Expanding nurse practice in COPD: is it key to providing high quality, effective and safe patient care?
The nursing role in COPD — and essentially in all chronic diseases — is becoming increasingly important and is characterised by continuity of care. Nurses are involved in the management of COPD at all stages, from prevention to provision of end-of-life care within a variety of settings, both in the community (including patients’ own homes and family practice) and hospitals. Nurses often play a key role in new care models based on different types of telemedicine support.5,6 Nurse-led consultations and disease management interventions are important interventions which enable nurses to provide, complement, or extend the care delivered by doctors. Nurse-led consultations carried out by experienced nurses frequently include tasks that traditionally belong to physicians, such as physical examination of patients, diagnosis and, in countries such as the UK, prescription of medicines. Nurse-led management interventions are aimed at helping patients cope with their condition and improve their quality of life. They include patient education, guided self-management, smoking cessation, and pulmonary rehabilitation programmes.Nurse-led consultations
Over the last decade there has been an expansion in the role of nurses in the management of respiratory diseases. A pilot study investigating the role of nurses providing respiratory care revealed that nurses were involved in the delivery of the majority (68%) of long-term respiratory disease management, primarily for asthma and COPD.7 The results of a survey conducted in 2006 describing nurse-led COPD clinics in general practice in the UK demonstrated that a large percentage of nurses in an advanced role recommended both pharmacological and non-pharmacological interventions, and autonomously provided follow-up care and confirmed diagnosis via spirometry.8
Studies evaluating the impact of nurse-led care in the management of various chronic diseases revealed that nurses and doctors generated similar health outcomes for patients.9–12 Similarly, studies in both acute and chronic care settings have shown that care provided by nurses is as safe as that provided by doctors.10,11,13 In addition, the systematic review by Horrocks et al. reported higher patient satisfaction with nurse-delivered care compared with care provided by doctors.13 In particular, patients were given significantly more advice about self-management and self-medication during nurse consultations. More recently, a study involving Danish nurses delivering consultations to patients after cancer surgery identified one of the reasons for increased patient satisfaction in the continuity of care which is at the core of the nursing profession.14Nurse-led management interventions
Traditionally, nursing care has been characterised by a holistic approach towards disease management. In COPD, nurses have been involved in delivering non-pharmacological interventions aimed at reducing symptoms and improving the quality of life of patients — such as smoking cessation, increased physical activity, and pulmonary rehabilitation.15 The increase in the prevalence of chronic diseases has led to the development of more comprehensive and multimodal approaches, combining some or all of these areas of traditional nursing care with patient education and mentoring interventions aimed at improving patient self-efficacy and enhancing long-term health status.
Smoking cessation interventions have been shown to be effective when used alone or in conjunction with other interventions.16–18 Evidence of the effectiveness of more comprehensive nurse-led multidisciplinary programmes is also starting to emerge. A one-year longitudinal study in 103 COPD patients investigating the effect of a nurse-led programme of pulmonary rehabilitation argues in favour of a positive impact of nurses’ interventions in the management of COPD.19 Patients in the intervention group experienced a significantly greater improvement in exacerbation frequency compared with the control group; no significant differences in functional capacity or quality of life were seen.19 A randomised controlled trial in 122 patients also evaluated the effect of a nurse-led care programme incorporating initial pulmonary rehabilitation and self-management education, provision of a written personalised COPD action plan, and follow-up care by monthly telephone interviews in patients admitted to hospital for COPD exacerbations.20 The study indicated that these interventions were associated with a reduced need for unscheduled primary care consultations and a reduction in deaths due to COPD, but did not affect the hospital readmission rate.
A recently published 12-month controlled clinical trial in which nurses acted as mentors to 106 COPD patients to increase self-management behaviours has shown that this approach significantly improved health-related quality of life (HRQoL), physical functioning, and increased time to death or readmission to hospital.21 In addition, it has been suggested that comprehensive nursing practice addressing the needs of patients with COPD could be beneficial for patients and their families.22 As COPD has a profound impact on both patients and their families, is complex and characterised by fluctuating symptoms, the education of families is extremely important for the effective management of this condition. The study by Ingadottir et al. involved 50 patients with COPD and was notable in that it was based on the establishment of family involvement.22 In this study, nurses assisted not only patients but also their families in learning to assess and take appropriate measures in relation to symptoms, establishing a close collaboration with family members and other healthcare professionals. In addition, nurses addressed specific health-related issues according to the needs of the individual patient. All the main variables measured — such as disease-specific HRQoL, number of hospital admissions, nutritional status, and anxiety and depression — improved significantly; measures of HRQoL also reached a clinically significant threshold.
Despite these positive results, two reviews of clinical trials aimed at assessing the effect of various interventions (self-management education programmes, telephone follow-up, physical activity) that were led, coordinated, or delivered by nurses failed to show significant patient benefit.23,24 More research including larger numbers of patients is needed to establish fully the effectiveness of nurse-led interventions and which model achieves the best outcomes.
Nurses have consistently shown a positive contribution in delivering the hospital-at-home and early discharge schemes for COPD.25,26 Under these schemes, patients with acute exacerbations are cared for at home by a specialist respiratory nurse with the support of a hospital-based multidisciplinary team. These interventions are particularly important considering that COPD exacerbations are one of the most common causes of hospital admission and are responsible for an increased demand of hospital beds. Two systematic reviews evaluating the efficacy of hospital-at-home care in patients with acute COPD exacerbations have shown that treatment of these patients at home resulted in a numerically reduced or unchanged mortality rate when compared with hospital inpatient care.25,26 This suggests that patients with acute exacerbations can be safely and successfully treated at home with support from respiratory nurses. In addition, discharge support and follow-up interventions, based on visits by nurses aimed at reinforcing education and promoting compliance with therapy, have been shown to be useful in shortening hospital stay.27