Abstract
Respiratory clinical guidelines provide clinicians with evidence-based guidance for practice. Clinical guidelines also provide an opportunity to identify the knowledge and technical and non-technical skills required by respiratory ward-based registered nurses. The aim of this review was to use a systematic process to establish the core technical and non-technical skills and knowledge identified in evidence-based clinical guidelines that enable the care of hospitalised adult respiratory patients.
17 guidelines were identified in our systematic review. The quality assessment demonstrated variability in these guidelines. Common core knowledge and technical and non-technical skills were identified. These include pathophysiology, understanding of physiological measurements and monitoring, education, counselling, and ward and patient management.
The knowledge and skills extracted from respiratory clinical guidelines may inform a curriculum for ward-based respiratory nursing to ensure optimal care of adult patients.
Abstract
Knowledge and skills identified in clinical guidelines provide a foundation for a curriculum for respiratory nurses http://ow.ly/w6TE301O5Ya
Introduction
Respiratory medical conditions contribute to significant levels of physical, social and economic burden experienced by patients and their families [1, 2]. Many patients with respiratory diseases may have episodes of worsening disease due to a variety of causes such as infection or responses to allergens [1]. Often these episodes require patients to be hospitalised and received ward-based therapy and care to the standard that is advocated in clinical guidelines and statements.
Evidence-based guidelines and statements for various respiratory conditions are recommended to health professionals as a summary of the evidence for treatment and therapies to ensure optimal patient outcomes. At an acute hospital ward level, clinical guidelines and statements could underpin the core clinical knowledge and skills required by registered nurses to deliver best practice in specialised respiratory wards. There is substantial evidence from across Europe that degree level education and staffing levels that incorporate staff–patient ratios are associated with a reduction in mortality [3]. From a specialist ward perspective, there has been limited attention given to the expectations in terms of knowledge and skills of registered nurses who provide care to respiratory patients and are not in advanced practice roles such as clinical nurse specialists and clinical nurse consultants.
Health professional societies have used consensus methodology to map clinical knowledge and skills as a process to develop ongoing educational and training activities [4]. It should be noted that the teaching and learning philosophy is not often derived during the consensus of core knowledge and skills that form a curriculum [4]. Consensus for such clinical training curriculums is often gained through expert opinion using surveys and modified Delphi methods such as e-Delphi [5]. An alternative approach to consensus by experts is the examination of evidence-based respiratory clinical guidelines to ascertain the knowledge and skills required for ward-based registered nurses to be able to deliver optimal care, which may not have been considered to date.
This review reports the exploration of evidence based-respiratory clinical guidelines as a frame of reference for the essential clinical skills and knowledge required at ward level to ensure registered nurses are adequately prepared to provide the highest level of clinical care to adult patients. The aim of the review was to use a systematic process to establish the core technical and non-technical skills and knowledge espoused in respiratory evidence-based clinical guidelines that enable the care of hospitalised respiratory adult patients.
Methods
The review’s objective was to identify key clinically relevant technical and non-technical skills and knowledge within evidence-based respiratory clinical guidelines. Clinical guidelines that reflect the most common respiratory conditions and specific clinical therapies associated with the care of ward-based adult patients were identified. These guidelines comprise asthma, chronic obstructive pulmonary disease (COPD), tuberculosis, lung cancer, pneumonia, influenza, smoking cessation, pulmonary rehabilitation and oxygen therapy.
Search strategy
A systematic search of respiratory clinical guidelines for acute hospital ward-based care was performed in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) [6]. An a priori protocol was developed and implemented reflecting PRISMA guidance. From July 2015 to May 2016 we searched the Cochrane Library, MEDLINE, PubMed, CINAHL and Embase electronic databases. In addition, we searched the National Institute of Clinical Excellence (UK), British Thoracic Society, Thoracic Society of Australia and New Zealand, European Respiratory Society, American Thoracic Society, and the Asian Pacific Society of Respirology websites for clinical guidelines relevant to the common respiratory conditions treated in acute hospitals and the use of specific disease-related therapies. The search terms guideline, asthma, chronic obstructive pulmonary disease, community acquired pneumonia, lung cancer, influenza, oxygen therapy, smoking cessation and pulmonary rehabilitation were combined and examples of abbreviations used include guide*, COPD, pneumon*, O2* oxygen, flu* influenza, pul* rehab*, smok* quit. Search limits included clinical guidelines published in the English language and the publication date was restricted to the past 7 years.
Eligibility criteria
Published evidence-based clinical guidelines that reflect the most common respiratory conditions and related therapies associated with ward-based respiratory patients’ care were identified. Statements, local guidelines and clinical protocols that had or had not been published as an evidence-based document were excluded.
Systematic review selection and data extraction
Both authors independently reviewed clinical guideline titles associated with hospitalised adult respiratory patients’ care prior to the full guideline being obtained. Any disagreements were discussed until consensus for inclusion or exclusion was achieved. Data were extracted from each guideline and any duplicate data noted.
Evidence-based clinical guideline quality assessment
The Appraisal of Guidelines for Research and Evaluation (AGREE) version two [7] was utilised to assess the overall quality of the published evidence-based clinical guidelines. The AGREE II instrument has 23 items in six domains that relate to the quality of a guideline. These domains comprised scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence. Each guideline was assessed in each of the six domains and a summary was tabulated (table 1).
Assessment of the guidelines in each of the six domains of the AGREE II instrument
Data synthesis
Both authors confirmed the inclusion of technical and non-technical skills and knowledge specific information, displayed in table 2.
Technical and non-technical skills and knowledge specific information required for each respiratory condition
Results
The total number of relevant respiratory clinical guideline citations retrieved was 10 from the database and electronic searches. A further 19 respiratory clinical guidelines and statements were identified on respiratory society’s websites. Duplicate clinical guidelines were removed and the 21 full versions of respiratory clinical guidelines were retrieved. Eligibility criteria were applied and four were considered ineligible leaving 18 respiratory clinical guidelines (figure 1) to be included in the analyses of clinical technical and non-technical skills and respiratory specific knowledge.
Overview of included respiratory clinical guidelines
18 respiratory clinical guidelines for adult care were identified and one guideline referred to two societies, ERS/ATS guidelines for severe asthma resulting in 17 guidelines. Of the 17 guidelines, the clinical diseases and therapies covered were asthma [9, 15, 18, 23], COPD [10, 24], lung cancer [11], pneumonia [12, 19, 20], tuberculosis [13], influenza [16, 21], pulmonary rehabilitation [14], oxygen therapy [17, 22], and smoking cessation [8].
Quality assessment of guidelines
Quality assessment was carried out using the AGREE II criteria, which include 23 items in six domains with a seven point rating scale for each item (table 1). The highest rating score of 161 was not achieved for any of the guidelines in this review. The tuberculosis guideline from NICE achieved a rating of 146.
Guideline-based knowledge
The guideline-based knowledge is summarised in table 2. The core areas of knowledge within these guidelines pertain to understanding the disease and associated pathophysiology along with physiological changes, awareness of the physiological measurements for monitoring patient health status, and disease treatment associated pharmacological and non-pharmacological interventions.
Technical skills
There were common technical skills identified in the majority of guidelines. These skills included assessing the physiological status of the patient through pulse oximetry, respiratory rate, heart rate, lung function using spirometry and peak flow tools, oxygen delivery devices, arterial blood gases, sputum assessment, and administration of intravenous and drug therapy.
Non-technical skills
The non-technical skills relate to the delivery of care planning and education support. Therefore the core areas in the guidelines reviewed that are patient focused involve: understanding teaching and learning techniques; counselling patients to change behaviour; and organisational and management skills for the delivery of care. In addition to patient related non-technical skills, this review found that professional development of ward-based nurses may include training associated with the implementation of new respiratory monitoring equipment and new standards for practice in clinical guidelines.
Discussion
This review of respiratory clinical guidelines identified 17 guidelines on respiratory conditions that form the majority of patient care in respiratory wards. There were several core areas of knowledge, technical topics and non-technical subjects that were common to many of the guidelines. The use of the AGREE II criteria demonstrates that within the guidelines associated with respiratory conditions there was variability in quality. This variability may be due to extensive evidence being distilled to provide more easily accessible and readable information for clinicians who use this guidance in their everyday clinical practice.
In terms of respiratory knowledge, core knowledge was found across several clinical guidelines. These knowledge areas comprise pathophysiology, treatments and interventions, and understanding of health status measurement. Technical skills contained within these guidelines were respiratory and haemodynamic monitoring, delivery of respiratory based interventions, and administration of intravenous and other therapies. The core non-technical skills that were identified included several key topics, of which some were patient focused and others pertained to nursing staff professional development.
This respiratory knowledge and skills could be the basis for education and skill development training for ward-based nurses to reduce any inconsistencies in the delivery of bedside care to the patient. Of equal importance is the maintenance of ward-based nurses’ ability to carry out technical and non-technical skills through regular opportunities to update their knowledge of the latest evidence associated with their ward-based practice.
A limitation of this review is that respiratory patients often have a number of comorbid conditions and they may require additional therapies such as noninvasive ventilation. These additional medical conditions, such as heart failure, sleep apnoea and diabetes along with symptom clusters such as breathlessness, pain and fatigue, may need to be mapped across the domains of knowledge, technical and non-technical skills to ensure comprehensive clinical care is available to adult respiratory patients. Another limitation of this review is that some guidelines may be either under review or were not identified during our search. Using the process outlined in this review, additional information from new guidelines could be mapped in a similar way in terms of respiratory practice knowledge and skills. A replication of this mapping process may be used for nurses who provide care for paediatric respiratory patients as a way to highlight their speciality ward-based knowledge and skills that represent their professional practice.
While international guidance for respiratory conditions aims ultimately to provide the best available evidence, various countries will have a different scope of practice for different disciplines. The information in this review needs to be considered in terms of each countries nurses’ industrial award change to conditions of employment and registered nurses scope of ward-level practice.
Conclusion
This review sought to outline the knowledge, technical and non-technical skills required to delivery optimal respiratory evidence-based guideline care. The core knowledge required by nurses spanned several guidelines and consisted of disease pathophysiology and pharmacological and non-pharmaceutical interventions. The technical skills promoted within these guidelines were respiratory and haemodynamic monitoring, delivery of respiratory based interventions and administration of intravenous therapy. In addition the non-technical skills were applicable to both patient-focused care and ward-based nursing staff professional development. While a limitation of this review may be that some guidelines were not identified, this process provides a foundation for building a professional curriculum to support the education and development of respiratory ward-based nurses to ensure the delivery of optimal patient care.
Footnotes
Conflict of interest None declared.
- ©ERS 2016
Breathe articles are open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.
References
