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Library of Congress Cataloging-in-Publication Data
Names: Preston, Wendy, editor. | Kelly, Carol (Carol Ann), editor.
Title: Respiratory nursing at a glance / edited by Wendy Preston, Carol Kelly.
Other titles: At a glance series (Oxford, England)
Description: Chichester, West Sussex ; Hoboken, NJ : John Wiley & Sons Inc.,
2017. | Series: At a glance series | Includes bibliographical references and index.
Identifiers: LCCN 2016007514 | ISBN 9781119048305 (pbk.) | ISBN 9781119048299
(Adobe PDF) | ISBN 9781119048275 (epub)
Subjects: | MESH: Respiratory Tract Diseases—nursing | Handbooks
Classification: LCC RC735.5 | NLM WY 49 | DDC 616.2/004231—dc23
LC record available at http://lccn.loc.gov/2016007514
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © Getty/IAN HOOTON/SPL
Joe Annandale, Chapters 52, 60
Katy Beckford, Chapter 11
Andrew Booth, Chapter 44
Joanne Bousanquet, Chapter 6
Michaela Bowden, Chapters 12, 45
Dave Burns, Chapters 13, 49
Julie Cannon, Chapter 32
Caroline Cowperthwaite, Chapter 30
Jo Coyle, Chapter 12
Alexandra Christie, Chapter 11
Nicola Cross, Chapter 51
Jennifer Daniels, Chapter 30
Annette Duck, Chapters 55, 61
Jan Dunne, Chapter 30
Paula Dyce, Chapter 30
Jenny Fleming, Chapter 57
Elizabeth Gillam, Chapter 53
Beverly Govin, Chapter 30
Karen Heslop-Marshall, Chapters 56, 58
Matthew Hodson, Chapters 22, 25
Tracy Kates, Chapter 27
Carol Kelly, Chapters 7, 17, 57
Lynn Keogan, Chapters 59, 62
Dave Lynes, Chapter 40
Victoria Malone, Chapter 30
Mike McKevitt, Chapter 42
Shauna McKibben, Chapters 8, 9
Tom Moreton, Chapters 26, 36, 37, 38
Sarah Murphy, Chapter 35
Sandra Olive, Chapters 19, 46, 47
Lorraine Ozerovitch, Chapter 31
Minesh Parbat, Chapter 48
Ella Pereira, Chapter 40
Wendy Preston, Chapters 2, 3, 4, 10, 29, 36, 38, 48, 54
Sam Prigmore, Chapter 5
Jaclyn Proctor, Chapter 16
Heather Randle, Chapter 3
Elaine Reid, Chapter 53
Jo Riley, Chapters 21, 43
Ann-Marie Russell, Chapters 23, 33, 34
Jane Scullion, Chapter 14
Rebecca Sherrington, Chapter 1
Clare Sumner, Chapter 30
Heidi Swift, Chapters 20, 50
Lisa Taylor, Chapter 24
Emma Vincent, Chapter 2
Liz Walker, Chapter 28
Lindsay Welch, Chapter 18
Carol White, Chapter 15
Steven Wibberley, Chapter 42
Jane Young, Chapters 39, 41
Respiratory nursing covers a diverse range of respiratory diseases including acute, chronic and acute on chronic presentations. Nurses caring for these patients need a variety of skills and approaches to provide holistic management in both the short and the long term. An insight into normal and abnormal anatomy and physiology is required but this needs to be related to the symptoms that the patient presents with; awareness of assessment, investigation, holistic treatment and care required for quality patient management are necessary in today's health care arena.
This book aims to provide a summary of topics related to respiratory nursing in an easy to read format with illustrations and diagrams to aid clarity. It is designed to provide a quick reference guide to common respiratory conditions, presentations and treatment options that require nursing care. Additionally, a focus on respiratory health will enable the nurse to promote preventative measures in both health and disease in order to prevent, minimise or control respiratory disease.
The book has been organised into parts, each containing chapters that focus on individual aspects of respiratory care. You may choose to read the book as a whole in order to gain an overview of respiratory nursing issues, or you may use it as a reference book which will guide you to further reading for each topic.
Respiratory Nursing at a Glance is aimed at nurses, health care professionals and students (nursing, medical and professions allied to medicine) at all levels providing an overview of relevant topics. As part of an established series it will be large enough to provide informative illustrations while being concise enough to provide quick reading and an overview of topics. The focus of nursing care adds depth by including holistic care from birth to death covering subjects like childhood development of the respiratory system, communication and end-of-life care. This book spans both acute and chronic spectra of respiratory disease and in doing so provides a comprehensive overview of the various disease trajectories followed by the majority of patients.
Wendy Preston
Carol Kelly
This book has been developed in collaboration with the Association of Respiratory Nurse Specialists (ARNS), which was created in 1997 by respiratory nurses and is still the only nursing-led organisation within the respiratory specialty field in the UK. ARNS has approximately 1500 members who are represented by an executive committee consisting of a broad range of expert respiratory nurses from a variety of backgrounds: nurse consultants, researchers, academics and nurse specialists working within primary, secondary and tertiary care.
ARNS collaborates with other respiratory care organisations, as well as government and NHS initiatives in order to influence policy and developments for respiratory services, such as the National Insititute for Health and Care Excellence (NICE) and British Thoracic Society (BTS) Guidelines.
Part 1 sets out to orientate the reader to the context of respiratory nursing, from its historical roots, through the various present day working environments where respiratory patients are cared for, and offers a vision for the future. It is hoped this will demonstrate the diversity and wide-reaching influence of respiratory nursing.
Before the influence of Florence Nightingale and the advent of modern nursing, the concept of nursing specialties was unknown. Nurses were expected to provide nursing care no matter what illness afflicted their patients. Patients in hospital were not segregated according to diseases until the early years of the twentieth century, when they were placed in specific areas according to their medical diagnosis. Following scientific and medical advances made during and after the Second World War, this knowledge gave the impetus to emerging medical specialties (Donahue, as cited in MacKinnon, 2002).
While nurses have been working within specialisms for over a century, Castledine (2004) argues that the first development of the clinical nurse specialist emerged in the UK in the mid 1970s. He argued that while the numbers of specialist nurses were increasing in the early 1980s, there was lack of guidance on the criteria for such posts and the first generation of nurse specialists developed lacking direction or control. It was this lack of evaluation or audit that later led to problems in identifying the necessary characteristics of the clinical nurse specialist (Castledine, 2004).
The second generation of clinical nurse specialists evolved in the 1990s in response to the publication of the Scope of Professional Practice (UKCC, 1992) and in reaction to the reduction in junior doctors’ hours and shortages of medical staff. However, it was not until the publication of the PREP (post Registration, Education and Practice) report (UKCC, 1994) that specialist nursing practice was defined as ‘Exercise higher levels of judgement and discretion in clinical care. Demonstrate higher levels of clinical decision making, monitor and improve standards of care through supervision of practice, clinical nursing audit, developing and leading practice, contributing to research, teaching and supporting professional colleagues’ (UKCC, 1994).
Although there were more specialist nurses, particularly respiratory nurse specialists, in post by the mid 1990s, within the nursing press it was argued that very few fulfilled the criteria set out in the literature (Christmann, 1965; Peplan, 1965; Oda, 1977) and summarised by Girard (1987) (Box 1.1).
The roots of respiratory nursing can be traced to the care and management of patients with tuberculosis (TB) and included roles such as the TB family visitor (similar to today’s health visitor) and the ward nurse who attended patients on the old TB wards (Figure 1.1).
Since the 1980s, as advances in medicine and changes in the delivery of health care continued, this resulted in an increasing number of respiratory nurse specialists working in a wide range of respiratory settings, for example working within TB clinics, sleep apnoea services, asthma and chronic obstructive pulmonary disease (COPD) nurse led clinics, ventilation services, pulmonary rehabilitation programmes and running nurse-led community based centres for people with respiratory disease. As the number of nurses working in respiratory care settings has increased, the improvements in knowledge and evidence of the psychosocial issues related to respiratory care, respiratory management and technologies have made a significant difference to the understanding of the needs of patients living with a respiratory condition.
Since the 1990s, the role of the nurse consultant has evolved including within respiratory care. There are a number of such posts currently established across the UK, although those roles vary and titles are inconsistent nationwide. These inconsistencies and variability in nurse consultant roles still needs to be addressed across all specialities (Giles et al. 2014).
It should not be forgotten that there are many other nurses, in hospital and community settings, as well as other professionals and providers who contribute to the specialist care of the person with a respiratory condition. Frequent changes in political climate, organisational changes, rising costs, pressures on health services and rapid advance of medicine and technology over the last 20 years have inevitably led to the creation of new and more effective ways for improving health care (BTS, 2014). With the predicted demands in numbers of the population with respiratory conditions in the UK, and the evidence of increasing morbidity, change is needed if the care of people with respiratory conditions in the UK is to improve.
While it is recognised that new roles will be developed (BTS, 2014), and specialist nurses roles will continue to evolve, health care providers should recognise the contributions to respiratory care made by nurse specialists over the past 20 years. There is a need to be cautious about replacing any roles before we have a clear idea of the pros or cons of specialist nurses. Modern respiratory nursing requires skill in leadership, management and providing compassionate nursing care and also recognising the cultural, physical, psychosocial and spiritual framework in which people with respiratory diseases live.
The development of advanced or specialist nursing has been long and complex, but while this process has led to innovations and developments within nursing, it could be argued that it has also led to confusion about what specialist nursing comprises. Specialist nursing is one of the most scrutinised and researched concepts, but there is still a long way to go. Specialist nursing can be described as a role, specialist or generalist in nature, or a level of practice, and as scoping areas of clinical, managerial, educational and research skill. Far more research is needed on the role and its effectiveness within clinical practice.
The delivery of effective, competent and safe respiratory care is a priority for specialist nurses working within hospitals. Engaging patients in their own health care is now recognised as a major component in enhancing a service that is not only patient-centred, but also of high quality. As much respiratory care is of chronic disease, it has to be organised in a way that is integrated with other resources so that contradictions and overlaps are avoided. This signposting and sharing of resources promotes the most effective and efficient combination of health professionals needed to deliver the complex care needs of this group of patients.
The role of the respiratory nurse in secondary care is vital in coordinating a care plan that is holistic, dignified and of a compassionate nature. Holistic patient care requires a multi-disciplinary team (MDT) approach involving health care professionals from a range of health and social settings and from a variety of organisations (e.g. in the UK from the NHS and local authority). The MDT includes physiotherapists, occupational therapists, psychologists and pharmacists. All have a key role in holistic care and input which may be for a short period (e.g. to give an opinion or specific therapy) or long term as part of a care plan (e.g. care provider).
Secondary care predominantly addresses diagnostics in the patient with complex needs and the acute and palliative changes that occur in chronic respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease, bronchiectasis and cystic fibrosis. In addition, the management of infections such as pneumonia, influenza and tuberculosis are common. The respiratory nurse provides care around exacerbation management, smoking cessation, disease education, energy conservation, rehabilitation, chest clearance and palliation. The role has been identified as a key component in providing support for the patient and their carer. In recent decades the number of different types of respiratory nurses employed by the NHS has increased and become more specialised. Roles are varied, with some covering respiratory disease in general with perhaps an area of speciality, while others are very specialised and focus on patients with a particular diagnosis, for example interstitial lung disease.
Different grades of nurses have evolved, with training now available to advance practice for health assessment, diagnostics and independent prescribing. Respiratory nurses can be caseworkers for their patients to allow coordination and continuity of care. The role is enhanced in many ways:
In turn, this specialist role can have a positive effect on NHS resources through improved nurse metrics and patient satisfaction, reduced admissions and readmissions and improved self-management strategies. However, with financial pressures putting these roles under threat, specialist nurses need to ensure they have evidence to prove they enhance services, and that they are cost effective. Audit, metrics and acquiring commissioned tariffs are crucial for long-term sustainability.
Secondary care provision varies significantly. For example, in the UK, services run across into or from primary care to provide integration and some trusts also manage GP practices. Ambulatory care provides acute care without hospital admission and is discussed further in Chapter 4.
Changing contracts, raised patient expectation and pay stagnation continue to affect morale in the current NHS. However, respiratory nursing remains a challenging and rewarding specialism which allows practitioners to assess, provide and evaluate evidence-based care on the ‘front line’.
The national Early Warning Score (EWS) is utilised in the secondary care environment to help identify patients who are clinically unstable and to prompt early escalation in their clinical management. Many hospitals use a EWS score routinely. For patients with chronic respiratory diseases their baseline score may be high because of increased respiratory rates and low oxygen saturations and in this case a modified score can be used. It is important that a comprehensive history includes the patient’s baseline function and observations (e.g. oxygen saturation levels). Most systems can be adjusted to take this into account to avoid inappropriate escalation.
The majority of care takes place in the primary care setting, approximately 90% of care interactions in the UK. As well as general practice, primary care also covers a full range of community care such as district nursing, pharmacists and dentists.
The primary care setting is becoming more diverse to meet the needs of a growing and ageing population. This can bring opportunities for nurses and an increased range of roles and advancing practice across a 24-hour period:
Practice nursing is a vast branch of nursing ranging significantly in scope and competence level. For many patients with a respiratory condition the practice nurse will be their key contact and coordinate care, often for entire families. They carry out annual reviews for long-term conditions such as asthma and chronic obstructive pulmonary disease (COPD). Many are qualified independent prescribers who diagnose, initiate treatment and titrate to optimise symptom control, and then develop and agree self-management plans with patients (Chapter 39).
A holistic approach is required to treat the patient not the disease, as many patients have co-morbidities (e.g. diabetes and heart disease). Practice nurses are often generalists and need to be multi-skilled with competency based qualifications, for example assessing and interpreting spirometry (Chapter 21).
Scope of practice and level varies significantly depending on variables such as the size of the practice. A large multi-GP practice may have several practice nurses who have a sub-speciality (e.g. lead the COPD or asthma clinic). Their role is also pivotal in public health and making every contact count. Many are qualified stop smoking advisers (Chapters 6 and 10). There are some strategies used in primary care to promote best practice and evidence-based care. The Quality and Outcomes Framework (QOF) sets out key elements of care that are monitored to improve outcomes for patients.
The World Health Organization identified that there is a need to identify all patients nearing the end of their life, not just those with cancer. Sixty-five per cent of deaths are non-cancer related, which includes respiratory causes, and these should receive equitable care (WHO 2015). General practice is in a prime position to meet the gold standards framework in end of life care (Chapter 61).
When general practice surgeries are closed, different systems are in place to provide out-of-hours service. This provides many opportunities for nurses at a variety of levels: from telephone triage nurses who assess patients, prioritise care and signpost to other services and self-care to advanced nurses who work on the same rota as GPs to assess, diagnose and treat patients in clinic environments and on home visits. A significant proportion of the workload is respiratory disease, infections and exacerbations. Communication with patients’ own GPs is important as long-term conditions can often be suspected and further investigation required.
Walk-in centres and urgent care are similar services that can be part of the out-of-hours service. Triage is again a key role and many services are nurse led. Joined up care is essential and can influence long-term management. For example, for an asthmatic patient who has frequent exacerbations and requires repeat prescriptions for an inhaler, their practice nurse needs to be aware of this in order to prompt a review of the management plan with the patient.
Community care is organised in many ways, depending on country and region. People with long-term conditions such as respiratory diseases often need their treatment coordinating by a case manager or a community matron. These are very experienced nurses who have health assessment and prescribing skills with a key role in admission avoidance.
Traditional roles such as district nurses continue to deliver the majority of care at home to people with long-term conditions, often in conjunction with community matrons and/or case managers. It is essential that nurses in these roles receive training in respiratory disease management and are able to access the wider multi-disciplinary team.
Care is delivered in a wide range of settings and is not exclusive to primary and secondary care. This chapter discusses the ambulatory care setting, intermediate (community) and tertiary care.
Traditionally, the care of many patients with emergency conditions has focused on inpatient hospital management but recently there has been increasing evidence that care can be safely and effectively managed out of hospital. Many acute medical conditions including respiratory disease can be effectively managed in this manner, with greater patient satisfaction. Effective ambulatory care provision is about providing same-day emergency care and avoiding admitting patients to hospital unless absolutely necessary.
The NHS as a whole is under pressure, with a shortage of acute beds. The ambulatory model used by different specialties has demonstrated a reduction in admissions and saved a considerable number of bed days. The Directory of Ambulatory Emergency Care for Adults lists pathways that can be transformed to either partial or full ambulatory care.
Ambulatory care teams work with a range of specialties to develop algorithms and pathway protocols, targeting those that GPs refer on a regular basis and seek alternatives to admission. There are some emergency department pathways that could be treated with ambulatory care thus avoiding admission. Examples of respiratory pathways:
Feedback from patients and carers on ambulatory treatment has been very positive. GPs have given positive feedback to the service and on average 40% of referrals, during the service’s opening times, have resulted in admission avoidance.
Ambulatory care complements services such as virtual ward and community matrons to facilitate acute review in timely manner when a patient’s condition deteriorates, thus avoiding admission and disturbance of care provision. When the acute stage is resolving, care can then be transferred back to these community services or to intermediate care.
Intermediate care services are provided to patients to help them avoid going into hospital unnecessarily or to help them be as independent as possible after discharge from hospital. These services are generally time-limited, until the person has regained independence or medical stability, and are provided in people’s own homes, in community hospitals or sometimes within local nursing homes. They should be multi-disciplinary and include clinical assessment, therapy (e.g. chest physiotherapist) and rehabilitation.
Intermediate care is necessary to ensure that older people with complex needs are seen by the right service for their needs at the right time, preventing admissions to acute hospitals or reducing length of stay. It also helps to ensure that life-changing decisions are not made prematurely about long-term care needs.
Palliative care is an essential element of many respiratory pathways and is often required in conjunction with respiratory and generic teams. Palliative care teams are structured in various ways, discussed in more detail in Chapter 61. Patients with respiratory disease should have equal access to services and specialist advice. It should be remembered that most palliative care is given by community teams such as district nurses and education should be provided.
Tertiary care is specialised consultative health care, often on an inpatient basis and on referral from a primary or secondary health professional. It usually takes place in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital. Some people with complex respiratory disease or rare conditions require referral to tertiary care.
Often, care will be shared between tertiary care and either secondary or primary care (or both). This is to facilitate the expert input for patient care while reducing the amount of times patients need to travel or be away from their relatives and carers.