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Doctor or nurse? The patients' choice
  1. A M Read,
  2. J F Mayberry
  1. Leicester General Hospital NHS Trust, Leicester, UK
  1. Miss Alison Read, Churchview, Crockwell Street, Long Compton, Warwickshire CV36 5JN, UK

Abstract

This project's aim was to assess patients perceived need for a specialist nurse in inflammatory bowel disease. A letter was sent to 64 patients with a summary of the potential role of a specialist nurse. Patients were asked to complete a questionnaire of 10 scenarios on who would be their preferred provider on the range of issues. There were 35 (55%) replies. When comparing the results between the consultant and the specialist nurse patients preferred to see a specialist nurse significantly in four scenarios, and patients preferred to see the consultant significantly in two scenarios. The results indicate that patients feel specialist nurses would have more time to discuss issues and they do not want to bother the busy doctors with them. But they do want doctors to carry out the medical aspects of their care.

  • specialist nurse
  • inflammatory bowel disease
  • patients' preferred care provider

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In 1994 Sheila Phillips won the 3M National Nursing Award for her development of an inflammatory bowel disease (IBD) specialist nurse in the outpatient department.1 Since then there have been a few appointments of specialist nurses in gastroenterology and some specifically for IBD. At this hospital there is no such nurse so this project's aim was to assess patients' perceived need for a specialist nurse in IBD.

Method

A letter asking people if they would participate in the audit was sent to 64 patients who had been seen at an outpatient clinic specialising in IBD during the last 18 months. It was accompanied by a summary (Appendix ) of the potential role of a specialist nurse. Such a specialist nurse would have a good understanding of IBD, provide advice on common problems, and help develop some solutions. The summary outlined the availability of such a nurse, that is, at outpatient clinics and throughout the week. His or her role in teaching other staff and coordination of home care were mentioned. Patients were asked to complete a questionnaire of 10 scenarios (Appendix ) on who would be their preferred provider on a range of issues. A prepaid envelope was enclosed for their reply.

Results

Sixty four letters, summaries, and questionnaires were posted to patients. After four weeks 35 replies (55%) had been returned. No second mailing was possible because the replies were anonymous. The results are in table 1; the scores for each selection were added together and the value split if a respondent had ticked two or three answers (that is 0.5 and 0.3).

Table 1

Results of questionnaire

Overall patients preferred to see a specialist nurse in five areas. On one occasion the nurse and dietitian were equal. Scenarios where nurses were significantly preferred to doctors related to diet, housing and social issues, obtaining leaflets, and who would spend the most time discussing patient focused problems.

Patients preferred to see a consultant on three occasions and this was significantly so when it concerned problems with IBD and for an annual review.

The question that dealt with a discharge showed that the specialist nurse and consultant were comparable but when comparing nurses and all grades of doctor the result is significant (z=2.8, p<0.005).

The social worker was favoured in the scenario about housing and social issues but only by one vote over the specialist nurse, with the specialist nurse and social worker scoring 13.5 and 14.5 respectively, which is not significant.

Discussion

Clinical nurse specialists are becoming more popular. There is much debate as to whether they are simply a cheaper option to doctors and a way by which to reduce junior doctors hours and work load or whether they enhance nurses' work and benefit patients.2This study was conducted to see who patients would prefer to see in various clinical scenarios. At present there is no clinical nurse specialist/nurse practitioner for IBD available at the hospital in which the study was conducted so the patients have not had any direct experience of such a role.

Patients have a significant preference for specialist nurses over the consultant in the following areas: diet, housing and social problems, and asking about patient education leaflets. They also felt nurses would spend most time talking to them, and to their families. For the questions on diet and the social/housing two other professionals scored highly, namely the dietitian and the social worker, but the specialist nurse still did better than the consultant.

Consultants were significantly more popular than specialist nurses when it came to clinical problems about IBD and for annual review. However patients felt specialist nurses have more time and want to see them for other aspects of their care. This could be either because they do not want to bother consultants with what they feel might be petty things or because they believe consultants are too busy and have only limited time in outpatients.

A survey be McGee et al looked at the expectations of senior personnel in NHS trusts with regard to specialist and advanced nursing roles.3 The top three activities identified were teaching (patients, staff, and carers), 207/230 (90%); clinical practice (direct care, specialised work, limited prescribing, diagnosing and treating in specific care programmes), 174/230 (76%); and consultant/advisor/leader to hospital/colleagues, 155/230 (67%).

There were no gastroenterology specialist nurses who responded to McGee's questionnaire, but this study shows there is a need by patients with chronic gastroenterological conditions for a designated gastroenterological nurse. Patients feel specialist nurses have more time to perform a teaching role. By teaching other members of staff about their condition and the needs of patients the quality of care may be increased in an area that patients feel is lacking (A Read, JF Mayberry; focus group in inflammatory bowel disease, unpublished).

Conclusion

Specialist nurses need to develop their role so that they are not seen simply as cheaper options but can provide a much needed service for patients with chronic diseases who want someone they can talk to and spend some time with them. This study did show that specialist nurses scored much higher than junior doctors throughout each scenario. Patients want to have some continuity in their care and they are aware that junior doctors are on rotation so will probably not see them at their next appointment. When patients have to repeat their history at each visit they feel the consultation is not beneficial. By seeing the same personnel each time, be it a consultant or a specialist nurse, the patient feels they are known to them and this helps to build up their trust.

How should hospitals develop this service? Should there be a specialist nurse for all gastroenterological patients or just for patients with chronic conditions, for example IBD? Should the specialist nurse be hospital based or also work in the community?

However, we must not forget that McSharry makes the point that specialist nurses have developed “within areas of nursing practice where the medical profession are least dominant, for example terminal or palliative care teams”.4 Does this mean gastroenterology is a medically dominated area and nurses will not be allowed to develop despite the wishes of the patients?

Appendix

A specialist nurse in IBD

A specialist nurse in IBD has a good understanding of the problems of patients and can be used as a source of information to help find some solutions to everyday problems.

Specialist nurses have a clinic of their own in the outpatient department. People can discuss problems, changes in medication, and health education is also given. The nurse is supervised by a consultant who can be called on for advice and to see complicated cases. This would reduce waiting times. For inpatients the specialist nurse would help plan homecare by contacting other agencies and professional bodies.

A specialist nurse would also be available to talk to patients and their families throughout the week. Specialist nurses teach other nurses about the condition and so lead to better overall care.

In summary, such a nurse will empower patients to help them make decisions about their individual care.

Appendix

Please choose one answer to each of the questions.

Please tick the appropriate answer or write an alternative in the other section.

Question 1

If you had problems with your IBD who  would you prefer to see:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A general practitioner

  • Other person (please specify)

Question 2

If you had a problem with your diet and your  IBD who would you prefer to see:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A general practitioner

  • A dietitian

  • Other person (please specify)

Question 3

If you had problems connected with your housing or any social issues who would you prefer to see:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A general practitioner

  • A social worker

  • Other person (please specify)

Question 4

If you wanted an explanation about your condition who would you prefer to see:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A general practitioner

  • Other person (please specify)

Question 5

If you wanted your family to talk to someone who would you prefer to see:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A general practitioner

  • Other person (please specify)

Question 6

If you wanted to ask about leaflets on the condition who would you prefer to see:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A general practitioner

  • Other person (please specify)

Question 7

For the annual medical review of your inflammatory bowel disease who would you prefer to see:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A general practitioner

  • Other person (please specify)

Question 8

If you wanted to get an outpatient appointment quickly who would you prefer to contact:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A general practitioner

  • Your consultant's secretary

  • Other person (please specify)

Question 9

If you were an inpatient who would you like to arrange your discharge:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A ward nurse

  • Other person (please specify)

Question 10

Who do you feel would spend most time discussing your disease with you:

  • A specialist nurse

  • A junior doctor

  • A consultant

  • A general practitioner

  • Other person (please specify)

References

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