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Respiratory care in

community settings
Niziol C (2004) Respiratory carfi in c(iniitiuri% settings. Nursing Standard. 19, 4, 41-45. Christie Niziol RGN, BSc(Hons), is
Date of acceptance: August 2^0 2 0 0 4 , , senior medical writer. Abacus
International, Bicester, and
in primary and/or secondary care settings. The nurse part-time RGN, Pattersons
may have a specialist role or may have a special Healthcare, Oxfordshire. Email:
Background This article reviews the nurse's interest in respiratory disease as part of a wider role, Christie.Niziol@abacusint.com
role in respiratory care in community settings.
such as that of a practice or community nurse (DoH
It aims to identify successful models of
2003). Other specialist nursing roles such as that
community-based respiratory care so that
future models and programmes can benefit. of the cystic fibrosis (CF) nurse, or nurses with a
Conclusion From the literature it is evident specialist interest in asthma, allergy, infection con-
that the nurse's role could be strengthened by trol or palliative care, are likely to include some
the national standardisation of education and community-based respiratory care. Respiratory care
the development of models of care and in the community is therefore covered by more than
relevant career paths. Improvements to patient one nursing role or job description.
care could include the addition of palliative
These elements provide the potential for a flexi-
counselling services, general psychosocial
ble and varied career path, which may be viewed
support care, auditing patient satisfaction and
implementing individualised care plans. as a benefit to a nurse pursuing a career in this
area. However, it is also possible that such diversity
might mean there are vastly different employment
THOROUGH and systematic review of the conditions and role responsibilities for identical job

A literature was conducted primarily using
PubMed. The review focused on the nurse's
role in providing respiratory care in community
titles (Mclntyre 2002). This could cause difficulties
for the respiratory nurse specialist who wishes to
transfer to another locality or position. National
settings, with some investigation of job satisfac- standardisation of respiratory nursing roles and
tion and morale. The aim of the review was to career paths in community settings may help to
investigate the diversity of nursing roles and mod- avoid such incongruencies. It is thought that/Agenda
els of respiratory community care, and the suc- for Change should help to make career progres-
cess of past and current strategies, with a view to sion clearer and fairer for nurses across all special-
suggesting improvements. The discussion, of and ties and geographical areas (NHS Modernisation
results from, the review are presented from the Agency 2004).
nurse's perspective, the patient's perspective and Expanded and specialised practice should create
the NHS perspective, and suggestions for improve- professional development opportunities for nurses, • Community nursing
ment are given. including the potential for increased expertise,
autonomy and management experience. It is hoped • Models and theories
that such changes will help to combat documented
The nurse's perspective
impeders to nurse morale and job satisfaction, for H Respiratory system and
It is envisaged that the future of nursing practice example, the perception of limited career progres- disorders
is one without the traditional boundaries of role or sion, which is especially pertinent for nurses with These key words are based
institutional settings (RCN 2003). The definition of family commitments (Ring 2002). The position of on the subject headings from
nursing is now more dynamic than ever as the divi- consultant nurse has been a positive development, the British Nursing Index. This
sions between primary and secondary care and and a growing number of consultant nurses cur- article has been subject to
between the duties of nurses, physicians and care rently lead respiratory nurse teams, with the aim double-blind review.
managers become less easily distinguished. Such of raising standards of care across primary and sec-
change is obvious in respiratory care in the com- ondary sectors and undertaking research work in
munity, where the role of the respiratory nurse spe- universities (Mclntyre 2002). dnJiriS archive
cialist (RNS) has become well established over the Educational preparation for expanded practice is
past ten years. important (Mclntyre 2002). Nurses should feel ade- For related articles and author
The remit of the RNS is clinical and consultative, quately prepared to take on the role, have verifi- guidelines visit our online
encompassing education, support, organisation of cation of their clinical competencies, have an archive at:
care, and the application of research (Rafferty and understanding of accountability and liability and www.nursing-standard.co.uk
Elborn 2002). The nurse-patient consultation may the ability to use evidence to underpin expanded and search using the key
take place entirely in the patient's own home and/or practice (Rushforth and McDonald 2004). Failure words above.
in a nurse-led outpatient clinic, or it may be held to do this means that professional development is

October 6A/ol19/no4/2004 nursing standard 41

the most psychosocial support. further depression and dissatisfaction with life. (Guthrie ef a/ 2001). 37 patients with severe COPD were sur- tory care to such patients in the community. the nurse must be aware liser treatment (Barta ef a/ 2002). life. is hypothesised that this is increasingly likely to be ity of life and the minimisation of disruptions becomes the case. If the patient is 42 nursing standard October 6A/ol19/nci4/2004 . The community setting is more other respiratory treatments. CF will be required to administer forms of respira. when the patient begins to express feelings of cialists in the UK (Mclntyre 2002).and educating patients and nurse in t a r g e t i n g these factors is apparent. One example is the patient with gen prescribing is transferred from GPs to hospital CF. unlikely to increase job satisfaction. the Acute disease once active treatment has been reduced Chest Triage Rapid Intervention Team (ACTRITE). It A large proportion of the caseload for an RNS will has been suggested that the role of the nurse should be managing patients with chronic obstructive pul. In this chronic condition. examples of this role are pro. or referral to in promoting both nurse morale and positive patient another health professional. In London. To improve patient outcomes through bations. Psychosocial prob- mental effect on nurse morale (Tovey and Adams lems have. This may empha- that provide on-going holistic care can only assist sise the need for more education. However. who had recently died as a result of COPD were Based in the A&E department. Some of the respondents stated that their COPD nurses assess whether the patient needs to only contact with healthcare services during their be admitted or assessed at home. For the patient with outcomes. low-up is thought to be appropriate for a propor- sion. that patients receiving long-term oxygen therapy should be reviewed at least once a year by practi- tioners familiar with this therapy (NICE 2004). and not generalised. ever the clinical need for hospital admission is not uations and disease stages. be expanded to incorporate triage of patients with monary disease (COPD). that the concerns of patients and carers appear to COPD is characterised by a chronic long-term dis- change sequentially with each disease state (Brissette ease progression interspersed with acute exacer- ef a/1988). however. support is readily available for respiratory nurse spe. a nurse specialising in as their oxygen requirements. proven to be the most difficult 1999). Thus. The co-ordinating provision of services at home . where duties include viewed as imperative (Guthrie ef al 2001). Nurses and even treated in the comfort of his or her home overseeing such therapy would be in a good posi- provides the benefits of continuity (Cottrell and tion to assess patients' psychosocial needs. Frequently. In Leeds. educated consultants {Pharmaceutical Journal 2QQ3). 25 carers of patients was followed in North Merseyside (Callaghan 1999). their carers about the disease and supporting them Administration of long-term oxygen therapy or during treatment. conducive to providing individualised support than can easily be managed in the patient's home with the restricted setting of a hospital appointment sys. the need for psychosocial support increases nition have grown considerably and educational at the point of need for long-term oxygen therapy. the development of well-organised for nurses to resolve in community-based COPD and well-equipped community respiratory care roles care (Heslop and Bagnall 1988). The scriptions. COPD. It is at this stage of limited resources or inappropriate organisational that the patient and the family are likely to require structures. During such exacerbations. may improve nurse satisfaction indirectly through Recent COPD clinical guidelines have recommended the perception of optimised care provision. This the patient's perspective role is commonly undertaken by the nurse and it For patients with life-threatening conditions. how- support must be tailored to patients' individual sit. COPD who arrive in A&E departments under these support for the patient and carer must be ongoing conditions. for whom the ability to be monitored. the patient is community-based respiratory care. It could also relatives' last year of life was through repeat pre- place the patient at risk of sub-optimal care. minimal disruption to daily life. ings of helplessness because of being a burden on cialist education programmes for such positions carers (Doi 2003). only three reported regular follow-up perception of inadequate care provision. increased mobility and vided from the UK (Cottrell and Burrows 1998) and independence in activities of daily living were all Canada (Brissette ef al 1988). with nurse-led home fol- and adapted to suit the stage of disease progres. a team of specialised surveyed. Such a service. such as nebulisers. One such model. as the responsibility for domiciliary oxy- more important. always easy to determine (Flanigan ef a/1999).such importance of the community-based respiratory as domiciliary oxygen . and feel- moves towards the national standardisation of spe. In the veyed about the factors that affect their quality of published literature. has also been shown to have a detri. Cottrell and strong preference for home versus hospital nebu- Burrows 1998). qual. The literature has identified that such patients tion of patients and is also acceptable to clinicians can feel abandoned at the palliative stages of the (Flanigan ef a/1999). as well Burrows 1998). psychosocial usually extremely short of breath and anxious. Freedom from fear. It is noted that expertise and role defi. A postal survey of tem and patients have expressed satisfaction with 82 patients with COPD in London confirmed a such services (Brissette et al 1988. at times. because with an RNS (Elkington ef al 2004).

which involved seven able patients are discharged with treatment dispensed European countries. management. led community-based techniques have been demon- In addition to patient preference and quality of strated in the literature. knowledge. control was found to correlate with lack of patient The literature review identified one study which education in the use of peak flow monitors and did not concur with this trend of patient prefer. according to GINA definitions. and plan strategies for resolving their prob- In Glasgow. In the London example. In North Hampshire. described in terms of daily visits. The service is supported in the psychosocial and social factors. lems. Poor at home (Pilling ef al 2003). esised to be due to differences in care organisa. those who received standard treatment in hospi. In this study. The reasons for United States. A ef al 2003). during which where the service was reported to have reduced progress and treatment compliance were moni. those recovering from hip or knee replacement The need for education in asthma management procedures (172). The nurse instigates investi. health. child minders and health vis- fewer deaths occurred in patients with COPD who itors to raise awareness and educate. Such programmes have in COPD in England and Wales (BTS 1997) showed been shown to improve health status and disease wide variation in mortality rates. that these results have not been con. while most patients are satisfied with the service and find most had moderate (40 per cent) to poor control it beneficial to have their acute episode managed (25 per cent). Only 35 per cent of patients were recent survey of patient satisfaction has shown that evaluated to have good asthma control. the nurse's role was gramme has been developed in Tyne and Wear. but it does highlight practitioner will teach the use of multidose inhalers the need for auditing services and obtaining patient (MDIs) to nurses who in turn teach patients (Hunter opinion on both the structure and provision of 2000). expressed best position to provide this education. In the a preference for home treatment. he or she receives regular visits from and care plans for physical health. including 'asthma schools' life. Similarly. Patient knowledge was found to have increased ratory care team made it possible for 68 per cent with this community intervention. in Wigan. the need for admission to hospital (Gibbons etal tored and education and reassurance provided 2001). the Roper (1994) (Milnes and Callery 2003). sistently replicated (Ram ef a/2004) and an improve. to the lungs and optimal asthma control for the cient to meet patients' needs. A large multicentre study. analysed the control of asthma and administered by the nurse. A 1997 audit of patient outcomes parties (Norton 1996).000 patients (Soriano visited at home for the following two weeks. asthma control (Norton 1996). A similar pro- erbation of COPD. including greater knowledge (Soriano etal 2003). and the setting patient (Price ef a/2002). vices. hysterectomy (238). a survey con- nursing framework was used to identify needs ducted in Leicester showed how children's views October 6A/0II 9/no4/2004 nursing standard 43 . which was hypoth. (Gravil etal 1998). respiratory nurses have worked tion and resources (Roberts ef al 2003). In London. in addition to noticing a positive change in however. Good asthma control correlated with hospital care surveyed 538 patients. Various nurse- (Shepperd etal 1998). (Pettersson et al 1999).discharged. The aim was to evening and overnight by the district nursing team help patients to promote and control their own (Callaghan 1999). than in running nurse-led asthma clinics (Norton 1996). with the special interest in asthma management is in the exception of the patients with COPD. This Oxford-based study of home versus medication. with school nurses. a nurse-led Asthma represents another respiratory condition service has been developed which incorporates with acute exacerbations and the potential for acute assessment and early discharge (Pilling etal chronic long-term disease progression. Patients are then symptoms in more than 2. Similarly. All patients. The Global 2003). It is therefore evident more targeted delivery of the inhaled medication that a community setting in isolation is not suffi. Patients are referred to the service by GPs Initiative for Asthma (GINA) set out minimum goals or A&E departments. and increase patient knowledge. the ACTRITE nurses. examples are given where a nurse this anomaly are not clear. a poor understanding of disease causes and asthma ence. the evolution of a community respi. the organisation of care can also affect clin. for the management of asthma (Bousquet 2000). Most families express satisfaction with such ser- tal (Heslop and Bagnall 1988). gations and performs clinical assessments and suit. should always be considered in conjunction with Asthma education is particularly important when the care delivered and the recipient of the care dealing with a paediatric patient. lent (Heslop and Bagnall 1988). as well as were treated by two community nurses. has not yet been reported (Smith ef al for individual self-management plans for children 2004). It can be argued that a nurse with a (96) and 32 with COPD. older patients is evident. in addition a (962) of patients in one three and a half year trial nursing audit evaluated the care received as excel- to be managed entirely at home during an exac. It should be noted. home visits and themed ical outcomes. A telephone survey of 47 paediatric community ment in other clinical outcomes such as lung respiratory centres in the UK emphasised the need function. Improved inhalation technique results in care (Shepperd etal 1998).

including those with clinical outcomes and the potential for decreased asthma or COPD . a specialist nurse can with COPD and the potential for reduced symp. Published examples have emphasised unique exam- nation is the lack of long-term follow-up and it ples of the organisation of such care. the NHS. prospectively designed to cap- ture these data for the purposes of health eco- nomic evaluation would help in this regard. with costs decreas- The importance of good listening skills is frequently ing in the second year of follow-up (Sharpies ef emphasised as being important to patients and al 2002). concluded that such programmes are cost-effec- tive (Gibbons ef al 2001. however. Pilling ef al cost the NHS £473 million annually (Norton 1996). the tal-based or physician-led services (Shepperd ef patient and the NHS. For secondary care. al 1998. Long-term trials. outcomes sought from most carers (Scott ef a/ 2003). General Medical Services (GMS) Contract (BMA munity-based care. In primary care. easily fulfil most of the contract requirements. of nurse-led respiratory care in the community set- nity-based programmes are compared to hospi. The potential for an increased GP cost savings in reduced hospitalisation for patients workload is clear. There is evidence of such award scheme. Therefore some authors have in the community setting are outlined in Box 1. while children led with physician-led respiratory clinics showed stressed the importance of good communication increased costs for the nurse-led service in the and relationship factors (Dixon-Woods ef al 2002). In Patient monitoring and care management can addition. GPs are facing an initiative known as the be more closely followed through nurse-led com. It is important to note that other non-economic In the UK. Asthma accounts for the potential for reducing in-patient bed days and 10 per cent of all primary care prescription costs waiting lists by avoiding inappropriate hospital (Gupta ef al 2004) and in 1996 was estimated to admission is clear (Flanigan ef al 1999. In addition. sharing patient manage- Respiratory diseases therefore have a huge impact ment with nurses may allow physicians to spend on NHS resources and budgets. rather than resource use. Ram ef al 2004). evaluated. organisation of care and ease of access to care A randomised controlled trial comparing nurse- were deemed important factors. One possible expla. Smith et al 2004). Ram ef al 2004. needed to be considered when auditing the suc. as opposed to healthcare 2003).cofyihiuftiity setting Benefits to the nurse Benefits to the patient Benefits to the NHS • Flexible and varied career • Less disruption to daily life H Fewer hospital admissions path H Fits with patient • Potential for reduced costs • Increased autonomy preferences 1! Reduced in-patient bed • Increased expertise • Improved quality of life days H Role expansion • Individualised support • Reduced waiting lists a Management experience B Patient and carer wellbeing • More physician time for • Potential for career • Increased independence patient care progression • Improved clinical outcomes • Increased patient • Research opportunities monitoring • Increased knowledge M Knowledge that care is • Attainment of national optimal targets • Attainment of local targets 44 nursing standard October 6A^ol19/no4/2004 . This should result in improved gent monitoring of patients . thus tom-relieving medication in asthma patients (Barta showing another benefit of such programmes to ef al 2002. ting has yielded many benefits for the nurse. Pilling ef al 2003. which is designed to promote more strin- appointment systems. is hypothesised that a decrease in costs and cess of community health services. resources would be seen over time (Norton 1996).through a financial-based point use of NHS resources. The potential benefits of respiratory care Soriano ef a/ 2003). more time with patients (Yodfat et al 1977). first year of the programme. COPD (Pilling ef al 2003). This conclusion has not consistently been estab- lished and some authors have reported an increase It is clear from the literature that the development or no change in costs when nurse-led commu. For adults. which can be fJ?^o¥p"C|irir'm'the . These factors should be of the trials were based on patient satisfaction considered when care is being re-organised or and support issues. one in four hospital admissions is due benefits to the NHS may be derived from com- to respiratory disease and half of these are due to munity-based respiratory care. 2003).

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