Incidence of pleural disease is increasing (Bhatnagar and Maskell, 2013), affecting 3000 people per million each year (Du Rand and Maskell, 2010). Patients can present with pleural effusions associated with pleural disease or other pathologies, such as alternative malignancy, infection or left ventricular failure (Bintcliffe et al, 2016). Breathlessness associated with pleural effusions can be disabling and, therefore, access to therapeutic and potential diagnostic pleural aspiration to provide immediate relief of symptoms is essential (Bintcliffe et al, 2016).
Traditional inpatient management of pleural effusions often requires protracted and costly admissions. New systems, such as outpatient pleural procedure clinics (PPC), have been developed to avoid this (Antunes et al, 2003, Hooper et al, 2015, Botana Rial et al, 2010). Outpatient pleural services aim to provide rapid access, reduce emergency hospital admissions and provide effective and safe care that is preferred by patients (Sura et al, 2012; Bhatnagar and Maskell, 2013; Devani et al, 2016).
Historically, pleural procedures, such as pleural aspiration, have been completed by doctors; however, in a small number of settings, nurses with training in thoracic ultrasound and the pleural procedures have been undertaking these tasks (Whittingham, 2014; Cole, 2016; Surange et al, 2010). When nurses perform these procedures, the strain on existing services can be reduced, creating a more resilient system (Cole, 2016). Advanced nursing roles can be seen in a number of different forms, for example non-medical prescribing and nurse-led endoscopy, and NPs performing pleural procedures is another example.
NP involvement in pleural procedure services has been studied in a number of single-centre evaluations using different models of working. In two single-centre studies, appropriately trained NPs were shown to be equally as effective and safe as doctors when completing pleural procedures (Reid et al, 2013; Noorzad and Ahmed, 2015). Results have also suggested that NP involvement may increase timely access to care and offer good value care with improved patient satisfaction (Whittingham, 2014; Davies Macmillan and Eaton-Smith, 2014). There is limited generalisability to these findings, but they can provide information about other services and are useful as pilot studies.
The present study aimed to gain insight into the impact of NPs in the pleural service within a hospital setting, specifically to see whether a model of a joint NP and consultant clinic increased capacity, and how the addition of two NPs, with one working in the clinic at a time, affected the team, the service and patients. The study was carried out in an UK NHS hospital with a catchment population of around 500 000.
Method
Design
The study adopted a mixed-methods service evaluation design using quantitative data regarding the number of patients seen within the clinic, and a qualitative aspect where key staff stakeholders were interviewed. Clinic numbers were assessed when NPs first started attending PPCs as additional staff members in a training context, and then again after 1 year when they were more experienced and working independently.
Rigour and validity
Staff members were interviewed using prepared guides with relevant topics to ensure consistency. The topics included what impact the staff felt NP involvement in clinic had been, what impact it had on the interviewee's role within the service, what the perceived impact on patient experience had been, whether there were any recognised differences between an NP or a registrar clinic or any concerns regarding NP involvement, and how the NP role could be developed in the future. Interview guides were reviewed and altered by participants prior to the interview to avoid missing relevant data. Wording was chosen carefully for clear understanding, promoting content validity. Interviews were semi-structured to allow for adaptation as relevant information came to light.
Participants
Quantitative data were collected on the number of patients seen in all PPCs over two 6-month periods. The first was at initiation of NP involvement (September 2016–February 2017) and the second, 1 year later (September 2017–February 2018), after NPs had gained competencies in performing pleural procedures. The sample included 42 clinics with a total of 219 patient appointments.
For the qualitative component, key stakeholder staff involved with the pleural service were interviewed. It was a relatively small, purposefully selected group to allow for in-depth understanding.
Data collection
The number of patients seen within each clinic were collected using computerised clinic lists and handwritten ad hoc additions, and entered into a database. Data remained anonymous and were stored in line with the Data Protection Act (1998).
Qualitative interviews were held with six key staff stakeholders involved in the clinic: a nurse practitioner, the lead pleural consultant, the departmental lead consultant, respiratory registrars who had experience of working in a PPC without NP involvement and a healthcare assistant.
Interviews were recorded and then transcribed to allow analysis and coding. The planned interviews took place in a private clinic room at a prearranged time to ensure confidentiality and lack of interruptions.
Ethical considerations
As this study was undertaken as part of an MSc dissertation, ethical approval was obtained from the university and confirmation was given in writing before data collection. Consent forms were signed by all interview participants involved in the study.
Data analysis
Quantitative data were analysed to see whether clinic capacity had increased once NP involvement had been established. Average numbers of patients seen in each clinic list were compared. The largest sample possible, allowing for annual variation, was used with the aim of providing enough data to reflect reality.
Interview data were analysed by coding and then generating themes (Bryman, 2015). To increase rigour and to confirm inter-researcher reliability, a number of the transcripts and coded data sets were reviewed by the university supervisor. The interviews were recorded to allow for checking if required.
Results
The addition of NPs in PPC increased the clinic capacity. In the second 6-month period, 5.86 patients were seen per clinic compared with 4.57 in the first 6-month period (Table 1). A one sided t-test showed significance (P=0.052). Interview data showed concordance with this result because four of the six interviewees specifically mentioned the increase in clinic capacity as an impact of NP involvement on the PPC. Interviewees perceived that the increased capacity allowed more ‘timely access’, which was essential for many of the patients with pleural effusions who were symptomatic.
| Period 1: September 2016–February 2017 | Period 2: September 2017–February 2018 | |
|---|---|---|
| Total number of clinics | 21 | 21 |
| Total number of patients seen | 96 | 123 |
| Average number of patients seen per clinic | 4.57 | 5.86 |
‘When someone rang up yesterday … despite the clinic already being overbooked, we could add that patient on today, who would not have managed to wait until next week because he was too breathless and that would never have been possible if you as the NP hadn't been there because I wouldn't have had the ability to do that in the time scale of the clinic.’
The increased clinic capacity also had a financial impact for the hospital. The hospital is paid for each clinic attendance with pleural procedures being paid on a best practice tariff. Therefore, increasing capacity increased the payments the hospital received. Employment of an NP to create extra capacity is more cost effective than employing a senior doctor, either registrar or consultant, as NPs are paid at a lower rate.
Quick access for symptomatic relief is important to maintain good quality of life, particularly for clinic patients who are often frail and may have limited life expectancy. It is also important to ensure rapidity of diagnostic tests, particularly to alleviate anxiety for those patients where a cancer diagnosis was a differential, create a familiar point of contact and allow a faster route to treatment.
The increased capacity was also perceived to add flexibility and responsiveness to the service.
‘With pleural disease often people don't have much time from feeling breathless to needing something doing so we have to be able to flex quite quickly.’
Interviewees thought that rapid access helped to avoid emergency admissions for those patients too breathless to cope at home, allowing for more outpatient-based management, and taking pressure away from the hospital front door and beds.
Perceived benefits on patient care
Staff members perceived several benefits for patients of NP involvement in PPCs. These included the continuity involved with a small, familiar team and the individualised care this can allow.
‘It's quite a small team … it's nice for them to meet the same familiar faces.’
There were suggestions that there was increased safety and effectiveness because NPs were more experienced in carrying out the procedures than some doctors, had increased focus on dignity and comfort, and procedures were less rushed than in previously overbooked clinics.
‘Nurses are doing them (pleural aspirations) more often … are more experienced and…not in a rush.’
Do NPs and doctors provide the same level of service?
There has been some concern historically about nurses taking on roles traditionally completed by doctors (Tye and Ross, 2000). Interviewees were asked whether they felt there was any difference between clinics in which a registrar worked with the consultant and those in which the NP worked with the consultant. Most felt there was no significant difference between the clinics. One interviewee felt some patients might prefer to see a doctor rather than an NP, but had not experienced this opinion first hand.
‘Some patients just want a doctor to do these things.’
Others expressed opinions that timely, competent access to the clinic was likely to be more important than the practitioner's profession.
‘I think the most important thing is just timely access, I don't think it really matters who does the procedure … as long as it is someone who is competent to do it.’
Favourable qualities of NPs in PPC, in comparison to doctors, included that NPs were perceived as being more systematically trained (working ‘by-the-book’), having greater experience and competency, being more focused on patient comfort, gentle, less rushed, easier for the patients to communicate with and better at explaining what patients needed to know. The obvious limitation to these assumptions is that they are the perceptions of other staff members rather than views directly expressed by patients. The lead pleural consultant felt more confident in NP-assisted PPCs than in registrar-assisted PPCs because he had worked more closely with the NPs and was aware of their level of competence.
Quality of the pleural service
Benefits of NP involvement for the pleural service itself were commented on in the interviews. NPs were felt to improve continuity and ‘smooth running’ (Interviewee 3), particularly in times of transition for the doctors. NPs were thought to make the service more reliable, resilient and flexible. It was felt time management in PPCs became better and clinics were less likely to overrun. The benefits of multidisciplinary working were discussed: ‘working together means you get the best of both worlds’ (Interviewee 5), increasing ‘patient-centred care’. It was also felt that having a number of people from different professions performing the same procedures within the PPC was safer from a clinical governance perspective.
Quality of procedures
By providing greater capacity in the PPC, it was thought that fewer pleural procedures were carried out in less planned, emergency settings, such as the emergency department or ‘ambulatory care’. This may have resulted in procedures being carried out by more experienced staff with specialist skills (such as ultrasound), improving quality and patient comfort.
‘Having permanent staff who can do those procedures, who are doing it at a high volume will probably lead to a better outcome for patients because you are not having people who are training always doing it.’
It was also thought that procedures completed by ‘experienced practitioners don't give the patients the same degree of pain’ (Interviewee 4).
Impact on staff
The impact of NP involvement in the PPC had direct implications for staff members. For NPs themselves, it was seen as a great opportunity to learn new clinical skills with the necessary training. There was satisfaction in increased independence and competence, and enjoyment from a more interesting and challenging workload. These skills were considered useful for other patients on the ward outside the PPC, decreasing the time it took for inpatients to have procedures, and reducing their length of hospital stay.
The impact of NP involvement in the PPC on other staff groups was also noted. There was a sense of ‘extra pairs of hands’ (Interviewee 5). Registrars felt NP involvement relieved pressure and reduced their excessive workload. It also reduced stress on consultants who felt that having NPs increased the reliability of the service and made clinics more efficient. This had the benefits of reduced waiting times for patients and the clinics finishing at acceptable hours.
There was recognition of the need to ensure that junior doctors would not miss out on opportunities to gain competencies in pleural procedures. It was commented that there needs to be a balance to ensure a safe, effective service for patients alongside the opportunity for junior doctors to learn. It was observed that NPs spent time teaching junior doctors on the ward and were able to provide closer supervision, which was ‘important for junior doctor learning and competence’ (Interviewee 3).
One consultant commented that having NPs share the workload in teaching junior doctors pleural procedure techniques, in a skilled and consistent manner, reduced their burden and increased their confidence that the teaching would be carried out to a high standard. They also hoped that NPs would eventually be able to help ensure registrars achieved the necessary ultrasound competencies for their training record.
Concerns
The main concern of interviewees regarding the role of NPs in PPC was that of limited NP time. There was a feeling that more NPs were needed to ensure a robust service and that NPs were having to ‘steal’ time from their other roles and responsibilities on the ward.
Future
Despite concerns regarding limited NP time, interviewees suggested how the service could develop further if there was more NP time. For the PPC, a move towards more independent clinic time was recommended, with the addition of daily emergency slots or a ‘hot clinic’ so that patients had even more rapid access to better avoid emergency admissions. A dedicated email or phone line was recommended for patients to self-refer, and for staff to refer via a route that would be manned by a team with a baton-type rota to avoid delays, and ensure service resilience if a particular individual was not available.
It was suggested that the NP role could be expanded to see inpatients for pleural referrals. This would allow more timely responses for these patients with the aim of reducing their length of stay. A more formal role in teaching, for example supervision for junior doctors inserting chest drains or gaining their ultrasound competencies, was also suggested.
Discussion
Results from this study concur with other studies that NP involvement in a PPC increases clinic capacity and, hence, timely access, improved experience for symptomatic patients and helps to avoid admissions (Sura et al, 2012; Whittingham, 2014; Devani et al, 2016; Fawzi et al, 2016).
In a single-centre randomised controlled trial, Reid et al (2013) found there was no statistically significant difference between appropriately trained NPs and doctors with respect to safety and effectiveness when carrying out pleural procedures, a view echoed by most interviewees in this study. Noorzad and Ahmed (2015) also assessed the safety and effectiveness of nurse-led pleural procedures and found that the complication rate was no different to that in published literature. Surange et al (2010) reported high patient satisfaction when pleural procedures were performed by a nurse. The NPs working in the study PPC are advanced life-support qualified, able to order radiology investigations and are non-medical prescribers, and hence, able to deal with any complications should they arise in the same way as a doctor. Procedures were performed in a specially designed treatment room based within the respiratory ward and outpatients department, in normal working hours and with an assistant to enable easy access to additional help should it be required, in the same way as a doctor performing the procedure.
Interviewees felt NP involvement in PPC helped to relieve some of the work burden of the doctors traditionally responsible for these services, making the service more robust and resilient (Cole, 2016).
Cole (2016) argued that NPs have an important role in training junior doctors. Thaivalappil et al (2013) reported that the addition of NPs in their pleural service increased junior doctor training opportunities. Opinions of interviewees in this study concurred, in that it is important to ensure that NP involvement in a PPC does not limit junior doctor learning opportunities and could be used to enhance opportunity.
A significant increase in clinic capacity was initially predicted; however, there are several reasons why this was not the case. First, there are no data available on how many patients would have been seen if the clinic was run with just a consultant rather than with the addition of an NP. The NPs started in the role at the beginning of a new service, and were initially inexperienced, requiring supervision. They gradually became more independent and were able to work simultaneously with the consultant rather than consecutively. Secondly, prior to the study, there was one pleural clinic per week, which was increased to three as the study began. While appointments were booked evenly over the three clinics, NPs were present at only one. There are no data on how many pleural procedures are performed elsewhere in the hospital, for example in ambulatory care or the emergency department, because this data is difficult to gather. It is assumed that there are fewer emergency admissions for patients with pleural effusions to these areas as more patients are being seen in a planned manner in the PPC. However, without the data on all patients with pleural effusions being admitted, this is difficult to say for certain: the increased numbers being seen in the PPC could instead reflect a growing incidence of pleural disease. There is no information on how long each clinic took. It would be interesting to quantify whether working simultaneously meant that clinics finished at the appropriate time rather than overrunning. There could have been random, unknown factors leading to an increase in the number of patients seen at a clinic, such as an increased incidence of pleural disease, reduced services elsewhere or greater awareness of the clinic's existence among patients and referrers.
Study limitations
A limitation in the study design is that interviewees were known colleagues of the interviewer, leading to a potential lack of neutrality if participants feared what they said would affect their working relationship, or wanted to please Doody and Noonan, 2013). Although acknowledged, it was unavoidable within this study owing to the small team. The subject matter was neither especially sensitive nor controversial, thus minimising the impact of this limitation.
Patients are key stakeholders in the PPC and their opinions were assumed by staff members and not solicited in this study. A future study on patient opinions would be useful to gain a broader, more accurate understanding of the impact of NP involvement.
The small scale and single-centre design inherent in the service evaluation limits the generalisability of this study to other departments or hospitals. The concept could be seen as a pilot and could be trialled and adapted to see whether it is a successful working model in other areas where procedures are required.
Conclusion
The study provides further data that NP involvement in PPC can have a positive impact on patient care and clinic effectiveness. It provided new data about the impact of NP involvement in improving staff satisfaction. The study has found that NP involvement in PPC has had multiple benefits. With the model of working used, clinic capacity increased and, therefore, timely access for patients was improved. Both NPs and doctors expressed satisfaction. The quality of the service and impact on individual patients was also perceived to be positive. Further research could be performed to ascertain the patients' opinion directly of NP involvement in PPC.
NP involvement in PPC has been adopted in a handful of centres in varying formats, but remains limited. This study adds to the body of data that suggests NP involvement should be increased and possibly made a standard practice. This could also be considered in other departments where procedures form part of outpatient clinic time.