European Oncology Nursing Society (2004) 8, 306–314

www.elsevier.com/locate/ejon

The professional role of breast cancer nurses

in multi-disciplinary breast cancer care teams
Z. Amira,*, J. Scullyb, C. Borrillb

a
Macmillan Practice Development Unit, School of Nursing, Midwifery and Health Visiting, University of
Manchester, Gateway House, Piccadilly South, Manchester M60 7LP, UK
b
Work and Organisational Psychology, Aston Business School, Aston University, Birmingham B4 7ET, UK

KEYWORDS
Breast cancer care
nurse; Nursing practice;
Multi-disciplinary team
working;
Patients advocate;
Nurses’ role in the team
Summary Since the 1970s breast cancer services have witnessed considerable
changes in the management of patients. One significant change was the introduction
of specialist core personnel, including the breast care nurse (BCN). The role of the
BCN has been gaining credence rapidly in the British NHS and this service is
perhaps the paradigm of care for other services.
With the lack of specific evidence of the role of specialist nurses in the breast care
team, the current study aims to explore this area by in-depth interviews with core
team members, and observations of 16 multi-disciplinary teams in England.
The study explores the following themes: Nurses’ unique informal management
leadership role in ensuring the co-ordination, communication and planning of the
team work; nurses’ innovatory role in making the bureaucracy respond to patients
and their relatives needs; nurses supportive role in the provision of expert advice
and guidance to other members of the team; nurses confidence and humour in
well- performing teams; and the limitations of the professional role of the breast
cancer nurse.
This study indicates that there is evidence that the BCN is practicing at an
advanced level of practice. However, there is a severe lack of evidence-based
description of that advanced practice. Cancer nurses including the BCNs should
develop and participate in programmes of research in line with cancer legislation
in order to build an evidence base that ultimately supports their unique role.
& 2004 Elsevier Ltd. All rights reserved.

Zusammenfassung Seit den Siebziger Jahren hat sich eine bemerkenswerte

Wandlung der Behandlung von Patienten im Rahmen der Brustkrebsversorgung
vollzogen. Eine wesentliche A. nderung war dabei die Ausbildung von
spezialisiertem
Kempersonal einschliehlich der Pflegekraft fu. r Brustkrebs (Breast Cancer
Nurse BCN). Die Rolle der BCN hat innerhalb des Britischen Gesundheitsdienstes
NHS rasch an Glaubwu. rdigkeit gewonnen, sodass diese besondere
Versorgungsleistung wohl zum Paradebeispiel fu. r Krankenversorgung an sich
geworden ist.
Angesichts des Mangels an spezifischen Nachweisen fu. r das Berufsbild
der speziellen Pflegekraft fu. r Brustkrebs im Rahmen eines Versorgungsteams zielt
diese Untersuchung darauf ab, dem mit Tiefeninterviews mit Angeho. rigen des
Kernperso- nals und Beobachtungen von 16 multidisziplina. ren Teams in England
abzuhelfen.
Die Studie befasst sich mit den folgenden Themen aus dem Arbeitsbereich der
BCN: mit ihrer einzigartigen informellen Fu. hrungsrolle im Management zur
Sicherung von Planung, Koordination und Kommunikation im Team; mit ihrer
innovativen Rolle bezu. glich der Reaktionen der Verwaltung auf Belange von
Patientinnen und deren

*Corresponding author. Tel.: þ 44-161-237-2159; fax: þ 44-161-237-2172.

E-mail address: ziv.amir@man.ac.uk (Z. Amir).
1462-3889/$ - see front matter & 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejon.2003.12.011
 The professional role of breast cancer 3

Angeho. rigen; mit ihrer hilfreichen Unterstu. tzung der anderen Teammitglieder
durch Anleitung und sachkundigen Rat; mit ihrem Selbstvertrauen und ihrer
emotionalen Stimmungslage in einem guten Team; und schliehlich mit den
Einschra. nkungen und Grenzen ihrer beruflichen Rolle.
Die Untersuchung la. sst Hinweise erkennen, dass die BCN ihre Ta. tigkeit auf
einem gehobenen Niveau an Berufserfahrung ausu. bt. Allerdings mangelt es
an einer abgesicherten Beschreibung dafu. r. Pflegekra. fte fu. r Krebserkrankte
einschliehlich der BCN sollten sich in U. bereinstimmung mit der Gesetzgebung zu
dieser Krankheit
weiterbilden und an Forschungsprogrammen teilnehmen, damit eine beweiskra. ftige
wissenschaftliche Grundlage geschaffen und so letztlich ihre einzigartige Rolle im
Gesundheitswesen gefo. rdert wird.
& 2004 Elsevier Ltd. All rights reserved.

Introduction personnel, including the clinical nurse specialist

Since the 1970s breast cancer services have
witnessed considerable changes in the manage-
ment of patients. There has been an increased
awareness of the problems that patients with the
disease face and, in some instances, what might
be done to help. The typical service for
symptomatic breast patients prior to the 1970s
was provided by general surgeons, usually within
general surgical outpatient clinics. The last three
decades wit- nessed multidisciplinary involvement
in the diag- nosis and management of breast
cancer. Professional groups such as the British
Breast Group and British Association of Surgical
Oncology (BASO, 1995) positively advocated multi-
disciplinary teams (MDT) for breast cancer in the
early 1990s. This model gained strong support in
the Calman–Hine recommendations (DoH, 1995)
and the implemen- tation circular that followed
it. Moreover, the NHS Executive cancer site-
specific Guidance (Working Party of the British
Breast Group, 1995) made the membership, roles
and working arrangements of breast teams an
explicit part of national policy. Core team
members of a breast cancer care team include
health professionals who have a particular
expertise, as well as designated time, to manage
breast cancer patients, and currently include
designated breast surgeons, breast care nurses
(BCNs), pathologists, radiologists and oncologists.
Teams function in designated cancer units char-
acterising the evident shift towards breast cancer
services that are predominantly characterised by:
*
individual specialisation in breast disease;
*
multi-professional working based on multidisci-
plinary breast teams; and
*
the increasing demarcation of breast services,
with designated clinics and facilities.
Integral to the provision of a high-quality
service is the collaborative functioning of
specialist core
(Poole, 1996). The first BCNs were recruited in
the mid-1970s. One aspect of their role was to
provide psychosocial support to patients. The role
of the BCN has been gaining credence rapidly in
the British NHS and this service is perhaps the
paradigm of care for other services.
Additional recommendations have also been
made by the recent publication of the Nurses
Contribution to Cancer Care (DoH, 2001b) and the
NHS Cancer Plan (DoH, 2000) supporting the need
for an increase in the number of cancer and
palliative care clinical nurses.
The BCN’s work has been evaluated in various
settings and findings have shown they have made
a significant contribution to patients’ well-being
(Walby et al., 1994). It is well documented that
the specialist nurses with specialist training in
counselling and communication are core members
of the multidisciplinary team (MDT), and provide
psychosocial support, education and information to
cancer patients, and this helps them to meet
their health-care needs (Addington-Hall et al.,
1992; McCorkle et al., 1989; Weintraub and
Hagopian, 1990; Ambler et al., 1999; Edmonds et
al., 1999; Rustoen et al., 1998). Notably, the
studies on BCNs have been written from a medical
perspective. In this sense they differ from the
multiple studies on the nursing profession which
have been written from a feminist perspective
(Annandale, 2002). Whilst this paper
acknowledges the limitations of the BCNs role in
relation to the wider power dynamics of the
consultant/ nurse ‘gendered’ relationship, it
seeks to explain the multiple professional role of
the breast cancer care nurse within the MDT
context.
Despite the increase in the number of clinical
nurse specialists, there is a paucity of research
studies to demonstrate their effectiveness. With
the current emphasis on clinical and cost-effec-
tiveness, there is an urgent need to evaluate the
contribution of the clinical nurse specialist. This is
 3 Z. Amir et
particularly important as clinical nurse specialists
are at the top end of the grading scale and are
viewed as costly. Thus there is an issue for those
purchasing health care that they need to see the
value of the contribution that the clinical nurse
specialist makes.
This paper argues that in addition to BCN’s
contributing to patients’ well-being, they demon-
strate professional organisational and
management work role competency, especially in
building and maintaining a therapeutic team to
provide opti- mum therapy (Fenton, 1985).
Furthermore, the quantitative stage of this study
(Haward et al., 2003) established that team
composition, working methods and workload are
related to measures of effectiveness, including the
quality of clinical care. One significant finding is
the strong and positive association between the
proportion of breast cancer nurse in the team and
the overall measure of clinical performance.
With the lack of specific evidence of the role of
specialist nurses in the breast care team (Richard-
son, 2001), the qualitative phase of the study
aims to highlight their professional role through
the findings of in-depth interviews and
observations of 16 multi-disciplinary breast care
teams in England.
Methodology
The qualitative phase of the national quantitative
study (Haward et al., 2003) explored team mem-
bers roles in the MDTs. Sixteen breast teams were
then selected for in-depth work from a sample of
85 teams that had participated in the quantitative
stage of the research. For the qualitative stage
the eight teams with the highest scores on team
working and effectiveness, and the eight teams
with the lowest scores on these dimensions from
the quantitative study, were selected. The ratio-
nale was to explore in depth which factors led to
effective team work and which factors mitigated
against effective team work. To avoid bias in the
qualitative stage of the research the field research-
ers were not told which of the 16 teams were the
high performing teams and which were the lower
performing teams. In preparation for the qualita-
tive phase a pilot study was conducted on one
breast care team, which assisted in an advisory
capacity. The three visits at this breast care team
familiarised the field researchers, who did not
have a medical background, with the area of
study, enabling the researchers to test the ques-
tionnaire on core team members and observe a MDT
meeting.
In addition to interviews, observations were
selected as another research method, to enable
the researchers to observe the activity of the MDT
meeting, and to provide an insight into the
interactions between team members in their
work- ing context. The researchers who
conducted the fieldwork were informed by an
understanding of research on sensitive topics
(Burgess, 1982; Lee, 1993) and aware of the
biasing effect of their own, and their gatekeepers
characteristics on the find- ings (Dingwall, 1980).
Each team was visited by two researchers, allowing
them to verify findings from their field notes and
compare the observations they had made at the
end of each day. The researchers spent between 2
and 3 days with all of the 16 breast cancer teams.
Selection of method: interviews
and observation
All of the core members from the 16 teams
approached agreed to be interviewed, and all of
the team leaders went to considerable effort to
assist in the arrangements to conduct the
research. Interviews were mainly conducted in
the respon- dents’ offices, which were generally
small and crammed with files. On a number of
occasions interviews took place in rooms adjacent
to wards, where it was possible to hear radios and
the bustle of people passing in the corridors.
Face-to-face structured in-depth interviews were
conducted with all of the core team members
individually. The time of the interviews ranged
between one and one and a half hours. In total 139
in-depth inter- views were conducted with: 24
BCNs, 25 consultant surgeons, 14 consultant
oncologists (clinical and medical), 20 consultant
radiologists, 20 patholo- gists, six other nurses,
and 30 other professionals who contributed to the
work of the breast care team (database manager,
administrators, clerical staff, other doctors).
A structured interview schedule, developed by
Hackman (1980) was used to assess the extent to
which the organisational context was supporting
the MDT working in breast care, and the impact of
this on team working and the delivery of patient
care. More specifically the aim was to gather
information on factors which promote team work-
ing, factors which detract from, or make team
working difficult, and to explore precisely how
effective team working contributes to providing
quality patient care. Team processes were
probed, which included clarity of objectives,
participation, task orientation, support for
innovation, reflexivity,
The professional role of breast cancer
communication, decision-making, formal and in-
formal leadership and organisational support. In-
terviewees were asked to describe occasions
when each of these factors were identified as
important to team effectiveness, or had
hampered team effectiveness. In addition, the
researchers probed key themes that merged during
the fieldwork visits, particularly during the
informal meetings with team members.
The research setting
The researchers observed all of the 16 MDT weekly
meetings, which lasted between 1 and 2 h, and in a
number of cases were invited to observe the
clinics. The field work spanned more than 45
days, and the researchers were aware of their
own sharp learning curve in relation to the
community they were studying during that period,
and how that might influence their findings. Both
researchers noted separately that gaining rapport
with each team seemingly became somewhat
easier as the study progressed, and recognised
how their con- fidence could potentially bias the
data collection. In this sense the study did not fit
easily into the ethnographical terms of ‘short’ or
‘long’ fieldwork (Gurney, 1991) work because the
landscape chan- ged considerably in every team
meeting, although the accounts of the different
team members shared more in common than not.
The venue and time allocated for each MDT
meeting varied considerably. At worst, teams
were meeting at an inconvenient time in a room
too small for the number of attendees, which
subse- quently restricted observation of the
clinical presentations. In one meeting the room
was so small professionals climbed over chairs and
their colleagues to view the clinical findings.
Meetings were observed that had been convened by
the Trust at a time that did not suit some of the
core team members. Two started at 7.30 a.m.
and another at 6 p.m. which meant attendance
was patchy, and not all of the team was involved
in patient care. In contrast others had lecture
style theatre facilities that enabled good viewing,
and ample space for other team members to
participate and view the clinical findings. Most of
the timings allocated for the MDT’s required the
core members to partici- pate in a working lunch.
In one team the BCN’s organised the MDT meeting
as a working breakfast. On another occasion the
room had an overlap booking and another team
consistently banged on the door to try and hurry
the breast cancer team out. The researchers
were told that this was a
3
regular occurrence. Overall the efficiency of MDT
breast cancer meetings depended upon the extent
of organisational support that was available to each
team. We observed how this factor impacted upon
the workload of the breast cancer care nurse, and
later in the process of analysis, were able to
identify how poor organisational support was
particularly evident in the less well performing
teams. We also observed how the deficits in the
organisational context were patched up by the
range of the tasks that the breast cancer nurse
undertook.
A number of the surgeons invited the
researchers to observe their clinics. Similar to the
MDT meeting the researchers witnessed the speed
at which the teams worked, and were told how
teams were managing eight times the number of
patients they were seeing 10 years ago. For one
team this had meant an increase from 200 new
patients in 1992 to 1700 in 1999, with no extra
resources, as well as the obligations to respond to
the waiting times for urgent referrals to be seen
within a 2-week maximum waiting time.
The researchers were also invited to meet the
team members in less formal settings, an aspect
of the fieldwork which allowed the researchers a
greater insight into the team dynamics and the
organisational setting (Strauss et al., 1985). In-
formal discussion was generally located around
food and ranged from canteen breaks to being
invited to dinner. Much of the discussion in these
informal meetings focussed on the extra pressures
on the service without the adequate resources
provided by government and the trust, and the
concern that the 2-week wait served to inflame
the possibility of a less adequate service for
patients who were not seen as high risk. However,
the setting also allowed the researchers to observe
how informal networks are a characteristic of
breast cancer care teams. The researchers own
feelings of exhaustion after each of the field visits
served to heighten their own awareness, and that
they were engrossed in a form of research method
that is the most personally demanding and
analytically com- plex.
Data analysis
Field work observations rendered a ‘rich’ but
unsystematic file of data. This problematic, which
is common to qualitative studies, has been mini-
mised by rigour in the analytical stages of the
research process (Bradburn, 1983) and we
selected grounded theory as the way forward
with our key
3 Z. Amir et
concepts (Glaser and Strauss, 1967). With the
exception of one respondent, who declined to be
taped all of the interviews were taped,
transcribed and entered into Atlas, a qualitative
analysis package. All of the respondents were
offered their tape and tape transcription. One
respondent accepted this offer, and the tape and
transcript was duly sent. The researchers moved
from the systematic selection of concepts and
problems drawn from observations of team
settings and the respondents’ interviews into
themes that could be theorised into a model of
the organisation (Becker and Geer, 1982).
The data were coded and emergent themes
drawn from the data in accordance with the broad
principles of grounded theory (Glaser and Strauss,
1967; Becker and Geer, 1982). To maximise
internal validity (Bradburn, 1983), confidential
summary reports were sent to each of the 16
teams, whose members were invited to comment
upon them. The reports con- tained themes from
their teams’ findings, and presented anonymous
recommendations that respon- dents had suggested
would improve team effective- ness. Three teams
replied; one team leader thanked for the report,
another asked for more feedback on leadership
and a third explained that subsequent changes
had been made in the team structure.
The field researchers learned first hand how
collaborative team research places extra strains
on ethical issues (Goffman, 1961). The
researchers were aware they would have not
easily gained access to this setting without the
project board being comprised of influential
members of the medical community. As such, their
status within the breast cancer community
facilitated in Dingwall’s (1980) terms ‘a hierarchy
of consent’ that enabled the ‘gatekeeping’ access
into the clinical commu- nity that was studied.
This ease of access was mitigated by an added
ethical awareness of how the community that was
being studied was studying the researchers. At the
time of this study it was not compulsory with the
new research governance guidelines to obtain
ethical approval to interview health-care
professionals; however, the ethical issues of
confidentiality and anonymity permeated the
research process from its inception to the
decision on data storage. During the fieldwork
participants were promised that their identity
would be kept confidential, a promise that has
been maintained.
Results
The researchers observed the distinct presence of
the BCNs in relation to the clinical staff nurses
that
worked with the team. In particular BCNs are
allowed to wear their own clothes and not the
standard nurse uniform of the particular trust. All
were extremely smartly dressed, and presented
an image of authority that was akin to the
manage- ment and higher medical structure.
However, there was no evidence to show that their
management role was valued by the hierarchy of
the trust that they worked for. Rather, the
themes identified below relate to their role
specifically within the team. The key findings of
the paper present three key themes that were
common to all of the teams, and one key theme
that was common to the well functioning teams.
Informal leadership role: nurses’ role
in ensuring the co-ordination,
communication and planning
The breast cancer care nurses were acknowledged
as the informal leaders of the team. Quality
health care requires co-ordination,
communication and planning, which can all be
enhanced by team working. Analysis of data from
the interviews indicates that BCNs have a very
significant role in the above three components of
quality health care. Above all, they are perceived
as the informal leaders of the teams:
‘‘I don’t have a lot of problems as the team leader. I
don’t find it takes up a lot of my time. I get a lot of
help from the breast care nurse, and in a way she is
seen as the official team leader’’ (surgeon).
A theme common to all of the teams was the
BCNs role in co-ordinating other core members of
the team:
‘‘I think that breast care nurses tread out of role in co-
ordinating and liaising, but I think without, and this
isn’t blowing our trumpet, I think without we wouldn’t
be as tight knit and as good at what we do as we
are’’ (BCN).
‘‘We are a team after all, so very much my role and
indeed yI am right at the hub, because I am main
liaison with everybody else including the patient’’
(BCN).
In general, they took responsibility to make
sure that internal communication within the team
is efficient:
‘‘Lately there was an incident where communication
was really very poor on an issue y. It became quite
apparent to me that we were about to embark on a
slippery slope. So, as a result of that I got a meeting
convened to make sure that all the team were
together in the same room, an agenda was written
The professional role of breast cancer
up y.. as a result of that we now run the team
meetings monthly’’ (BCN).
This included planning and documenting the
team meetings:
‘‘I have to say that. She is responsible for all the
documentationFI write some of the clinical
docu- mentation but she is responsible for a lot of
the preparation and presentation of all the
documents’’ (surgeon).
‘‘I am the one that tried to co-ordinate the bits that
we need to put through, organise the joint audit
meeting, etc., that we have with MrFas the lead
clinician, on the accreditation process’’ (BCN).
In some teams nurses build up contacts with
relevant agencies outside the team itself:
‘‘There is a good relationship with the Directorate and
the managers. Obviously, It’s down to myself and them
liaising together’’ (BCN).
‘‘I have found I have built up relationships and
networks with people at the regional cancer project
team and you can solve problems easier’’ (BCN).
However, despite the recognition within the
teams of the breast cancer care nurse as informal
leader and key co-ordinator there was no
evidence to show that they had been promoted in
any of the teams as the official leader.
Furthermore, when discussions with the trusts
management were high on the agenda, or
external meetings were held where important
decisions were made it was the designated
leader, normally the surgeon, who attended, and
made the decisions.
The innovatory role: nurses’ role in
making the bureaucracy respond to
patients and family
A key role that was identified in this study was
that of innovation, and managing the bureaucracy
to respond to patients and family immediate
needs. BCNs are constantly faced with the fact
that patients’ needs are often not met because of
the way the bureaucracy functions. The findings
showed evidence of innovations that had been
introduced by the breast cancer nurses despite
the difficulty of trusts’ organisational
bureaucracy. Since policy changes often cannot
be initiated in time to meet patients’ immediate
needs, the BCN identified ways to work around a
bureaucratic system.
BCNs reported undertaking deconstruction and
reconstruction of the environment/system of care
to make radical changes to the nature of caring,
so
3
that quality health care could be achieved. As the
patients’ advocate, they considered implementing
innovative changes as integral part of their role:
‘‘As I said, breast care nurse brings things and we
design formsFI’ve designed GP referral forms. I think
evolution isn’t it? We started really doing the FNAs
in one day and bringing the X-ray department to the
same floor. This was also progression y’’
(Oncologist).
Their role involves developing and using a
network of contacts in different departments
throughout the system that can assist them in
getting things done efficiently:
‘‘As a nurse I can implement a lot of things within
my domain to make it work, such as bringing the
outpatients staff in, bringing the ward staff in and
making them part of the team’’ (BCN).
In their co-ordinating role, BCNs managed to
speed-up processes, which are resulted in better
outcomes for patients:
‘‘Yes. And I have to say I don’t know if it is the role
of the breast care nurse but we do a fair amount of
not letting things go unless they’re addressed, and
round- ing people up’’ (BCN).
‘‘We have changed practice, either I take the form
down personally and then the lady’s is given her
date or there is a phone call made from clinic to
check that they can do it’’ (BCN).
‘‘y. therefore, I was able to take the X-ray forms to
the X-ray department and talk to the consultant
radiologist, and explain the situation, and we were
actually able to schedule the scans, yy, so we will
have the results by the time, well, before the time she
(the patient) would come in for surgery’’ (BCN).
The professional counsellor support role:
the provision of expert advice
The BCNs were observed providing expert advice
and guidance, both formally and informally, to
other members of the team in the MDT meetings.
The ability to assess patients’ concerns that are not
always as apparent to the other members of the
team, was a commonality to all of the MDT
meetings. This key finding was supported by the
evidence from the one to one interviews which
showed how they formulate plans to deal with
these concerns, which reduce the anxiety of both
the patients and the other members of staff and
increases the staff’s confidence in working with the
patient. In short they applied a knowledge that
spans the patient care journey, as well as managing
the dynamics of the team meetings. In the MDT
meetings they were called upon to provide a profile
3 Z. Amir et
of the patient’s personal needs, and they spoke of
this aspect in their interviews:
‘‘I can think of a specific young patient who had breast
cancer, who was very frightened about her breast
problem and I think the team worked very well
there, giving her the psychological support that she
needed and we were able to make the diagnosis very
quickly for her and give her all the treatment
options, we were able to give her time to discuss it
with more than one person’’ (BCN).
Notably, their role supports other core team
members who spoke of the burden of maintaining
the intensity of treatment, which would be intol-
erable without the softer more emotion-focused
approach of their nursing colleagues. In
particular, oncologists and surgeons recognised
the impor- tance of this form of support:
‘‘This patient probably should be seen quicker than
say within three weeks’ because the history she’s
giving, it was completely different to what we read on
the paperFthe referral letter. So, with their (BCNs)
information we expedited the referral and saw them
earlierFthere have been several cases like that
where we have benefited from their (BCNs) skills’’
(Oncologist).
‘‘I would not wish to do this sort of work without their
(nurses) help really, because the patients will talk to
them about aspects of the disease, their lifesty-
leFwhich they (the patients) would not mention to
meFhow the disease and treatment affect their life,
their concerns about their domestic circumstances,
their relationships. Personal things that they wouldn’t
wish to discuss with me, and I’ve found that the
most helpful aspect of it’’ (Surgeon).
‘‘That’s why we rely on nurses and as I said, they
are our right hand. We can’t function alone’’
(Oncologist).
‘‘In actual fact, I (surgeon) think if you were to ask the
patient who was the most important person, they
would say undoubtedly the breast care nurse’’.
In their interviews the BCN’s explained how
they recruit and train volunteers to work in the
clinics, a fact that was substantiated by informal
discussion with the volunteers, who were ex-
patients and provided support to new patients.
This form of support ranged from sitting with a
new patient and talking to them to walking them
from one depart- ment to another, and inviting
them to join support organisations.
In addition to the written information that the
BCN’s kept in their offices the researchers were
also shown the range of attractive swimwear and
fashionable scarf cool caps that patients were
able to purchase at cost price. On two occasions
these garments had been identified in the USA
and sent
for by the BCN’s. Also a considerable effort had
been made by the BCN’s to make sure that their
‘breaking bad news’ room was the most appro-
priate and softly furnished environment.
The combination of the dual role as both
patient advocate and management served to add
value on patient care.
Confidence and humour in the
MDT meeting
The researchers found no sharp distinction between
the accounts of the BCN’s in the most- and less-
effective performing teams. However, the re-
searchers noted from their observations of the
MDTs that in some meetings the BCN’s had a greater
say than others, were confident to challenge the
ideas of other team members, and that frequently
the debate was accompanied by humour. This was
made apparent on one occasion when a surgeon
was challenged, and good heartedly accepted that
not only daughters of patients should be seen at
higher risk of breast cancer but also the families
of sons. Although this combination of confidence
and humour was not the case in all of the high
performing teams it was not evident in any of the
less well performing teams.
The limitations of the professional role of
the BCN
The authors noted at the start of this paper that the
wider power dynamics of the consultant/nurse
‘gendered’ relationship are discussed elsewhere
(Annandale, 2002), but not, in relation to team
working. Yet, this study also acknowledges the
limitations of the BCNs role, which was pointed
out on a number of occasions, particularly in
relation to BCNs having any power to make
decisions outside the team:
‘‘But when it comes to those sorts of political things
I’ve no say really because I’m a nurse and not a
doctor’’(BCN).
Discussion
It is the contention of this paper that within the
breast cancer team, BCNs are located at the
juncture between the dominant influences of
surgery, psychology, management, patients and
oncology. They are poised between medical and
 The professional role of breast cancer
scientific knowledge of the disease and the illness
experience of their patients and have to mediate
between medical practice and its distressing
impact on their patients. In addition to their
prescribed medical role in the breast care team
they are the conduits of medical management, as
well as the representative patients advocate. In
short the deficits in the trusts organisational
context was patched up by the range of the tasks
that the breast cancer nurse undertook in the
team context.
The results from the current study strongly
suggested that BCNs had a positive impact on the
quality of care. The role of the BCNs is best
understood within the context of the multidisci-
plinary team. While the role is distinct and
unique, it entails considerable interaction and
some degree of overlap with the roles of other
health profes- sionals involved in the care of
women with breast cancer. A significant
component of the BCNs role involves coordination
and liaison with other treat- ment team members.
As was demonstrated very clearly, BCNs are highly
valued within the treat- ment teams, precisely
because of their ability to link between members
of the team, and between women (and their
families and friends) and the team. The main
emphasis in relation to core components of the
role was the BCN as a pivot lynchpin of the
treatment team. This related to the perception of
the BCN as a conduit of information from women
patients to treatment team members, and from
the treatment team to the women. These nurses
also function as a conduit of information between
members of the team, they provide members of
the team the information about what has
happened to patients within other areas of the
hospital and during other treatment modalities.
Thus, the BCN facilitates information sharing and
knowledge of each patient’s progress and needs
within the treatment team. This important aspect
of their role occurs in many different modalities,
ranging from formal multidisciplinary team meet-
ings to less formal discussions with individual
team members.
The perception that as specialist nurses, BCNs
gain access to different information from patients
is significant here. It is a commonly held perception
that the BCN’s emphasis on support and holistic
care of the individual woman means that she feels
comfortable in sharing feelings and information
with the nurse, which she may not bring up with
other treatment team members.
Additionally, BCNs are viewed as a positive
resource within the treatment team. They ensure
that care flows smoothly: namely, that referrals
happen when needed, that other health profes-
3
sionals have adequate information about patients
and breast cancer issues, and that women are
prepared for each treatment stage.
The data from this study indicate that there is
evidence that the BCN is practicing at an
advanced level of practice. What is also clear is that
there is a severe lack of evidence based
description of that advanced practice. Cancer
nurses including the BCNs should develop and
participate in programmes of research in line with
cancer legislation in order to build an evidence
base that ultimately supports their unique role in
cancer care provision.
The discussion in this paper has focused pre-
dominantly upon the BCN professional role within
the team, illuminating their multiple role and
their ability to manage the collective throughput
of the patient, as well as supporting their team
collea- gues. However, the authors have also
noted that tensions do arise when decisions are
made outside of the team context, and when the
breast cancer nurses have not been privy to the
macro level decision making process.
Finally, BCN’s were repeatedly identified as
central to the delivery of Breast Cancer services.
They are perceived by their colleagues as con-
tributing to patient well –being and
demonstrating professional and management work
role compe- tency. Nevertheless, this study has
not addressed issues around the effectiveness of the
BCN from the patients’ perspective. It was beyond
the remit of the current study to assess whether
the existence of the BCN makes any difference to
patients’ outcomes. The possible beneficial effect
on pa- tients’ outcomes warrants further
investigation.
References
Addington-Hall, J.M., MacDonald, L.D., Anderson, H.R., 1992.
Randomised controlled trial of effects of co-ordinating care
for terminally ill cancer patients. British Medical Journal 305,
1317–1322.
Ambler, N., Rumsey, N., Harcourt, D., Khan, F., Cawthorn, S.,
Barker, J., 1999. Specialist nurse counsellor interventions
at the time of diagnosis of breast cancer: comparing
advocacy with a conventional approach. Journal of
Advanced Nursing 29 (2), 445–453.
Annandale, E., 2002. Feminist Theory and the Sociology of
Health. Routledge, London and New York.
Becker, H., Geer, J., 1982. Participant observation: the
analysis of qualitative field data. In: Burgess, R.G. (Ed.),
Field Research: a Sourcebook and Field Manual. Routledge,
London and New York, pp. 80–97.
British Association of Surgical Oncology (BASO), 1995. Guidelines
for surgeons in the management of symptomatic breast
disease in the United Kigdom. European Journal of Surgical
Oncology 21 (Suppl. A), 1–13.
Burgess, R.G., 1982. Field Research: A Source Book and Field
Manual. Routledge, London, New York.
 3 Z. Amir et
Bradburn, N.M., 1983. Response effects. In: Rossi, P., Wright, J.,
Anderson, A. (Eds.), Handbook of Survey Research. Academic
Press, New York.
Department of Health, 1995. Policy framework for
commission- ing cancer services: A Report by the Expert
Advisory Group on Cancer to the Chief Medical Officers of
England and Wales, London HM Stationary Office.
Department of Health, 2000. The NHS Cancer Plan.
Department of Health, London.
Department of Health, 2001b. The Nursing Contribution to
Cancer Care. Department of Health, London.
Dingwall, R.G., 1980. Ethics and ethnography. Sociological
Review 28, 871–911.
Edmonds, C.V., Lockwood, G.A., Cunnigham, A.J, 1999.
Psycho- logical response to long-term group therapy: a
randomised trial with metastatic breast cancer patients.
Psycho-Oncol- ogy 8, 74–91.
Fenton, M., 1985. Identifying competencies of clinical nurse
specialists. Journal of Nursing Administration 15 (12), 31–37.
Glaser, B., Strauss, A., 1967. The Discovery of Grounded
Theory.
Aldine, Chicago.
Goffman, E., 1961. Asylums. Penguin, Harmondsworth.
Gurney, J., 1991. Female Researchers in Male Dominated
Settings: Implications for Short-term versus Long-term
Research in Experiencing Fieldwork an Inside View of
Qualitative Research. Sage Publications, Newbury Park
London New Delhi.
Hackman, R.J., 1980. Work Redesign. Addison-Wesley,
Reading, MA.
Haward, R., Amir, Z., Borrill, C., Dawson, J., Scully, J., West, M.,
Sainsbury, R., 2003. Breast cancer teams: the impact of
constitution, new cancer workload, and methods of opera-
tion on their effectiveness. British Journal of Cancer 89,
15–22.
Lee, R.M., 1993. Doing Research in Sensitive Topics. Sage
Publications, London, Thousand Oak, New Delhi.
McCorkle, R., Benoliel, J.Q., Donaldson, G., et al., 1989. A
randomised controlled trial of home nursing care of lung
cancer patients. Cancer 64, 1375–1382.
Poole, K., 1996. The evolving role of the clinical nurse
specialist within the comprehensive breast cancer centre.
Journal of Clinical Nursing 5 (6), 341–349.
Richardson, A., 2001. Developing, delivering and evaluating
cancer nursing services: building the evidence base.
Nursing Times Research 4, 726–735.
Rustoen, T., Wiklund, I., Hanestad, B.R., Moum, T., 1998. Nursing
intervention to increase hope and quality of life in newly
diagnosed cancer patients. Cancer Nursing 21, 235–245.
Strauss, A., Fagerhaugh, S., Suczeck, B., Weiner, B., 1985.
The Social Organisation of Medical Work. Chicago
University Press, Chicago.
Walby, S., Greenwell, J., Mackay, L., Soothill, 1994. Medicine
and Nursing Professions in a Changing Health Service. Sage,
London.
Weintraub, F.N., Hagopian, G.A., 1990. The effect of nursing
consultation on anxiety, side effects, and self-care of
patients receiving radiation therapy. Oncology Nursing Forum
17 (Suppl. 3), 31–36.