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Nurses lead the way in respiratory care

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VOL: 103, ISSUE: 24, PAGE NO: 42

Monica Fletcher, MSc, BSc, is chief executive, Education for Health, Warwick

Specialist nurse roles in respiratory disease were first developed 20 years ago in response to infectious respirato...

Specialist nurse roles in respiratory disease were first developed 20 years ago in response to infectious respiratory diseases including TB, pneumonia and polio. By 1989 the British Thoracic Society (BTS) expressed support for these roles and stated that 'properly trained nursing colleagues working in a liaison capacity between hospital and community should now be attached to all hospital respiratory departments' (Margereson and Esmond, 1997). The BTS now claims that three times the number of respiratory nurses and doctors are needed in order to cope with the growing problem of lung disease in the UK.

Respiratory diseases are a major cause of morbidity and mortality and the UK has one of the highest death rates from these conditions in Europe (World Health Organization, 2001). Excluding pneumonia, 20% of the deaths in the UK each year are due to respiratory diseases, accounting for more deaths a year than ischaemic heart disease (BTS, 2006).

Respiratory disease places a huge demand on NHS resources, costing over £6.5bn each year (BTS, 2006). There are estimated to be 24 million respiratory-related consultations each year in primary care and almost 18% of all GP emergency consultations are for respiratory disease. The BTS (2006) suggests that 31% of all people and two-thirds of all children under five will visit their GP at least once a year due to a respiratory condition, mainly acute infections, asthma and COPD.

Specialist roles in medicine developed as a result of an expanding body of medical knowledge and a recognition that a single physician could not retain all the knowledge needed to deal effectively with every disease. Consequently, as healthcare has become more specialised and complicated, specialties have developed within specialties. This is now evident in secondary care, where the role of the respiratory physician is well established.

Traditionally, relationships between GPs and respiratory specialists in hospital have been good (Holmes and Macfarlane, 1999). Respiratory specialist roles are now developing in primary care. The concept of GPs with a special interest (GPwSIs) was introduced in The NHS Plan (Department of Health, 2000) and these roles challenge traditional models of specialist care. Although the number of respiratory GPwSIs was initially slow to grow, the General Practice Airways Group suggests it is now increasing (Pinnock et al, 2005).

The development of clinical specialist roles in primary care has tended to focus on the role of the GP. However, the government supports a multidisciplinary approach to developing clinicians with a specialist clinical interest, and nurses and other allied health professionals are being encouraged to consider these roles.

The driver for the development of specialist respiratory roles in primary care has been the revised GP contract, introduced in 1990, when GPs were first paid for running chronic disease management clinics. This enabled them to appoint suitably qualified and experienced nurses to undertake key roles in caring for people who have chronic diseases.

Different models and titles have developed for nurses' work with patients who have respiratory disease. These include respiratory nurse practitioners, nurse specialists and practice nurses with a special interest in respiratory disease. Some of these nurses work exclusively with patients who have respiratory disease, while others are generalists with a special interest. All are improving patient care and need to draw on their knowledge and experience outside the respiratory specialty when managing patients, as the case study (right) illustrates.

There is a growing body of evidence supporting the effectiveness of specialist nursing roles. A systematic review of 34 randomised controlled trials comparing nurse practitioners and doctors who provide care in primary care concluded that nurses can provide high-quality care for patients as effectively as their GP colleagues, and patients report high levels of satisfaction (Horrocks et al, 2002). This supports Spitzer et al (1974), who demonstrated that appropriately trained nurses can perform patient assessments as thoroughly as physicians.

Unfortunately there is a lack of evidence specifically evaluating the nurse practitioner role in respiratory disease in primary care. However, a randomised controlled crossover trial of nurse practitioner versus doctor-led outpatient care in a bronchiectasis clinic showed that care provided by the nurse practitioner service was as safe and effective as that led by doctors (Sharples et al, 2002). This finding is similar to that in the study by Nathan et al (2006), which showed that follow-up care by a respiratory specialist nurse of patients admitted with acute asthma can be delivered with an effectiveness and safety comparable with that given by a doctor.

Nurses need education and training to manage the care of patients with respiratory disease, particularly those with co-morbidities and complex health needs. Specialist respiratory care is not about titles but ensuring that patients have access to a health professional who can assess all their needs and manage these effectively.

CASE STUDY: Assessing more than respiratory disease

Liz Bryant, a nurse practitioner for 16 years, based in Coventry, is a qualified nurse prescriber. As a lead respiratory practitioner, she is responsible for medication reviews and providing guidance in respiratory management to patients and colleagues.

Mrs Smith is 63 and suffers from asthma, type 2 diabetes and coronary heart disease. She has had triple bypass grafts and is clinically obese. She lives with her 67-year-old husband.

Ms Bryant identified that Mrs Smith needed an asthma review by a 'flag' on the practice computer when Mrs Smith requested a repeat prescription.

Ms Bryant assessed Mrs Smith and found she had breathlessness at rest and at night. Her breathlessness woke her several times a night. She was sleeping with five pillows and found her night cough and the summer heat troublesome.

It would have been easy as a respiratory practitioner to conclude that Mrs Smith's asthma was the cause of these problems. Ms Bryant may have first suggested that her inhaler technique was checked and her concordance assessed before looking at increasing her medication.

Ms Bryant was aware there are many causes of breathlessness and took Mrs Smith's pulse, as she suspected a cardiac problem. She found her to have an irregular heartbeat. Mrs Smith described episodes when she has a 'fast heartbeat'. Ms Bryant carried out an ECG which revealed atrial fibrillation.

Mrs Smith was prescribed anti-platelet therapy, and Ms Bryant referred her for review of anticoagulation treatment and possible cardioversion. She is helping her manage her breathlessness and reassuring her that it is not caused by her asthma.

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