Covid-19 has sped up the trend of people turning to self-testing and home-administered wound care. But what do these changes mean for nurses and their patients? Kathy Oxtoby reports
There was a time when only a doctor or nurse would deliver a diagnosis. Or patients with a wound would routinely go to the surgery for a nurse to dress it. But over the past 40 years or so, do-it-yourself healthcare has been emerging.
Self-testing has become common for pregnancy and for monitoring blood glucose. Now patients can self-test and monitor a myriad of conditions, from sexually transmitted infections (STIs) to diabetes, from urinary tract infections (UTIs) to high blood pressure. Patients still might go to the surgery for wound care but many have become more empowered towards self-care – for which, thanks to technological advancements, they can also receive ‘virtual’ help.
Then Covid-19 arrived. Self-care in the home became more of a necessity than an option. People had to access appointments at home because they were self-isolating and surgeries cut back on face-to-face consultations during the lockdown. In spring, traditional services, such as sexual health clinics, were stopped. Nurses suddenly had to learn remote ways of working and patients had to learn about testing techniques to manage their own conditions.
As we entered a second lockdown, those new ways of working were useful once again. There maybe further lockdowns, But even if not, it seems unlikely healthcare will return to the way it worked before.
Below are examples of how Covid-19 has affected wound care and testing. The analysis continues below.
|Home wound care|
During lockdown, healthcare assistants (HCAs) at Granta Medical Practices, near Cambridge, set up a service with the support of the nursing team, to assess photos of patients’ wounds, providing patients, families and carers with instructions via video, and the necessary materials to enable them to dress their wounds at home. Jenny Aston, an advanced nurse practitioner (ANP) at the practice, says that while some wound management has since been brought back into the surgery, home wound care has continued where possible.
The video monitoring was also a valuable source of social contact for patients, particularly the older shielding population, she says. Debbie Brown, clinical director at Lewisham CCG, south-east London, and an advanced clinical practitioner at Burnt Ash Surgery, Lewisham, says her practice has been using video calls to teach patients, their family members and carers how to remove dressings, irrigate wounds and apply wound care products. They also take photos and send updates to the practice.
Blood pressure check
Since lockdown, more patients have been buying blood pressure (BP) monitors instead of coming into the surgery. At Ms Brown’s practice, for example, patients are shown a video of how to use the monitors. They take readings at home and email the results to the surgery. BP monitoring also encourages self-care, ‘putting the patient in control of reducing their BP to within target levels’, by cutting their salt intake and alcohol consumption, increasing activity and stopping smoking, says Ms Brown. Ms Roye believes home BP monitoring ‘will definitely continue’. ‘It’s good for the patient to see what’s going on with their BP, and it helps them to make decisions about, say, changing their diet,’ she says.
Pulse oximetry tests for measuring oxygen levels are another purchase patients have been making since the pandemic started. Pulse oximeters are cheap and patients can buy their own, or possibly borrow them if the practice has some available. Nurses say the test is proving useful for COPD patients and Covid-19 patients to know when their O2 sats are dropping dangerously low. However, Carol Webley-Brown, a practice nurse at One Health in Lewisham, says for some patients, who have mental health issues and learning disabilities, their panic and anxiety levels have been such that it has ‘been difficult to stop admissions to A&E’.
Self-testing can be helpful in cardiology for problems like palpitations. Some smartphone apps give a pulse rate, and some even record an ECG. Ellen Shuker, an ANP at Ashfield House Surgery, near Mansfield, Nottinghamshire, is aware of ‘lots of apps that monitor heart rate automatically, which can email the surgery’.
Prior to the pandemic, Ms Roye says people were encouraged to check their blood sugar levels at home, but home testing has become more common since Covid-19. However, Ms Shuker points out that with diabetes management, people also need to be responsible for their diet and alcohol intake.
The charity Self Care Forum says: ‘The average person with diabetes spends six hours a year with a health professional. It is the decisions that they make in the other 8,754 hours that will determine the quality and length of their lives.’
Cervical screening was suspended by GP practices during lockdown, but has now resumed. It looked likely that home cervical screening would become a reality last year. In London, there were plans for a pilot scheme that would give some women self-sampling kits. The pandemic put this on hold. However, from November, GP practices in North Central and North East London will be invited to take part in the YouScreen study, offering HPV self-sampling to non-attenders in the NHS Cervical Screening Programme (NHS CSP). Some nurses are sceptical about these tests. ‘I don’t see how women can do their own test and take an adequate sample,’ says Ms Aston. And Ms Shuker says patients would need to be educated not only to carry out the test, but also to store it, and she questions how this self-sampling would be quality controlled.
Sexual health and family planning
Some STI testing, such as for chlamydia, can easily be done at home. Ms Roye says patients can collect swab kits from the surgery or have them sent to their home address, along with a video, which gives instructions on how to do the test. She says self-swabbing has increased by about 50% since the pandemic, and envisages this trend will continue because testing for STIs at home ‘takes away a lot of the embarrassment and stigma’ associated with these conditions.
Many women were swapped to the self-administered contraception Sayana Press during the Covid-19 crisis, instead of their previous depo injection, which had to be given by the nurse every three months. At Ms Roye’s practice, 100% of women who had depot injection would visit the practice for it. During lockdown, 90% self-injected with Sayana Press. She estimates 70% will continue to do so ‘because they’re used to doing this themselves, and why have the inconvenience of making an appointment for something they can do at home?’
UTI self-testing is a ‘success story’ at Ms Webley-Brown’s practice, as ‘patients seem very happy to test with the strips. The reporting is surprisingly accurate. That may because practice nurses are better at teaching this test as it is simpler than other self-tests,’ she suggests. Ms Shuker sees UTI self-testing continuing to be popular, but warns that antibiotic stewardship will be important to prevent patients repeatedly asking for antibiotics to treat what they believe to be an infection, which may in fact require further investigation.
The increase in self-care
Before the coronavirus pandemic, nurse appointments were at a premium so health bodies had long been encouraging people to take care of themselves at home.
‘Self management and home assessment are part of a wider continuum,’ Helen Donovan, RCN professor lead for public health explains. ‘Self-care is always used as part of a range of options,’ she adds.
Julie Roye, an ANP at Oakview Family Practice, Lewisham, south-east London, agrees but adds the ‘pandemic increased what was already happening’. She believes this approach has brought advantages, giving people ‘choice and convenience’, eliminating ‘unnecessary and time-consuming appointments’.
A ‘great believer’ in self-care, Ms Aston says it is important to help people to be more independent and to take care of themselves by taking ‘ownership of their problems’.
But while self-testing and self-care might be quick and easy ways for patients to take charge of their health, they also have their drawbacks.
Self-testing can lead to unnecessary health checks, such as those carried out by the ‘worried well’, which can then lead to increased demand and cost for what are already over-stretched health services.
‘We already have patients who do a lot of research before they come to us, who incorrectly self-diagnose. So, we’ve got to be careful that self-testing doesn’t get out of hand – encouraging self-testing, but not self-diagnosis’ says
There is also the possibility that self-testing could shift control too far towards patients and away from the expertise of healthcare professionals, including nurses, to the detriment of care.
Dr Crystal Oldman, chief executive of the Queen’s Nursing Institute (QNI), says there will always be ‘inherent risks in asking a person who is not a qualified healthcare professional to carry out any kind of nursing or medical procedure themselves’.
‘These risks can be mitigated by developing a close and collaborative relationship between the nurse and the person whose care they are responsible for. There is always a risk that a person undertaking the test for themselves may not follow the correct procedure and thus invalidate the results.’
She advises that healthcare providers ‘must be diligent in ensuring that the systems used for self-care, including self-testing, are as robust as possible, with regular reviews.
‘The rise of self-care is just another reason that nurses who are leading and managing services in the community need a highly developed and regulated set of specialist skills,’ she says.
Patients still need support
So there seems little evidence the role of the nurse will be diminished because of the rise in self-care.
Patients still need support and to be taught how to self-test. Nurses still need to explain test results and their implications, checking these details are understood, and to counsel patients. Then there is always the possibility that patients may not do the tests correctly, meaning nurses will
need to monitor their results and show them the correct way
Home testing may not always be appropriate for all individuals or all conditions, Ms Donovan says. And while the pandemic may have led more people to turn to managin their conditions at home, ‘people should be reassured their practice nurse is still there for them and GP practices have
procedures in place for seeing patients in the current environment.
‘Importantly, people with long-term conditions should make sure they keep their review appointments and don’t just rely on home testing and monitoring,’ Ms Donovan says.
Looking ahead, this growing trend for patients to self-test could enhance nurses’ roles by giving them more time to focus on more complex conditions, including chronic disease management, Ms Roye suggests.
Nurses could even extend their role to carry out on-thespot testing for Covid-19. In September, health secretary Matt Hancock was reported as ‘optimistic’ that new technology is on the way to enable GPs to test patients for Covid-19 in their practices with an immediate result. Equally,
nurses could test patients too, but while welcoming the idea, Ms Aston questions ‘whether we’d have the capacity to do it – it couldn’t be part of our normal work’, she says. More self-care could be an answer.
Whatever its future direction, self-testing and self-care at their best are not about shifting responsibility from the nurse to the patient, but about working together to get a good decision and to manage an ongoing condition.
As Ms Webley-Brown says: ‘Patients who have a great relationship with their nurses and enjoy patient education, health promotion and self-care are a dream to work with. Working in partnership is so rewarding on both sides.’
Benefits and drawbacks of self-testing
- Is easy and quick
- Provides an opportunity to monitor existing problems and any potential health concerns
- Empowers patients
- Frees up more time to focus on patients with complex conditions
- May not always be appropriate for all individuals or all conditions
- Has the potential to make the ‘worried well’ even more worried, adding to nursing workload
- May not be done correctly
- Can encourage self-diagnosis, which could be the wrong diagnosis