ERS Congress Trip Report – Kate Lippiett, ARNS Research and Education Sub Committee Chair
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by Kate Lippiett, Chair of the ARNS Research and Education Sub Committee
I was lucky enough to receive an ARNS bursary to support my attendance at the European Respiratory Society (ERS) Congress in Vienna. The ERS Congress is an annual conference that brings together the world’s respiratory experts to present and discuss the latest scientific and clinical advances across the entire field of respiratory care. 67 nurses from across the world submitted abstracts and my abstract was chosen for an oral presentation.
My research looked at improving care for people living with multiple long term condition. This is important for our respiratory patients because many people with chronic respiratory disease also have other multiple long term conditions. For example, on average patients with COPD have five different multiple long term conditions and more patients with a diagnosis of COPD will die from cardiovascular causes than from respiratory failure.
In the UK and other countries, nurses manage patients with long term chronic conditions in primary care. Despite an holistic person-centred approach being an important part of nursing practice, nurses tend to be trained in condition specific management of disease.
In the UK, people with long term conditions are seen at least once a year in primary care for an annual review of their condition, for which their general practice is paid. If people have more than one condition, they may be asked to come in several times to their general practice, often to have very similar measurements (for example, blood pressure) and questions asked of them (for example, around smoking cessation). We piloted a longer, two-part review of all an individual’s long term conditions. In practice, this meant that people attended their general practice twice. First, for a short appointment with an unregistered health practitioner where measurements and bloods would be taken. Second, for a longer review with a registered healthcare professional, normally a nurse.
We conducted a secondary analysis of the qualitative data of a mixed methods study. I used abductive analysis, iteratively comparing and contrasting empirical materials (interviews with nurses, doctors, administrative staff, and patients) with theoretical materials (chronic care model, burden of treatment theory). In brief, the chronic care model was developed by Wagner in the 1990s and sets out a framework for a coordinated service model that enables patients with long-term conditions and clinicians to work together to determine and shape the support needed to enable them to live well with their conditions. Burden of treatment theory identifies the work that healthcare systems and professionals confer on patients and the capacity (resources) available to patients to carry out this work and suggests that where workload outweighs capacity, burden may occur.
Nurses undertook the multiple long-term condition reviews in 15 of our 16 practices. We identified two overarching themes: healthcare professionals’ understanding of reviews’ purpose; challenges and opportunities for nurses delivering reviews.
Some nurses utilised reviews as data-gathering exercises, facilitating collection of nationally driven financial incentives linked to single conditions. In general practices in which these nurses worked, little consideration appeared to be given to nurses’ capabilities and skills, and training required to support this. Other nurses used reviews as opportunities for meaningful discussion of complex problems, leading to action. In these instances, general practices gave considerable attention to nurses’ capability and skills, and training required.
Importantly, we found that reviews allowed nurses to focus on the delivery of person-centred, holistic care, attending to patient rather than professional priorities. Some nurses found this empowering, others found the move from single condition management frightening and uncomfortable. Some nurses who initially found the reviews uncomfortable described increased job satisfaction once they had been got over their initial discomfort. Patients clearly valued reviews where opportunities for meaningful discussion and action were paramount and could find reviews that were used as data-gathering exercises distressing.
It’s very much ‘Well why isn’t it like this? Why isn’t it like that? What did you do here?' It’s almost formulaic and I need to ask you these question and I need this answer and this is how it should be…If I have someone like that then I’ve very much let’s just get through the questions and let’s just get through the tick boxes and then I’ll go…I feel if you see someone like that I generally go away feeling really rubbish. There have been times I’ve gone away and I’ve walked out and I’ve cried.
Nurses valued organisational support for training in person-centred, multiple long-term condition management. Where training was discussed, the focus was upskilling on single conditions (for example, undertaking post graduate courses in asthma, COPD, diabetes, cardiovascular disease) rather than on upskilling in multiple long-term conditions. There was no consensus on how best this training should be delivered.