European Journal of Oncology Nursing xxx (2015) 1e7

Contents lists available at ScienceDirect

European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

The role of advanced nursing in lung cancer: A framework based

development
A. Serena a, b, c, *, P. Castellani b, 1, N. Fucina b, 1, A.-C. Griesser b, 1, J. Jeanmonod b, 2,
S. Peters b, 3, M. Eicher a, c, 4
a
b
c

Institute of Higher Education and Research in Health Care, University of Lausanne, Switzerland
University Hospital Center of Lausanne, Switzerland
University of Applied Arts and Sciences Western Switzerland, School of Health Fribourg, Switzerland

a r t i c l e i n f o

a b s t r a c t

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

Purpose: Advanced Practice Lung Cancer Nurses (APLCN) are well-established in several countries but
their role has yet to be established in Switzerland. Developing an innovative nursing role requires a
structured approach to guide successful implementation and to meet the overarching goal of improved
nursing sensitive patient outcomes. The Participatory, Evidence-based, Patient-focused process, for
guiding the development, implementation, and evaluation of advanced practice nursing (PEPPA
framework) is one approach that was developed in the context of the Canadian health system. The
purpose of this article is to describe the development of an APLCN model at a Swiss Academic Medical
Center as part of a specialized Thoracic Cancer Center and to evaluate the applicability of PEPPA
framework in this process.
Method: In order to develop and implement the APLCN role, we applied the rst seven phases of the
PEPPA framework.
Results: This article spreads the applicability of the PEPPA framework for an APLCN development. This
framework allowed us to i) identify key components of an APLCN model responsive to lung cancer patients' health needs, ii) identify role facilitators and barriers, iii) implement the APLCN role and iv) design
a feasibility study of this new role.
Conclusions: The PEPPA framework provides a structured process for implementing novel Advanced
Practice Nursing roles in a local context, particularly where such roles are in their infancy. Two key points
in the process include assessing patients' health needs and involving key stakeholders.
2015 Elsevier Ltd. All rights reserved.

Keywords:
Lung cancer nurse
Advanced practice nursing
Lung neoplasm
Supportive care

1. Introduction

* Corresponding author. Centre Hospitalier Universitaire Vaudois, Avenue Pierre

Decker 2, 1011 Lausanne, Switzerland.
E-mail addresses: andrea.serena@unil.ch (A. Serena), pascale.castellani@chuv.ch
(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 Lausanne, Switzerland.
3
Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne,
Switzerland.
4
cole de sante
 Fribourg HES-SO, Route des Cliniques 15, 1700 Fribourg,
Haute e
Switzerland.

In order to meet complex lung cancer patients' health needs, the

role of the Advanced Practice Lung Cancer Nurse (APLCN) is wellestablished in North America, Australia and several North European countries. Yet to date, no such role has been developed in
Switzerland. Indeed, the Master of Science in Nursing has been
introduced relatively recently in Switzerland (since 2000 in the
German-speaking part and since 2009 in the French-speaking part
of Switzerland). Considering epidemiologic trends in lung cancer
and the psychosocial and physical burden of these patients, it is
imperative to develop the APLCN role in the Swiss context.
Globally lung cancer is the most common cancer, both in terms
of new cases and deaths (Ferlay et al., 2014). Common physical
complaints reported by lung cancer patients include dyspnea, fatigue, pain, anorexia, cough, and insomnia (Cooley, 2000; Iyer et al.,

http://dx.doi.org/10.1016/j.ejon.2015.05.009
1462-3889/ 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Serena, A., et al., The role of advanced nursing in lung cancer: A framework based development, European
Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.009

A. Serena et al. / European Journal of Oncology Nursing xxx (2015) 1e7

2013). Importantly, the physical symptoms resulting from the disease 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 cancer
carries a high disease burden and patients report high levels of
unmet supportive care needs related to psychological and physical
aspects of daily life (Li and Girgis, 2006; Sanders et al., 2010).
In recognition of the needs of cancer patients, the European
Partnership for Action Against Cancer (EPAAC) recommends a
specialized Multidisciplinary Team (MDT) that includes an expert
nurse to provide expert clinical advice to patients, exchange key
patient information and care recommendations with the MDT
(Borras et al., 2014). The APLCN supports and counsels patients and
families during all stages of the disease providing emotional,
informational and behavioral support. These activities focus on: i)
developing patient self-management of symptoms, ii) improving
communication within the care team and iii) ensuring continuity of
care (Moore, 2002). To date, there are limited data on the effectiveness of such specialized nursing roles for improving outcomes
or continuity of care (Aubin et al., 2012). Two initial studies on the
clinical effect of specialist nurses (Bredin et al., 1999) and the role of
APLCNs (Moore et al., 2002) point to positive outcomes on lung
cancer patients, with decreased self-reported breathlessness,
enhanced performance status, as well as improved emotional state
and patient satisfaction.
In line with the EPAAC recommendations, the University Hospital of Lausanne (CHUV) has launched a Thoracic Cancer Center
and we undertook a structured process to develop, implement and
evaluate a novel APLCN role as key component of a MDT within this
Thoracic Cancer Center. The APLCN focuses on delivering and
coordinating care for patients complex care needs and thus the role
includes expanded autonomy beyond the traditional scope of
nursing practice. Accordingly, this role can be considered within
the domain of Advanced Practice Nursing (APN) (Bryant-Lukosius
et al., 2004).
Introducing a new APN role is a complex and dynamic process
that must overcome a number of barriers including: i) lack of
clearly dened role and goals/expectations, ii) stakeholders'
confusion related to describing the APN role, iii) difculty in
identifying 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 effective
means to overcome these barriers. One such approach is the
Participatory, Evidence-based, Patient-focused process, for guiding the development, implementation, and evaluation of advanced
practice nursing (PEPPA framework) (Bryant-Lukosius and
DiCenso, 2004). The PEPPA framework was developed in the
context of the Canadian health system for APN role development.
However, to our knowledge, this framework has not been tested
outside of North American context (McNamara et al., 2009).
Therefore, we aim to describe the development of an APLCN model
at a Swiss Academic Medical Center as part of a specialized Thoracic
Cancer Center and to evaluate the applicability of the PEPPA
framework in this process.
2. Method
The PEPPA framework was developed to address implementation challenges for APN roles (Bryant-Lukosius and DiCenso, 2004)
and is designed to: i) use the best available evidence and relevant
sources of data to identify needs and establish goals and clearly
dene the role, ii) support the development of patient-centered
nursing practice, iii) use APN skills/knowledge in all role dimensions, iv) engage key stakeholders in the development and

implementation process, and v) dene outcomes and promote

ongoing role development through monitoring and evaluation.
The framework comprises nine-phases: 1) dene the patient
population and describe current model of care; 2) identify stakeholders and recruit participants; 3) determine the need for a new
model of care; 4) identify priority problems and goals to improve
the model of care; 5) dene the new model of care and the APN
role; 6) plan implementation strategies; 7) initiate the implementation plan; 8) evaluate the APN role/new model of care; and 9)
conduct long-term monitoring of the APN role/model of care. For
the introduction of the APLCN role, we applied the rst seven
phases of the framework.
2.1. Phase 1: dene the patient population and describe current
model of care
The rst phase intends to dene the clinical pathway of a specic patient population and map how care providers interact with
patients and families (Bryant-Lukosius and DiCenso, 2004). We
dened the patient population as those undergoing treatment for
lung cancer at the tertiary academic medical center. To describe the
current model of care, we used a middle-range nursing theory, the
Nursing Role Effectiveness Model (NREM) (Irvine et al., 1998) to
guide the new model of care (see Method phase 5). This model is
useful to depict a complex system of interrelated factors within a
practice setting that impact role effectiveness (Sidani and Irvine,
1999). The NREM is based on the structure-process-outcome indicators of Donabedian's (1980) that has long been used to describe
the relationship between patient characteristic variables, nursing
interventions, and patient outcomes (Irvine et al., 1998).
The current model of care has been described by existing
guidelines used in the hospital medical oncology and thoracic
surgery departments. In addition, between January and May 2013,
22 exploratory, semi-structured interviews were conducted, with a
convenience sample of expert-providers. Participants for exploratory interviews were purposefully selected from the departments
of oncology, thoracic surgery (malignancies), pneumology, and radiation oncology. Health care professionals included head physicians and nurses of the respective services, clinical providers
(physicians and nurses) stafng the inpatient and outpatients
wards as well as data managers who help to coordinate patient ow
through their services. The aim was to describe the current illness
trajectory of lung cancer patients and existing supportive care infrastructures from the time of diagnosis through the end of
oncology treatment or to the palliative phase and to determine the
need for a new model of care. All interviews followed a selfdeveloped 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 and
lasted on average 45 min. The CNS took notes during the interviews
that were coded by the CNS and clustered based on thematic
analysis following an inductive approach to the data (Braun and
Clarke, 2006; Sim, 1998). Thematic analysis followed the six phases proposed by Braun and Clarke (2006): 1) familiarizing with
data, 2) generating initial codes, 3) searching for themes, 4)
reviewing themes, 5) dening and naming themes, and 6) producing the report.
2.2. Phase 2: identify stakeholders and recruit participants
Role acceptance and the support of key stakeholders are
fundamental for successful implementation of a new role. Further,
stakeholder participation at the onset of the project is critical for
ensuring commitment to the project, providing support for planned change and establishing a culture of shared values and beliefs

Please cite this article in press as: Serena, A., et al., The role of advanced nursing in lung cancer: A framework based development, European
Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.009

A. Serena et al. / European Journal of Oncology Nursing xxx (2015) 1e7

necessary to operationalize the role (Bryant-Lukosius and DiCenso,

2004). When identifying key stakeholders for APLCN role development and implementation, we sought professionals involved in
the lung cancer clinical pathway such as, clinical nurse specialist,
oncologists, thoracic surgeons, radiologists, radiation oncologists,
pathologists, pneumologists, and project coordinator for the
development 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 limitations
of the current model of care from the perspective of both patients
and care providers. To accomplish this, we conducted a descriptive,
cross-sectional study to describe the unmet supportive care needs
of lung cancer patients during the early systemic treatment phase
(Serena et al., 2012). Patients (18 years and older) diagnosed with
lung cancer (within the past 4 months) who were undergoing
systemic treatment were invited to participate in the needs
assessment. Patients were recruited from both inpatient and outpatients settings over a 13 month period following a nonprobability consecutive sampling method. Unmet supportive care
needs were measured by the validated French version of the Supportive Care Needs Survey Short Form comprising 34 items (SCNSSF 34) (Bonevski et al., 2000; Bredart et al., 2012).
Additionally, the series of qualitative interviews with health care
providers (see phase 1 above) were also focused on assessing
structure, process and outcome. Specically we aimed to identify
health care system factors (i.e. NREM structure indicators)
contributing to unmet patient needs and shortfalls of current
practice (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 and
tools for assessing physical/psychological symptoms, ii) current
interventions implemented in response to detected physical/psychological symptoms, iii) satisfaction with interdisciplinary
collaboration within the care team, iv) translational blocks between
theory and practice, and v) perspectives and attitudes towards the
APLCN role. Data were collected and analyzed as described above
(phase 1).
2.4. Phase 4: identify priority problems and goals to improve the
model of care
This phase is intended to reach consensus on the core challenges
to be addressed in order to better meet patient care needs and
delineate related goals and objectives (Bryant-Lukosius and
DiCenso, 2004). This consensus process was achieved via a series
of strategic meetings with engaged stakeholders. The meetings
were used to present the data and analysis of the previous steps
and included iterative discussions to create priority lists that were
rened until consensus was reached. The result of this phase
comprised a list of priority goals to achieve the maximum quality
improvement of the clinical pathway through the implementation
of an APLCN role.
2.5. Phase 5: dene the new model of care and the APLCN role
Broadly, this phase aims to map priority goals identied in phase
4 into the new model of care and new nursing role (BryantLukosius and DiCenso, 2004). The priority goals serve to focus the
design of the new model of care and the APN role, in this case the
APLCN role. Central to this step is identifying a guiding theoretical
framework for the APLCN clinical interventions, identify the best
available evidence on effectiveness of interventions to improve
patient outcomes, dening how the role will be involved in new

care practices and goal-related strategies, identifying the skills and

knowledge needed for the APLCN and outlining the scope of
practice for the APLCN.
As the goals for this new role (i.e. NREM e nursing-patient
sensitive outcomes) focus on improving unmet care needs of lung
cancer patients, we selected the Theory of Symptom Selfmanagement (TSSM) (Hoffman, 2013) as a guiding theoretical
framework for designing the APLCN clinical interventions and
gauging expected patients' outcomes. This middle-range nursing
theory was formulated by Hoffman (2013) and maps Bandura's
notion of self-efcacy (Bandura, 1997) onto the Theory of Unpleasant Symptoms (Lenz et al., 1997). The TSSM is used to guide
oncology nursing via perceived self-efcacy-enhancing symptom
self-management interventions to reduce patients' symptom
burden associated with cancer and its treatment and thus enhance
quality of life (Hoffman, 2013).
To identify the best available evidence on nursing interventions
related to the APLCN role relevant to the clinical context of CHUV,
we conducted a selective literature review. The aim was to identify
non-pharmacologic interventions addressing physical and psychosocial burden and improving self-management in lung cancer
or oncology populations with similar physical and psychosocial
symptoms. A selective literature review of CINAHL and PubMed,
was conducted with the search strings lung cancer AND selfmanagement, lung cancer AND non-pharmacological intervention, fatigue AND non-pharmacological intervention, lung
cancer AND nursing, supportive care AND lung cancer and
supportive care AND oncology. Selection criteria were: i) relevant
studies published in peer-reviewed journals between 1999 and
August 2014, ii) in English language, iii) guidelines, randomized
controlled trials (RCTs), systematic reviews and meta-analysis
focused on non-pharmacological interventions concerning psychological and physical symptoms and concerning lung cancer
patients or patients with similar symptom burden, iv) articles that
were focused on model of cancer nursing specialized or specialized
nursing, v) studies that describe non-pharmacological intervention
that can be carried out by nurses (in the context of the Swiss law)
evaluated as feasible in the CHUV setting by expert stakeholders of
APLCN project's working group. Following the evidence hierarchy
approach 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 implementation
and denes outcomes for the evaluation phase (Bryant-Lukosius
and DiCenso, 2004). This step is fundamental to minimize barriers and prepare the clinical setting to receive and accept the new
APLCN role. This was accomplished in a stakeholder brainstorming
session identifying barriers and potential facilitators of role introduction. Moreover, two strategic planning meetings were held to
identify the metrics and nursing-sensitive outcomes (milestones)
for evaluating the feasibility of the APLCN role in the multidisciplinary team (see results).
2.7. Phase 7: initiate the implementation plan
According to the developers of the PEPPA framework, it is rarely
possible to have all implementation strategies in place at the time
when the role is introduced (Bryant-Lukosius and DiCenso, 2004).
Thus, there is a exible back and forth between steps 6 and 7 to
structure a stable, long-term monitoring of the APN role and model
of care (Bryant-Lukosius and DiCenso, 2004). To implement the

Please cite this article in press as: Serena, A., et al., The role of advanced nursing in lung cancer: A framework based development, European
Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.009

A. Serena et al. / European Journal of Oncology Nursing xxx (2015) 1e7

APLCN role, we maintained a continuous quality appraisal process

wherein the stakeholders provided ongoing feedback in monthly
progress report meetings, and this is identied as a process rather
than a singular event.

A, Patient) and the current model of care was a critical and rational
rst step for dening the APLCN role.

3. Results

We leveraged the existing working group of stakeholders

brought together to guide the implementation of specialized
Thoracic Cancer Center. Thus we were not forced to identify participants as separate and distinct process. Enlisting these stakeholders in a working group enabled multiple viewpoints to be
considered and buy-in across the care team. This group met weekly
throughout the project period, validated the project plan and the
achieved milestones. It supported the process of role clarication,
role acceptance, and the identication and discussion of strategies
to deal with potential barriers and facilitators to role implementation. For feasibility reasons we could not include patients,
families and nurse managers in this group of participants, but we
included their viewpoints during the development process
(described below).

The process of developing and implementing an APLCN role in a

multidisciplinary team began in January 2012. The proximal goal
was to delineate and implement the APLCN role into a health care
setting in Switzerland that has yet to dene APN roles. The ultimate
goal being to enhance the effectiveness of multidisciplinary care
with the inclusion of nursing interventions targeting the unmet
self-management needs of lung cancer patients. The results of each
phase of the PEPPA framework process is described in the context
of 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 current
model of care

3.2. Phase 2: identifying stakeholders and recruiting participants

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

The current model was delineated via semi-structured interviews (see method, phase 1 and phase 3) and by analyzing the
existing guidelines used in the medical oncology and thoracic
surgery departments. This process revealed that most patients with
lung cancer are treated in three different disease trajectories
involving systemic therapy combined (or not) with radiotherapy
and receiving (or not) surgical intervention before/after systemic
therapy. Less frequently, patients receive surgery only or radiotherapy only. The diagnostic process and medical management
were guided by national/international guidelines built on the best
available evidence. However, interviewees reported a paucity of
guidelines/evidence concerning supportive care and nursing interventions. They conrmed that this resulted in inconsistent
supportive care based on individual preferences of nurses or other
health care professionals.
The systemic therapy is nearly always proposed to lung cancer
patients. Further, as lung cancer is often detected in advanced
stages, these patients often need high levels of supportive care
(Joyce et al., 2008; Temel et al., 2006). Therefore, we focused on
developing an APLCN clinical pathway for lung cancer patients
receiving systemic therapy combined (or not) with radiotherapy.
The initial steps for clearly identifying the patient population (Fig. 1,

As noted previously we conducted supportive care needs assessments. Of 220 eligible patients, 106 were approached by physicians and 37 patients agreed to participate (response rate 34.9%).
Across the ve domains of the SCNS-SF 34, participants reported
the 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 in
patient care and support and sexuality domains (mean 33.2 and
22.8 respectively). This small study highlighted the difculty in
recruiting patients and the high levels of psychological and physical
unmet supportive care needs among lung cancer patients.
Although the sample size was limited, results were in line with
prior reports of physical and psychological symptom burden in
similar patient populations (Li and Girgis, 2006; Sanders et al.,
2010). Importantly, our needs assessment also underscored the
importance of improving personalized information and patient
education. Notably, more than half of patients desired more information on self-care management which could be done at home. In
fact, 65% of patients expressed dissatisfaction concerning being
informed about things you can do to help yourself to get well and
60% concerning being given information (written, diagrams,
drawings) about aspects of managing your illness and side-effects
at home (Serena et al., 2012).
In the present study, we conducted semi-structured interviews
with 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). Thematic analysis revealed four main emergent themes. These
included: i) coordination/communication among health professionals, ii) information and symptom management education,
iii) psychological assessment, iv) using evidence based nursing
guidelines and support nursing staff sharing specic nursing
knowledge. These topics were used as core elements of the new
role/model of care for responding to patient's needs and addressing
the shortfalls of current practice.
3.4. Phase 4: identifying priority problems and goals

Fig. 1. Dening the role of Advanced Practice Lung Cancer Nurse (Framework adapted
from Irvine et al., 1998).

During 2013, two strategic meetings with key stakeholders were

held to nd consensus on the priority problems in meeting patient
supportive care needs and how the APLCN role would be introduced to meet these needs. Results of the needs assessment and
emergent themes of interviews were presented and discussed.

Please cite this article in press as: Serena, A., et al., The role of advanced nursing in lung cancer: A framework based development, European
Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.009

A. Serena et al. / European Journal of Oncology Nursing xxx (2015) 1e7

Stakeholders agreed that APLCN implementation could be an

appropriate response concerning priority goals to improve the new
model of care providing i) patient psychosocial support, ii) patients
self-management education, iii) ensure a continuity of care and iv)
support nursing staff sharing specic nursing knowledge.

health care providers and for facilitating continuity of care (Fig. 3).
The APLCN role and intervention model of care were accepted by
key stakeholders in December 2013 setting the stage for
implementation.
3.6. Phase 6: planning implementation

3.5. Phase 5: dening the model of care and the APLCN role
To meet the priority goals dened by key stakeholders, we
designed an APLCN interventions based on the principles of the
TSSM as well as a selective literature review and synthesis of
available evidence concerning care for lung cancer patients. Twelve
studies/guidelines were included (see owchart, Fig. 2). The selective literature review allowed us to identify i) instruments to
assess physical and psychological needs of lung cancer population
(or oncology populations with similar needs), ii) nonpharmacologic interventions addressing the physical and psychological needs of patients, and iii) descriptions of existing APLCN
roles (Supplemental Material 2, online only).
The APLCN role involves both independent functions (autonomous actions initiated by nurse in response to patient's needs) and
interdependent aspects (activities shared with other members of
health-care team) across 5 key practice domains (Fig. 1B, Process).
The APLCN's independent role comprises: i) providing psychological support to patients and families, ii) monitoring and managing
physical symptoms and providing symptom-management education and iii) providing timely patient information regarding disease
and symptoms (Table 1). The interdependent role centers on: i)
coordination and continuity of care, ii) supporting the nursing staff
by sharing specic nursing knowledge related to the specic patient population and symptom-management (Table 1).
The model of care incorporating the APLCN role (Fig. 3) is
designed to meet the priority goals identied in the structured
process. APLCN-led interventions were targeted for the patient
population dened in Phase 1 (lung cancer patients receiving
systemic therapy combined (or not) with radiotherapy. Specically,
the APLCN-led intervention includes four systematic, alternate
face-to-face/telephone consultations. Information exchange between the APLCN independent role (psychological support; monitoring and manage physical symptoms and self-management
education; patient information-giving) and the MDT is fundamental for fostering a collaborative approach across specialized

An integral step in the implementation planning phase involves

identifying: i) goal-related outcomes which are expected after the
introduction of APLCN role (outcomes), and ii) degree of education
and training for the new nurse (structure). Based on TSSM clinical
theoretical foundation we dened clinical outcomes (lung cancer
symptoms, self-efcacy for managing symptoms and, unmet supportive care needs) (Fig. 1C) to prepare the feasibility study. In line
with international recommendations, the APLCN model of care of
CHUV and the Swiss nursing education context we dened that the
APLCN had: i) a Clinical Nurse Specialist degree, ii) at least 2 years of
experience in oncology care, and iii) successfully completed the
education program oncology communication skills delivered by
the Swiss Cancer League (Fig. 1A, Nurse).
Planning emphasizes minimizing role barriers and maximizing
acceptance of the new APLCN role. This includes addressing challenges regarding APLCN role ambiguity and resistance from both
physicians and nurses. To overcome this we employed several
communication strategies over a 3-month pre-launch period: i)
meeting with implicated oncology nursing staff to share ways that
supportive care for lung cancer patients could be improved, ii) key
stakeholders consensus regarding priority goals were presented to
the nurse's managers across the oncology department and thoracic
surgery ward, and iii) the project was presented to all nurse teams
of the oncology, thoracic surgery and radiotherapy departments.
Six months post introduction of the APLCN role, a clinical case
report concerning the APLCN contribution to the care pathway was
presented to the stakeholders to tangibly demonstrate the value
and impact of the role using a real-world example. The overall aim
of this multilevel communication strategy was to present the
contribution of the APLCN to the goals dened in phase 4 to
strengthen the support of key stakeholders for the APLCN role. As
turnover is regular in academic training hospitals, the role is
introduced to new oncology and radiotherapy fellows/trainees
every 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 undergoing ongoing renement as part of a continuous quality
improvement 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) and
feasibility of the APLCN-led intervention (process) is critical for
success.
4. Discussion

Fig. 2. Flow diagram of selective literature review.

Herein we described the development process of the new

APLCN role within a Swiss Thoracic Cancer Center enter. We
employed the PEPPA framework to dene the APLCN role (Fig. 1),
and the APLCN-led intervention plan (Fig. 3). This framework was
developed and implemented in the context of the Canadian health
system (Bryant-Lukosius and DiCenso, 2004). In the present project, we introduced an APN role (APLCN) in a Swiss Thoracic Cancer
Center. As the initial empirical demonstration of the applicability of
the PEPPA framework in Europe, we have expanded the theoretical
utility of this model. This process could be used by clinicians,

Please cite this article in press as: Serena, A., et al., The role of advanced nursing in lung cancer: A framework based development, European
Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.009

A. Serena et al. / European Journal of Oncology Nursing xxx (2015) 1e7

Table 1
Independent and interdependent role of Advanced Practice Lung Cancer Nurse.
Responsibilities

Process (tasks)

Psychosocial support

 Assess patient's psychological distress using Distress Thermometer (Lynch et al., 2010).
 Provide emotional support to patients and family (i.e reduce stress, anxiety, adjustment to illness, change in
body image).
 Provide support concerning practical problems (i.e. transportation, nancial problems).
 Assess patient's physical symptoms using the Lung Cancer Symptom Scale (Hollen et al., 1999).
 Work with patient to identify uncomfortable disease related symptoms applying a therapeutic education
approach for self-monitoring and self-management at home.
 Discuss potential treatment side-effects and provide instruction for self-management (i.e. breathlessness;
fatigue; anorexia, sleep disturbances).
 Adjusting language to meet the patient's emotional state and using lay language to explain the disease,
procedures and treatments.
 Provide information and written reference materials regarding the disease, treatments, symptoms selfmanagement and external support possibilities (i.e. patient association).
 Refer patient and families to specialist professionals (i.e. social worker, nutritionist, and psycho-oncology)
according to the severity of the assessed psychological or physical problem.
 Attend weekly multidisciplinary tumor-board meetings to provide ongoing clinical overview on patients'
therapy and disease evolution.
 Organize multidisciplinary meetings with patients/family to share viewpoints, develop coherent
therapeutic and enable patients to take an active role in therapeutic decision-making.
 Support the staff working with lung cancer patients (particularly other nurses), providing expert
information, advice and organizing time for dissemination about nursing or supportive cares research
results.
 Collaborate in research projects and in developing evidence-based nursing guidelines (primarily in the eld
of nursing and secondarily in medical or other health sciences).

Monitoring and managing physical symptoms and

providing symptom-management education

Providing patient/family information regarding

disease and symptoms

Coordination and Continuity of care

Supporting the nursing staff

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

researcher and administrator to develop, implement and plan the

evaluation of an introduced APN role, particularly in the oncology
domain. The PEPPA was particularly useful as the APN role is yet in
its infancy in Switzerland. Two key points of PEPPA framework that
appear to be fundamental for successfully introducing a new APN
role implementation include the patient need assessment and
involving key stakeholders into the process (Bryant-Lukosius and
DiCenso, 2004).
In developing the novel APLCN role, the NREM and TSSM were
complementary theoretical foundations for dening the APLCN
role. The NREM focused development on how the structure factors
interact with process factors affecting nursing sensitive outcomes

for the APLCN role (Fig. 1). The TSSM has been useful for describing
the interrelationship between nurse assessment of patient physical/psychological needs and APLCN interventions for developing
patient self-care and symptom-management and with the goal of
improving their performance outcomes.
The APLCN is both an expert resource and bridge for communication and continuity of care through the care pathway. Two
studies have assessed the APLCN role in relation with patients who
had completed rst-line treatment (Bredin et al., 1999) and during
the follow-up phase (Moore et al., 2002) observing positive impact
on patient physical and psychological outcomes.
The APLCN model described in this article was designed specically for the Swiss health system context and the local context of
a Thoracic Cancer Center of CHUV. While our APLCN role mirrors
both British APLCN model (Leary et al., 2014; Moore, 2002; Moore
et al., 2006; White, 2013) and the oncology nurse navigators in the
United States (Horner et al., 2013), novel oncology role development process needs to be adapted to the local context. Indeed, the
developers of PEPPA underscore the importance of considering the
local context (i.e. current model of care and patients' needs
assessment).
Future work will include the ongoing feasibility and acceptability study (ClinicalTrials.gov, Number: NCT02362204). This examination will assess the APLCN role using the structure-processoutcomes framework to move optimize APLCN role's effectiveness
and setting milestones for long-term monitoring of the APLCN role
and model of care (i.e. phase 8 and 9 of the PEPPA framework
respectively). In parallel, ongoing work will emphasize maintaining
consensus regarding scope of practice to ensure long-term sustainability of the APLCN role. In this way, the APLCN role may able
to provide ongoing, high-quality services meeting the needs of
people affected by lung cancer and this could include expanding
the role into initial diagnosis phase, post-surgical and follow-up
phases.
In summary, we present a structured approach for developing
and implementing a new APLCN role into a health system context
that has yet to widely establish APN roles. The PEPPA framework
provides a systematic process using a health-oriented, patientfocused, participatory and stakeholder-driven process as a strategy

Please cite this article in press as: Serena, A., et al., The role of advanced nursing in lung cancer: A framework based development, European
Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.009

A. Serena et al. / European Journal of Oncology Nursing xxx (2015) 1e7

for overcoming barriers in the development and introduction of the

APLCN role. While a development APN role in Switzerland is still its
infancy, this project represents a nurse-led response to meet the
unmet needs of lung cancer patients.
Acknowledgements
This work was supported by key professionals of Thoracic
Cancer Canter of the University Hospital of Lausanne: Prof. Dr.
Hans-Beat Ris, Dr. Alban Lovis, Prof. Dr. Laurent Nicod, Dr. Hasna
Bouchaab, Dr. Mahmut Ozsahin, Dr. Nicolas Peguret, Dr. Igor Letovanec, Dr. Catherine Beigelman-Aubry, Claire Zurkinden, Jacqueline
lanjoie-Petite. Scientic consultation
Bulliard and Marie-Rosalie Me
was provided by Prof. Kate White, Prof. Diane Morin and Prof. Serge
Leyvraz. Dr. Andrew Dwyer and Dr. Franois Mooser provided
editing 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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Please cite this article in press as: Serena, A., et al., The role of advanced nursing in lung cancer: A framework based development, European
Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.009