Abstract
AIMS:
Although chronic diseases are the most common and expensive health problems, they are preventable too. Nurses play a key role in the care of these patients. One of the important roles of nurses is consultation role. Due to the high impact of nurse consultant role on health promotion and also the fact that this role is not fully understood in Iran, this study aims at clarifying the role of nurse consultant.
MATERIALS AND METHODS:
This is a qualitative study with content analysis approach conducted through semi-structured interviews in Isfahan University of Medical Sciences from April to December 2017. A total of 35 participants (11 patients, 9 nurses, 6 faculty members, 4 postgraduate students, and 5 nursing managers) were included in the study. Sampling was done based on purposive sampling method, and participants were asked to express their opinions about nurse consultant.
RESULTS:
In this article, we discussed the following three categories and seven subcategories: (1) nursing consultation as a treatment facilitator (nursing consultation as a way to reduce the treatment course, nursing consultation as a way to reduce complications, and nursing consultation as a way to reduce costs); (2) professional performance in nursing consultation (nursing consultation based on problem-solving and evidence-based practice and management and teamwork in nursing consultation); and (3) prerequisites for the nursing consultation role (supporting nurses and introducing the role in decision-making units and creating demand).
CONCLUSION:
Nursing consultation has an essential role in patient health promotion. Therefore, it is better that nurses and other health-care team should be familiar with this vital role.
Keywords: Chronic diseases, consultant nurse, health promotion
Introduction
Chronic diseases, as long-term life-threatening diseases, increase the financial, social, and psychological burden of patients.[1,2] They contribute to 60% of global mortality and this will reach to 80% in 2020.[3] Frequent hospitalization, use of health services, taking multiple medications, and reduction of the autonomy are among the problems of patients with chronic diseases.[4]
Nurses play a key role in the care of patients with chronic diseases and are considered as the basis of maintaining and promoting health in these patients.[5,6] Health promotion is defined as the process of empowering people to increase control on their health and leads to positive results in activities related to health.[7,8] It seems that nurses have the most important performances in health promotion,[7,9] but chronic disease management requires new considerations.[10] It should also be noted that each client has his/her own characteristics and is not classified in certain groups based on age, race, gender, socioeconomic status, culture, and education levels because chronic disease does not always have a similar path of disease process. Thus, the solutions and resources that clients and families require vary to a great extent.[9] So, according to completely different understanding of the diseases and their management, for different patients, it is necessary to examine acceptance, knowledge, and understanding of patients separately. Therefore, it is essential to employ consultation appropriate to each patient.[11]
One of the important roles of nurses is the role of consultant. Nursing consultation refers to a collection of activities offered to patients to improve, maintain, or rehabilitate their problems.[12] In 1999, the Development of Health circular in the UK announced that the goal of creating nursing consultation role is to contribute to better outcomes in health for patients, by improving services and quality, and the role of nurse consultant was first established in 2000 in the UK.[13,14] Nurses are required to offer nursing consultation to encourage individuals, families, and community in performing self-care activities that increase self-confidence, responsibility of individuals, health promotion, and health motivation.[15,16] On the other hand, this role has a great impact on the health promotion of chronic patients.[12,17,18] The results of nursing consultation include improving quality of life, satisfaction, awareness, and adherence in patients; preventing and reducing distress, stress, anxiety, and complications; reducing costs and readmission; and also preventing worsening of the disease and mortality.[12,19,20,21,22] Unfortunately, in Iran, patients do not receive nursing consultation services and this role does not have a real status. Moreover, some nurses in Iran are not familiar with this critical and necessary role.
In most countries, nursing consultation role is a well-known and accepted role, and numerous researches have been conducted on nursing consultation role.[12,21,23,24,25,26] However, no article has been found which clarifies the role of nurse consultant in Iran, and researchers that examined the effect of nursing consultation on various diseases were unfamiliar with nursing consultation role and used group education and psychosocial counseling or nursing supporting role instead of nursing consultation role.[27,28,29,30,31] As mentioned, this critical role is unknown in Iran; hence, this study aims to clarify the role of nurse consultant.
Materials and Methods
This study is a qualitative one with content analysis approach conducted through semi-structured interviews in Isfahan University of Medical Sciences from April to December 2017. Content analysis is a research method to make real inferences from data within the text, to create knowledge and new insights to reveal fact. It also aims to obtain a clear and concise description of the phenomenon.[32]
The study population included 35 participants (11 patients, 9 nurses, 6 faculty members, 4 postgraduate students, and 5 nursing managers). Sampling was based on purposive approach, with maximum diversity in terms of age, gender, work experience, and workplace. The sampling continued till saturation. Inclusion criteria for faculty members, nursing managers, and postgraduate students included experience in the field of research subject and willingness to participate in the study. Nurses at the graduate level should have at least 2 years’ clinical experience or have a Master's degree or PhD in nursing. Inclusion criteria for patients were a history of at least 1 year from the initiation of the disease[21] and be helpful in explaining the role. Exclusion criteria were lack of desire to continue in the study and those patients who were diagnosed to have psychiatric disorders.
Interviews were conducted as semi-structured face-to-face interviews. At first, general questions were raised, and the interview process was guided according to the responses of participants. Participants were asked to express their opinions about nurse consultant, chronic patients’ needs, how they should give consultation service to patients, and generally any experience and idea in this regard. Each interview lasted between 40 and 60 min.
After interviews, the researcher listened to the recorded tape carefully. Then, it was transcribed, and content analysis method of Elo and Kyngäs was used. First, the text was read carefully, and then word, sentence, or paragraph was chosen as semantic unit. After that, semantic units were further analyzed and incorporated based on similarities, and codes were extracted. Similar codes were classified in subcategories, and these subcategories formed categories based on similarities. Finally, categories were extracted.
Rigor
The accuracy of the data was evaluated using Lincoln and Guba's ideas. That is, to check the credibility of data, various in-depth interviews were conducted with different peoples. Member check and peer check were done. To evaluate the dependability of data, all details of the research were stated and recorded one by one. For confirmability, colleagues and other faculty members who were familiar with the analysis of qualitative research and not involved in the study were asked to offer their reviews and feedback. And, for transferability, research results were presented to a number of nurses and faculty members who did not participate in the study in order to judge them on the similarity between the results and their experiences.
Ethical consideration
This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (393305). In order to conduct the study, the researcher went to the research environment, introduced herself, explained the objectives of the research, and informed consent was provided. The time and place of the interview were also determined according to the participants’ consent. Each participant was assigned a code, and they were also reminded that they could leave the study whenever they wished to.
Results
Table 1 shows the characteristics of the participants.
Table 1.
Characteristics of the participants in this study
| Participants | n | Gender | Average age | Average experience/duration of disease |
|---|---|---|---|---|
| Patient | 11 | Three women and one man | 62 | 14 |
| Nurse | 9 | Women | 35 | 11 |
| Faculty member | 6 | Two men and four women | 53 | 25 |
| Nursing manager | 5 | Four men and one woman | 47 | 18 |
| Graduate student | 4 | Women | 33 | 4 |
This article discussed the following three categories and seven related subcategories: (1) nursing consultant as a treatment facilitator (nursing consultation as a way to reduce the treatment course, nursing consultation as a way to reduce complications, and nursing consultation as a way to reduce costs); (2) professional performance of nursing consultants (nursing consultation based on problem-solving and evidence-based practice and management and teamwork in nursing consultation); and (3) prerequisites of nursing consultation role (supporting nurses and introducing the role in decision-making units and creating demand). The categories and subcategories are summarized in Table 2.
Table 2.
Categories and subcategories of this study
| 1. Nurse consultant as treatment facilitator |
| 1. Nursing consultation as a way to reduce treatment course |
| 2. Nursing consultation as a way to reduce complications |
| 3. Nursing consultation as a way to reduce costs |
| 2. Professional performance of nurse consultation |
| 1. Nursing consultation based on problem-solving and evidence-based practice |
| 2. Management and teamwork in nursing consultation |
| 3. Prerequisites of nursing consultation role |
| 1. Supporting nurses and introducing this role in decision-making units |
| 2. Demand creation |
Nursing consultant as treatment facilitator
Nursing consultation as a way to reduce treatment course
Chronic patients encounter many problems in the course of their treatment and many are confused in this way. Disease complications, drug side effects and comorbidities are examples of the problems of chronic patients and have no solution to solve them. Nurses’ guide can help reduce much of this confusion. One of the nursing managers stated:
“Having good dominance on patients and treatment team, nurses can help patients decide which physician to refer to and which stages to complete. A simple example is when we get a cold; people think if they go to a lung specialist, they’ll feel well soon. Therefore, if he goes to a general physician who has experienced so many common cold diseases, he can receive much help.”
One of the patients said:
“After surgery, the patient feels many problems…there is no access to hospital and doctor as well. These problems pile up and solving them seems difficult…”
Other patients who participated in this study also had issues such as problems with referring to the doctor and a lot of problems and questions. Hence, nurse consultants can help patients solve their problem and guide them, and the treatment process will be shorter. For example, nurse consultants can guide patients to select proper physician appropriate to their diseases, to refer to physiotherapist, and to help them in diagnostic procedure.
Nursing consultation as a way to reduce complications
Guiding the patient in terms of adherence to treatment regimen, coping with disease, creating self-control, and considering his/her mental problems can reduce many disease complications. One nurse expressed:
“The carer said that the patient had been taking such medicine for ten years. I (nurse) asked, didn’t he (patient) feel any side effects? He answered yes, when he took pills he felt dizzy within two hours. We as nurses should educate them to take patient's blood pressure first and give the pill next.”
Adherence to treatment is low in patients with chronic diseases because they are usually tired of illness and do not have motivation or they are alone. A coronary care unit (CCU) nurse stated:
“We have a patient who is an overeater and doesn’t follow his diet, so whatever we teach is not useful.”
The effect of nursing consultation to reduce complications has been proved, and nurses in this study also revealed it. participants in this study said that nurse consultant can affect important role in reducing complication and readmission, therefore the burden on hospitals will reduced.
Nursing consultation as a way to reduce costs
All interviewees acknowledged that, if there is a nurse consultant, both patient and health system costs will be reduced. One of the nurses expressed:
“For poor people, treatment is too expensive thus prevention and health promotion behavior through nursing consultation is much better than treatment.”
This category showed that patients, nurses, nursing managers, and faculty members all agree that nursing consultation is needed in Iran and in the absence of such a possibility, patients encounter many problems. Moreover, nurse consultants can help patients in many cases; for example, referring, supporting, empowerment, creating self-care, and reducing costs.
Professional practice in nursing consultation
Nursing consultation based on problem-solving and evidence-based practice
In all resources dealing with nursing consultation, it is stated that nursing consultation is performed in the form of problem-solving and evidence-based practice, and all participants who were somehow familiar with nursing consultation pointed to this topic too. A Ph.D candidate and a nursing manager expressed:
Ph.D candidate:
“When a patient is faced with a problem, we guide him/her and in fact undertake problem-solving; we solve the problem by consultation.”
Nursing manager:
“Nurse consultant must offer consultation based on evidence. Then he should put it aside and see which evidence is consistent with the patient's condition.”
Management and teamwork in nursing consultation
Nursing consultation is not possible without considering the treatment team. A faculty member of nursing school believed:
“It is essential to have a consultation team. For example: nutritionist, physiotherapist and psychiatrist or…I think it's better to act professionally since we want to have problem-solving.”
Professional practice in nursing profession promotes professionalism which is quite obvious in the consultant role of nurses as participants have pointed to this issue.
This category states that nursing consultation is a special role and doing through problem-solving process and evidence-based practice, also in nursing consultation creating team is necessary.
Prerequisites of nursing consultation role
Support nurses and introduce the role in decision-making units
Due to the fact that professional roles including nursing consultation role have no position in Iran and nurses do not provide services in this role, policymaking organizations should support this role adequately to establish proper status.
Two faculty members expressed:
“The system must have a regular schedule and provide conditions…it doesn’t have at the moment…patients don’t know where to refer. No status is defined for us.”
“…the status of (nurse consultant) is of high importance. If we can define the role, we can offer it but if we have no status we cannot. Anyway, nurses must be supported in terms of legal and moral issues.”
Given that nursing consultation is one of the main roles in nursing, and on the other hand, patients will benefit greatly from the role service, this role should be considered and it is better to pay more attention to this role.
Demand creation
One of the postgraduate students, concerned with patients’ health in an environment outside of hospital, stated:
“Wide advertisement must be done (for nursing consultation role) like medical consultation programs shown on TV…we can invite a nurse consultant once…it must be culturized…”
Having said that, although patients with chronic diseases need nursing consultation, they are not aware of their needs, and need is different from demand. Two faculty members expressed:
“We need to improve the Public health culture for nurse consultant role. Community health literacy should be high so that people demand such a role. We need demand, we must create demand. So, consultation is a crucial point in demand creation.”
“Need is different from demand. Need exists. If need is to turn into demand, it’ll be an additional stage.”
This subcategory also states that, although patients need consultation, they may not express it. In many cases, patients think that their problem do not have a solution and they do not follow the solution, therefore some patients do not look for nurse consultant. Hence, it is the duty of nurse consultant to inform and guide them.
The categories show that chronic patients have many needs and problems and are confused as to how to solve them. However, there is great potentiality in nurses who are aware of the importance of nursing consultation role to provision of services.
Discussion
Nursing consultation as treatment facilitation includes the following subcategories: nursing consultation as a way to reduce treatment course, nursing consultation as a way to reduce complications, and nursing consultation as a way to reduce costs that seem to be compatible with the results of some studies on nursing consultation. In their article, de Souza Braga et al. also deal with the impact of nursing consultation on the adherence to treatment and reduction of complications.[12] In Gerrish et al.'s article, it is stated that nursing consultation is effective in the physical and psychological outcomes of patients.[19] In Chiu and Wong and Dedoncker et al.'s study, the experimental group had a significant decrease in blood pressure, and also follow-up program, self-care, healthier life style, and awareness of risk factors had been improved.[33,34] Studies show that reduced readmissions, reduced length of hospitalization, and increased communication with community services are the results of nursing consultation, that leads to health promotion and saving costs.[19,35]
The category of professional performance in nursing consultation (nursing consultation based on problem-solving and evidence-based practice and teamwork in nursing consultation) is similar to some articles. Currey et al. stated that nursing consultation role leads to evidence-based care development.[36] In Gerrish et al.'s study, problem-solving and teamwork are mentioned as consultant nurses’ acts.[19] Team work is also a crucial element of consultation role and is based on priorities required to change the given organization.[13,23] In Baldwin et al.'s study, nurse consultants tended to consider patients in the treatment team and they wished to include other team members; for example, a doctor or nutritionist to be involved in the discussion when the patient is receiving consultation.[37]
Another category of this study was prerequisites for the consulting role of nurses (supporting nurses and introducing the role in decision-making units and creating demand).
In some studies, supporting nurses and introducing the role in decision-making units is mentioned. In this regard, studies mentioned the need for supporting the role, clarifying it to organizations, changing organizational culture, and had emphasized for the necessity of acceptance of the nursing consultation role by other colleagues.[38,39,40] In these studies, nurses did not have enough support. In contrast, in many articles, nurses received adequate support from the organization, physicians, and nurse colleagues.[41,42,43] Franks also reported that the development of this role occurs not only through clinical needs but also through political motives such as the need for the development of nursing roles and economic change.[17] Therefore, these results are consistent with our results that demonstrate the necessity of support of nurse consultants and introducing it to organizations.
Stichler stated that patients know that they need help but resist in the process of making the changes to meet their goals and do not have demand.[44] This result is consistent with our research, but in contrast, Ryan et al. stated that patients express their satisfaction with nursing consultation.[45] Woodward et al. also stated that even the reluctance of patients to refer to a hospital for physicians’ visits and fatigue of multiple visits make the nursing consultation role more crucial for patients.[41] Considering the importance of nursing consultation role in health promotion, and reducing costs, it seems that this role in nursing needs to be more valued. Hence, we hope that managers and policymakers create a suitable role position for nurse consultants in Iran.
Limitations and strengths of the study
The limitations of the study were that it was not possible to interview some nurses or nursing managers because of lack of enough time and also there was lack of access to full text of some articles. The study strengths were conducting study through help and guide of two supervisor and advisor in associate professor degree of this research and theses. Addressing an important issue such as nursing consultation role can be considered as a high strength in this study.
Conclusion
With regard to the importance and need of nursing consultation role and its impact on patients’ health promotion, we can make nurses familiar with this essential role through explaining and clarifying it so that we can step forward in improving the quality of nursing care, health promotion, reduction of hospital readmission, and reduction of complications in patients with chronic diseases.
Financial support and sponsorship
This study was funded and supported by the Department of Research and Technology, Isfahan University of Medical Sciences, who played no role in the study design, data collection, analysis, and writing or submission of publications.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We would like to thank all of the professors who contributed to this research by their scientific guidance. The research team also expresses greatest thanks to all participants in this research including patients, nurses, faculty members, graduate students, and nursing managers.
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