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The role of the nurse in patient self-care

At a time when consultations for minor ailments are costing the NHS £2bn a year, (equating to £250,000 per general practice), it is imperative that practice nurses feel able to take the initiative and start making a difference to these figures. Nurses have always had huge capacity to influence patient behaviour - Florence Nightingale, one of history's most famous nurses, was seen, first and foremost, as an educator.

The Self Care Campaign, launched in March 2010, aims to encourage health professionals to tackle the burden put on the NHS by minor ailments. The Campaign has shown how much money the NHS could save without the need to cut any services. There is evidence to suggest that investment in self-care could reduce visits to GPs by up to 40%.1

Every year, 57 million GP consultations involve minor ailments that can be self-treated.2 If nurses can take on more responsibility for helping patients to self-care for minor ailments, this will free up GP time to see patients with more serious illness. Many practices are seeing increasingly ageing patient populations with more complicated health needs. At practices around the country nurses are up-skilling and taking on new responsibilities to help patients to self-care.

The following case studies reflect the changing picture of general healthcare practice across the UK and the expanding roles of nurses, healthcare assistants (HCAs) and support staff.
Culm Integrated Centre for Health

The problem of the ageing patient population is one that is prevalent at Culm Integrated Centre for Health in Cullompton, Devon.

At this practice, nurses have been encouraged to take a proactive approach to encourage patients to self-care and reduce demand on GPs' time. This means that some receptionists have taken on tasks completed by HCAs,including giving advice on diet and lifestyle, and treating minor cuts and burns. As a result of this, practice nurses are now free to take a leading role in encouraging self-care for minor ailments.
 
The practice has implemented a GP triage system to stress the importance of the nurse role. Using this system, patients calling the surgery for a same-day appointment are directed to the most appropriate person to treat them, who, in many cases, is not the GP. Being recommended by the doctor has made patients much more receptive to receiving self-care advice from nurses and HCAs.

Mags Pryke, practice nurse at Culm, noticed that many of the patients she was seeing with minor ailments were coming because they lacked the confidence to self-care. In her capacity as a nurse, Mags is able to listen to the patient and give individual advice and encouragement in a way that a GP might not have the time to do. Included in her new responsibilities, Mags teaches people practical skills, such as recognising symptoms, treating wounds and dressing burns. This approach is extremely valuable to both patients and the NHS: patients are able to pass on tips to friends, family and neighbours; and practice nurses at Culm have benefited from feeling that they are making a difference.

Since she began giving advice about self-care, Mags has noticed that there have been many fewer repeat visits by patients with minor ailments. This is indicative of the impact that nurses can have to help cut unneccessary GP appointments.

The surgery's commitment to self-care means that soon, the practice nurses, HCAs and receptionists may be up-skilled even further, allowing them to take on even more responsibility for self-care. In the meantime, Mags thinks the practice's self-care effort would benefit from a cohesive set of self-care materials to back up the information they are giving to patients.

Nuffield Road Medical Centre
At Nuffield Road Medical Centre, Cambridge, the nursing team has noticed a recent decline in the level of self-care practised by adult patients. Angie Carpenter, a practice nurse with a special interest in diabetes, said that an increasing number of her patients are not able to perform basic self-care, such as cleaning a cut.

Nurses attribute this seeming inability to self-care to a lack of responsibility for health on the part of patients. This appears to be symptomatic of the demand-led culture to which the NHS has now fallen victim. But with the health white paper stressing patient responsibility and the government's emphasis on responsibilities rather than rights, nurses know it is becoming more important to show patients what they can do to self-care.3

Nurses at Nuffield Road work together to encourage self-care, so that patients receive a consistent message. They also share information about services, facilities and self-care tips with each other and their colleagues in the surrounding area. The more knowledge the nurses amass, the more they can pass on to their patients.

Although the nurses feel that self-care has been somewhat lost as part of the patient culture, they feel that every appointment is an opportunity to try to bring it back.

Parkside Medical Centre
Parkside Medical Centre in Camberwell, south-east London, has implemented a nurse-led model to increase its capacity to self-care, give more responsibility to nurses and cut the trust's bills.

Nurses at the practice run the walk-in clinic from 8am until 10am daily, with just one on-call doctor as back-up. This model has reduced patient waiting times and increased the practice's commitment to self-care, with patients now benefiting from the nurses' knowledge of self-care for minor ailments and long-term conditions. As a large number of patients attending the walk-in clinic present with minor ailments, nurses have a great opportunity to teach about self-care.

Nurses only refer a patient to a doctor when they feel unsure about an issue, and Mick Davey, practice manager at Parkside, says that although 30 to 40 patients are regularly seen at each walk-in clinic, normally only one or two are referred on.

As a result of the practice nurses taking on responsibility for minor ailments, waiting times to see a doctor have reduced from two weeks to 48 hours. This has directly benefited patients with long-term or more serious illnesses who do need to see a GP.

The nurses at the practice have benefited from increased responsibilities and a boost in status in the eyes of their patients. Claire Ramsay, a nurse practitioner who leads the walk-in clinic, says her duties are now comparable to those of a GP. Claire now takes histories, conducts examinations and tests, interprets results and prescribes.

Patients were unhappy with the switch to a nurse-led practice when it was first implemented. However, since then nurses have been able to change patient perceptions through consultations. The nurses have a 15-minute consultation slot, and patients have enjoyed the opportunity to explain their complaint in full and receive a considered opinion. Now, many patients ask for the nurses by name when they come to make appointments. It is these strong relationships that will be valuable in the future when helping a patient self-care for a long-term illness.

Mick Davey sees the walk-in clinic changing the culture at Parkside. More and more patients are happy to see a nurse rather than demanding to see a doctor. As Mick says, there is an increasing awareness that nurses “get the job done”.
The nurses at Parkside use their roles as educators to give self-care advice to patients. Nurses build on their acquired group knowledge by browsing the internet with their patients during consultations. Often this leads to the patient going away with a print-out or link to a useful website that they can follow up themselves, rather than visiting the practice repeatedly.

Conclusion
Nurses should not be afraid to take on more responsibility to help their practice encourage self-care and free up GP consultations for long-term and serious illnesses. Nurses across all settings have always had great capacity to influence patient behaviour and, in the current climate, this is more important than ever.

When the Self Care Campaign launched in March, some critics said that self-care would mean no care. However, as the work around self-care described in this article has shown, patients have the potential to become better informed about their care, and to learn skills they can use in the future from the healthcare professionals who are most qualified to teach them.

References
Department of Health. Self care - a real choice: Self care support - a practical option. London: DH; 2005.
Tisman A. The economic burden of minor ailments. Self-Care 2010;1(3):105-16.
Department of Health (DH). Equity and excellence: Liberating the NHS. London: DH; 2010. Available from: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli...