VOL: 103, ISSUE: 25, PAGE NO: 34-35
Samantha Walker, RGN, PhD
Director of education, research and development, Education for Health, Warwick.
This article reports on a study undertaken to ascertain whether allergy training for primary healthcare professionals would improve the quality of life of patients with allergies.
Abstract: Walker, S. (2007) The impact of allergy training for primary care nurses. nursingtimes.net.
Introduction:Allergic diseases affect approximately 20% of the UK population, and it has been recommended that frontline allergy management should be in primary care. S astudy was undertaken to ascertain whether allergy training for primary healthcare professionals would improve the quality of life of patients with allergies.
Method: A multi-centre community-based parallel group randomised trial was undertaken in 12 GP practices to compare the practice of GPs and practice nurses who had undertaken training with those who had received no specialist training.
Results: Health professionals who received training reported increased confidence in history-taking, skin-prick testing, treatment strategies and use of nasal spray devices. Patients whose health professional had received training experienced significant improvement in their symptoms compared with those in the control group.
Conclusion: These findings highlight the effectiveness of professional education and show that practice nurses have the potential to make a substantial difference to the lives of patients with allergies.
People with chronic respiratory and allergic conditions are just one group of patients competing for limited resources as the NHS faces increasing financial pressures and healthcare resources become ever more stretched.
While scientific and technological advances have raised patients’ expectations, the majority of these patients do not require highly technical and expensive care from hospitals - but they do need access to high-quality primary care services delivered by appropriately trained primary healthcare professionals working as part of a team.
Allergy in primary care
Allergic diseases, including hayfever (allergic rhinitis), food allergy, drug allergy and allergic asthma affect approximately 20% of the UK population (Royal College of Physicians, 2003). Respiratory allergies are simple and inexpensive to treat with pharmacotherapy, although basic training in disease management is needed to deliver the best care for patients. Nurses with an interest and training in rhinitis and allergy have an important role to play in the management of these patients, who often have co-existing asthma and rhinitis.
- Rhinitis is defined as a collection of symptoms, including:
- A runny and/or blocked nose;
- Sometimes postnasal drip (mucus running down the back of the throat);
These symptoms, which can occur for an hour or more most days, can result in significant morbidity and research shows that they may adversely affect concentration, reduce productivity and impair learning ability in children and adolescents (Vuurman et al, 1993).
Results from a study designed to investigate quality of life in adults with rhinitis revealed that, in addition to actual symptoms of rhinitis, people experienced impairment of quality of life through systemic symptoms, sleep disturbance, limitations on activity and emotional problems (Juniper and Guyatt, 1991).
The cost implications associated with lost work days due to rhinitis are also significant; for example, a US study showed that allergic rhinitis resulted in approximately 811,000 missed work days, 824,000 missed school days and 4,230,000 reduced activity days when the participant felt less able to carry out normal activities (Malone et al, 1997).
A report from the Royal College of Physicians (RCP, 2003) recommended that the front line for allergy management must be within primary care, under clinical leadership from specialist centres. It also recommended improved access to postgraduate training as an essential prerequisite to improving the management of these patients in primary care.
Ensuring that patients with symptoms of rhinitis have access to the best treatment should be high on any practice nurse’s agenda, as most can be managed successfully in primary care. Management consists of pharmacotherapy, including antihistamines and nasal corticosteroids (which are extremely effective if taken regularly and as prophylaxis), with avoidance of allergen triggers where possible. It is worth pointing out that most trials of cat and house dust-mite avoidance show no benefit over placebo.
The effect of allergy training
There is little published evidence that training healthcare professionals actually improves patient outcomes, however the whole premise of CPD and medical education is based on this assumption. To test it, we performed a study to compare the effectiveness of standardised allergy training for primary healthcare professionals provided by the charity Education for Health with usual care in promoting improvements in disease-specific quality of life in adults with perennial rhinitis.
The allergy study
We conducted a multi-centre, community-based parallel group randomised trial of an educational intervention compared with usual care (Sheikh et al, 2007). Twelve general practices were recruited from the West Midlands. Each consenting practice was asked to nominate two people to participate in the allergy training: a GP and a practice nurse who had not previously received postgraduate allergy training.
The training (the intervention) consisted of an allergy course run by Education for Health, which contains 11 modules covering all aspects of allergic disease. The course was delivered free of charge by an experienced Education for Health allergy trainer over a six-month period using a combination of a distance-learning package and three days of face-to-face instruction. As part of the rhinitis section, health professionals participated in a practical session on the correct use of nasal sprays and were provided with standard instructions for nasal spray use, which they were encouraged to give to patients to accompany prescriptions for topical nasal preparations. Box 1 gives further details of the intervention pathway.
Box 1. Pathway for professionals receiving the intervention
All adult patients (aged 18 and over) with perennial rhinitis on the practice lists of participating health professionals were eligible to participate. Patients were randomised to the intervention group (where they received care from a trained allergy health professional) or the control group (where they received routine care and a leaflet on rhinitis management).
The primary outcome measure was the change in score inthe validated Rhino-conjunctivitis Quality of Life Questionnaire (RQLQ) between the two groups of patients, from baseline (which was taken before the health professionals received allergy training) to 13 months after randomisation (six months after completion of the intervention).
Effects on professional competence and confidence were measured (on completion of the training intervention and six months later), with an audit questionnaire using a Likert scale where a score of 1 = less confident and 5 = more confident. An overall evaluation of satisfaction with the allergy training module, including evaluation of content, administration and relevance to clinical practice, was completed by the health professionals at the end of the six-month training period.
Findings from the study
Twenty health professionals from 12 general practices participated in the study and subsequently received the intervention. Of the 350 patients assessed for eligibility, 290 satisfied our inclusion criteria; of these, 202 agreed to participate. All 202 patients (43% male; mean age 57 years) were included in the intention to treat (ITT) analysis. The per-protocol analysis (patients who complied with their group allocation), was confined to the 157 patients who received the intervention as intended. Participants were comparable at baseline in terms of age and sex profile.
Patient-related outcome measures
In the ITT analysis, improvements in RQLQ from baseline were observed in the intervention group but not in the control group (p=0.08). In the per-protocol analysis, RQLQ scores improved significantly in the intervention group but not in the control group (intervention vs. control p=0.05). Patients who attended the intervention physician/nurse experienced significant improvement in global assessment of nasal symptoms compared with those in the control group.
Healthcare professionals’ self-rated improvement at the completion of the module compared with baseline showed that the educational intervention was perceived to be of educational value in increasing self-assessed confidence and behaviour. The greatest improvements in confidence were reported in:
- History-taking (100% of participants);
- Skin prick testing (80%), allergy diagnosis (80%);
- Treatment strategies (90%);
- Practical use of nasal spray devices (80%).
The majority (75%) also reported an increase in prescriptions for nasal steroids. The allergy training module was well evaluated, the learning objectives being met by 100% of participants. Participants also reported that the module was relevant to their current practice and that the content was appropriate; 78% said that they had acquired new knowledge/skills.
This study has shown that a standardised allergy training intervention for health professionals led to improvements in disease-specific quality of life and in global assessment of nasal symptoms among patients with perennial rhinitis when compared with usual care. The training programme resulted in improvements in health professionals’ perceived confidence in managing allergic conditions.
The allergy module is a standardised module carrying 30 points at degree level (level 3) and is accredited by the Open University. It is delivered by a combination of distance-learning and three taught study days; both the distance-learning pack and the study days were rated highly by students. It is difficult to attribute the improvements in quality of life to a specific part of the training intervention, although training in the diagnosis and practical management of rhinitis accounted for a substantial part of it.
The audit of practitioner confidence and competence demonstrated clear improvements in self-reported confidence, particularly in teaching patients how to use nasal spray devices and advising them about regular nasal steroid use.
The control group in this study continued with their ‘usual care’, which consisted of a leaflet about the prevalence and treatment of rhinitis and access to a nurse/doctor who had not received allergy training. The leaflet gave detailed advice on drug treatment and allergen/trigger avoidance in the form of a basic self-management plan. Despite being part of a clinical trial, and having received written instructions on managing their symptoms more effectively, patients in the control group showed no improvement in quality of life. This suggests that written instructions alone have little clinical impact and that access to trained healthcare professionals, as well as appropriate instructions, is necessary. This is in line with other studies showing the limited effects of self-management plans alone without education.
Conclusion and implications
In this study, standardised allergy training was well evaluated by healthcare professionals and resulted in improvements in health-related quality of life in patients with perennial rhinitis. These findings make an important contribution to the scientific literature and highlight the importance of continued investment in professional education. In today’s climate of financial instability and with a culture of evidence-based practice, it important that we are able to show a clear benefit of this investment to patients as well as health professionals. Allergy-trained practice nurses have the potential to make a substantial difference to the lives of rhinitis sufferers, and should expect great job satisfaction from doing so.
Implications for practice
- Allergic diseases, including hayfever (allergic rhinitis), food allergy, drug allergy and allergic asthma affect approximately 20% of the UK population (RCP, 2003).
- Most allergy management should take place in primary care under clinical leadership from specialist centres (RCP, 2003).
- Improved access training is an essential prerequisite to improving allergy management in primary care.
- Standardised allergy training for health professionals improves disease-specific quality of life and global assessment of nasal symptoms among patients with perennial rhinitis in primary care.
- Training improves health professionals’ confidence in managing allergic conditions.
- The study highlights the importance of continued investment in professional education.
The reference for the full report of this study is
Sheikh, A. et al (2007) Standardised training for healthcare professionals and its impact on patients with perennial rhinitis: a multi-centre randomised controlled trial. Clinical and Experimental Allergy; 37:1, 90-99.
This article is published with the support of the Association of Respiratory Nurse Specialists
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