Specialist liaison nurses

Evidence for their effectiveness is limited

General practice p 706

The number and the roles of clinical nurse specialists continue to increase in many areas of health care, despite limited evidence about their use. Some see the role as a threat to generalist nurses1 or even to primary care physicians. Nevertheless, nurses now lead services, admit and discharge patients, make autonomous clinical decisions, and organise programmes of care.2 What do we know about the use of such nurses and about their effectiveness?

The largest group of specialist nurse roles, in both hospital and community settings, are Macmillan nurses, who provide palliative care, followed by specialist nurses in diabetes, asthma, stoma wound care, infection control, and HIV/AIDS.3 One more recent trend has been for clinical nurse specialists based in hospital to serve as liaison nurses to the community, providing care across organisational boundaries, particularly in chronic disease management. A database maintained at the University of Sheffield identifies 603 specialist posts in 40 acute trusts, but most of these emerging new initiatives have not been reliably evaluated. The UK nursing registration body (the United Kingdom Central Council) does not define standards or set specific training for clinical nurse specialists or nurse practitioners, and, since the title is not protected, it can be used by any registered nurse.2 The council has, however, issued proposals for a professional standards framework for these developing roles.4

In terms of what these specialist nurses do best, however, there is less consensus. Training led by nurse specialists may be effective, with a study comparing specialist and generic community nursing for HIV/AIDS finding that both generic community nurses and patients benefited from specialist nurse input.5 Community nurse managers interviewed in an earlier study thought that the introduction of HIV/AIDS specialist nurses had resulted in improved patient care, improved knowledge among district nurses, and better communication between hospital and community.6

Few randomised controlled trials have looked specifically at the value of clinical nurse specialists in terms of clinical and cost effectiveness, although evaluative surveys have revealed high levels of satisfaction with the care received.7-10 One randomised trial investigated the role of the specialist nurse for patients with stroke in the community and showed that specialist nurse intervention (advice, information, and support to patients and their families) resulted in, at best, a small improvement in social activities, and only for mildly disabled patients.11 A randomised trial of the effects of a specialist nurse coordinator for terminally ill patients showed little difference in patient or family outcomes.12 However, the coordination service was more cost effective than standard services for patients with a life expectancy of under one year.13

Another study assessed a one year programme for patients leaving hospital after myocardial infarction.14 The programme combined monthly telephone monitoring of psychological distress symptoms with home nursing visits in response to high levels of distress. The nurses had coronary care experience but no specialist mental health training. The study showed no impact on either survival or psychological outcomes. Another nurse liaison initiative in secondary prevention after admission with myocardial infarction or angina, reported in this week's issue (p 706), represents an essentially negative study: three full time trained nurses followed up only 320 patients for one year, with no significant effects on clinical outcomes, including blood pressure control, cholesterol or smoking reduction, fitness, or weight.15

Evidence of nurse led interventions in heart failure is more positive. Nurses‘ involvement in predischarge patient education and home visiting, concentrating on adherence to treatment and recognising early signs of deterioration, has shown significant reductions in readmission rates and quality of life. 16 17 Another nurse specialism with positive outcomes is anticoagulation management: nurse specialists are no more expensive than the consultant service,18 are at least as effective in terms of control,19 and offer some clear advantages, such as provision of domiciliary care for housebound patients and acceptability to general practitioners and patients.20

So what might we conclude from these conflicting data? On current evidence it seems that specialist nurses are not likely to have a positive impact on care outcomes if their role is essentially coordination of existing services, especially if such services are themselves of variable quality.16 However, when nurses have a well defined role in actually delivering clinical care, additional and specialised care such as medication monitoring, or specific patient education they seem to be effective. Nevertheless, further studies are needed to assess the clinical and cost effectiveness of specialist nurses in each role and setting—and this shouldhappen before their services are more widely adopted.