Consultation clearly delineates the man and his caregiver, spouse, and partner at the center of this model of care. The Prostate Cancer Specialist Nurse provides a hub of survivorship care embedded within the wider multidisciplinary team with clear role distinction and overlaps with other disciplines. For example, the consultant urological surgeon will only be involved with the treatment of radical surgery itself, but the specialist nurse can further support treatment decisions through information and support, if required. Whereas, often, the specialist nurse will take the lead on managing the after effects of treatment and symptom management as detailed in Table 2. Evidence supports that, often, prostate cancer specialist nurses take the lead on triggering referrals to wider members of the multidisciplinary team (MDT), such as physiotherapists, sexual counselors, or referrals back to the overall responsible clinician,58 as conveyed in Figure 2. Each member of the MDT team has defined roles in providing optimal care and treatment, but as a collective team, their contributions fit together and complement care delivery, like a jigsaw puzzle, tailored to the individual man and his partner. At the center of survivorship care, the prostate cancer specialist nurse acts as the “hub” along the cancer care continuum.
This review set out to critically review existing models of consultation to inform an appropriate model of consultation for use in prostate cancer care. Historically, most consultation models have been developed for GPs, therefore limiting their transferability for use in cancer care. The limitation of such models is evident, such as Byrne and Long,34 which is heavy focused on the biomedical approach and lacks consideration of psychosocial factors that might be important to the patient during consultation. Traditionally, consultations have been carried out by doctors and focused on a very disease-focused model whereby the doctor leads the consultation, with very little input from the patient.32 The critique of such models is that they focus primarily on the physical processes, such as pathology, biochemistry, and disease status, while psychological and social factors, or indeed the individual man, are not fully considered in management plans.
Consultation models provide structure for complex interactions in modern healthcare.8 Each consultation with a patient/family is exceptionally unique and provides the healthcare professional with a very privileged glimpse into a person’s life and concerns at that moment. The nurse consultation provides the main opportunity to explore the patient’s problems and identify areas of most concern. Evidence supports that patients value nurse consultations, and some patients have reported greater satisfaction with nurse consultations in comparison with GP consultations, as patients articulated that they felt they understood their condition more clearly and had more time allocated to them compared with GPs.64
A number of consultation models have attempted to embed a person-centered approach to consultation, such as Refs40,42,50,52,53. But we argue, how can such models be implemented in a standardized way to ensure that the individual consultations between healthcare professionals and patients are targeted to areas that are of most concern to the patients? Inevitably, healthcare professionals all have different levels of interpersonal and communication skills, and thus, some individuals will be more successful in eliciting concerns from patients than other healthcare professionals. Moreover, evidence acknowledges that the clinician’s comprehension of the effect of the disease and treatment on the patients’ daily lives is poorly understood.65 As a consequence, in response to this problem, over the past 3 decades, many standardized measures have been developed to capture patient reported outcomes, including quality of life, anxiety and depression, symptom status, physical function, mental health, supportive care needs, and wellbeing. The prostate cancer consultation model is the first, to date, to recognize the importance of systematic assessment of the patient concerns to then target the consultation, which may result in greater satisfaction with care and tailored self-management advice and promote targeted and better management of health problems in line with patient need/priorities.61,62
One of the main criticisms of consultation models to date is that they risk oversimplifying a highly complex interaction between the patients/family and their healthcare professional. More recent consultation models in the literature begin with establishing a rapport and identifying problems and concerns. Many models suggest using good interpersonal skills and facilitating problem identification through the use of open questions. While open questions are aimed to enable patients an opportunity to answer in their own words or own way, often, men with prostate cancer are reticent or embarrassed to disclose concerns such as erectile dysfunction, changes in body image, or fear of cancer recurrence.10
The Prostate Cancer Consultation Model clearly distinguishes that patients’ needs during the consultation with a healthcare professional may change over the cancer care continuum, and new and emergent needs may affect the man’s quality of life over time.12 Furthermore, our model of consultation for use in cancer care is also one of the first models to embed the evidence base and research as a prerequisite to the consultation to ensure optimum evidence-based shared management plans.46 The findings from this review has identified that no matter the clinical context of the consultation, there are common factors that must be completed by the healthcare professional that include the following: (1) establishing and maintaining a good relationship, (2) structuring the consultation, (3) obtaining and gathering of relevant information, (4) prioritizing, (5) clinical reasoning and judgment, (6) information giving, (7) management plan, and (8) record-keeping and safety netting.
In light of recent changes in the economy and the drive for cost-effective healthcare, current cancer care practice needs to be reviewed and revised.2,3 This review has made an important contribution by developing a model of consultation for prostate cancer care that advanced specialist cancer nurses can use because until now, there is no model fit for use in cancer care. The Prostate Cancer Care Model of Consultation provides an illustrative framework that cancer nurses can use in the development of their roles and clinical practice. But undoubtedly, this field needs further research to empirically test models of consultation in routine clinical practice. Further research is needed to understand whether the models of consultation improve nurse education in advanced roles, as well as their effect on nurse and patient satisfaction, administrative efficiency, and patient outcomes/safety.
One of the major challenges of this review is the confines of the evidence presented; as such, our findings are constrained owing to the limitations of the reported literature. Despite this, the review team followed up a rigorous and transparent review methodology based upon the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines19 to promote reproducibility. This review has enabled a broad summary of the evidence, which has facilitated refinement of future research directions and identified a number of important clinical implications in consultation in prostate cancer care.
This systematic review has identified that there are many models of consultation in the reported literature. We have developed a consultation model informed from critical appraisal of the evidence for the context of cancer care, but further research is needed to empirically test consultation models in routine clinical practice. Consultation models should not be followed rigidly but adapted to the individual healthcare professional allowing natural warmth, compassion, and empathy to flow the consultation to ensure individual personalized care.
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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved
Consultation models; Prostate cancer care; Systematic review