Journal of General Practice Nursing

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DISCUSSION i
use of nitric oxide monitoring (FeNO) — something I have
used in practice to enhance asthma diagnosis for eight years
and find very helpful. Poor prescribing will only be revealed
if we routinely interrogate our prescribing data —which can
be done with relative ease in general practice — and then act
either through education or patient reviews. CS
I don’t believe any clinician wants to do a‘poor job’, but you
‘don’t know what you don’t know’, so obviously education
and training are key. The way to really raise the bar would
be to ensure all those involved in respiratory care meet a
standard competency level, but clinical practice changes
and we need to encourage individuals to keep up to date.
Not all nurses read scientific journals or are interested
in evidence-based practice, but we need to find ways of
bringing evidence to them in a variety of ways and make
sure we spend time implementing guideline-driven care.
Specifically with regard to diagnosis, good history
taking is vital, so having the time to undertake a structured
consultation is important. However, in many cases objective
tests are also necessary for a definitive diagnosis. Spirometry
is increasingly performed in primary care, but the results
and quality of the tests are variable and unless it is of the
correct standard then it will lead to misdiagnosis (Primary
Care Commissioning, 2013).The major professional societies
and educational organisations all advocate the development
of a recognised national register for those who undertake
spirometry and interpret the results.The inclusion of FeNO
in the BTS/SIGN (2014) guidelines should see the expansion
of near-patient testing in general practice, as well as the
increased use of blood eosinophils. MF
WHAT IS THE VALUE OF SPECIALIST RESPIRATORY
NURSING? HOW IS THIS ROLE DEFINED AND HOW DO
YOU MEASURE/ASSESS ITS ‘VALUE’ OR ‘QUALITY’
Defining who is a specialist nurse can be controversial as
there is a lot of specialism in general practice with some
so-called‘general practice nurses’trained to a high level and
offering great care. However, the specialist nurse is generally
perceived as someone who sees patients with a specific
condition, e.g. respiratory disease.What is important is that
the majority of care will not involve the specialist team—
diagnosis is usually carried out in general practice, as is the
majority of ongoing management. It is only a very small
proportion of patients with asthma and very severe COPD,
or those at end of life, who may ever see a specialist. It is vital
that the practice team and the‘usual’nurse is well-trained
and clinically up to date, as it is these healthcare professionals
who will provide most of the care. CS
The majority of‘airway’diseases —mainly asthma and
COPD— can and should be managed in primary care by
nurses interested in respiratory conditions. However, very few
of these would call themselves specialist respiratory nurses.
I believe there is a difference between generalist nurses who
have additional skills in particular disease areas and those
who are true specialists — it’s similar to a GP with an interest
in respiratory conditions and a respiratory consultant. In a
true integrated care model, the specialist nurse should be part
of the extended primary care team and be available for nurses
and GPs to access for advice on more complex patients.
For many years — and not only in respiratory care —
we have struggled to determine the true value of specialist
nurses.This is not because they are not respected for their
skills — numerous studies have demonstrated high patient
satisfaction. However, in the strictly budgeted NHS it is
important to demonstrate the economic value of our work,
which is defined as‘outcomes relative to costs’.This is a hard
task, but one that needs to be addressed, otherwise I fear we
could see the gradual decline of specialist nurses. MF
IN THE FUTURE, WHAT ONE THING DO YOU THINK
SHOULD BE DONE TO ENSURE THAT PATIENTS WITH
RESPIRATORY CONDITIONS RECEIVE THE PATIENT-
CENTRED CARE THAT THEY NEED?
If there could be a minimum standard of care offered to
patients with respiratory conditions, it should be that each
practice has a named GP and nurse who are appropriately
trained, assessed, competent and feel confident to deal
with respiratory conditions commonly seen in primary
care, and that the whole practice team has a minimum
level of competence. To see a Quality Award in all practices
would be fantastic. CS
Patient-centred care requires a change in attitudes and
we need to challenge our perceptions. The biggest issue is
the attitudes of nurses themselves. In 2011, Education for
Health undertook a study (Upton et al, 2011) on shared
decision making among practice nurses and found that it
was often used to support the nurse’s agenda rather than
as an expression of equality — nurses used it to try and
persuade patients to do what they wanted. If this is the
common understanding of patient-centred care, then we
still have quite a long way to go! MF
REFERENCES
British Thoracic Society, Scottish Intercollegiate Guidelines
Network (2014) British guideline on the management of asthma.
Thorax 69(Suppl): 1–192
NHS England (2014) FiveYear Forward View. NHS England,
London. Available online:
uploads/2014/10/5yfv-web.pdf
Primary Care Commissioning (2013) Guide To Quality Assured
Diagnostic Spirometry. Available online:
Royal College of Physicians (2014) Why asthma still kills: the
National Review of Asthma Deaths (NRAD) Confidential Enquiry
report. RCP, London
Upton J, Fletcher M, Madoc-Sutton H, et al (2011) Shared decision
making or paternalism in nursing consultations? A qualitative
study of primary care asthma nurses’views on sharing decisions
with patients regarding inhaler device selection. Health
Expectations 14(4): 374–82
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RESPIRATORY CARE TODAY 2015,Vol 1, No 1 11