How Education of Gp and Practice Nurses has Empowered Practitioners to Manage C.O.P.D Better in Southampton.
The Department of Health’s ‘National Strategy for Chronic Obstructive Airways Disease’ (C.O.P.D) (2009) outlines the need to “empower frontline staff to lead change that improves quality for patients’. This sets a precedent for the importance of education for staff. A recent study by Professor Peter Griffiths, Director of The National Nursing Research Unit, Kings College London demonstrated that nurses who had had training in C.O.P.D, C.H.D or Diabetes and Hypertension in Primary Care were making a difference through improved outcomes in clinical practice (Primary Health Care, 2010).It is important that for good outcomes nurses/clinicians feel adequately prepared to manage C.O.P.D and it would also be prudent to involve those at the front line especially nurses in training and update (Niziol, 2004).
In order to follow up this recommendation locally, the Community C.O.P.D Team Commissioned by the Primary Care Trust set up a programme to help update nurses and clinicians in C.O.P.D Management in November 2009 consisting of two day study spaced a week apart. Three lots of sessions were offered between November 2009 and January 2010. Topics covered are outlined in list below:
C.O.P.D anatomy and physiology
Spirometry interpretation, procedure and maintenance
Nutrition
Medication management
Use of local and National Guidelines
Pulmonary Rehabilitation Service
Management of exacerbations
Heart Failure
Inhaler technique
Telemedicine
45 Practices Nurses from 36 practices including Walk-in Centres and RAPID Response Teams and one G.P attended the sessions; outcomes expressed through nurse feedback from study sessions included;
- Training helped to update on how to diagnose C.O.P.D.
- Demonstrated how the Community Copd service works and what it can offer patients in general Practice.
- How to educate and involve patients.
- Use of the C.O.P.D team as a resource for support and advice.
- Equipping staff to gain confidence in their clinics or set up a clinic.
- Networking and learning from peers, sharing expertise and benchmarks of good practice.
Demonstrations of Empowerment in Action.
Telemedicine.
Experienced nurses gained update to extend their service and incorporate the option of Telemedicine for their patients through the C.O.P.D Team. This particular aspect has been focused on and carried further in one surgery where development of a questionnaire to help involve patients in their care by being involved was introduced and is running as a trial for development within their Long Term Conditions Team (see appendix 1 for example of questionnaire). This project is in its early stages, but demonstrates how education and support can help enable/ empower clinicians and nurses to extend their skills and be more confident in their approach towards patients. Appendices 2-3 demonstrate questions that can be asked through the Docobo system and the advantages and disadvantages of using the service in Primary Care locally.
Meeting with the user group from the Community Team.
As an ongoing development from this, the surgery is hoping to encourage users and carers to form a small group to provide feedback and recommendations on improvements to C.O.P.D services and possibly network with users of the Community C.O.P.D Pulmonary Rehabilitation team. This will depend on local support and resources.
Advantages
Feedback from current users would be very valuable information to work on and could help identify ways of improving the service and how to involve others (Black and Jenkinson, 2009).They would have active experience of the service and is using experience of others or qualitative information to promote future development. Users views of their experiences are paramount to improving care reflected in the INVOLVE Project (Hanley et al, 2004)). This could be done through written narrative of comments given by each member in discussions (Williamson, 2007).This is information that has already been gathered in a preliminary audit report by the Community C.O.P.D Team, so it would be a resource that could be used immediately (Southampton City P.C.T, 2009).
Disadvantages.
The users in the community belong to different practices and live in different geographical areas to current organisation; being involved in further activities alongside telemedicine may be difficult practically and financially. Payment of users would be necessary for any local group formed to help with the initiative for ‘active citizenship’; funding and how it is managed would have to be agreed (Turner and Beresford, 2008).Timing response to the service would need to be up to date and taken shortly after their experience otherwise accurate accounts maybe hampered by users forgetting how they felt at the time (Black and Jenkinson, 2009).Not all users think alike or judge a service the same way, so clear understanding of what is required and ensuring new users and professionals understand there will be different perspectives given (Williamson, 2007).
Practice Visits.
Part of the role of the C.O.P.D Community Specialist Nurses has been to visit practices and update the teams on services available through the Community team and come alongside nurses to offer support encouraging good practice through evaluating where they are and how they could improve their service.
Aspects of this may involve updating their spirometry equipment, attending the education sessions, suggestions for updating their templates to cover guideline requirements on management, how to refer once clear diagnosis has been established or practical demonstration of use of equipment.
From this experience a two way interaction is developing between Primary Care and the Community enhancing communication and in so doing improving patient outcomes. One G.P has offered advice on literature to update skills and keep up to date with evidence based practice when taking respiratory clinical history. Out of 37 practices, 12 practices have not responded to the offer of educational update.
Resistances.
Some of the resistances encountered preventing some practices form updating were:
1. Nurses already having qualifications in C.O.P.D and perceiving there wasn’t a need to update.
2. Doctors taking control of C.O.P.D in practice.
3. No nurses in the practice doing C.O.P.D.
4. Unclear on need for full spirometry for initial diagnosis.
5. Swine flu epidemic and staff shortage in some practices.
6. Sense of feeling threatened by outsiders giving advice.
7. Inadequate equipment or resources to update.
8. Fear of change.
User Experience.
The best possible evidence and demonstration of empowerment of practitioners/clinicians is the good effect they have on users and carers in the community. One particular patient had taken time to contact the C.O.P.D team to say that it had been 32 weeks since his last admission; this would have involved good communication skills between the C.O.P.D team, Community Matron, Primary Care and the patient involved. Increasing staff awareness and updating staff increases confidence and safer practice and comes in line with clinical governance
.
Success in moving forward with C.0.P.D means greater participation of users and professionals working together, especially in Primary Care (Rudolf, 2009). Users and carers are becoming more aware of what they can expect. From 1966 to 1995, 86% of users wanted more ‘humanness’ and 63% wanted more ‘involvement’ from Primary Care, with a move away from ‘paternalism towards partnership’ (Coulter, 2005).
The prevalence of C.O.P.D in the Britain is at about three million at present and locally C.O.P.D is responsible for double the number of admissions compared to asthma, therefore it is important to direct the emphasis of care towards reducing these admissions and take the opportunity to incorporate locally effective strategies to involve patients in development of their own care (B.T.S, 2006). By using the expertise of the C.O.P.D Community Team to help promote better understanding of C.O.P.D locally and encouraging innovation and development, ultimately it is the patients who will benefit from a more clinically effective service.
References.
Black, N and Jenkinson, C. (2009) How can patient’s views of their care enhance quality improvement? British Medical Journal. 339, 202-205: [Online] Available from:
{Accessed 3/12/09}.
British Thoracic Society. (2006) The Burden of Lung Disease. 2nd ed. A Statistics Report from the BTS. 2006. 1-42: [Online] Available from:
{Accessed 28/12/09}.
Coulter, A. (2005) what do Patient’s and the Public want from Primary Care? British Medical Journal. 331:1199-1201: [Online] Available from:
{Accessed24/10/09}.
D.O.H (2009) National Strategy for Copd.London StationaryOffice:[Online] Available from:
{Accessed 12/10/09}.
Hanley, B., Bradburn, J., Barnes, M., Evans, C. Goodare, H., Kelson, M. Kent, A., Oliver, S., Thomas, S and Wallcraft, J. (2004) Involving the Public in NHS.Public Health and Social Care Research: Briefing Notes for Researchers (2nd eds). London: National Institute for Health Research: [Online] Available from:
{Accessed 02/01/2010}.
Niziol, C. (2010) Respiratory Care in Community Settings. Nursing Standard. 19 (4) 41-45.
Primary Health Care (2010)Practice Nurses Shown to Improve Patient Outcomes.Primary Health Care. 20 (1) 4
Rudolph, M. (2009 Chronic Obstructive Pulmonary Disease. Highlights from the A.T.S International Conference, San Diego. Bridging the Evidence to Practice Gap in Asthma and C.O.P.D from an International Perspective. British Medical Journal 9-4 Satellite. UK: BMJ Publishing Group L.t.d.
[Online] Available from:
{Accessed 3/12/09}.
Southampton City Primary Care Trust. (2009) Community C.O.P.D Team Interim Report. Short Term Service Specification October/November 2009. Unpublished data: Southampton Community Healthcare, Southampton.
Turner, M and Beresford, P. (2008) Contributing on Equal Terms: Service User involvement and the Benefits system. Bristol: The Policy Press: [Online] Available from:
{Accessed 14/11/09}.
Williamson, C. (2007) How do we Find the Right Patients to Consult? Quality in Primary Care: 15, 195-9: [Online] Available from:
{Accessed 02/01/2010}.
Appendix1. Initial Draft Questionnaire to Gain Interest in Telemedicine.
Name of User and /carer.
Date
We are hoping to develop our services for C.O.P.D at the Surgery to improve the quality of care given and reduce admissions to hospital. We wish to involve our patients in the design of a new service called Telemedicine and would be grateful if you would answer this questionnaire to help us assess the level of interest.
Telemedicine is basically the use of electronic technology to transfer information from one site to another without the need of moving the user. In this situation a ‘health hub/handset device’ is connected to the user’s telephone line free of charge and the user can input data according to set questions programmed on the handset. This information is sent down the telephone line to a computer terminal manned by health professionals who then check the responses every 24 hours and plan an appropriate course of action, primarily through telephone contact and followed up by home visits, if symptoms are deteriorating and need attention.
Leaflets and further information on Telemedicine are available at the surgery or from your Clinic Nurse. A website link for further information is available at:
Please circle the answer that applies.
1. Have you heard of Telemedicine before?
YES/NO
2. If you haven’t heard of Telemedicine would you like to know how this service could help support you?
YES/NO
3. Would you be interested in supporting the team with developing this service for other patients?
YES/NO
4. Would you like the Clinic nurse to contact you to discuss the Telemedicine option?
YES/NO
5. Do you have any other suggestions you would like to share for improving your care?
YES/NO
Please write in space below your suggestion.
6. If you have experienced the use of Telemedicine, would you recommend it?
YES/NO
Please state in space below your reasons.
Thank you for participating in this survey. Please post your reply in the envelope provided.
We look forward to hearing from you and will be in contact shortly if you wish to find out more about how this service could help you.
Chris Parkinson. Respiratory Nurse Specialist.
Appendix2.
Questions that can be asked on telemedicine:
Has your sleep been affected by coughing and shortness of breath?
Are your ankles or feet swollen this morning?
How has your general health been in the last 24 hours?
e.g. 1=. Normal for me .....to scale of 10 = extremely poor.
Have you been feeling more tired than usual in the last 24 hours?
Blood pressure.
Pulse oximetry
Take your temperature and enter value.
E.C.G (Electrocardiogram).
Have you been able to eat at least 3 small meals in the past 24 hours?
Enter the scale of breathlessness you have today?
Have you produced sputum in the last 24 hours?
Have you had to use your reliever in the past 24 hours more regularly?
Do you have a cough?
Has your sleep been affected by your cough?
Follow the scale and input if change of colour of sputum.
Docobo L.t.d (2002-2009)
Appendix3. Shows table identifying local advantages and disadvantages of Telemedicine services for C.O.P.D Locally.
Advantages / Disadvantages1.Users can stay at home but keep in contact with local services daily. Useful for more housebound patients. Reduce hospital attendances. / 1. Some Users may prefer not to dwell on their condition daily. Some may become isolated or care could substitute doctor intervention.
2. Reassurance for Users and Carers on condition daily. / 2. Some Users are suspicious of technological equipment use in their home and how secure their information is.
3. Professionals can monitor deterioration and intervene earlier and help avoid admissions. / 3. Resources and staff available in Primary Care are limited. Time would be an issue as calls to patients are time consuming. Visits are limited to doctors only.
4. Users are actively encouraged to participate and give feedback on the system and also the care received.
Greater communication between disciplines would be required. / 4. At present the service does not offer visual communication. One patient’s perception of condition maybe different to another. Thorough knowledge of patient history and diagnosis would be necessary and not all information is up to date in the community. Electronic information is limited in the community unlike Primary care access to notes. Sharing information across disciplines is restricted.
5. Being involved with the telemedicine also means being involved with the community C.O.P.D team or Hospital service; both has other services such as Pulmonary Rehabilitation and involvement with P.P.I groups connected to the P.C.T. / 5. Staff would need to be trained in Primary care; certain levels of intervention such as prescribing would be limited to only those qualified in the community.
6. Encourages self care through having a support service available if needed. / 6. Patients may have other illnesses which require regular follow up in Primary Care anyway and so not need/desire daily intervention or telemedicine. There could be overlapping of services between Secondary Care, Primary Care and the Community.
7. Being involved in the new project of telemedicine locally helps with improved communication and understanding of services for both professionals and Users/carers. Even if it does not prove ideal, Users will have had a say in their experience of care given. / 7. The system relies on 24 hour follow up which isn’t always possible in Primary Care setting. Regular contact is agreed in the community through a contract basis which is individual to each User and carer’s needs. Assessing lung condition electronically is limited as other problems could be the cause.
(Mini report by Chris Parkinson, Community C. O.P.D Respiratory Nurse. Feb 2010)
1