VOL: 97, ISSUE: 26, PAGE NO: 59
Gary Porter-Jones, BSc, RGN, DipN, is a respiratory nurse specialist, department of respiratory medicine, Bangor General HospitalGary Porter-Jones, BSc, RGN, DipN, is a respiratory nurse specialist, department of respiratory medicine, Bangor General Hospital
The developing role of nurses and the environment in which we work places increasing demands on us. Challenges continually arise to test our skills.
One such scenario for me was being asked to lead the development of a local tuberculosis (TB) policy.
North Wales is a geographically large, mainly rural area served by three NHS trusts administered by the same health authority. The health authority's consultant in public health medicine responded to the need to standardise TB treatment and management across North Wales by commissioning a local policy in keeping with recommendations made by The Interdepartmental Working Group on Tuberculosis (1996) and the British Thoracic Society (2000).
The key issues that need to be covered by a local policy, as identified in these documents, are:
- Aims and objectives;
- Contact tracing;
- Immunisation policy;
- Identification of cases;
- Occupational health;
- Prisons and other institutions;
- Education and training;
- Monitoring and audit;
- Case management;
- Health education;
- Outcome monitoring;
- Provision of adequate resources;
- Hospital infection control;
- Research and audit;
- Screening of vulnerable groups;
- Management of outbreaks.
Respiratory nurses were seen as being in a prime position to lead this development and were asked to take on this responsibility.
As a respiratory nurse in north-west Wales, I relied on the expertise of colleagues in North East Wales NHS Trust and Conwy and Denbighshire NHS Trust. A number of meetings were held in which working practices were scrutinised. These were compared with the direction offered by the British Thoracic Society (1994) in its guidelines on TB control and prevention and modelled on this approach (at the time, the society's 2000 guidelines had not been published). Additional guidance was taken from Immunisation Against Infectious Diseases (Salisbury and Begg, 1996).
It was encouraging to note that the vast majority of working practices reflected the recommendations of the British Thoracic Society, and those that did not had been adapted to address the specific needs of this rural area. The BTS guidelines were being used as intended: with the flexibility to be adapted to individual need.
Documentation was an area in which there was little standardisation.
All three trusts used different forms to detail and screen the contacts of TB index cases, immigrants from high-risk countries and people who had visited high-risk countries. Different methods of data collection and storage were also being used, with one area using an electronic database and the others relying on paper files for all information.
The implications of patient group directions and patient-specific directions, formerly known as group protocols (National Assembly for Wales, 2000), in supplying and administering medicines were also central to the discussions as some differences in approach were identified.
Within six months of the first meeting the first draft of the policy had been completed and sent to all key personnel in TB management for comment. This group included respiratory physicians, paediatricians, paediatric nurses, general physicians, GPs, microbiologists, community nurses and health visitors. The feedback was positive and supportive.
The draft policy addressed all the relevant issues that were pertinent to the whole of North Wales. It gave clear guidance on managing and treating TB and which staff should be involved. After minor amendments the policy was printed, bound and ready for distribution.
Respiratory nurses were responsible for developing the policy, from conception through to typing and distribution. It was a challenging but valuable exercise and one that put us firmly in the driving seat of policy-making.
The lessons we learnt were that policies should be formally reviewed annually to ensure that they remain relevant and based on current evidence, and that this review process should begin almost as soon as the policy has been distributed so that there is enough time to identify and address any new issues. Not only should the policy be widely distributed but it should also be advertised well. People can implement it only if they know about it.
New BTS guidelines, which were published in November last year, made a number of changes to the management of TB in the UK. These will be included in the policy when it is reviewed.
Policies and guidelines are fundamental to best practice. Their existence allows for the audit of practices and benchmarking. Further improvements in practice can result from positive attitudes to this evaluation process.