Nurse-led Clinics in Respiratory Care: a Literature Review

Nurse-led Clinics in Respiratory C are a Literature ReviewINTRODUCTION1. What is a hold in-led clinic?As the coined term suggests, a keep-led clinic is a wellness trade focalise in which fellates are involved in high level specialist procedures and assessments. In much(prenominal) centres, sucks are the deprecative decision makers, being involved in patient reverence at the micro-, meso-, and macro-levels. While the office staff of the physician in the provision of wellness precaution is undisput equal to(p), the deity-like circumstance that medical practitioners typically fox 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 an some other(prenominal) hand, defined by the Oxford Medical Dictionary as health care professionals that are practised and experienced in nursing matters and entrusted with t he care of the sick and the carrying out of medical and surgical routines, are better placed to provide this crucial follow-up, especially in the care of patients with degenerative diseases.According to Hatchett (2003), a think of-led clinic is a clinic in which obliges have their own patient suit 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 Hatchetts own words, the roles which nurses adopt in these revolutionary settings lavatory be broadly classified as follows (Hatchett, 2003)EducationPsychological supportPatient monitorThe initiation of nurse-led initiatives probably owes its origins to the rise in nursing specialties in the building blocked 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 supporter delivery and the indite 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 ii-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 asse ssments and evaluations, and health counselling. entirely 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 fusion 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 forethought of continuing disease which build upon skills such as counselling, teaching and health promotion which are key to contemporary nursing practice, as well as newfoundly 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 do a reality if adequate training and education, as well as put inive leadership are in pl ace (Wiles et al, 2001).2. The general roles of nurses in chronic care directionThe 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) fix up diagnostic interventions just like a medical practitioner would, the present-day nurse is able to ask for laboratory or clinical diagnostic tests to promote the process of diagnosis. Furthermore, a well-trained nurse will also be able to read and interpret laboratory results effectivelyMake and receive referrals directly charm 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 pa tients for specified conditions, within agreed protocols in order to make the best subroutine of the often limited hospital resources, a nurse should have the power to recommend patients for hospital admission and concomitant dischargeManage patient case loads in nurse-led clinics, nurses are also liable 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 prudence 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 defribillationPerform minor surgery and outpatient procedures especially in stain clinics. While nurses a re 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 professionalTake a lead in the way local health services are organised and in the way they are runNurses 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 line of reasoning 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 c ase 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 focusing 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 revaluation the evidence to support these modern 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 evidenceThe 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 ma ke 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 utter of the art intervention.3.1 Nurse-led interventions in the management of diabetesNumerous 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 bump 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 diseaseCare of patients with cardiovascular diseases is broad and involves many aspects, from risk factor management (non pharmacologic interventions), primary and secondary prevention of clinical events, pharmacological therapy, surgical procedures, etc. Through a large well-designed haphazardized controlled trial in Scotland, Campbell et al (1998) showed that nurse-led clinics were practical to implement general practice and led to an strong increase in various aspects of the secondary prevention of coronary heart disease. Significant improvements were noted in aspirin management, blood pressure management, lipid compose management, diet and physical activity, regardless of the individual patients baseline cardio performance or status. However, surprisingly, thither was no recorded improvement on locoweed 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-effe ctive in terms of role adjusted bread and butter 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 strong. 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 rheumatologyThe 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 nevertheless 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 pIn addition, patient satisfaction is often 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 re awaiters concluded that a nurse-led clinic is effective and safe and is associated with additional benefits, such as greater omen control and enhanced patient self-care, compared with standard outpatient care.3.4 Nurse-led interventions in crab louse careThe effectiveness of nurse-led care in different common cancer afflictions has been researched variousl y. 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 possibi lity of patients cut back confidence in nurses ability and preference for standard medical doctor care. Clinical outcomes were also greatly improved as shown by less repelling 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 contagious diseaseUsing 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 pick 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 contagious disease (Poppa et al, 2003). A sma ll 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 mass 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 convoluted diseases with poor prognoses, such as cancer, HIV and coronary heart diseases, care of patients with respiratory diseases which generally have be tter 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 a good deal 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 creation of nurse-led clinicsGovernment 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 Governmen t 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 belowTo 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 prescribeTo modernise the roles of instruct nurses and health visitors in supporting the new health strategy and other policiesTo see more nurse-led primary care services to improve accessibility and resp onsivenessThe 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 fatality 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. Sev eral of these are also applicable to respiratory diseases these includeSmoking cessation clinics using national smoking cessation guidelinesHealthy lifestyle clinics in collaboration with other health professionals to address factors such as diet, nutrition and exercise, thus improving overall healthCare for patients with congestive cardiac failure under home-based initiativesNurse-led chest pain clinics or risk factor screening and reduction clinicsNurse-led blood pressure clinics to identify and help manage blood pressure disorders and medication adherence5. Review objectivesThe objectives of this review areTo briefly summarise various studies on effectiveness and cost-effectiveness of nurse-led interventions in common respiratory diseasesTo critically appraise the methods employed by these studiesTo evaluate, interpret, and where possible, compare the findings of the various studiesTo explore the applicability and generalisability of the results to practice in the appropriate pat ient populationTo make suggestions for future studies in this area.METHODSLiterature searchA 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 whitethorn have been missed in the primary search.Some studies were excluded based on the followers criteriaThey were not conducted in patient populations with respiratory diseasesIndependent nurse-led interventions were not investigatedThe study populations being investigated were mixed in terms of diagnosis, which would affect the integrity of the study findings for resp iratory diseasesThe methodology and/ or statistical analysis methods were not clearly elucidated6. Nurse-led clinics in the management of respiratory diseases a review of the evidenceThe role of the specialist respiratory nurse has evolved since the early 1980s 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 asSupervising nebuliser and inhalator techniquesMonitoring progress, i.e. by periodical assessment of lung function and exercise capacityEducation on the specific disorder, medications, potential adverse events, etcCounselling and education on positive lifestyle, or non-pharmacological, changesAdherence support and monitoringThe 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 BronchiectasisNurse-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 outcomeNurse-ledDoctor-ledMean difference(95% CI)p-valueForced expiratory volume in one second (FEV1) (%)1.871.860.01 (-0.04 to 0.06)Forced expiratory volume in one second (FEV1) (L)69.769.50.2 (-1.6 to 2.0)Forced vital capacity (FVC) (%)87.687.6-0.02 (-1.5 to 1.4)12 minute walk surmount (m)76574618 (-13 to 48)Infective exacerbations (patient years of follow up)262 (79.4)238 (77.8)0.34Hospital admissions attributable to patients bronchi ectasis43230.22As 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 thetwo 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. Theauthors 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 integrate in the study design, there is the possibility of a carryover effect with crossover study designs, with the danger that the e ffects of the earlier treatment is falsely attributed to the final observationaltreatment. 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 AsthmaSimilar 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 docto r 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 every 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 pose 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 harmonize 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. M ean change in bloom of youth 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 outcomeNurse-ledDoctor-ledOdds ratio(95% CI)Mean difference(95% CI)p-valueChange in thrill flow1.39 (-3.84 to 6.63)0.122Infective exacerbations (%)45.649.20.86 (0.44 to 1.71)0.674Quality of life87.687.6-0.02 (-1.5 to 1.4)Asthma Questionnaire0.78 (-0.64 to 2.19)0.285St George Respiratory Questionnaire1.08 (5.05 to 7.21)0.891The possible limitations associated with this study is the large amount of missing data for some outcomes, especially peak flow and quality of life