NBOCA for Nurses: What can nurses take away from the latest findings?
Gabrielle Thorpe, School of Health Sciences, University of East Anglia
Many nurses specialising in coloproctology will review the latest NBOCA State of the Nation report looking for information about their own Trust’s/Health Board’s data, and how this compares to other Trusts/Health Boards, but may not consider the findings in relation to their own practice or nursing service. However, when examined through a lens of improvement, there are many ways in which specialist nurses – arguably the lynch pin of the wider colorectal team – might use the report to identify benchmarks against which they can evaluate their own nursing service and contribute to the wider team improvements, thereby enhancing the performance of the whole colorectal team within which they work. This short article offers some reflections on how nurses might apply the findings of the NBOCA report to their own practice.
Recommendations 1, 4 and 5 may not be nursing-specific, but they do highlight the importance of data and of understanding the process of care. With Quality Improvement an expectation for all nurses working in advanced and specialist roles, it is essential for nurses to generate service data that accurately reports service and patient outcomes and to ensure that wider decisions about care with which they are involved are documented on central systems to facilitate audit. And it is not just about outcomes, specialist nurses can apply their in-depth knowledge of the colorectal pathway to create clear and detailed process maps to identify where factors hindering effective care are occurring. This is not just about NBOCA; identifying and capturing more detailed process and outcome measures will help nurses to demonstrate the effectiveness and impact of their service and recognise areas for improvement.
Colorectal nurses are well-placed to influence the proportion of people who are offered mismatch repair (MMR) assessment to identify Lynch Syndrome (recommendation 2) through mainstreaming. Mainstreaming is a term used to describe point-of care pre-test counselling and consent by a member of the colorectal cancer team (Miles, 2023). Many colorectal specialist nurses have undertaken additional training to improve detection of Lynch Syndrome through the National Genomic Medicine Service Alliance (GMSA) Transformation Project (NHS North Thames Genomic Medicine Service, 2022), informed by an RM Partners (NW & SW London Cancer Alliance) project conducted in 2020-21 and led by the St Mark’s Centre for Familial Intestinal Cancer (Monje-Garcia, 2023).
A sobering finding in the report is that between 1 April 2022 and 31 March 2023 less than 35% of diverting ileostomies were closed within 18 months of the original cancer surgery. Colorectal and stoma care specialist nurses are ideally placed to work with their teams to increase the proportion of people who have their stoma reversed within 18 months of anterior resection for rectal cancer (recommendation 3), starting with detailed process mapping of the patient journey from their primary surgery to reversal in order to identify organisation-specific factors hindering timely stoma reversal and potential areas for improvement. This analysis can be used to develop a Standard Operating Procedure or policy for loop ileostomy reversal, creating process standards against which service performance can be measured and areas for improvement addressed. Innovations in care that might help to support improvements include early reversal within 14 days of primary surgery for highly selective cases (O’Sullivan et al, 2022) and using the virtual ward model of care to facilitate stoma reversal surgery as a same day or 23-hour admission, which is being safely implemented in a small number of units (e.g. Cambridge University Hospital, University Hospitals of Leicester). However, innovations which change standard practice require the involvement and commitment not just of the whole colorectal team, but of wider services involved in managing the patient journey. The RCS Close It Quick QI Collaborative provides an ideal opportunity for Trusts to address this important national priority, with colorectal and stoma care specialist nurses integral to ensuring its safe and effective implementation.
Read the report again with a nursing lens to consider how you can use the findings to make a difference within your own unit.
References
Miles, T (2023) Mainstreaming cancer susceptibility gene testing. https://www.genomicseducation.hee.nhs.uk/genotes/knowledge-hub/mainstreaming-cancer-susceptibility-gene-testing/ Accessed 31/01/25
Monje-Garcia, L et al (2023) From diagnosis of colorectal cancer to diagnosis of Lynch syndrome: The RM Partners quality improvement project. Colorectal Disease 25(7) doi: 10.1111/codi.16707
NHS North Thames Genomic Medicine Service (2022) National GMSA Transformation Project: Lynch Syndrome. https://norththamesgenomics.nhs.uk/national-gmsa-transformation-project-lynch-syndrome/#progress Accessed 31/01/25
O’Sullivan, NJO et al Early Vs standard reversal ileostomy: a systematic review and meta-analysis. Techniques in Coloproctology 26(11): 851-862. doi: 10.1007/s10151-022-02629-6