The ‘hub and spoke’ model in Figure 7.1 is supported by the NMC. It gives you the opportunity to be allocated to one clinical area for a period of time while also having the opportunity to be allocated to a spoke area and short insight visits.

Fig 7.1 Hub and spoke placement model

In this model, any area could be either a hub or a spoke placement. Some teams and departments may be accessed by an insight visit. Your placement will most likely be composed of one hub with several planned spoke opportunities and insight visits. Discussing the opportunities available with your mentor is important at the start of the placement.

The length of the placement may depend on the year of study as well as local arrangements between the university and clinical areas. Box 7.1 outlines a theoretical example of what a first year nursing student’s 18-week (‘year-long’) placement might look like. This sample placement demonstrates a wide range of learning opportunities that can stem from a core hub placement. It is important to remember that a cancer patient can be nursed in any clinical environment. Some placements will be much shorter than this, most ranging between 8 and 12 weeks. This is dependent on the school of nursing and your stage of training.

Box 7.1 A theoretical example of a first year nursing student’s 18-week placement

Weeks 1–5: Hub – oncology ward

Focus on essential skills, professional behaviour and safeguarding. Observing cancer treatments: cytotoxic, biological and endocrine therapies.

Insight visits: radiotherapy, theatres.

Weeks 6–7: Spoke – oncology outpatients

Initial patient consultation, treatment decision making, follow-up clinics.

Insight visits: oncologist, site-specific nurse specialist, radiology investigations.

Weeks 8–10: Spoke – district nurse

Insight visits: Macmillan nurse, complementary therapist.

Weeks 11–13: Spoke – palliative day care

Insight visits: pharmacist, end of life coordinator, pain specialist team.

Weeks 14–18: Hub – oncology ward

Consolidate learning, reflect on the patient pathway.

Insight visits: dietician, discharge coordinator, occupational therapist, physiotherapist, social worker.

These placement experiences reflect the patient journey and will give you some insight into how teams can complement each other with the work they do to provide holistic patient care.

Activity

You are allocated to a general medical ward as a hub placement for 8 weeks. Make a list of the spoke placements and insight visits you might be able to go to that will support the care of a person with cancer.

NMC Domain 1: 1.7

NMC Domain 4: 4.2; 4.4; 4.5

How each team/specialty works in the practice placement

The following individuals, teams and departments are potential spoke placements or insight visits within a hub placement. Some might be new to you while you may already have worked with others and understand their role.

Health and safety requirements in the departments that may be visited from the hub placement

Reflection point

Reflect on your practice placement and consider if any role or specialty can be added. Maybe you have had a patient who has accessed a different service while you have been there. Jot down notes about this role and how the team on your practice placement liaised with this person/team. Consider how this enhanced the care and experience for your patient, family and your own learning experience. Also think back to lectures you have had. Write a short paragraph about this role that could, in theory, be added to the list above.

NMC Domain 1: 1.9

NMC Domain 4: 4.4; 4.7

For students who are not working on a specialist chemotherapy/radiotherapy ward, it is important to understand the precautions necessary if escorting a patient to one of these areas or if you spend a day in one of the departments. If you have attended an induction day for the placement, you may have covered these safety topics and this will be a refresher for you.

Cytotoxic medicines

Handling oral or intravenous cytotoxic drugs is extremely hazardous and this is not to be undertaken by a student nurse. Even if you are completing an oral drug administration round while being observed by a registered nurse, you should NOT handle these drugs. It is the responsibility of a qualified member of the team who has received training in cytotoxic handling.

Although you will not be administering cytotoxic medicines, you will be handling body fluids (urine, faeces, vomit) that may contain degrading by-products of the drug. In addition, if there is a spillage of cytotoxic drugs, you may be at risk if the correct procedures are not followed. The effects of exposure to cytotoxic drugs are irritation of the skin in the short term, the risk of developing a cancer, infertility and embryonic mutation (if exposure occurs while pregnant). However, these effects are very rare and usually occur in individuals who administer intravenous cytotoxic medicines all day, every day, for a number of years. By taking protective measures, the overall risk to your health is minimal.

Cytotoxic drugs are excreted in all body fluids but most of the drug is excreted by the kidneys in urine. The drug usually stays in the body for a number of days, but some drugs are slowly excreted, taking up to 48 days to clear.

While patients are undergoing inpatient intravenous cytotoxic treatment, they will generally be on a fluid balance chart to ensure their fluid balance is maintained. They will therefore be asked to collect their urine in either a disposable urinal or bed pan. The first principle is to dispose of the urinal/bed pan as soon as possible so that the urine left in a bathroom or lavatory can’t be knocked over accidently (as well as for infection risk and hygiene reasons). Ask patients to use the nurse call buzzer when they have finished to ensure swift disposal.

Many cancer wards use absorbent granule sachets added to a bed pan or urinal before patients micturate. This ensures that the body fluid becomes semi-solid on contact and reduces the risk of spillage.

Note: before adding absorbent sachets, you must check whether a urinalysis (dip stick) is required. Some cytotoxics have side effects that damage the bladder lining, and all urine must be checked for the presence of blood to ensure immediate action to prevent severe damage. Also, before adding absorbent sachets, you should check if a specimen is required, such as a mid-stream urine (MSU) specimen. If one is required, take this in the normal way but label the bottle and the specimen request form with a ‘hazardous waste’ sticker before sending to the laboratory.

When you are ready to remove the bed pan/urinal, put on an apron and a pair of gloves and take the bed pan/urinal to the sluice. Once in the sluice, you will need to weigh the bed pan/urinal to attain an accurate volume to record on the fluid chart (making sure you subtract the weight of the bed pan/urinal and the absorbent granules). Then place the bed pan/urinal in the macerator (masher).

As well as body fluids, you may encounter a cytotoxic spillage. This is where a drug has leaked from either the bag or cannula or a urinal/bed pan has been knocked over. In this event, you will need to locate a ‘cytotoxic spillage kit’. This should hold all the necessary equipment to clean up the spillage. As a student, you should not undertake the clean up, but may need to go and collect the spillage kit, so find out on the first day where it is stored. You may need to stay with the spillage, alerting passers by of the hazard.

Activity

Locate the cytotoxic spillage kit on your placement. Find out what is in the kit and read the local policy of how to deal with a spillage.

NMC Domain 3: 3.6

Extravasation

One of the most common emergencies you may encounter in your placement is extravasation. This is where a drug (in this case, a cytotoxic drug) leaks from the cannula into the surrounding tissues causing damage. If left unattended, this condition can cause permanent damage and may require major plastic surgery to repair tissue damage.

There are many factors that may influence whether a patient experiences an extravasation:

Patient factors

• Number of previous cannulas or venepunctures.

• Very old or young patients.

• Confused, restless or sedated patients.

Drug-related factors

• Nature of the drug – pH, concentration, temperature.

• Amount of drug.

• Duration of exposure.

Healthcare professional-related factors

• Cannulation skill.

• Frequency of undertaking procedure.

• Selection of type/size of cannula.

• Selection of site of cannula.

To prevent an extravasation, it is essential that the cannula is secured in a manner so that the entrance can be observed. Many health trusts use guidelines such as the Visual Infusion Phlebitis (VIP) score as a way of monitoring and documenting the status of a cannula. Infusions should be monitored at least every hour, and bolus injections (where the drug is injected into the intravenous line) should be give very slowly through a fast-flowing drip. All intravenous lines should be carefully maintained and free flowing prior to any cytotoxic administration. The antecubital fossa should not be used, and any limb where sensory damage is present should be avoided. In addition, lymhoedematous limbs should be avoided, for example when a woman with breast cancer has had her axilla lymph nodes surgically removed and consequently the arm has become swollen due to the lack of lymphatic return.

Activity

How can you minimise the risk of extravasation? What are the principles of good cannula care? How might you recognise an extravasation? Does your trust use a VIP score?

NMC Domain 3: 3.2; 3.3; 3.4; 3.6

If an extravasation is suspected, swift action is required. Cytotoxic drugs are categorised into groups depending on the damage they may cause if they extravasate: neutral, irritant and vesicant. The management of each type of drug that extravasates will be treated differently: either spread and dilute or localise and neutralise. Each department that administers cytotoxic drugs should have a policy for how each drug should be handled in the event of it leaking. Each department will also have an emergency extravasation kit which comprises all equipment needed.

It is important to know where essential equipment is kept, even if you are visiting a clinical area for just 1 day. Being able to locate items quickly is an important part of team working.

Activity

Locate the emergency extravasation kit on your placement. Read the local policy, paying attention to the main methods of treatment: ‘spread and dilute’ or ‘localise and neutralise’.

Look at a patient’s cytotoxic prescription. Identify the extravasation category of each cytotoxic drug. How would you ‘hypothetically’ treat the patient if an extravasation occurred?

Have a look at The National Extravasation Information Service Website. Find out about the green card reporting system:

http://www.extravasation.org.uk/home.html (accessed November 2011).

NMC Domain 3: 3.1; 3.2; 3.3; 3.4; 3.6

Radiation

You may be asked to escort a patient to have radiation treatment planned or to be given radiotherapy. It is important that you stand outside the treatment room when asked (or you might be asked to wear a lead apron) and that you adhere strictly to the safety requirements in the department. If you think you might be pregnant, it is important to tell your mentor or ward manager, in order for a risk assessment to be completed. This information will be kept confidential if you want it to be, but it is important that you protect yourself.

Obviously radiation has health implications, and ensuring you are not exposed to it is the key to protecting yourself. Every unit that administers radioactive treatment has guidelines called the ‘local rules’ that set out safe practice to protect all individuals. The key principles of the local rules of radiation safety are time, distance and using barriers. As a student nurse, you should never enter a room where a patient has a radioactive source within their body or is receiving external beam radiation (discussed in Chapter 13). Look for the radiation warning sign to identify potential patients. Where a radiation source can be removed temporarily (such as a ‘selectron’ machine), a qualified member of the team can switch the machine off. Once you have checked that the radiation has been safely removed, you may enter the room.

Planning insight visits and opportunities as part of the practice placement

Activity

Locate the ‘local rules’ in your placement. These are set by the Health and Safety Executive and are implemented wherever radiation protection is required. Every area that administers treatment involving radiation must have a set of local rules.

NMC Domain 3: 3.4; 3.6

As you prepare for this placement, having considered the wide range of teams and services available as part of the cancer and palliative care specialty, review your competency documentation and essential skills clusters and note down the areas that you need to focus on. Considering the spoke opportunities now night be a way of achieving a wide variety of competencies.

Activity