�nursinginpractice . com – for clinical and daily updates 31 performed in line with standards , or that have been misinterpreted . It ’ s a good thing that we are trying to achieve a high standard of care .
But we do also need more clinicians who are trained in quality-assured spirometry . As we lose nurses from general practice , or more plan retirement , we are at risk of losing more of those with experience in spirometry . Others may not be interested in going through the whole accreditation process ; speaking from personal experience , it is a lengthy undertaking and of course it costs money .
What would you say has been achieved by nurses in general practice in respiratory care ? Nurses are doing a fantastic job . They ’ re educating patients about asthma and COPD so they can understand their condition – something that was lacking a lot in the past . Nurses often deal with complex asthma and COPD , creating self-management plans and providing emotional support to patients .
While nurses in general practice may not perceive themselves as respiratory nurse specialists , I think they should . They do have that level of expertise . I think nurse prescribing is also allowing for better access to care for patients – they can be seen by a nurse , who will help tailor care to their needs .
However , as we know , the level of training will vary from practice to practice , within practices , from city to city and from country to country in the UK . Training is something that should be more standardised .
Nurses ’ approach is very different to the medical approach . We come from a different profession . Research shows that when a patient comes to see a nurse they feel they ’ re not rushed , they feel they are taken care of in a holistic way and that they are listened to . Nurses usually have slightly longer appointments , which is also a big benefit , and I do think patients value the caring approach that nurses bring .
Where I work , we are very multidisciplinary team – we have nurses providing some respiratory care and myself with a special interest . We also have lots of pharmacists and several GPs with an interest in respiratory care . We are constantly working to enhance our respiratory care as a team , with various qualityimprovement projects running in the background .
The latest project is to identify patients with severe asthma in our practice to make sure they are coded accordingly and are under the care of a respiratory physician , and secondary care if required . Patients with severe asthma are on six-monthly rather than yearly reviews . They are well educated on the early signs of exacerbation – they know they need to call the GP practice , and they will be seen by the duty doctor or by me to ensure we prevent escalation , prevent unnecessary hospital admission and prevent damage to their lungs .
We know for example that COPD patients who have exacerbations are much more likely to experience cardiovascular events post-exacerbation . They may have a stroke or heart attack as a result of that , the lung damage during each exacerbation is usually irreversible and lung volumes will reduce in such patients .
What should GPNs have in their sights right now ?
• Be proactive and take our education into our own hands . The level of education clinicians receive in general practice does need to be standardised . That may be largely out of our control but there are free training and resources available from the PCRS , ARNS , BTS and other organisations that are supporting primary care in respiratory disease . There is also a free course for nurses
Resources
• Association of Respiratory Nurses . arns . co . uk .
• Primary Care Respiratory Society . pcrs-uk . org
• Association for Respiratory Technology and Physiology . artp . org . uk
• British Thoracic Society . brit-thoracic . org . uk
• elearning for healthcare : Respiratory disease . tinyurl . com / elfh-respiratory
• Supporting breathlessness . supporting-breathlessness . org . uk /
When patient comes to see a nurse they don ’ t feel rushed , they feel taken care of in a holistic way and listened to that is not widely known about , available on elearning for healthcare ( see Resources ). As discussed above , GPNs should have proper access to diagnostics so they can refer patients to diagnostic services as required .
• All asthma patients need asthma management plans to reduce the risk of life-threatening exacerbations . We also need to emphasise to patients the importance of avoiding triggers . This is discussed during consultations , but perhaps we don ' t talk enough about the impact of air pollution , which contributes to many premature deaths . Comorbidity is another thing to consider . In the future , we need to develop a holistic management plan that includes all a patient ’ s medical conditions and considers all the treatments and advice , which might contradict each other .
• Challenge perceptions around asthma . What patients might call ‘ mild asthma ’ doesn ’ t exist – asthma still kills . It is often underplayed and it ’ s seriousness not acknowledged . So we should never be prescribing salbutamol only .
• Remember non-pharmacological treatments . This is important for patients with COPD and breathlessness . Shortness of breath in COPD might often be linked with levels of anxiety . Professor Morag Farquhar and her team at the University of East Anglia have created a useful online resource to support breathlessness ( see Resources ).
• Check patients are receiving the follow-up they need . If we do suspect asthma , we should record them as suspected asthma or suspected COPD . We should contact patients so that they don ’ t vanish off the radar , ensuring the diagnostics have been done and that they have been referred if needed . However , we do need to remember that with asthma , the diagnostic tests are only supporting the clinical diagnosis . For a diagnosis of COPD , we typically want to see obstruction on spirometry , so it is important that we follow the proper diagnostic process in patients with respiratory symptoms . Make sure you have audited patients who have very high use of salbutamol .
• Consider using a template message to inform patients about trigger control . This is a useful option if you use a messaging system . Speak to each patient about the triggers they have and then signpost them to information on prevention and control .
• Check that systems are in place to follow up patients after exacerbations . Was the exacerbation managed at home or were they seen in A & E ? Ensure they are next being reviewed by a clinician who is trained to do so and can adjust their medication if necessary and monitor them . Again , we know people are highly vulnerable in the period after an exacerbation .
• Address inequalities . We have something of a national postcode lottery for respiratory care . The inhalers on some local formularies may not have been updated for a few years even when there may be newer products on the market . Someone in one area might get an inhaler that has better evidence than an older inhaler . I believe this should be regulated more centrally , rather than locally because it is contributing to health inequalities across the country .
Aleksandra Gawlik-Lipinski is an advanced nurse and paramedic practitioner , an independent prescriber and a respiratory nurse specialist working in general practice at Herne Hill Group Practice in south London . She is vice-chair of the research and education subcommittee of the ARNS and co-chair of the BTS nurse special advisory group , and is currently undertaking a PhD focusing on mortality in childhood asthma .