The specialist practice nurse is employed as a British Heart Foundation (BHF) Heart Failure (HF) nurse and is based in secondary care. Along with networking with a wide range of health care practitioners providing a seamless service between primary and secondary care her role also involves evidence-based care to clients with chronic heart failure (CHF).
CHF is a complex syndrome that results from a structural or functional cardiac disorder that impairs the ability of the heart to function as a pump. This results in the heart not being able to pump enough blood to meet metabolic demands of the body (Clinical Resource Efficiency Support Team (CREST), 2005). The most common cause of HF is coronary artery disease, hypertension and valvular disease. It is a chronic condition, which may fluctuate, and result in repeated hospital admissions. The incidence and prevalence of heart failure is on the increase and with the current ageing population it is likely to continue along this trend. It is currently the most common cause of hospital admission in clients over the age of 65 years and accounts for 1 - 3 % of the National Health Service’ expenditure, the majority of which is associated with inpatient care (CREST, 2005). The Nursing and Midwifery Council (NMC, 2010) defined specialist practice as “...the exercising of higher levels of judgement, discretion and decision making in clinical care” and requires that specialist practice nurse is competent in clinical assessment and diagnosis in their area of practice. These also include the skill of advance decision making and the ability to ensure high levels of communication, consultation and collaboration with other members of allied health care professionals. Advanced skills in assessment ensure that the specialist practitioner can respond to the clients’ physical and psychological needs. Debate continues regarding how a nurse obtains these competencies. Gibson and Bamford (2003) suggest that formal education ensure that specialist practitioners are more competent and confident in their roles. However Raja-Jones (2002) suggest that formal education should not stand-alone and that clinical experience is required in order to obtain competence. The author believes that clinical experience is essential in order to obtain the skills but this experience should be underpinned by theoretical knowledge gained by formal education. Scott, (2005) suggests that nurses with suitable experience and education are a valuable and essential part of the nursing workforce – they have the potential to act as leaders, resulting in a more individualised way of working with clients and carers and a more holistic approach to care. However in order to improve care it is essential that the specialist nurse provides a client focused approach and has a good understanding of evidence based care and provide the client with assessment and care planning, high level communication skills and provision of information and support for clients, their families and carers ( Stenner et al, 2011) Florence Nightingale, who believed in cure that focused on unity, wellness and the interrelationship of human being and their environment, is considered to be one of the first holistic nurses. The holistic theory puts clients perceived needs first and offers care not only for the body but also the human spirit.
The HF nurse assesses her clients holistically in a variety of ways to clients both at home, telephone reviews, telehealth monitoring and nurse led clinics. Skills acquired by the HF nurse enable the nurse to carry out a holistic assessment of the client. These skills enable the nurse to work more autonomously, recognising deteriorating symptoms of heart failure and allow her to act appropriately to improve the outcome for the client.
According to Newson, P (2008), holism can be defined as ‘whole’. This suggests that to obtain a complete picture on an individual all aspects of the person being assessed should be explored. To ensure that assessment is holistic, attention should also be paid to spiritual desires and expressions, always giving recognition to the values, beliefs and cultural norms of the individual. Holistic care draws on the nurse’s knowledge, theories, expertise and intuition to guide nurses in become therapeutic partners with the clients in their care. Haworth and Dluhy, (2001), suggest that holism is the relationship between biophysical, social, psychological and spiritual dimensions of the human condition. A more analytical approach within holistic assessment is examined by Binnie and Titchen (2000) who describe the ‘patient centred approach’ - this process focuses on working with clients beliefs, values, engaging a sympathetic presence, sharing decision making and providing physical needs. Binnie, (2000) goes on to describe this model of nursing as “style of practice that demonstrates a respect for the client as a person”, its aim is to transform clients experiences of illness, taking them from fear to confidence, distress to coping. The author feels it is important that the nurse builds up a trusting, genuine, caring relationship with the client this as will enable the nurse to obtain an important insight into how the client (and carers) perceive and deal with the illness and what factors may determine subsequent health outcomes. Stewart and Blue (2004), state that an assessment which is holistic, accurate, relevant and complete will enable the HF nurse to formulate a flexible and individualised plan of care to improve the health outcomes for the client.
Holistic assessment depends on effective communication, a skill required by the specialist nurse to listen and impart relevant information that is a vital component of every consultation, Mc Evoy, (2000). Communication is considered a basic tool in the healthcare relationship. It is the process by which information, meanings and feelings are shared by persons through the exchange of verbal and non-verbal messages. Balzer-Riley, (2004), defines communication as “the reciprocal process in which messages are sent and received between two or more people”. Likewise for the client Beauchamp,et,al (2002), supports the need for good communication highlighting that clients require necessary information to aid in their understanding of their condition and to make informed choice. However Kirk, (2005) states that some clients like open communication about their illness while others are ambivalent, wanting to be told, but not really wanting to know all details. These contrasting opinions highlight the difficulties for the practice nurse to provide effective communication and therefore it is import to treat each client, family and carers as individuals. The process of communication is a fundamental part of the development and maintenance of identity and through our exchange of messages with one another that we have a sense of who we are. With this is mind the author feels it is important to remember that the communication skills we use in our professional relationships will differ from those we use in our social relationships. Therefore to enable good communication skills and achieve a comprehensive history the practitioner should establish a good rapport with the client, gathering information in a systematic, sensitive and professional manner observing the clients verbal and non verbal communication. Open ended questions, active listening, reflection of feeling and empathy building is paramount to ensuring effective communication and allows a trusting relationship (Burnard, 1996). The specialist nurse should be aware of tone and pitch of voice when communicating with clients. A calm and even tone is said to be the most effective approach when appropriate (Mc Cabe and Timmins, 2006) by changing these factors in the same sentence you can convey an entirely different meaning. Bach and Grant (2009), also feel that essential communication skills are deemed to be listening and attending, empathy, information giving, and support in the context of a therapeutic relationship. The author believes that good communication allows a trusting relationship to be forged that it will allow open and honest conversation between all parties. Mc Cabe and Timmin, (2006) also suggests that open and honest communication enables the client to feel relaxed and secure enabling effective communication. Effective communication is a prerequisite to a good leader and is a vital skill to enable the HF nurse specialist to carry out assessments and empower the client through education so that they can effectively manage their disease. Knowledge of the disease facilitates the client in adapting to behaviour changes such as restricted fluid and salt intake, adhering to pharmacological treatment, monitoring of symptoms and seeking assistance when deterioration symptoms of HF are apparent. Assessing client’s history is a skill increasingly being untaken by the specialist heart failure nurse and involves collating information from a range of sources to develop a complete picture of the individual being assessed. The accuracy of information gained depends on the quality of the communication between practitioner and the HF client, (Walsh et all, 2000). However without a deliberate systematic series of actions, the care given can be haphazard and ineffective. After all, if the care is not effective, why deliver it? (Newson, 2008). The procedure allows clients to present their account of the problem and provides essential information for the specialist nurse (Lloyd, H. et al, 2007). The information should be gathered in a calm and confident manner, summarising the information gathered to create or reject hypotheses as to the nature of the client’s problem, ( Burnard, 1996). The specialist nurse should avoid the use of technical terms or jargon and wherever possible use the clients own words. Literature suggests that clients with heart failure have disease-specific barriers to effective communication such as short term memory, confusion and fatigue (Rodgers et al, 2003,Resnizky and Bentur, 2006), therefore it may be a reasonable option to ask family for their opinion regarding the clients health, if the client is unable to self-report. The information gained during history taking allows the nurse to decide which body systems to examine in more detail and to the extent of the investigations (Price et al 2000). During history taking the specialist nurse should initially base questions using PQRST model for symptom analysis (Morton 1993) and, with the clients permission record written notes at intervals to minimise distraction for both the client and specialist nurse. This detailed symptom analysis may assist the specialist nurse to eliminate or to acquire the information required to consider a list of differential diagnoses. History taking results in subjective data. Following history taking the specialist nurse needs to collect objective information in the form of a physical examination (Griffith, 2004). The author uses the SOAPIE health assessment process described by Fitzgerald (1995) ensuring a thorough, systematic health assessment is carried out with HF client. However it is important to perform a review of all systems since this can disclose information which the patient has overlooked (Brickley and Szilagyi, 2007) and Walsh, (2006) further advises that a review should be taken in logical ‘head to toe’ order.
HF places a great deal of stress on all forms of relationships, often creating psychological issues. However through good communication skills and the provision of adequate time the specialist nurse can assist the client in expressing their concerns. Chronic conditions, including HF have a 40% incidence of depression (Kirk and Le Geyt, 2010), and causes physiological changes that are associated with increased morbidity and mortality in clients with HF, failure to identify depression and offer psychological support will have a detrimental effect on the overall management of the client. National Guidelines advocate the utilisation of an allied health care professionals (multidisciplinary team) approach in the management of heart failure clients (NICE, 2010: CREST, 2005). The health care professional team have been shown to reduce hospital admission in clients with HF (Holland et al, 2005). As a HF nurse the author ensures that all the appropriate team members are involved in the clients care and involvement should be individualised but generally includes, cardiologists, physician, community nurses, general practitioners, social workers, dieticians, physiotherapists, occupational therapists, pharmacists and palliative specialist nurses. As well as psychological support the client may have spiritual needs, which is an essential aspect of holistic client care, identifying cultural and spiritual needs is essential in the assessment of chronic conditions as well as ascertaining the existence of an advance direction in order to formulate a management plan. The specialist nurse must be aware, sensitive to and respect the importance of clients specific religious beliefs, values and customs and treat all clients as individuals, treating them with respect and dignity (NMC, 2008). Clients will benefit if nurses adopt a systematic approach to assessing spiritual needs (Govier, 2002), whereas Buswell, (2006) argues that although the nurse practices holistic assessment, the area of spiritual assessment and care is often overlooked. This may be due to the fact that nurse education does not adequately prepare nurses to provide spiritual care as it is seen as the realm of chaplains. However to treat clients well the HF nurse must take into account the value of spiritual elements such as faith, hope and compassion in the healing process (Oates, 2004). The author feels it is important the HF nurse moves towards a more holistic view of care for HF clients. This not only includes the disease process but also a non material element emphasising the connections between the mind and body. Spiritual aspects of care can become increasingly important when the HF client enters end stage heart failure. Many clients with HF will deteriorate over a period of 2 -5 years, characterized by increasing debility that requires frequent hospital admissions. The Department of Health (DOH) has issued guidelines to aid in the decision making process as to when to refer to palliative care specialists. The national gold standards framework (GSF) prognostic indicator guidance (2011) state that clients with HF should be referred to palliative care team if two of the following criteria are met: the nurse should not be “surprised” if the client were to die within the next year, repeated hospital admission with HF. Alternatively some health care professionals feel that it is appropriate to include the palliative services at diagnosis (Connelly and Beattie, 2004). A study by Day et al, (2006) documented that specialist palliative care professionals frequently had concerns regarding their competency in managing HF clients and advocated that HF nurse should continue to be a key worker, with the palliative care team as a useful resource. The author feels that the HF nurse specialist is ideally placed to provide support to the client and family. By communicating at a “human level” can assist in holistic care ensuring that the client and family feels valued, heard and safe in the knowledge that the health care service is providing care tailored towards their needs. The uncertain trajectory of HF can influence the social wellbeing of not only the client but also the family and carers (Murray et all, 2005). Assessment of current social circumstance determines immediate and future practical social care and financial needs (Thackwray, 2011). Questions about a client’s financial condition should be unhurried and handled sensitively by the specialist nurse. This might include discussion about social support and benefits. Intensive home care support has been shown to result in improved quality of life and decreased hospital admissions for clients with HF (Coats, 2005), the HF nurse can play an essential part in obtaining such things as increased home help or financial assistance. Clients, family and carers may need a broad area of support and for the HF nurse to be able to help them access this support requires an equally broad knowledge of the service and agencies available (Stewart and Blue, 2004). However in reality the author finds that this type of support is sometimes only is gained through experience and often by “trial and error”. Sometimes accessing this type of support can often be difficult and may involve having to plough through a myriad of bureaucracy to get the resources that clients are due.
The holistic assessment is a core element in gathering information, making the information accessible and has to be an ongoing process throughout the clients’ illness. Thackwary, (2011) goes on to say that the specialist nurse is ideally placed to obtain accurate information through expert communication skills, history taking and clinical examination and ensures that future changes in the clients condition can be measured and treatment evaluated. The author agrees with Scott (2005) that the specialist nurse is central within the multidisciplinary team ensuring good communication within the team and an effective liaison. However, in order to practice safely the specialist practitioner must ensure they have the skills and competencies required.
This in turn will result in improved client care, improved outcomes and more importantly increasingly empowered clients and families.