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Practice comment

GP practices must ensure nurses are trained to do spirometry

  • 5 Comments

With the development of the national COPD strategy more spirometry is likely to be undertaken in primary care, but are nurses competent to carry it out, asks Monica Fletcher

Why do some GPs assume their staff can just pick up a spirometry machine, read the basic manual and then be proficient?

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Performing and interpreting spirometry is a skill. It takes theoretical knowledge, practical application and a lot of practice.

Healthcare professionals are responsible and accountable for their own competence, including in spirometry. It is also the practice team’s responsibility, especially those who supervise others, to be clinically competent.

If you take your car to a garage for repair, you would expect the garage to ensure the mechanic was competent. If you had an accident because of their incompetence, you would be entitled to apply for compensation and could even proceed with a negligence claim.

It is in employers’ best interests to ensure their staff are trained and competent. So why should primary care be any different?

GPs and practice managers employ practice nurses and must ensure they are appropriately educated. In addition to their clinical skills, these nurses need to be aware of medicolegal issues and codes of conduct.

‘How would a member of the public know if they had been misdiagnosed with asthma rather than COPD?’

We have a draft national chronic obstructive pulmonary disease strategy that states improving the rate and accuracy of diagnosis is vital. Two of its main objectives are to: identify people earlier, as an estimated two million are undiagnosed; and improve diagnosis, ensuring people are not misdiagnosed. This will, inevitably, mean more spirometry being undertaken in primary care, which poses the questions: who will do this and how competent are these practitioners?

As part of a national survey, Education for Health found only 12% of nurses undertaking spirometry had any form of accredited training to do so and fewer than half (49%) of those diagnosing and managing COPD had formal accredited training (Upton et al, 2007). How
can this be allowed to continue, when government rhetoric – both previous and current – focuses on improving the quality of overstretched health services?

Transferring services into primary care should not be to the detriment of quality. The general public trust doctors and nurses and believe they are competent until proven otherwise. But how would they know if they had been misdiagnosed with asthma when they have COPD?

We have to clean up our act in primary care. GPs and their teams have risen to the challenges of the operating framework. Next, NHS primary medical services providing regulated activities will need to be registered with the Care Quality Commission from 1 April 2012. These include GP practices and out of hours services. Since patient safety and safeguarding the public is a high priority for the commission, GP practices will be open to scrutiny.

I am proud of the UK primary care system. My work gives me the opportunity to travel the globe and view other healthcare systems, and I have witnessed what happens in countries that do not have adequate services. We should not be waiting until we are forced to improve care for people with COPD. We should act now, while the strategy focuses attention on this condition.

Let us embrace the national strategy for COPD when it is finally published. It will be a vital framework for improving the care of thousands of people with this debilitating condition and appropriately trained and competent nurses will be able to play a crucial role in its implementation. However, nurses will have to ensure they receive this training, which employers must be prepared to pay for. l

MONICA FLETCHER is chief executive, Education for Health

  • 5 Comments

Readers' comments (5)

  • Lynnie

    Its not doing the spirometry that's a problem. Its not brain surgery afterall. The proceedure is fairly straight forward to do, but the interpretation of the spirometry is another matter. Many practice nurses and GP's dont do enough spirometry to be good at the interpretation of the results - which in itself is dangerous. When they introduced spriometry into primary care it was with little thought about who takes responsibility for the interpretation of the results and the other battery of tests like gas transfers etc that was formerly done by chest clinics. I would urge all nurses to look at their practice and wonder - if they miss something from the interpretation of the spirometry - who is responsible? You could get the GP to check the spirometry result but I wonder how many of them know how to read it either ...... any research been done on that?

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  • Monica Fletcher points out that the study undertaken by Education for Health demonstrated that relatively few nurses undertaking spirometry had accredited training. I suspect that may be because, as far as I’m aware, there was only one accredited course in the UK (BTS/ARTP) at the time of the study. There are, however, many other (not accredited with the BTS/ARTP) good quality courses/training sessions available, which adequately prepare staff to perform and interpret spirometry to a very high standard and I would urge staff to seek them out if they are unable to access an accredited course.

    Lynnie (comment) also makes a useful point about the need for staff to be suitably trained to undertake and interpret spirometry in primary care. I agree that this is absolutely essential. In my view, the person that undertakes the test with the patient should also be the one responsible for interpreting the results. I disagree, however, with Lynnie’s comment that spirometry is straight forward to do. It certainly is straight forward so long as you’ve been appropriately trained, but unless you are also competent in interpreting the results, you can never be sure that you performed the test correctly and that it was undertaken reliably by the patient (hence my argument for the same person performing the test and interpreting the results). I’d also question the accuracy of Lynnie’s suggestion that gas transfer testing is being undertaken in primary care settings. Lynnie asks whether the ability of GPs to interpret spirometry results has ever been studied. Yes it has, on numerous occasions. Here are 2 that I remember: I recall an early small study undertaken by the BTS COPD Consortium back in the years when spirometry began becoming common in primary care (1999 I think). The study showed that practices nurses were better than GPs at correctly interpreting spirometry, and, more recently, a study by Chavannes et al (2004) concluded that receiving appropriate training is important, but even then GPs failed to recognise important spirometric abnormalities.

    I agree with both Monica and Lynnie that any member of staff undertaking spirometry, whether in primary or secondary care, requires appropriate training so that patients are assessed, diagnosed, and managed correctly.

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  • Monica Fletcher points out that the study undertaken by Education for Health demonstrated that relatively few nurses undertaking spirometry had accredited training. I suspect that may be because, as far as I’m aware, there was only one accredited course in the UK (BTS/ARTP) at the time of the study. There are, however, many other (not accredited with the BTS/ARTP) good quality courses/training sessions available, which adequately prepare staff to perform and interpret spirometry to a very high standard and I would urge staff to seek them out if they are unable to access an accredited course.

    Lynnie (comment) also makes a useful point about the need for staff to be suitably trained to undertake and interpret spirometry in primary care. I agree that this is absolutely essential. In my view, the person that undertakes the test with the patient should also be the one responsible for interpreting the results. I disagree, however, with Lynnie’s comment that spirometry is straight forward to do. It certainly is straight forward so long as you’ve been appropriately trained, but unless you are also competent in interpreting the results, you can never be sure that you performed the test correctly and that it was undertaken reliably by the patient (hence my argument for the same person performing the test and interpreting the results). I’d also question the accuracy of Lynnie’s suggestion that gas transfer testing is being undertaken in primary care settings. Lynnie asks whether the ability of GPs to interpret spirometry results has ever been studied. Yes it has, on numerous occasions. Here are 2 that I remember: I recall an early small study undertaken by the BTS COPD Consortium back in the years when spirometry began becoming common in primary care (1999 I think). The study showed that practices nurses were better than GPs at correctly interpreting spirometry, and, more recently, a study by Chavannes et al (2004) concluded that receiving appropriate training is important, but even then GPs failed to recognise important spirometric abnormalities.

    I agree with both Monica and Lynnie that any member of staff undertaking spirometry, whether in primary or secondary care, requires appropriate training so that patients are assessed, diagnosed, and managed correctly.

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  • oops sorry didn't meant to click "submit" twice.

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  • As a COPD Nurse working in Primary Care, I have encountered a number of Practice Nurses who do spirometry without any accredited training. We offer their respective Practices support by reviewing their COPD Register but our team often feel that we end up being the GP's QOF Nurses. We urge Practices to send their nurses to training but basing from experience, the common problem the Practices have is the amount of training their Practice Nurses have to undergo,eg CVD, family planning,etc. Also, not all Practice Nurses have interest in Respiratory and spirometry training is not something they look forward to.
    I have done the BTS/ARTP course in spirometry myself and it was surely time consuming and entails a lot of hard work.
    What I hope for is that there will be an accredited spirometry course that is easier and more accessible for our Practice Nurses. I heard that there are plans of having a an online training for spirometry similar to ECDL. Watch this space.

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