The NHS Dumfries and Galloway Integrated Respiratory Team (IRT) works across a 2500 square mile remote and rural health region in the UK and provides a service to a population of 148000, with 45% of the population living remotely from the largest town settlement (National Records of Scotland, 2024). The IRT provides a regional service for people with chronic obstructive pulmonary disease (COPD), adult asthma, sleep disordered breathing, long-term oxygen therapy requirements, and interstitial lung disease. The IRT consisted of nine respiratory nurse specialists.
The arrival of the SARS-CoV-2 pandemic in March 2020 was a major challenge for the IRT to be able to provide safe, effective and evidence-based care remotely over the course of the pandemic. The IRT agreed that it was vital to re-evaluate all standard operating procedures to enable the team to continue to provide a high standard of ongoing care for patients referred to and within the service.
PM (the principal investigator) who was then also the IRT lead, conducted an international e-Delphi study (as part of a PhD programme of work) to define the core components that should be included at a clinical review for people with sleep apnoea (Murphie et al, 2018a). This work informed the development of a sleep clinic review template that included the most important core components that were identified from the e-Delphi study to include in a clinical review of people with sleep apnoea syndrome. This template was then implemented in three NHS health regions using a mixed-methods implementation study and was refined following feedback from the participants (Murphie et al, 2018b). This preliminary work informed the development of the other disease-specific templates by the IRT at the onset of the pandemic.
The use of templates as tools to assist with the delivery of clinical reviews is not a new concept and they can facilitate a structured and more guided review process and support care consistency. They have been used in clinical practice for more than two decades (Ahmed et al, 2012; Billiones, 2014) and have been shown to improve patient safety (Gilliland et al, 2018).
At the onset of the SARS-CoV-2 pandemic in early 2020, the IRT worked collaboratively to develop disease-specific templates based on the success of previous work by PM on the sleep apnoea review template. They unanimously agreed to co-develop templates for use in COPD, asthma, interstitial lung disease and oxygen assessment, based on current guidelines (Suntharalingam et al, 2017; National Institute for Health and Care Excellence (NICE), 2017; Hopkinson et al, 2019; Murphie, 2021; NICE, 2024).
The IRT was unable to conduct in-person reviews due to the risk of infection transmission and aimed to develop a consistent team approach on how to conduct safe, effective, and evidence-based teleconsultation reviews.
Methods
Design of the templates
From April to May 2020 nine IRT nurse specialists collaborated to develop the templates' contents based on current guidelines in these disease areas. No disease-specific templates were previously used by the IRT.
Intervention and implementation strategy
Individuals in the IRT took the lead in developing the templates where they had a special interest in these conditions. The templates were piloted and refined as feedback was received from the IRT, until agreement was reached on the final versions. The templates would be used by all the specialist nurses for all teleconsultation reviews of adult patients with COPD, asthma, interstitial lung disease and those requiring long-term oxygen therapy assessment.
Data collection via semi-structured interviews
In February 2023, semi-structured interviews were conducted by PM with eight of the IRT members who consented to participate, and interviews were recorded using Microsoft Teams. A specific topic guide was developed and used in all interviews to maintain consistency and reflexivity in the interview process (Table 1).
| Main question | Additional questions |
|---|---|
| 1. I am interested in your views on whether you think there is any value or not in using a structured respiratory review template in your clinical practice. For example, is it worthwhile? Did you already have one in use previously before their introduction? | If you did use a template, can you clarify what is different about your previous way of working? |
| 2. I am interested in your views of any evidence that you are aware of to support using structured respiratory review templates in your clinical practice | What do you perceive as any advantages and disadvantages to using the templates in your clinical practice? |
| 3. Are you aware of any pre-pandemic evidence to support the use of structured respiratory templates in clinical practice? | Can you clarify what you think is or is not worthwhile using such respiratory templates in a clinical review? |
| 4. Do you think that using the templates in your clinical reviews has saved any time in your clinical practice? | Can you expand on this please? |
| 5. Have you had any feedback from your clinician colleagues or patients on the use of these structured templates in your clinical reviews? | Have you had any positive or negative feedback regarding this? |
| 6. Have you found any situations where the structured template is not suitable for use in a clinical review? | Can you expand on this please? |
| 7. What do you think is the impact of the templates on the way you conduct a clinical review:
|
Can you clarify any additional impacts, either positive or negative, of using the template? |
| 8. Are there any additional components that could/should be added to the templates − or how could they be improved? | If yes, can you clarify? |
| 9. Do you think you will continue to use/adapt the structured respiratory review templates in the future? | Can you expand on this? |
| 10. I am interested in your views about the IRT's individual knowledge and skills and whether you feel the templates are useful or not in your personal style of consultation | |
| 11. Have you any additional observations or comments you would like to make regarding the use of the structured respiratory review templates? | Can you expand on this? |
| 12. I am interested in the structure of the IRT and how individual members conduct clinical reviews within their clinical practice | |
| 13. I am interested in how the MDT network communicates within your service and how each team member contributes to developing and delivering respiratory clinical reviews |
Key: IRT=integrated respiratory team; MDT=multidisciplinary team
Data analysis of the interviews
All interviews were thematically analysed using NVivo software version 1.7.1. NVivo is a computer software program that allows researchers to manage, analyse and visualise qualitative data and documents systematically and individually. The recorded interviews were coded using NVivo and 13 themes were generated.
Results
Following analysis of the semi-structured interviews in the NVivo software, 13 themes from the interviews were transcribed and thematically analysed. The themes that emerged and the interviewee comments recorded were as follows:
Discussion
The arrival of the COVID-19 pandemic in March 2020 had a major impact on the delivery of guidelines-based care by the IRT. The team had to pause all routine in-person clinical reviews that previously were conducted in clinics or during home visits across the region.
Before the pandemic the IRT did not use a universal structured template for conducting clinical reviews. They subsequently went on to develop evidence-based clinical review templates for COPD, asthma, interstitial lung disease and oxygen assessment based on the current published guidelines in these conditions and the previous work by PM on the development of the sleep apnoea and continuous positive airway pressure (CPAP) review templates.
The use of templates in the clinical setting is not a new concept and they have been used in primary care for a number of years (Swinglehurst et al, 2012; Mann et al, 2018; Morrissey et al, 2021). The IRT were not aware of any similar structured clinical review templates being used in other secondary care settings before the pandemic and each team member used their own clinical judgement on what to include in their reviews of patients before the templates were implemented.
Some team members said in their interviews that the templates supported them to conduct a thorough and structured review that meant that they did not miss out any important clinical observations. A number of interviewees said the templates saved time, with some commenting that once a patient review was complete, the template contents facilitated rapid dictation of a letter to the patient's GP recommending next steps.
All eight interviewees said that the templates facilitated structured and consistent reviews, with some commenting that it was reassuring that the whole team were working to a common standard.
They also felt that the consistency of reviews was important in supporting patient safety, particularly when in-person reviews were not permitted. The fact that the templates were developed using the latest evidence-based guidelines was an important factor for the IRT and the templates were also seen as supporting newer staff members to develop their knowledge and skills in these chronic respiratory diseases.
In all eight interviews no perceived adverse impacts on clinical autonomy, clinician/patient relationships or person-centred care when using the templates were reported. Also, there had been no negative feedback from clinicians or patients.
One important observation was that patients needed to have a confirmed clinical diagnosis before the templates were used, to avoid any possible misdiagnosis and the templates may be less useful where an asthma/COPD overlap may be diagnosed.
Regarding MDT working, there was a consensus from the IRT that the template was very helpful in wider MDT discussions where there were complex cases that needed to be discussed with the medical team or other allied health professionals such as the physiotherapists, occupational therapists, pharmacists, psychologists or the palliative care team at the weekly MDT meeting.
One interviewee reported that the templates supported them in adhering to their NMC Code, in terms of prioritising people, practising effectively, preserving patient safety and clinician safety, and promoting professionalism and trust (NMC, 2018).
Another important theme that emerged from the interviews was that IRT members continue to use the templates 4 years on from the onset of the pandemic and they refine and update the templates when new disease-specific guidelines are published.
Strengths and limitations
Reflexivity refers to the process of critically self-reflecting throughout the research process to appraise one's own biases and preconceptions (Noble and Smith, 2015; Dodgson, 2019). Upholding reflexivity was an important consideration in this qualitative research study. Maintaining critical distance and impartiality during the data analysis was especially crucial since PM served as both principal investigator and a practising clinician with more than 23 years of experience working as a respiratory specialist nurse. As an ‘insider researcher’ PM may have had certain beliefs and perspectives that could potentially have influenced the research findings. PM took care to actively seek out criticisms and negative opinions about the templates during the interviews so that a full range of viewpoints could be captured. A topic guide was used during all eight interviews to ensure that the same questions were asked consistently by PM (principal investigator) (Table 1).
The interviews were conducted in February 2023 – 3 years after the implementation of the templates by the IRT. PM left the team in June 2020 and a new team lead, YS, was in post from May 2020. The fact that the templates continue to be used and the IRT plan to continue to use and refine them as needed as part of their ongoing clinical practice would indicate that this has been a beneficial process that has supported the delivery of best evidence-based practice, patient safety, and structured and consistent MDT working within the IRT.
The same IRT members who helped develop the templates were the subject of the research, which is potentially a limitation of the study. However, the templates were developed to reflect current guidelines and the fact that they continue to be used beyond the pandemic would suggest that they have been a useful service development and evaluation tool.
There have been some concerns raised by other clinicians that the use of templates are a ‘tick-box exercise’ (Mann et al, 2018; Morrissey et al, 2021). Standardised review templates are used widely in primary care reviews of chronic conditions to systematise care processes and to document outcomes of patient-generated reviews. The use of such templates has the potential to impact clinician interactions and conversations during the reviews, which could potentially restrict a more patient-centred approach (Mann et al, 2018; Morrissey et al, 2021). However, this was not the experience reported by the IRT in this implementation evaluation. The use of the templates to guide consultations was not found to have a negative impact on clinical reviews in this research.
It would be interesting to understand whether other respiratory nursing teams have adopted guideline-based templates in their services during the pandemic and if so, whether they found similar outcomes. This is an area for future research.
Conclusion
In this qualitative research evaluation, the templates were intentionally designed to facilitate guidelines-based care by the IRT. The IRT reported that the use of the templates had no negative impacts on clinical autonomy, patient/professional relationships or patient-centred care. They reduced variation and standardised practice in the IRT service. With the advent of the SARS-CoV-2 pandemic and beyond, introducing a structured review template has facilitated more remote reviews with care outcomes reported to be equivalent to in-person care. Remote reviews support environmental sustainability, the delivery of person-centred care and, additionally, can be cost-effective due to reduced travel and providing care in patients' homes. The continued use of the templates in the IRT's practice 3 years on from their introduction is an indication that this has been a service improvement for the IRT, with many positive outcomes. The templates may benefit other respiratory teams should they wish to adopt them.