Jessica Greenwood BSc (Hons), Dip (Nurs), RGN.
Clinical Nurse Specialist for Urological Cancers, Chelsea and Westminster Hospital NHS Trust, LondonUp to 50% of men develop benign prostatic hyperplasia (BPH) by the age of 60, with incidence increasing to 80% by the time men reach the age of 80 (Kirby, 2003). The clinical manifestations of BPH are known as lower urinary tract symptoms (LUTS) and they affect 40-50% of men over the age of 70 (Abrams, 1994; Kirby and McConnell, 1999).
Up to 50% of men develop benign prostatic hyperplasia (BPH) by the age of 60, with incidence increasing to 80% by the time men reach the age of 80 (Kirby, 2003). The clinical manifestations of BPH are known as lower urinary tract symptoms (LUTS) and they affect 40-50% of men over the age of 70 (Abrams, 1994; Kirby and McConnell, 1999).
Prostate cancer is the second most common cancer afflicting men - behind lung cancer - and is expected to overtake lung cancer by 2020 (Kirby et al, 2001). Collectively, disorders of the prostate are a major source of discomfort and disease in middle-aged and elderly men.
In 2001, there were more than four million men over the age of 65 in the UK (National Statistics, 2001), with average life expectancy now put at around 80 years. Estimates suggest that the UK population will increase by 60% by 2020 (Brody, 1985).
This increasingly ageing population (Garraway et al, 1991; Chute et al, 1993), combined with a greater public awareness and media attention on men's health and effective treatments, is likely to result in more men presenting with symptoms related to prostatic disorders.
Men with LUTS present with symptoms of urinary storage and/or voiding (Box 1). Although voiding symptoms are more common, storage symptoms are reported to be more aggravating and have a greater impact on a patient's quality of life (Box 2) (Peters et al, 1997; Scarpa, 2001).
LUTS are rarely life-threatening (Hirst et al, 2000; Scarpa, 2001) but in a few men, if left untreated, they can lead to more serious conditions such as acute urinary retention, urinary tract infections, bladder stones and bladder decompensation (Anderson et al, 2001).
The importance of assessment
Traditionally, the assessment of men with LUTS has been the domain of the urologist. However, in recent years this has changed. Access to 'office-based' diagnostic aids - for instance, portable bladder scanners - and an increased understanding of which tests are important and which are not has increased the number of men being managed either in primary or shared-care settings (Kirby, 2003).
Over the past 20 years there has also been a dramatic change in our approach to the treatment of LUTS and BPH. Previously, the emphasis of treatment was on relieving bladder outflow obstruction with surgery, such as transurethral resection of the prostate (McNicholas, 2002). But recently this emphasis has been changing. Surgery is still indicated for men with complications such as renal impairment, or in those where pharmacotherapy fails. However, in men with uncomplicated LUTS (which constitute the vast majority), the priority of treatment is to relieve bothersome symptoms (Hirst et al, 2000).
This is achieved with a variety of lifestyle and behavioural interventions used either as primary treatment strategies or to complement safe and effective pharmacotherapies. For men whose symptoms do not bother them, a conservative approach such as watchful waiting/active monitoring is safe and effective (McNicholas, 2002). The most appropriate management strategy depends on patient-reported symptoms, their impact on quality of life, urinary flow rates, postvoid residual volumes, and the patient's overall general health.
When assessing men with LUTS, symptom severity should be categorised, and this is best achieved through taking a careful history and using a validated symptoms score, such as the AUA-IPSS (American Urological Association-International Prostate Symptom Score), which has been proven to provide valuable, reliable and reproducible symptom evaluation data (Barry et al, 1992; Wennberg, 1995). Enough time should be allowed for the patient to freely express the degree to which the symptoms affect his quality of life or that of his partner.
This, along with the results of simple investigations, provides the assessor and the patient with a framework around which to make management decisions. These are based on balancing symptom severity and distress against the benefits, risks and side-effects of proposed interventions (Neal et al, 1997).
Patients with mild to moderate LUTS may find relief from their symptoms by making behavioural and lifestyle modifications such as avoiding caffeine and alcohol, fluid management, double voiding and bladder retraining (Greenwood and Emberton, 2002).
The National Institute for Clinical Excellence's guidelines (2001) on referral practice encourage reassurance, fluid management, caffeine avoidance and preventing constipation before starting medical therapy or referring from primary to secondary care. This information is commonly provided by urology specialist nurses, who see patients in dedicated specialist clinics.
A number of studies are currently under way to explore the effects of giving patients lifestyle advice in more detail (Box 3).
Cultural influences also need to be considered, since they may impact on how much patients report certain symptoms. A patient's ethnic origin, for example, may determine how they will perceive certain types of illness and how they may feel about reporting symptoms to a health-care professional (Hirst et al, 2000).
It takes time to carry out an effective, comprehensive and holistic assessment of men with LUTS, and for a full open dialogue to be exchanged between the assessor and patient. Treatment decisions - whether watchful waiting, a trial of behavioural and lifestyle modifications, pharmacotherapy or surgery - should be made jointly by the health-care professional and the patient (Hirst et al, 2000). As well as improving compliance, such patient involvement may also improve their overall satisfaction with the service they receive.
The Scope of Professional Practice (UKCC, 1992, now the Nursing and Midwifery Council) liberated nursing practice from its previous rules and limitations to enable nurses to become more responsive in meeting patient needs (Gidlow and Roodhouse, 1998).
This facilitated the development of nurse-led clinics, where the primary focus is to meet patients' perceived unmet needs, improve the quality of services and solve actual or potential patient problems (Loftus and Weston, 2001). Nurses are capable of achieving quality in health care through continuity and the provision of direct patient care, education and time.
Furthermore, a more holistic approach to patient assessment and care can be provided by combining the communication skills and the physical, psychological, social, emotional and spiritual assessment skills inherent in nursing with acquired medical knowledge and competence in technical or diagnostic skills.
Loftus and Weston (2001) concluded that there was a consensus in the research-based evidence, suggesting that when outpatient care was led by nurse practitioners this had a positive impact on the quality of care patients received.
The National Audit Office has also promoted nurse-led clinics as a way of providing more efficient outpatient care, while cutting waiting times - both aspects that benefit patients (Lipley, 2001).
NHS reorganisation has resulted in a more business-like approach to health-care delivery, with changes in public-health needs being reflected in decisions about which services should be provided or expanded.
Benign prostatic hyperplasia is a clear example of a condition which is increasing in prevalence because of the demographic shift towards an ageing population. It is becoming an increasing burden on restricted medical resources, due to an increase in public awareness, and therefore symptom presentation (Garraway et al, 1991).
Urologists are a precious restricted resource and their numbers are unlikely to increase in the same proportion as the incidence of BPH or public demand for access to investigation and specialist advice.
Shared care, structured guidelines, agreed pro formas and the appropriate expansion of nursing practice all offer solutions to the problem of limited resources.
The benefits of nurse-led clinics in urology are well documented (Akbar et al, 1996; Booth et al, 1996; Joyce and Pope, 1996; Gidlow, 2001; Lipley, 2001; Martell, 2001). Nurses play an important role in assessing, diagnosing and managing LUTS/BPH. Nurse-led clinics provide patients with access to one-stop LUTS assessment. Unlike medical clinics they are frequently protocol-led, only appropriate investigations are performed, and the results are rapidly available, preventing a delay in providing the patient with a management plan.
Many nurse-led clinics have already been set up to assess men with LUTS. However, there is considerable variation in the care provided by nurses (Akbar et al, 1996; Gidlow, 2001; Martell, 2001).
The British Association of Urological Nurses (BAUN) has established a working party to produce guidelines addressing this area of health care (Greenwood and Dingemans, 2003).
BAUN clinical guidelines for LUTS
Practitioners are becoming increasingly aware of the need to construct health-care practices and ensure direct patient care is influenced by sound evidence (Greenwood and Dingemans, 2003). Guidelines aim to help the multidisciplinary team meet patient needs, while making the best possible use of finite resources and taking due regard of the current health-care context (Greenwood and Dingemans, 2003).
The overall aim of the BAUN guidelines is to improve standards of clinical practice and the quality of care patients receive (Box 4). They are based on a systematic and critical review of current literature and are not intended to be prescriptive. This would fail to take into account local policy, practice and population needs, as well as the established or emerging competency of the nurse(s) currently working with men with LUTS (Greenwood and Dingemans, 2003).
BAUN expects the guidelines to be adapted to local needs and follow audit of existing services. The seven key areas covered by the guidelines are outlined in Box 5. As well as audit, the guidelines suggest further factors to consider before setting up a nurse-led clinic for assessing men with LUTS. These include the following:
- Will the nurse need to discontinue some aspects of his or her current nursing role to run these clinics?
- How much supervised practice will be required before the nurse undertakes this new role?
- How will the new role be evaluated (Greenwood and Dingemans, 2003)?
The guidelines suggest undertaking a SWOT - strengths, weaknesses, opportunities and threats - analysis when setting up a new service.
Reviewing the strengths and weaknesses of a service will help identify which aspects will need to be developed further and which will require change. Opportunities and threats tend to stem from sources external to the nurse, patient group and even the urology unit itself. A SWOT analysis should be as objective as possible, to ensure that the assessment covers actual and potential problems around which a problem-solving framework can be built to address the issues or to meet needs in advance of launching the service.
The guidelines also include competencies for nurses assessing men with LUTS and a proposed training schedule. These aim not only to provide clarity and uniformity of nursing roles and contribution in LUTS assessment clinics on a national scale, but also to assist nurses in highlighting areas of personal and professional development. The latter will enable nurses to extend their practice and to facilitate a structured LUTS service.
The development of this aspect of nursing practice is in line with the current philosophy of the Department of Health (Gidlow, 2001) and has the support of the Nursing and Midwifery Council (2002). The NMC welcomes evidence-based expansion of practice, provided the nurse receives appropriate training for any new role.
With increased clinical skills and knowledge come associated professional and legal issues. Each nurse is responsible for their own practice and should recognise their own level of competency and accountability (NMC, 2002). NHS indemnity, consent, negligence, protocols and accountability are all discussed within the guidelines.
The next steps
The BAUN guidelines were launched in November at the association's annual conference in Telford. All its members will receive a copy of the booklet by the end of the year, and in the future they will be able to download copies of the guidelines from the BAUN website at www.baun.co.uk. Non-members should contact the BAUN secretariat (Box 6).
In time it is hoped the guidelines can be built upon to create an educational resource pack with an accompanying CD-Rom and will be used alongside the soon-to-be-published BPH management guidelines from the British Association of Urological Surgeons (BAUS).
BAUN is currently working on further guidelines for other nurse-led clinics and aspects of urological nursing practice, such as the instillation of intravesical therapies. The first of these, which focuses on mitomycin C instillation, is due to be published in the new year, with immunotherapy guidelines to follow.
Nurse-led clinics are not a cheap option, as such initiatives require investment in training, education, evaluation, resources and time, to ensure the service is provided appropriately and to the highest level of quality.
Any expansion in a nurse's practice should be informed by a philosophy rooted in improving the quality of patient care as opposed to expanding nursing practice merely as a result of cuts in junior doctors' hours, for example.
Nurses must be committed to evaluating their roles and practice, to not only maximise the benefits to their patients but also to inform future nursing developments. Audit and patient satisfaction surveys are useful tools that can help demonstrate the impact and acceptability of nurse-led services.
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