Nurse-led Clinics in Respiratory Care: a Literature Review

Published Date: 13 Sep 2016 Last Modified: 15 Jan 2018

INTRODUCTION

1. What is a nurse-led clinic?

As the coined term suggests, a nurse-led clinic is a health care centre in which nurses are involved in high level specialist procedures and assessments. In such centres, nurses are the critical decision makers, being involved in patient care at the micro-, meso-, and macro-levels. While the role of the physician in the provision of health care is undisputable, the deity-like status that medical practitioners typically have in the mind of patients, coupled with the limited time available for individual patient consultations, make it hard for these group of health care professionals to tackle the ‘softer’ side of patient care. Nurses, on the other hand, defined by the Oxford Medical Dictionary as health care professionals that are trained and experienced in nursing matters and entrusted with the care of the sick and the carrying out of medical and surgical routines, are better placed to provide this essential follow-up, especially in the care of patients with chronic diseases.

According to Hatchett (2003), a nurse-led clinic is a clinic in which nurses have their own patient case loads of whom they take complete charge. Hatchett broadly describes the components of such a clinic. There would be an increase in autonomy associated with the nursing role in the nurse-led clinic, with the power to admit, discharge or refer patients, as appropriate. In Hatchett’s own words, the roles which nurses adopt in these revolutionary settings can be broadly classified as follows (Hatchett, 2003):

• Education
• Psychological support
• Patient monitoring

The initiation of nurse-led initiatives probably owes its origins to the rise in nursing specialties in the United Kingdom. Throughout primary and secondary care, nurses are taking senior positions in health care institutions, such as nurse specialists, nurse practitioners, nurse consultants, nurse prescribers, etc, leading to a marked change in service delivery and the profile of the nursing profession. In addition to the usual registered nurse training, nurses working at higher levels of practice receive training to acquire a range of other medical skills such as physical examination and medical history taking in order to recognise abnormal clinical findings.

In a two-phase exploratory study to evaluate the domains of structure, process and outcome of nurse-led clinics in supporting intermediate care after the acute phase of disease, Wong et al (2006) interviewed nurses from 34 clinics and 16 physicians and observed 162 nurse-led clinic sessions. Their findings demonstrated the high level of skill and experience of the nurses who ran the clinics. Their work involved skills such as adjusting medications and initiating therapies, and diagnostic tests according to protocols. Interventions included assessments and evaluations, and health counselling. All patients studied showed improvement after the nurse clinic consultation, with the best rates reported in wound and continence clinics; satisfaction scores for both nurses and clients were high. However, although physicians valued their partnership in care with the nurses, they were concerned about possible legal liability resulting from the advanced roles assumed by these nurses.

Ultimately, nurse-led clinics provide an integral and invaluable patient-centred approach to the management of chronic disease which build upon skills such as counselling, teaching and health promotion which are key to contemporary nursing practice, as well as newly acquired medical skills. The advent if nurse-led clinics provides an opportunity for nurses to develop enhanced roles in which they can achieve more autonomy in their practice. This can be made a reality if adequate training and education, as well as effective leadership are in place (Wiles et al, 2001).

2. The general roles of nurses in chronic care management

The chief nursing officer, Sarah Mullally has proposed ten key roles for nurses in autonomous patient care. These are outlined below as cited by Hatchett (2003):

• Order diagnostic interventions: just like a medical practitioner would, the present-day nurse is able to ask for laboratory or clinical diagnostic tests to aid the process of diagnosis. Furthermore, a well-trained nurse will also be able to read and interpret laboratory results effectively
• Make and receive referrals directly: while the all-important roles of nurses are recognised, the need for a multidisciplinary approach to patient care remains key in order to optimise patient outcomes. Accordingly, nurses should be able to recognise the patients’ needs and refer them to the appropriate health care service as required. Similarly, nurses should be ready to accept referrals from other health care disciplines as necessary.
• Admit and discharge patients for specified conditions, within agreed protocols: in order to make the best use of the often limited hospital resources, a nurse should have the power to recommend patients for hospital admission and subsequent discharge
• Manage patient case loads: in nurse-led clinics, nurses are also responsible for managing their individual case loads. It is important to delegate patient cases to other members of the team, when necessary to ensure that patients receive the best care possible.
• Run clinics: the autonomous role of the nurse in a nurse-led clinic includes all aspects of the management and day-to-day running of the clinic.
• Prescribe medications and treatments: nurse prescribers are able to advise patients on appropriate treatment, based on diagnosis of ailment and individual characteristics and laboratory findings.
• Carry out a wide range of resuscitation procedures, including defribillation
• Perform minor surgery and outpatient procedures: especially in injury clinics. While nurses are probably not equipped to carry out full-fledged surgical operations alone, they are trained to conduct emergency processes as appropriate.
• Triage patients, using the latest information technology, to the most appropriate health care professional
• Take a lead in the way local health services are organised and in the way they are run

Nurses have always been considered as a supplement to the fundamental care provided by medical doctors. In fact, in some geographical regions, nursing roles are limited to menial tasks such as changing bedpans etc. In the new age, the nursing role as we know it is becoming increasingly important with nurses taking on infinitely more clinical roles. This has led to controversial debates with critics arguing that nurses cannot replace doctors in the provision of health care services. As Richard Hatchett very astutely pointed out (2003), the increased autonomy being acquired by nurses is not a bid to compete with medical doctors. Instead, “it is a case of considering who can provide the most appropriate service to the patient” (Hatchett, 2003).

Thus, it is clear that the roles of nurses in chronic care management is very diverse and can be integrated into any nurse-led clinic intervention to the utmost benefit of the patient and all stakeholders. There have been numerous studies on the role of nurses in the care of patients with chronic diseases. In addition, and more specifically, the feasibility and benefits of implementing nurse-led clinics in practice have also been investigated to some extent. In the subsequent sections, we will review the evidence to support these innovative nursing interventions in an attempt to make the best use of health care resources.

3. Nurse-led clinics in the management of chronic care diseases: the evidence

The World Health Organization (2002) defines chronic diseases as health care problems that require ongoing management over a period of years or decades. The nature of these disease conditions make it necessary to provide long term care and follow-up for the afflicted patients. Nurse-led interventions have been investigated a wide range of chronic diseases. It could be a logical, user-friendly, cost-effective and practical approach to improving long-term patient outcomes and should be explored fully to maximise the contributions of nurses to the chronic care management.

Although this review aims to analyse the effectiveness of nurse-led clinics in the treatment of respiratory diseases, a prior look at the role of these interventions in the management of other chronic care diseases will provide an insight to the general contributory roles of nurses and will serve as a foundation for complete understanding of this state of the art intervention.

3.1 Nurse-led interventions in the management of diabetes

Numerous studies have evaluated the benefits and practicalities of nurse-led clinics in the long-term management of diabetes. The renal diabetic nurse specialist is described as an “essential player” in organising the management of, and to meet, all aspects of need of this group of patients (Marchant, 2002). An unintended benefit of a nurse-led clinic to reduce cardiovascular risk is improved glycaemic control, HbA1c (Woodward et al, 2005). In particular, nurse-led diabetic clinics have been shown to benefit specific ethnic groups. Matthias et al (1998) identified the needs of diabetic patients from minority ethnic groups, such as blacks and Asians and postulated that nurse-led clinics were of particular benefit in this patient group. As epidemiological data show that diabetes is most common in minority ethnic groups (Carter et al, 1996), the importance of these innovative interventions is further emphasised.

3.2 Nurse-led interventions in the management of cardiovascular disease

Care of patients with cardiovascular diseases is broad and involves many aspects, from risk factor management (non pharmacological interventions), primary and secondary prevention of clinical events, pharmacological therapy, surgical procedures, etc. Through a large well-designed randomised controlled trial in Scotland, Campbell et al (1998) showed that nurse-led clinics were practical to implement general practice and led to an significant increase in various aspects of the secondary prevention of coronary heart disease. Significant improvements were noted in aspirin management, blood pressure management, lipid profile management, diet and physical activity, regardless of the individual patient’s baseline cardio performance or status. However, surprisingly, there was no recorded improvement on smoking cessation, which would have been a beneficial intervention in most acute and chronic disease states, including respiratory diseases.

In addition to the apparent effectiveness of the nurse-led clinics in the long-term primary and secondary prevention of coronary heart disease, the optimal use of nurses in the care of these patients has been shown to be cost-effective in terms of quality adjusted life years (QALYs) (Raftery et al, 2005). In this large cost-effectiveness analysis, although the cost of the nurse-led clinic intervention was £136 higher per patient, the differences in other National Health Service (NHS) costs was not statistically significant. Furthermore, there were 28 more deaths in the non-intervention group leading to a gain, in the intervention group, in mean life-years per patient of 0.110 and of 0.124 QALYs.

3.3 Nurse-led interventions in rheumatology

The role of clinical specialist medical doctors in the care of their patients is unquestionable; however, the role of nurses in the therapy area of rheumatology (i.e. in patients with rheumatoid arthritis) is also well documented. Hill and colleagues (1994) clearly demonstrated the effectiveness, safety and acceptability of a nurse practitioner in a rheumatology outpatient clinic. Although this was a small study with a sample size that only included 70 patients, the statistical significance of the findings of this randomised controlled trial cannot be ignored. In patients managed in the Rheumatology Nurse Practitioner clinic, pain, morning stiffness, psychological status, patient management and satisfaction all improved significantly (p = 0.001; p = 0.028; p = 0.0005; p<0.0001; p<0.0001, respectively). It is worthy of note that these improvements were not mirrored by patients who were managed in the Consultant Rheumatologist clinic.

In addition, patient satisfaction is frequently higher in patients who are allocated to nurse care than those allocated to standard medical care (Hill, 1997). In yet another study by Dr Jackie Hill, a registered nurse at the Academic and Clinical Unit for Musculoskeletal Nursing in the Chapel Allerton Hospital in Leeds, the researchers concluded that a nurse-led clinic is effective and safe and is associated with additional benefits, such as greater symptom control and enhanced patient self-care, compared with standard outpatient care.

3.4 Nurse-led interventions in cancer care

The effectiveness of nurse-led care in different common cancer afflictions has been researched variously. An extensive review article by Loftus and Weston (2001) discussed the patient needs that could be met by nurses working in nurse-led clinics and highlighted the experience and skills of advanced nursing practice that make such innovative care a reality.

The types of nurse-led interventions are as varied as the different types of cancers for which they are used. These range from nurse-led telephone clinics in patients with malignant glioma (Sardell et al, 2001); nurse-led follow up in patients receiving therapy for breast cancer (Koinberg et al, 2004); and nurse-led screening programmes in Hong Kong Chinese women with cervical cancer (Twinn and Cheung, 1999).

In a randomised controlled trial in a specialist cancer hospital and three cancer units in southeastern England, Moore et al (2002) assessed the effectiveness of nurse-led follow-up in the management of patients with lung cancer. The findings of the study showed high levels (75%) of patient acceptability. This negates the possibility of patients’ reduced confidence in nurses’ ability and preference for standard medical doctor care. Clinical outcomes were also greatly improved as shown by less severe dyspnoea at three months (p=0.03), better scores for emotional functioning (p=0.03), and less peripheral neuropathy at 12 months (p=0.05).

3.5 Nurse-led interventions in the management of HIV infection

Using a rigorous model of comprehensive care nurse-led clinic in genitourinary medicine to compare nurse-led and doctor-led clinics at a central London medicine clinic, Miles and colleagues (2003) reported reliable and valid results to support the use of the nurse-led variety as an acceptable alternative to the existing doctor-led clinics. More specifically, the British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH) advocate the benefits that can be accrued from a nurse-led educational intervention in the care of patients with HIV infection (Poppa et al, 2003). A small pilot study that investigated the effects of a 6-month nurse-led educational programme reported that improved virological responses were seen in treatment-experienced patients (Alexander et al, 2001).

While a majority of the studies on nurse-led clinics in other chronic diseases can be broadly applied to nurse-led care in patients with respiratory diseases, differences in the nature of these diseases and the necessary care pathways mean that the extent to which these tested interventions can be applied to other therapy areas is, in actual fact, limited. Government policies that advocate the clinical and economic effectiveness of nurse-led interventions frequently pool together evidence from all therapeutic areas. Indeed, it can be hypothesised that, if nursing interventions are shown be practical alternatives for medical care in complex diseases with poor prognoses, such as cancer, HIV and coronary heart diseases, care of patients with respiratory diseases which generally have better prognoses should be easily, effectively and safely undertaken by qualified and well-trained nurses.

Nevertheless, these findings of the effectiveness of nurse-led interventions in the numerous chronic diseases explored in previous sections, should be applied to the different patient population with respiratory diseases. As much as possible, research findings from similar patient groups should be applied in clinical practice in order to ensure that evidence-based practice in this case is relevant.

4. Government policies influencing the establishment of nurse-led clinics

Government health policies in the United Kingdom actively support the extension of nurses’ skills into areas such as nurse prescribing and the development of nurse practitioner posts (NHS Plan 2000; Department of Health). Government initiatives that that strive to reduce consultation waiting times and optimise the use of medical practitioners indirectly support the establishment of nurse-led clinics. The Government has endorsed the implementation of nurse-led clinics as a means of increasing access to specialist health care and treatment more quickly and also as an effective way to manage chronic conditions (Hatchett, 2003).

In the Department of Health (1999) document, ‘Making a difference’, government plans for strengthening nursing contribution to health care is presented. The Government has launched an ambitious programme of measures to improve the National Health Service and the health of the public, and the role of the nursing profession in this initiative cannot be overemphasised.

The key nurse-related points of the document are outlined below:

• To extend the roles of nurses, midwives and health visitors to make better use of their knowledge an skills – including making it easier for them to prescribe
• To modernise the roles of school nurses and health visitors in supporting the new health strategy and other policies
• To see more nurse-led primary care services to improve accessibility and responsiveness

The document highlights numerous nurse-led initiatives that have been effectively implemented all around the United Kingdom. A nurse-led minor injury service in rural Cornwall has provided patients with a number of benefits: easier accessibility, reduced waiting times, reduced need for on-site medical; attendance, increased patient satisfaction and reduced need for transfers to local Accident and Emergency departments. Similarly, a nurse-led rapid response team in Peterborough responds to acute crisis cases and allows patients to be nursed at home. Evaluation has shown that 71% of patients referred to this ‘hospital at home’ service would have been admitted to hospital if the service did not exist. Other effective live nurse-led services include a nurse-led rheumatology service in Merseyside and a nurse-led intermediate care unit in Liverpool.

Furthermore, several nurse interventions are advocated in the document for contributing to the management of cardiovascular disease. Several of these are also applicable to respiratory diseases; these include:

• Smoking cessation clinics using national smoking cessation guidelines
• Healthy lifestyle clinics in collaboration with other health professionals to address factors such as diet, nutrition and exercise, thus improving overall health
• Care for patients with congestive cardiac failure under ‘home-based’ initiatives
• Nurse-led chest pain clinics or risk factor screening and reduction clinics
• Nurse-led blood pressure clinics to identify and help manage blood pressure disorders and medication adherence

5. Review objectives

The objectives of this review are:

• To briefly summarise various studies on effectiveness and cost-effectiveness of nurse-led interventions in common respiratory diseases
• To critically appraise the methods employed by these studies
• To evaluate, interpret, and where possible, compare the findings of the various studies
• To explore the applicability and generalisability of the results to practice in the appropriate patient population
• To make suggestions for future studies in this area.

METHODS

Literature search

A search of two major databases, MEDLINE and EMBASE, was conducted to identify articles published from 1990 through 2008. Search terms that were used include nurse, nurse-led clinic, nurse-led interventions, respiratory diseases, asthma, chronic obstructive pulmonary disease, bronchiectasis, tuberculosis, cystic fibrosis, cost-effectiveness analysis, cost-benefit analysis, and economics. A secondary search of the reference lists was then conducted to identify relevant articles, editorials, and other unoriginal reports that may have been missed in the primary search.

Some studies were excluded based on the following criteria:

• They were not conducted in patient populations with respiratory diseases
• Independent nurse-led interventions were not investigated
• The study populations being investigated were mixed in terms of diagnosis, which would affect the integrity of the study findings for respiratory diseases
• The methodology and/ or statistical analysis methods were not clearly elucidated

6. Nurse-led clinics in the management of respiratory diseases: a review of the evidence

The role of the specialist respiratory nurse has evolved since the early 1980’s with the support of the Royal College of Physicians (RCP 1981). The possible complexity of respiratory patients’ regimens necessitates support with various aspects of their care plans, such as:

• Supervising nebuliser and inhaler techniques
• Monitoring progress, i.e. by periodical assessment of lung function and exercise capacity
• Education on the specific disorder, medications, potential adverse events, etc
• Counselling and education on positive lifestyle, or non-pharmacological, changes
• Adherence support and monitoring

The role has developed further with nurses providing nurse-led clinics in chronic obstructive pulmonary disease (COPD) and asthma along with nurses providing early supportive discharge and ’hospital at home’ for patients with COPD (French et al, 2003). Some schools of thought argue that nurse-led clinics would culminate in the neglect of the more traditional nursing roles, as nurses focus on a more medical-focused aspect of patient care. However, research in other therapy areas, such as rheumatology (Hill et al, 1994) and mental health (Reynolds et al, 2000) shows that nurses can effectively combine the medical role with the traditional nursing approach. Nursing care strives to provide a holistic approach to care through practical management of disability, education and counselling and referral to other health care services as required (Rafferty and Elborn 2002).

6.1 Bronchiectasis

Nurse-led clinics have been evaluated, compared with regular doctor-led clinics, in a single randomised controlled trial in patients with bronchiectasis, a respiratory condition in which there is widening of the bronchi or their branches (Sharples et al, 2002). The study was a randomised controlled crossover trial including 80 patients in a bronchiectasis outpatient clinic. Patients received 1 year of nurse led care and 1 year of doctor led care in random order, and were followed up for 2 years. Various outcome indicators were used in the comparison, including lung function and exercise capacity, infective exacerbations, hospital admissions, quality of life and cost-effectiveness of the intervention. The results of this study are illustrated in Table 1 below.

Table 1: Nurse-led and doctor-led care in care of patients with bronchiectasis (Sharples et al, 2002)

Measurement outcome	Nurse-led	Doctor-led	Mean difference (95% CI)	p-value
Forced expiratory volume in one second (FEV1) (%)	1.87	1.86	0.01 (-0.04 to 0.06)	-
Forced expiratory volume in one second (FEV1) (L)	69.7	69.5	0.2 (-1.6 to 2.0)	-
Forced vital capacity (FVC) (%)	87.6	87.6	-0.02 (-1.5 to 1.4)	-
12 minute walk distance (m)	765	746	18 (-13 to 48)	-
Infective exacerbations (patient years of follow up)	262 (79.4)	238 (77.8)	-	0.34
Hospital admissions attributable to patient’s bronchiectasis	43	23	-	0.22

As the table above clearly shows, there was no statistical difference in FEV1/FVC percent predicted or distance walked between nurse led and doctor led care in the

two treatment periods. Furthermore, 262 episodes of infective exacerbations were recorded by patients in the nurse practitioner-led care group in 79.4 patient years of follow up, compared with 238 in 77.8 years in the doctor-led care group. Thus, nurse practitioner-led care is associated with a relative rate of exacerbations of 1.09 (95% CI 0.91 to 1.30), p=0.34.

Using the St Georges Respiratory Disease questionnaire to assess differences in health-related quality of life between the two groups, there was no statistically significant differences in each of the scores for Symptoms, Control, Impact or total score. Also, the study showed that nurse-led care resulted in significantly higher costs per patient compared with doctor-led care; this was largely due to the difference in the number of hospital admissions and intravenous and nebulised antibiotic costs. The

authors concluded that nurse practitioner-led care for stable patients within a chronic chest clinic is safe and is as effective as doctor led care, but may use more resources.

This study has several potential limitations which could invalidate the findings. As the study relied on patient report to record the prescriptions issued by general practitioners, these may have been underestimated and could grossly affect the cost analysis. Conversely, the nurse practitioner was required to record prescriptions and tests issued at the clinic, and thus these records are probably more reliable and she would be more likely to have ensured that patients left with supplies of routine treatment. Another possible drawback of this study is the use of a crossover design in the methodology. Unless a wash-out period is incorporated in the study design, there is the possibility of a carryover effect with crossover study designs, with the danger that the effects of the earlier treatment is falsely attributed to the final experimental

treatment. In this study, there was no allowance for a washout period and thus this could affect the reliability and validity of the study results. This order and time effect needs to be checked for within the analyses but it can rarely be excluded as potential biasing factors (Pocock 1983). However, as recruited patients received the interventions in random order, this may negate the carryover effect.

Despite the possible limitations of the study that could potentially hinder its applicability in practice, the findings support the implementation of a nurse-led clinic in patients with chronic cases of bronchiectasis as an alternative to the standard rigid medical care.

6.2 Asthma

Similar to the findings in the study by Sharples and colleagues (2002) in patients with bronchiectasis, Nathan et al (2006) more recently compared the effect of follow-up by a nurse specialist with follow-up by a respiratory doctor following an acute asthma admission. In a single centre prospective randomised controlled trial, 154 patients admitted with acute asthma were randomly assigned to receive an initial 30-min follow-up clinic appointment within 2 weeks of hospital discharge with either a specialist nurse or respiratory doctor. The intervention comprised a medical review, patient education, and a self-management asthma plan. Further follow-up was then arranged as was deemed appropriate by the corresponding doctor or nurse, and all patients were asked to attend a 6-month appointment.

Despite hospital outpatient follow-up, there was a significant proportion of patients in both groups who had exacerbations. However, there was no statistically significant difference between the two groups (Table 2). In the same manner, there was no statistically significant difference in quality of life assessed with two different validated questionnaires, the Asthma Questionnaire and the St George Respiratory Questionnaire. Mean change in peak flow at 6 months was similar between the two groups, probably indicating equivalence of the two tested interventions. Nathan et al (2006) concluded that follow-up care by a nurse specialist for patients admitted with acute asthma can be delivered equivocally with comparable safety and effectiveness to that traditionally provided by a doctor practitioner.

Table 2: Nurse-led and doctor-led care in follow-up care of patients admitted with acute asthma (Nathan et al, 2006)

Measurement outcome	Nurse-led	Doctor-led	Odds ratio (95% CI)	Mean difference (95% CI)	p-value
Change in peak flow	-	-		1.39 (-3.84 to 6.63)	0.122
Infective exacerbations (%)	45.6	49.2	0.86 (0.44 to 1.71)	-	0.674
Quality of life	87.6	87.6		-0.02 (-1.5 to 1.4)	-
Asthma Questionnaire	-	-		0.78 (-0.64 to 2.19)	0.285
St George Respiratory Questionnaire	-	-		1.08 (5.05 to 7.21)	0.891

The possible limitations associated with this study is the large amount of missing data for some outcomes, especially peak flow and quality of life measures, which could be a major source of bias. On investigation, it was found that the majority of missing data was from younger patients; thus this could alter the validity of the study results and these findings should probably be applied cautiously in the younger patient population. Unfortunately, this is the population in which asthma is most prevalent. All nurses and doctors included in the study followed national and international guidelines; thus the study could be largely representative of clinical practice in reality.

Another study evaluated the benefits of specialist nurse education following accident and emergency attendance for acute asthma (Levy et al, 2000). In this prospective randomised controlled trial in 211 adult patients with asthma, participants were offered three 6-weekly outpatient appointments with a specialist asthma nurse for a structured asthma consultation, after attendance at the accident and emergency department. Findings of the study led the researchers to conclude that hospital-based specialist nurses reduced asthma morbidity by improving patient self-management behaviour in acute attacks leading to reduced symptoms, improved lung function, less time off work and fewer consultations with health professionals.

Dickinson et al (1997) demonstrated the benefits of a targeted nurse-run asthma clinic care in a seven-partner general practice in a mixed urban and rural area of North Lincolnshire in the east of England. One hundred and seventy three patients with asthma completed 12 months follow-up in a nurse-run asthma clinic. A longitudinal comparison was conducted in terms of: changes in morbidity index category, inhaler technique score, knowledge score, use of inhaled steroids, use of salmeterol, method of administration of beta(2)-agonist medication and frequent use of peak flow meters.

The number of the patients with high morbidity fell drastically from 123 (71.1%) at the initial consultation to 14 (8.1%) at the 12-month review. Those with full marks on inhaler technique rose significantly from 28 (16.2%) to 142 (82.1%), and with patients with full marks on asthma knowledge also increased from 7 (4.0%) to 98 (56.6%). The numbers of patients using inhaled steroids and salmeterol rose from 127 (73.4%) to 171 (98.9%) and from 5 (2.9%) to 35 (20.2%), respectively. Regular use of peak flow meters in 157 subjects aged 5 years and over rose from 43 (27.4%) to 116 (73.9%). These findings are quite outstanding and the data clearly demonstrate the benefits of targeted proactive nurse-run asthma care in terms of reduced morbidity for patients.

In extending the results of these clinical trials to real life clinical practice, care should be taken to consider the patient populations that have been included in the study protocol and the study designs, e.g. duration of follow up etc. Also, individual patient characteristics should always be considered as idiosyncrasies could always alter the implications of clinical studies in individual patients.

6.3 Chronic obstructive pulmonary disease

There is arguably more research in the roles of nurses in the care of patients with this debilitating disease than any other respiratory affliction, probably because out of one in four hospital admissions that are for respiratory diseases, chronic obstructive pulmonary disease is implicated in at least half of these cases (Pilling et al, 2003). Nurses have a major impact on the management of patients with COPD, and should be actively involved in care pathways to improve patient and staff satisfaction (Marley, 2000). Dramatic improvements have been demonstrated in COPD patient care in nurse-led clinics (Stothard and Brewer, 2001).

The rise in the rate of hospital admissions for patients with COPD, coupled with the limited physician consultation hours, has led to the development of nurse-led care for this group of vulnerable patients. In particular, nurse-led home care for patients with COPD is widely advocated by experts, and has been shown to be cost-effective by reducing the need for hospital care (Gibbons et al, 2001). Similarly, a community based nurse-led scheme, implemented in the Chest Clinic, Derriford Hospital, in Plymouth, has resulted in early identification of problems, thus leading to timely interventions and reducing the number of consequential hospital admissions (Barnett, 2003).

Pilling and colleagues explored the Wigan model that is in place in the Royal Albert Edward Infirmary in Wigan. This service, which was established in 1999, is a specialist nurse-led service with referrals from general practitioners, the accident and emergency department, and the medical assessment unit. The role of nurses herein includes:

• Clinical and physical investigations
• Treatment decisions
• Discharge decisions
• Home visits

A recent survey in this institution showed that a majority of patients were happy with the service; in addition, most patients believe that this nurse-led service led to a beneficial improvement in symptoms and the occurrence of acute episodes.

In The Netherlands, Vrijhoef and colleagues (2007) assessed the effects of patients outcomes when care of patients with stable COPD were transferred from the traditional respiratory care physician to the respiratory nurse. In this randomised controlled trial, 187 eligible patients were randomised to receive nursing care (93 patients) or to receive the usual care, i.e. from the physician (87 patients) and were followed up for 9 months. The endpoint outcomes for the study were: clinical parameters, health status, self-care behaviour (including knowledge), patient satisfaction, and consultations with key care providers.

At the end of the follow-up period, the respiratory nurse (3.1, standard deviation: 0.7) reported more consultations than the physician (2.0, standard deviation: 0.9). With a p-value of 0.007, this difference is statistically significant. This is probably inherent in the nature of the nursing profession; nurses are more patient-focused in their practice and tend to be more attentive to their patients’ needs and problems. In addition, patients cared for by the nurse showed worsening in mean forced vital capacity and no difference in self-assessed condition, while improvements were found for subjective knowledge (p = 0.017), self-assessed rate for coping with COPD (p = 0.045), overall satisfaction (p = 0.003), and the majority of individual indicators of satisfaction. With these encouraging results, Vrijhoef et al (2007) concluded that the assignment of care for outpatients with stable COPD to the respiratory nurse, working under a protocol, is justified in terms of patient outcomes.

In COPD, simple nurse interventions that don’t necessarily involve complete autonomy have also been shown to lead to vast improvements in patient outcomes. Wong et al (2005) showed how a nurse-initiated telephone follow-up programme could increase patients’ self-efficacy in managing dyspnoea and decrease the utilisation of health care services. In a randomised controlled trial 60 participants with COPD were equally randomised to telephone follow-up and control. The validated Chinese self-efficacy scale was used to assess self-efficacy. Measures of health included the number of visits to the accident and emergency department, hospitalisations and unscheduled visits to the physician.

The results of the study showed that self-efficacy scores improved significantly (p=0.009) in patients who were followed up by telephone compared with those patients in the control group who received usual care. Accordingly, Wong et al (2005) concluded that nurse-initiated telephone follow up was effective in increasing self-efficacy in managing dyspnoea. The fear of activity-induced dyspnoea in COPD patients can be severely debilitating leading to reduced confidence in the ability to perform everyday activities; thus interventions to alleviate or reduce this symptom would be pivotal in long-term management of this group of patients. The homogeneity and small sample size of the study is a potential limitation and the study needs to be replicated in other settings in order to strengthen its external validity.

6.4 Tuberculosis

Tuberculosis is an infectious disease that is commonly characterised by the formation of nodular lesions (otherwise known as tubercles) in the tissues. Although this disease state is associated with myriad symptoms, pulmonary tuberculosis, which afflicts the respiratory system, is arguably the most common. Nurses have a very important contributory role in the care of patients with tuberculosis. In a qualitative ethnographic study in patients with multi-drug resistant tuberculosis, Palacios et al (2003) outlined the essential roles of members of the nursing profession in the community-based treatment program. These include (Palacios et al, 2003):

• Patient identification
• Patient assessment and evaluation prior to, and during, therapy
• Managing emergency situations, including triage procedures
• Educational activities for patients and other health care professionals involved in the care of multi-drug resistant tuberculosis
• Co-ordination activities, including, but not limited to, overseeing health care workers and effective communication with team members

6.5 Cystic fibrosis

Specialist nurses have been identified as being integral to the multidisciplinary management of cystic fibrosis (Kerem et al, 2005), a hereditary disease that affects the cells of the exocrine glands and that is commonly associated with severe respiratory infection complications. The management of this debilitating condition, as expected, is complex and involves multiple health professionals. Specialist nurses, in particular, are a major source of care and support for patients and their family members and friends.

Recently, using a qualitative study design of interviews, Savage (2007) examined patients’ and parents’ perspectives on how specialist nurses help in the management of cystic fibrosis. Specialist nurses were described as making a particular contribution to helping children and parents manage challenges and difficulties that arose in their daily lives. Specifically, they were more accessible, formed personal relationships that were considered beneficial to the patient and family, had ‘expert’ knowledge and attended to emotional and social care of children and their parents, as well as tackling the clinical aspects of care.

While there is a dearth of literature on actual nurse-led interventions in the management of patients who are affected by this disease state, the role of the cystic fibrosis nurse specialist is well documented (Dyer, 1997):

• Diagnosis
• First intra venous (IV) course
• Starting school, college, or work
• Home care, e.g. IV and enteral drug administration
• Transition phase, i.e. from paediatric care to adult care
• Genetic counselling
• Fertility issues
• Heartlung transplant
• Oxygen dependency
• Ventilatory support feeding
• Terminal care
• Bereavement follow up

7. Conclusions

In keeping with the Government policy to reduce patient waiting times and optimise the use of health care professionals’ consultation times, the implementation of nurse-led clinics in the follow up of patients with chronic disease conditions in currently generating a lot of interest in the health care sector. Although the role of the medical practitioner cannot be replaced, the emerging contributory role of the nursing profession cannot be underestimated. In addition to the well-documented beneficial multidisciplinary approach to health care provision, nurses are increasingly taking on independent and autonomous roles with resulting positive patient and health care sector outcomes.

Comparing the evidence on the nurse-led interventions in respiratory care and other chronic diseases, such as cancer care, cardiovascular disease and rheumatology, similar results are reported showing the feasibility and practicality of nurse-led interventions in these patient populations. The intrinsic requirements of long-term maintenance in patients with respiratory diseases, including correct inhaler techniques, adherence, self peak flow measurements, and lifestyle interventions, make it a logical opportunity for nurses to contribute to the improvement of patient outcomes with minimal regular input from the medical practitioner.

Health care policy makers and decision makers need to take these findings into consideration when planning the resource allocation of the often-limited health acre resources. Logically, nurses should take on as much of patient care as they are trained to carry out. Nursing care represents a cost-effective alternative to the standard medical care without compromising the quality of patient care. In addition, as showed by a number of the reviewed studies, nurse-led clinics are also associated with additional benefits, including more personal and individualised care, increased patient and family satisfaction and, in some cases, improved patient outcomes and survival.

In conclusion, the introduction of nurse-led clinics in the management of chronic respiratory diseases from asthma, COPD, and bronchiectasis, should be actively advocated as a means to improve patient care and outcomes and consequently save costs. As with any other new health care service, auditable variables should be established to help evaluate the clinic and strive towards constant improvement.

Critical Self Appraisal

By working on this project, I have been able to conduct a comprehensive literature review, and have a better knowledge of the relevant background field extending from the practical issues in nurse-led clinics, respiratory diseases, chronic care management, and autonomous nursing practice.

During the course of this assignment, I have acquired a wide range of knowledge and skills. Most importantly, the benefit of good time management is evident to me; I was able to precisely organise the various stages of the project to achieve good outcomes, while saving valuable time.

These are all important research skills, which will surely prove invaluable to me as I embark on future clinical investigations. The knowledge I have gained, and some of the skills especially the analytical skills will be useful even in everyday practice as I strive to provide the best evidence-based interventions in patient care.

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