Coronary heart disease (CHD) and the impact it has on society will to continue to increase, as the average age of the population rises. Advances in prevention and treatment have increased survival rates in patients with CHD. Continuing interventions for patients already diagnosed with CHD impacts on further coronary events they may experience and ultimately impacts on their mortality. Many patients are aware of what they need to do to improve their health status and therefore decrease their morbidity. Nurses can assist patients to develop and maintain altered healthcare practices and this is recognised as an important advancement to their level of self-care.
One opportunity that is under-recognised in the management of CHD is the use of nurse-led clinics. A nurse-led clinic has been defined as having a focus on health rather than illness and an emphasis on life management rather than diagnosis and intervention. These attributes need to be clearly defined within the structure and function of the clinic. Nurse-led clinics are not new, but the benefits of these clinics and how they support positive outcomes for patients have not been well studied.
Reviews on Effectiveness of Nurse-Led Clinics
A systematic review on the topic of the effectiveness of nurse-led clinics for patients with CHD was completed in 2005 and identified five studies that had reviewed aspects of nurse-led clinics in relation to secondary preventative care of CHD (Page et al, 2005). These five studies evaluated interventions related to education, assessment and consultations. The interventions included the angina plan which was a nurse-led facilitated self help programme; nurse-led health education and motivational interviews for patients awaiting coronary artery bypass; audit and recall of patients initially assessed in a nurse-led clinic and recalled if the patients CHD symptoms or clinical assessment were poor; and two studies that provided secondary preventative care appointments by specialist cardiac nurses.
Clinical improvements were clearly demonstrated by the nurse-led clinics in all of the studies and these included a decrease in anxiety and depression; an improvement in quality of life, general health and lifestyle. Follow-up was improved in both nurse-led clinics and general practitioner groups of the studies and patients reported high levels of satisfaction. Other beneficial effects to patients were demonstrated, including a reduction in severity of angina and improved medication compliance. However, these were subjectively reported.
Subjective reporting has been questioned as to the reliability of self-reported outcomes (Kirvesoja 2000). However, subjectivity gives the patients perspective and ultimately this is what we want to influence and evaluate. It may be this perspective that will motivate the patient in improving their healthcare practices.
Motivating Patients for Self-Care
Many chronic disease sufferers will be motivated to attend a nurse-led clinic where they have the ability to improve life outcomes; whether it is a decrease in symptoms or an increase in the attribute they can undertake. Sometimes something as small as an improvement in how someone mobilises around their home or makes their own bed with no chest pain, is enough of an incentive for them to become involved in a service where they may be assisted to regain some function.
Additionally, general practitioners and nurses thought establishment of the clinics led to an enhanced service for patients. The nurse-led clinics are also viewed as an effective means to improve the scope and structure of care delivery, provide the ability to implement best evidence, and demonstrate a commitment to improving patient care. The benefits to patient care are what persuaded many clinicians to undertake the implementation of a nurse-led clinic. However, the sustainment of the clinics was affected by the lack of both training and resources available to both the nurse and the clinic.
Clinics Increase Job Satisfaction for Nurses
Nurse-led clinics provided benefits in addition to improved patient outcomes, including professional autonomy of nurse practitioners. In the systematic review both general practitioners and nurses thought that the clinics extended the nurses role, increased their confidence, skills and job satisfaction. Nurses also sensed that the nurse-led clinics enhanced their relationship with the patient, due to the increased amount of time spent with the patient and the enhanced continuity of care.
The review suggests that nurse-led care for secondary preventative care of CHD patients is an effective adjunct of supplementary care to general practitioner advice and care and is as beneficial as general practitioner care. The implementation of a successful nurse-led clinic is dependant on the nurse being adequately trained in the care of a patient with CHD and having clear and appropriate expectations formulated both within the clinic and within the relationship with the medical officer.
One of the studies included in the systematic review did a further follow up study and describes four themes associated with the successful implementation of a nurseledclinic;
Patient care (the perceived idea that the clinic will improve patient outcomes),
Development of nursing skills (training and support issues),
Team working (communication, support and sharing the same belief), and
Infrastructure (staff shortages and financial incentives).
Nurse-led clinics have revealed both clinically sound and perceived benefits to the patient, by focussing on promoting health traits and putting emphasis on cardiac management. Nurse-led clinics are an effective adjunct to general practitioner clinics; however the nurses should be adequately trained to be able to manage each patient’s preventative care effectively and according to previously defined clinic guidelines.
The financial benefits have not been adequately studied, but perceived benefits from improved cardiac health and possible decreased admission rates will equate to the increasing number of patients with CHD becoming less of a financial burden on the healthcare system. Current community requirements would support nurse-led clinics as a preferred model of care.
Royal Adelaide Hospital
and Discipline of Nursing,
University of Adelaide
Nurse-led clinics are an increasingly popular phenomenon that have been endorsed in the UK from the 1990s. They are often regarded as a key step in the modernisation of healthcare and are found in hospital out-patient departments, GP surgeries and health centres.
But why develop a nurse-led clinic?
For patients, such clinics can:
Provide a patient-centred approach to the management of chronic diseases;
Offer increased patient access;
Provide quicker access to medicines;
Shorten hospital stays, and
Provide vital psychological support.
There are also benefits for doctors. Clinics:
Free up doctors’ time allowing them to see more patients, and
Foster increased cooperation and collaboration between nurses and doctors.
For nurses, nurse-led clinics encourage professional development.
The ability to make detailed care decisions (admit, discharge, refer), and
The opportunity to focus on the key nursing activities (counselling, teaching and health promotion).
Richard Hatchett, author of Nurse-led Clinics: Practice Issues, outlines ten key steps for the successful running of a nurseled clinic:
1. Build a business case
2. Define aims and objectives
3. Establish patient criteria
4. Plan publicity
5. Select location
6. Gain support from colleagues
7. Plan your professional development
8. Consider medicines management
9. Plan audit and evaluation
10. Facilitate ongoing improvement
For more information:
Please see Hatchett, R. (2008) Nurse-led clinics:
10 essential steps to setting up a service.
Nursing Times; 104: 4, 62–64.