Leading change

The Nurse Consultant in the chest clinic at the Royal Victoria Infirmary, Newcastle Upon Tyne Foundation Trust led on the development and implementation of a new Cognitive Behavioural Therapy (CBT) service for patients with Chronic Obstructive Pulmonary Disorder (COPD). By extending the respiratory nurses’ CBT skills, the programme has improved patient outcomes as well as experience and use of resources.

Where to look

The Chest Clinic has approximately 17,000 patient attendances per year.  Patients have a number of respiratory problems including Asthma, Bronchiectasis, Chronic Obstructive Pulmonary Disease (COPD), Cystic Fibrosis, Interstitial Lung Disease (ILD), Lung Cancer, Occupational Lung Disease and Tuberculosis. After completing a research project on the impact of COPD from a patient’s perspective the nurse consultant identified that patients commonly experienced symptoms of anxiety and depression in addition to frightening breathlessness. The nurse consultant identified unwarranted variation in that the existing service provided a purely medical model to treat these conditions therefore not addressing wider holistic needs of the patient. The nurse identified an opportunity to develop the service to address the impact of COPD on well-being, by including a psychophysiological model, ensuring that evidence based practice was being used effectively. Indeed, NICE (2014) suggests that people with anxiety and other common mental health disorders should be offered evidence-based psychological interventions such as CBT as a first line of treatment.

What to change

As identification of these conditions in primary care has been shown to be difficult for a variety of reasons (Nice 2014) the nurse consultant felt there was an opportunity to address such symptomatology in the patients receiving care in the respiratory services in order to improve their outcomes.

The Nurse Consultant led on the development and implementation of a respiratory nurse led CBT-based service, through the education and training of the respiratory nurses within the service, as well as a quantitative analysis to assess the impact this had on patients.

How to change

Having completed a Post Graduate Diploma in Cognitive Behavioural Therapy, the nurse consultant developed a bespoke CBT treatment (The Lung Manual) programme for respiratory patients and piloted this treatment package at the chest clinic.  Home visits were also offered to patients with severe respiratory disease.

The evaluation tested the impact of the new model of care utilising the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS), as well as considering the impact on admissions to hospital and patient experience. 1500 patients were seen in clinic or at home and screened using the tool. Of these, fifty nine percent (885 patients) exhibited symptoms of anxiety and were considered for the treatment package with the CBT principles embedded.

Four nurses were trained to deliver the Lung Manual intervention to enhance their understanding, knowledge and skills in addressing emotional distress. The Lung Manual CBT Model is a collaborative patient centred intervention that helps support patients with long term conditions to manage their illness. Digital technology was also harnessed to develop a blended learning foundation course for staff working in the physical health setting to enrich their CBT skills.

Once education was completed, staff could offer the Lung Manual treatment package to patients. They were able to work collaboratively with individuals and their families to co-develop individualised psychophysiological treatment plans. The aim was to equip patients and their families to make informed choices and manage their own health. These plans were routinely reviewed based on individual (subjective) responses to the efficacy of the treatment to manage their symptoms. The responses were based on the HADS scores and patient experience.

The nurse consultant maintained oversight of the programme offering supervision and support to the nurses delivering the new model of care to ensure this remained evidence based and the treatment aligned to that described in the manual.

Adding value

Better outcomes –The results demonstrated that anxiety levels were significantly reduced in patients receiving the CBT package, with fewer hospital admissions and decreased emergency department attendance also recorded. Eighty five percent of patients treated under the new CBT model completed the full course of CBT which indicates high levels of engagement in this patient cohort.

Better experience – In addition to the outcome measures outlined above, patient feedback was sought by an independent research nurse. Patients overwhelmingly found the enriched intervention useful to address breathlessness, changing their lifestyle e.g. stopping smoking or losing weight and managing symptoms of anxiety and depression. Patient said they would prefer to see their respiratory nurse involved in their care than be referred to another service for CBT, as they may not fully understand the complexities of COPD and its symptoms. Some examples of feedback include:

“Very good to look at the whole person.  I found the techniques useful.”

“Certainly beneficial, positive thoughts and coping strategies, able to more readily accept my condition and prognosis.”

“Absolutely brilliant – makes a big difference to my life.”

Better use of resources – Importantly, CBT delivered by respiratory nurses has been identified as a clinically and cost-effective treatment for anxiety in patients with COPD in comparison to lower level interventions previously relied upon such as brief advice and self- help leaflets.

Challenges and lessons learnt for implementation

A key benefit of enhancing the CBT skills of respiratory nurses is their sound knowledge base of the impact of respiratory conditions such as COPD so they are in a position to offer a multi-faceted service as a part of one clinic.

Developing dual respiratory and psychological skills allows them to distinguish and manage physical and psychological causes of symptoms in their patients, which can result in better health and wellbeing, increased quality care and efficient use of health care resources.

A challenge can be integrating innovative models of care such as this into existing healthcare systems especially where there are traditional ways of working.

Due to the success of the programme, respiratory nurse led CBT is now embedded into the offer to respiratory patients locally who exhibit symptoms of anxiety & depression.

Research associated with this programme of work has been accepted for publication.

For more information contact

Dr Karen Heslop-Marshall
Nurse Consultant
Karen.Marshall1@newcastle.ac.uk