- Email: [email protected]
Reflections on the development of nurse-led back pain triage clinics in the UK
International Journal of Orthopaedic and Trauma Nursing (2011) 15, 113–120
www.elsevier.com/locate/ijotn
Reflections on the development of nurse-led back pain triage clinics in the UK Margaret M. Murray MSc, RN, ONC, NDN (Independent Nurse UK)
*
South Tees Acute Trust, Marton Road, Middlesbrough 3BW, UK
Summary This paper discusses the development of the first Nurse-led triage clinic for back pain developed in the United Kingdom (UK). It identifies some of the health policies that support development of new ways to deliver services within the UK’s National Health Service (NHS), and explores some of the drivers that enabled such changes. The importance of using evidenced-based practice in developments is noted with some of the benefits to patients, consumers and organisations outlined. The reality of this type of service and its contribution to enabling the organisation to deliver on targets that have been part of regular health care expectations, are noted. Importantly, the Spinal Assessment Clinic (SAC) was a local solution to a local problem. However, the commitment to develop the service underpinned by evidence has made it possible to share this example of best practice with others who have then been able to adapt this to their own ‘local needs’. Consequently this approach has become accepted practice within the NHS, the service has been recognised as important to South Tees Trust in delivering back pain services, and the author was awarded the Order of the British Empire (OBE) in 2002 for her work. c 2010 Elsevier Ltd. All rights reserved.
KEYWORDS Back pain triage; Service development; Evidenced based practice; Audit and research
Editor’s comments This paper describes an important and defining development in nursing that took place some time ago. It occurred at a time which is likely to be seen as a cross-road in the development of advanced nursing practice. There was a clear focus on both quality of care and effectiveness. These were being addressed through innovative approaches to developing the sills of senior practitioners. The developments described here offer an insight into how much difference a highly skilled advanced practitioner can make to assessing the needs of patients and ensuring that their subsequent care is based on need. Back pain continues to have an enormous impact on individuals and society. The approach described in this paper is one option in a world where it is important to make sure that sufferers are supported appropriately by a skilled professional in a system which puts the patient’s needs at its centre. JS
Introduction * Contact address: 60 Cookgate, Nunthorpe, Middlesbrough TS7 0PZ, UK. Tel.: +44 01642 318782. E-mail address: [email protected]
Over the last 30 years the delivery of healthcare has altered in the UK. Some of this has been driven
1878-1241/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2010.11.004
114 by reform of the NHS evident in policy. The main policy drivers pivotal to re-shaping services were ‘‘The Health of The Nation’’ (Department of Health, 1992), ‘‘A First Class Service’’ (Department of Health, 1998), ‘‘The NHS Plan’’ (Department of Health, 2000a, b) and the ‘‘NHS Improvement Plan’’ (2004). More recently, policy has placed emphasis on clear quality requirements based on evidence (National Service Frameworks, 2010) and how liberating some of the talents in the NHS and working in different ways alters how services can be delivered (Department of Health, 2010). Hence, since the 1990’s there has been an emphasis on provision of care which should be clinically effective, underpinned by Evidenced Based Practice (EBP) and include patients as well as clinicians in decision making (Smith 1991; Sackett et al. 1996; Department of Health, 2010). With increasing new and innovative ways of working, the NHS, wishing to recognise this type of work, collaborated with the Hewlett Packard Company to develop an award which would celebrate some of these successes. The Golden Helix Award was inaugurated in 1991 to mark the contribution of healthcare teams to the development of innovative services (Hewlett Packard, 1994). An example of the evidence needed in service development was seen in the presentation given by the Spinal Assessment Clinic (SAC) team as one of the finalists in the Golden Helix Award of 1997 (Greenough et al., 1997). Working in new ways to develop services is challenging, but the initial audit and research conducted by the SAC demonstrated that both innovation and vision is needed. This, however, must be supported organisationally with resources for training/development for modernisation of healthcare delivery to be successful. The initial results from the audit and research conducted by the SAC on clinical effectiveness summarised how the SAC functioned and were initially presented in London in 1997 and subsequently at further meetings regionally, nationally and internationally. In modernising the NHS there has been some ‘blurring’ of roles and increasing Multi-Disciplinary Team (MDT) working. The value of working collaboratively is that the expertise of each individual team member is used but the overall outcome has more impact. This has been identified as beneficial in managing back pain (Koes et al. 2001). It has now become accepted both in primary and secondary care that the first point of contact for the person with back pain does not have to be a medically qualified practitioner. Whilst new services have been developed and provide safe high quality care, there is a need to provide evidence that these
M.M. Murray services make a difference. Consequently inauguration of such services has required commitment to audit, research and outcome evaluation, with data collected from patients, professionals and organisationally to enable monitoring of progress. In the field of orthopaedics this concept is one that has been embraced with a number of new ‘Nurseled’ or ‘Allied Health Professional (AHP)-led’ outpatient services along with diversification of roles in the ward setting and relevant development of educational preparation. Development of these services has enhanced the patient’s journey with a significant impact on the provision of optimum care in the modern NHS. In some cases developments have been in response to an identified problem in the system or as a means to re-shape and deliver patient services. It had become obvious that the different skills of team members could be used in alternative ways to optimise patient outcomes. In the case of Low Back Pain (LBP) there was recognition that only a small number of patients need surgery (Ehrlich 2003; Waddell 1998) yet many were waiting months to be seen by a surgeon. There was increasing acknowledgment that this condition was best managed by embracing traditional and complementary medicine within a multidisciplinary service (Waddell 1998). This was an activity of high volume and high cost for the NHS with estimates that it consumed £6,000million annually (Underwood 1998). Altering provision was perceived to be potentially beneficial providing it was underpinned by collated evidence of clinical and organisational effectiveness. The aim of this paper is to describe the steps taken to develop the first nurse-led triage clinic for back pain management in response to the issues raised above. It will then discuss the data gathered over a number of years which demonstrates how the development of the service has helped to alter patient pathways and demonstrate clinical effectiveness.
Back pain management Over the years many different treatments have been advocated for back pain, some of which could be labelled as traditional but often emerging under the umbrella of complimentary medicine (Cueller et al., 2003). The evaluation of these treatments has often indicated that for some the treatment effect was short-lived or had no impact on sustaining an improved quality of life. Whilst this wealth of information and research was readily available, questions were raised about which options were
Reflections on the development of nurse-led backpain triage clinics in the UK most likely to optimise patient care? Waddell (1998) undertook a review of the various treatments with a focus on quality of research, clinical effectiveness and outcomes. Earlier recommendations (Waddell 1998) were considered by some at the time to be radical, because of the increased emphasis on MDT working and moving focus from secondary to primary care. It was recommended that management of back pain should use a MDT approach including discussion with patients regarding realistic options. This placed an emphasis on controlling the condition and enabling improved lifestyle. The approach avoided a focus on a ‘cure’ and emphasised the value of exercise. The potential effect this could have on resource distribution from secondary to primary care, and subsequent impact on budgets was noted.
Service development South Tees Trust in the North-East of England had a problem with managing some aspects of its LBP referrals and, as an organisation, made a commitment to alter orthopaedic services in attempts to resolve this. In 1992 an orthopaedic surgeon had been appointed with a specific remit to develop a ‘Back Pain Service’ with a dedicated weekly clinic for back pain patients. At the time of his appointment his waiting list was zero weeks. By the time he had been in post for twelve months the waiting time was 64 weeks. This was unacceptable to all concerned. A working group was created that included all stakeholders from both primary and secondary care, embracing the MDT concept and with commitment from managers and commissioners. The aim was to inaugurate a new style of triage clinic that became known as the Spinal SAC and which would use a Nurse-led approach. The purpose of the clinic was to triage patients within six weeks of referral letter from a General Practitioner (GP). As this was the first time in the UK that such an approach had been used, careful arrangements were made at the outset for monitoring of outcomes using research and audit data. Time and resources were committed to the training and development of the nurse who would undertake extended scope practice. As there were no formal education programmes to meet such needs in 1993, in the first instance training and education were conducted using the ‘shadow training method’. This required the nurse to observe, take a history and examine the patient. Using knowledge of anatomy, physiology and pathology there would be an analysis of the history presented and the find-
115
ings from the examination, comparing this to the norm in order to arrive at a nursing diagnosis. The nurse would then clinically present this to the orthopaedic surgeon, providing written and verbal evidence of the logical process undertaken and including recommendations for intervention. This facilitated development of protocols which acted as a baseline standard to open the clinic, thus enabling the first patients to be triaged.
Nurse led clinics In the UK healthcare system nurse-led clinics in a number of specialities have often evolved driven by the need to deliver more timely services through the development of ‘‘multifaceted’’ roles (Lucas 2009). Part of the nurse’s role is gathering data about patient outcomes which allows progress to be monitored objectively. Another aspect of the role is undertaking a thorough history and physical examination so that a nursing diagnosis can be made which informs intervention decisions. Such role development reflects aspects of practice described in the study by Drozd et al. (2007) in which ‘‘partner/guide, risk manager, comfort enhancer and technician’’ were identified and which can be seen in the role of the nurse in the SAC. The nurse needs to be competent at taking history, examining patients, providing education, arranging investigation, follow up appointments and discussing options for intervention. This is a complex role requiring the nurse to act autonomously. During the initial development of the SAC this was acknowledged, with time identified to enable professional development.
Monitoring The SAC commenced in March 1993 and continuous monitoring of interventions and outcomes has demonstrated clinical effectiveness. As part of routine appointments in SAC patients are asked to complete a Low Back Outcome Score (LBOS) questionnaire (Greenough and Fraser 1992). This is a method used to measure the functional capacity of patients. It includes assessment of Activities of Daily Living (ADLs) and distress levels, allowing measurement of objective data. This tool has been used sequentially in subsequent appointments and as part of long-term follow-up providing outcome scores that can be compared. One aim of the clinic was to provide a method to ‘‘fast track’’ any patients potentially requiring surgery, so that the surgeon could arrange access to operation more quickly. This has been shown, in
116 the small percentage of patients who need surgery, to be important. In the case of patients’ not needing surgery, a diagnosis was provided and followed up with information, advice and education about how LBP could be managed with increased selfmanagement. These monitoring arrangements have allowed a consistent approach to be taken from the outset and the clinic has extended its practice with the impact demonstrated through a number of audit and research projects.
Demonstrating success in back pain triage As with any research or audit, evaluating the service takes time and resources. For the purpose of this paper a summary of key points will be made, these include various audit or research projects conduct by the SAC which were approved by the relevant audit and research committees prior to being conducted. This demonstrates the natural progression needed to build evidence of how the SAC has impacted on service development and identifies involvement of professionals and patients in the process. The results of these projects have been reported to the Trauma and Orthopaedic division and management group to provide information for evaluation and business planning. Mention is made above of the ‘natural progression’ of building the evidence, this in essence means that careful steps were taken to ensure the work of the SAC was providing clinical effectiveness in a safe environment. The nature of the triage appointment meant that the patient was being seen by a nurse for diagnosis, so it was appropriate to assess this aspect first. The first audit conducted was a retrospective chart audit on patients seen wherein the nurse had identified potential for surgical intervention. This included a cohort of 178 patients seen in the first eighteen months that the clinic operated and was conducted by an orthopaedic registrar attached to the team, but who had no contact with the patients included in the study (Short et al. 1996). On comparing the nursing documentation/diagnosis to that of the consultant orthopaedic surgeon a correlation of 78% agreement on diagnosis was demonstrated. The next stage of audit was to evaluate the diagnostic agreement in non-surgical patients. This proved to be logistically more difficult. Following clinical discussion it was felt important that patients should be seen and examined by the nurse and orthopaedic surgeon on the same day so that the history and examination was presented in the
M.M. Murray same ‘Time-frame’. To enable this, five clinics were identified where triage patients would be seen by both staff members and a comparison of history and examination would be made at the end of the sessions. This included a cohort of 50 patients and at the end of this audit there was a 92% agreement between the nurse and the surgeon. These results from a professional perspective indicated clinically effective care. It was also felt important to evaluate this from a ‘customer perspective’. The next stage of audit, therefore, was to write to patients who had been triaged and treated wholly under the remit of Nurse-led care, discharged to their GP and had not seen the surgeon. This project was conducted with two cohorts of patients; 100 in each group seen in two consecutive years, who were asked for their opinion of the clinic, of the class sessions they had attended and they were also asked to complete another LBOS questionnaire. This was undertaken using a postal survey. Although there are critics of this method, it is acknowledged that it is a way to monitor progress and gather a large amount of data. The return rate in these surveys was over 80% which was accepted as satisfactory. Indeed De-Vaus (2002) identifies 60% as an acceptable response level in research, so this return rate provided powerful evidence. The results showed that the LBOS had improved from 29 at triage to 35 on review (P < 0.01). In both cohorts the patients rated the clinic as ‘Very Good ‘ 76% and 87% or ‘Fairly Good’ 18% and 11%, respectively on each of the two occasions. Only 6% in audit one and 2% in audit two finding it of little or no help. When asked for the opinion of education classes the satisfaction rate decreased to 67%. It is well known, however, that changing health beliefs can be complex (Telford et al. 2006). At this stage perhaps part of the problem was recognition by patients of the increased need to actively participate to impact upon their ADLs and the time commitment needed to maximise outcomes. At this time the other aspect evaluated from a ‘customer’s’ perspective, was to canvass the opinion of GPs as the team were keen to identify if the service met their needs and if patients, having attended the clinic, were more able, in primary care, to manage their own LBP. We therefore wrote to the GPs of the same patients who had been included in the previous audits to ask for information about the use of prescribed medication for back pain in the year prior to the first appointment in SAC and in the year following discharge. This showed the same levels of 30% and 18%, respectively, more in 14% in both audits but less in 48%
Reflections on the development of nurse-led backpain triage clinics in the UK and 45%, with some records incomplete. Thus it appeared that patients who had attended the SAC were more able to manage a flare-up of pain in long-term control of the back pain problem. In the second audit we also asked about visits to the GP for LBP in the year prior to and the year after SAC intervention. It was noted that 82% went less often to the GP after attending the SAC. The above audits have taken place over a number of years and provide the basis for continued development of the concept of the SAC which inevitably has required expansion of the team at South Tees.
Capacity of sac ‘fast track’ surgical cases As previously stated only a small number of patients with LBP need surgery (Ehrlich 2003; Waddell 1998) but it is acknowledged that in such cases patients need to see the surgeon more quickly and this was a key result required by the organisation at inauguration of the SAC. As the initial audits on diagnosis had noted efficient co-relation, plotting the patient pathway from referral to time of surgery enabled identification of delays in the system and evaluation and alteration of the surgical pathway could be considered. The main delays were in patients having to be seen by the surgeon for a scan to be requested and in providing results of the scan. Thus this part of service needed to be altered. A first step was taken by enabling a scan to be requested based on the Nurse Practitioner (NP) assessment. In 1996 this could not be requested by the NP writing the scan request, although this has now changed. It was also felt that educationally this would provide continued opportunity for clinical support if the NP did a case presentation with recommendations on scans and intervention at the weekly clinical meeting. This system was implemented and audited in two consecutive years demonstrating 84% and 82% of scans being positive. The audit also showed that waiting time for surgery had been reduced by this step. The delay in having a results appointment had also been addressed by arranging for an associate specialist orthopaedic surgeon to provide extra sessions for these patients. This coincided with the provision of perioperative care by a Spinal NP with increased emphasis on pre-operative teaching and post-operative follow-up by nurses in the SAC. This has shown increased satisfaction of patients with this style of care (Holmes et al. 2002). This groundwork in altering provision for this group of patients in the SAC has demonstrated benefit to patients and to the organisation.
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This development has enabled the surgical pathway to be changed, creating a ‘fast track’ for surgical patients and providing an opportunity for increased collaboration across departments, especially with radiology services. This increase in collaboration developed when national recommendations were being made by the Royal College of Radiologists (2003) on new ways of working and safety aspects including awareness of radiation training for non-medical staff. In South Tees this has provided an opportunity to develop robust protocols, so written requests are now accepted from non-medical practitioners who have completed the relevant training, thus establishing new ways of working. Further evaluation of the pathway continued to demonstrate a delay between the date of the scan and the date of results. Hence, from 2007, in collaboration with the radiology services, appointments were identified in both radiology and SAC so that patients could be seen on the same day for a scan and results. As with all NHS appointments, there is opportunity for patients to have a choice as to when they want to attend an appointment by using the ‘Choose and Book’ system (2006). In practical terms, this meant that to have a scan and results appointment on the same day was not possible seven days a week. However, at the triage appointment, when it is decided to proceed to arrange a scan, the options are carefully explained by the nurse including scan availability Monday to Friday or availability of scan and results on the same day. The patient then has all information prior to choosing scan appointments. This increased the options available to patients and has had a definite impact on ‘fast tracking’ of patients. Within the South Tees Trust health screening and pre-assessment occur at the same appointment when the patient is put on the waiting list for surgery. The impact of this can be seen in Table 1 below which is taken from the NHS Spinal Top Tips 18 week
Table 1
Typical surgical pathway SAC.
General practitioner referral
(1) SAC triage clinic (NP) (2) MRI scan + results same day with wait listing for discectomy (3) Pre-op education session (NP) (4) Day case disc surgery (5) 1st Post-op (NP) (6) 2nd Post-op and discharge to GP (NP)
Time from clock start (weeks) 3 5 10 14 16 20
118 pathway (Department of Health, 2008) and shows the pathway taken by one of the patients seen in the SAC in 2007 with stages 1, 3, 5 and 6 being conducted by NP. Simultaneously the patients are provided with a ‘helpline card’ so that if more advice or support is needed between formal appointments, there is an easy way to access help. Thus the SAC has been able to deliver on this key point identified at service inauguration and the development has been underpinned by EBP with patient and organisational benefit.
Organisational impact At inauguration of the service one nurse was employed with two hours clerical support. The SAC was based in the Trauma and Orthopaedic Division and clinical supervision/support was provided by the named orthopaedic surgeon. As stated, there was commitment to develop the evidence of how this service would impact. This was a challenge, but it had been identified in planning and discussed at the interview stage so there was an expectation of the post-holder (NP). It was obvious that this style of development would have resource implications as audit and research evidence takes time and money to gather, but as it was a means of demonstrating clinical effectiveness, it was also acknowledged as an important step. Organisationally, this type of development provided opportunities for new ways of working with increased collaboration across the MDT and facilitated improved links with colleagues in primary care. As part of the development would see staff working in different ways and extending roles, it was also clear that this would impact on the educational preparation of staff. To this end, the organisation has worked very closely with the local university on course provision at undergraduate and post-graduate level (Madhok and Stothard 2002) across the MDT sector. As roles and services in the NHS have altered over the years, the need to use EBP has been widely accepted but the reality and resource implications of the appropriate educational preparation has not always been so clearly defined. The collaboration in Teesside between the Trust and the University was a welcome example of creative ways to optimise orthopaedic service provision underpinned by educational preparation. Once the initial evidence from the SAC demonstrating clinical effectiveness had been generated and referral rates monitored, it was obvious that staffing needed to be increased. At the end of the second year a further nurse was recruited. Clerical
M.M. Murray support was expanded and team dynamics have varied over the intervening years, depending on work-loads but based on EBP. As previously identified results of the initial work had been presented at a number of meetings and colleagues from other organisations have requested the opportunity to visit and observe in the SAC. The team was asked to develop a course so that nurses from other trusts could develop competency in this speciality and staff have now been able to access training in this way. Similar services based on the South Tees model, but adapted to local needs, have been developed and this style of service has become an accepted norm in the UK. There is, of course, a commitment in the NHS to share practice, identified by Robertson (2005) who gives an outline of why this should happen. Such visits, sharing of practice and provision of training were a natural progression in development, although this involved considerable time commitment. However, the overall benefit is seen by increased numbers of patients in the NHS accessing triage appointments more quickly, ensuring longer term benefits directly to the patient. The efficiency of any service and the impact of collaborative practice were monitored for outcome which has been considered an important aspect of work within South Tees. There were five main entry points for OPD appointments in back pain – Pain Management, Neurosurgery, Rheumatology, Orthopaedics and SAC. A cross sectional group of professionals from these divisions, including medical, nursing, physiotherapy and audit personnel, started meeting to discuss ways that back pain services might be streamlined. This demonstrated similarities and variances in practice with some of the information being anecdotal. However, it was also possible to compare data generated previously in divisional service evaluations. One of the difficulties encountered with audit is funding. In 2000 the group were successful in gaining a grant via the Health Action Zone (HAZ) route, which enabled a wider audit project to evaluate efficiency. This study chose an index period of six months in 1998. At this time South Tees had eight hundred patients for whom the main reason for referral was that the GP had requested an appointment for assessment of back pain. These patients were referred to the five specialty groups. The audit tracked patients for 2 years after their first appointment as well as the six months before the index period to evaluate hospital service provision for LBP. This included timing from referral to first appointment. Hospital outpatient department (OPD) allowed for evaluation of the re-referral rates seen in Table 2. This audit demonstrated
Reflections on the development of nurse-led backpain triage clinics in the UK Table 2
119
Efficiency of hospital services.
Results
SAC
Neurosurgery
Ortho
Rheumatology
Pain
Pt’s seen Mean wait/days Surgery (%) Intra hospital (%) GP re-refer
597 42 8 4.9 3.7
95 78 19 33.7 3.2
45 103 11 26.7 11.1
35 82 0 8.6 2.9
29 77 0 10.3 17.2
effective triage of patients attending the SAC previously reported by Plant et al. (2005) showing efficiency of hospital services for LBP.
Conclusion This paper has explored the drivers for the development of a new nurse led service in the NHS for Back Pain Triage. It has identified the careful arrangements made to monitor impact and outcomes and it has noted how evidence from audit and research can be used to provide information to service users and organisationally. This commitment to provision of high quality data and information has enabled business planning to take place. Although the style and resources of the service are different to when it was inaugurated, this is based on evaluation of impact and value. The service is provided using extended scope practice with protocol based care and the development has provided the staff involved with the opportunity to use clinical judgement and EBP. As the NHS Implementation Plan (2000 1.7) states, there is a need to ‘‘improve the quality and overall experience of the patient’’. In the context of safe governance, this nurse-led style underpinned by evidence is an important contribution that has impacted positively on the quality of service for this group of patients.
Ethical statement Not applicable.
Role of funding source None to disclose.
Conflict of interest No conflict of interest as the article is a report of work completed when a full time member of staff at South Tees.
Acknowledgment The work completed in the developing the concept of the SAC and the commitment to the principles of evidenced based practice would not have been possible without the vision, clinical support and direction of Professor Charles Greenough. The close professional working relationships that have developed over this time within the SAC and external links created in a MDT remit are a testament to his leadership, which at times challenged but provided an environment of mutual respect and growth.
References Cueller, N.G., Cahill, B., Ford, J., Aycock, T., 2003. The development of an educational workshop on complementary and alternative medicine: what every nurse should know. Journal of Continuing Education in Nursing 34 (3), 128–135. De-Vaus, D.A., 2002. Surveys in Social Research, 3rd ed. UCL press limited, Gower St., London. Department of Health, 1992. The Health of the Nation. DoH, London. Department of Health, 1998. A First Class Service. DoH, London. Department of Health, 2000a. The NHS Plan. DoH, London. Department of Health, 2000b. NHS Implementation Plan. DoH, London. Department of Health, 2008. Top Ten Tips 18 Week Spinal Surgical Pathway. DoH, London. Department of Health (2010) Liberating the NHS Equity and Excellence. Drozd, M., Jester, R., Santy, J., 2007. The inherent components of the orthopaedic nursing role: an exploratory study. Journal of Orthopaedic Nursing 11, 43–52. Ehrlich, G.E., 2003. Bulletin of World Health Organisation [WHO]. Low Back Pain Policy and Practice 81 (9). Greenough, C.G., Fraser, R.D., 1992. Assessment of outcome in patients with low back pain. Spine 17, 36–41. Greenough, C.G., Murray, M.M., Holmes, M., 1997. Golden Helix Quality Award Whitehall London ‘‘The Spinal Assessment Clinic’’. Hewlett Packard, 1994. The Golden Helix Award System Development, Google accessed 2009. Holmes, M., Basu, P., Pratt, D., Greenough, C.G., 2002. Nurse practitioner led management of lumbar spine surgery patients – A prospective randomised study. Journal of Bone and Joint surgery British 84-B (Supp. 1), 95. Koes, B.W., Van Tulder, M.W., Ostelo, R., Burton, A.K., Wadell, G., 2001. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 26, 2504–2513.
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Lucas, B., 2009. The emergence of specialist orthopaedic nurses and nurse-led pre-operative assessment in the 1990’s. Journal of Orthopaedic Nursing 13, 204–207. Madhok, R., Stothard, J., 2002. Promoting evidence based orthopaedic surgery – An English experience. Acta orthopaedica Scandinavica (Suppl. 305), 73. National Service Frameworks and strategies, (last review 2010). www.nhs.uk/nhsengland/NSF accessed 11/11/2010. Plant, M., Chadwick, R., Greenough, C.G., Murray, M.M., Strachan, R., Milligan, K., Hughes, J., Carter, E., Puttick, S., Robertson, J., 2005. Hospital services for low back pain – Are they efficient?. Journal of Bone and Joint Surgery 87-B. Robertson, S., 2005. NHS EVIDENCE – Knowledge ManagementIdentifying and Sharing Best Practice (Access 11/08/09). Royal College of Radiologists, 2003. Making the best use of a department of clinical radiology: guidelines for doctors, 5th ed. London Royal College of Radiologists.
Sackett, D.L., Rosenburg, W.M.C., Gray, J.A.M., Hynes, R.B., 1996. Evidence based medicine what it is and what it isn’t. BMJ 312, 71–72. Smith, P., 1991. Where is the wisdom? The poverty of medical evidence. BMJ 303, 798–799. Short, R.M., Murray, M.M., Greenough, C.G., 1996. The implementation of a nurse-led spinal assessment clinic. Journal of Bone and Joint Surgery 78-B (Supp. 1), 61. Telford, K., Kralik, D., Koch, T., 2006. Acceptance and denial: implications for people adapting to chronic illness: literature review. Journal of Advanced Nursing 55 (4), 457–464. Underwood, M.R., 1998. Crisis: what crisis?. European Spine Journal 7 2–5. Waddell, G., 1998. The Back Pain Revolution, 2th ed. (2004). Churchill Livingston, London.
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Reflections on the development of nurse-led back pain triage clinics in the UK Margaret M. Murray MSc, RN, ONC, NDN (Independent Nurse UK)
*
South Tees Acute Trust, Marton Road, Middlesbrough 3BW, UK
Summary This paper discusses the development of the first Nurse-led triage clinic for back pain developed in the United Kingdom (UK). It identifies some of the health policies that support development of new ways to deliver services within the UK’s National Health Service (NHS), and explores some of the drivers that enabled such changes. The importance of using evidenced-based practice in developments is noted with some of the benefits to patients, consumers and organisations outlined. The reality of this type of service and its contribution to enabling the organisation to deliver on targets that have been part of regular health care expectations, are noted. Importantly, the Spinal Assessment Clinic (SAC) was a local solution to a local problem. However, the commitment to develop the service underpinned by evidence has made it possible to share this example of best practice with others who have then been able to adapt this to their own ‘local needs’. Consequently this approach has become accepted practice within the NHS, the service has been recognised as important to South Tees Trust in delivering back pain services, and the author was awarded the Order of the British Empire (OBE) in 2002 for her work. c 2010 Elsevier Ltd. All rights reserved.
KEYWORDS Back pain triage; Service development; Evidenced based practice; Audit and research
Editor’s comments This paper describes an important and defining development in nursing that took place some time ago. It occurred at a time which is likely to be seen as a cross-road in the development of advanced nursing practice. There was a clear focus on both quality of care and effectiveness. These were being addressed through innovative approaches to developing the sills of senior practitioners. The developments described here offer an insight into how much difference a highly skilled advanced practitioner can make to assessing the needs of patients and ensuring that their subsequent care is based on need. Back pain continues to have an enormous impact on individuals and society. The approach described in this paper is one option in a world where it is important to make sure that sufferers are supported appropriately by a skilled professional in a system which puts the patient’s needs at its centre. JS
Introduction * Contact address: 60 Cookgate, Nunthorpe, Middlesbrough TS7 0PZ, UK. Tel.: +44 01642 318782. E-mail address: [email protected]
Over the last 30 years the delivery of healthcare has altered in the UK. Some of this has been driven
1878-1241/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2010.11.004
114 by reform of the NHS evident in policy. The main policy drivers pivotal to re-shaping services were ‘‘The Health of The Nation’’ (Department of Health, 1992), ‘‘A First Class Service’’ (Department of Health, 1998), ‘‘The NHS Plan’’ (Department of Health, 2000a, b) and the ‘‘NHS Improvement Plan’’ (2004). More recently, policy has placed emphasis on clear quality requirements based on evidence (National Service Frameworks, 2010) and how liberating some of the talents in the NHS and working in different ways alters how services can be delivered (Department of Health, 2010). Hence, since the 1990’s there has been an emphasis on provision of care which should be clinically effective, underpinned by Evidenced Based Practice (EBP) and include patients as well as clinicians in decision making (Smith 1991; Sackett et al. 1996; Department of Health, 2010). With increasing new and innovative ways of working, the NHS, wishing to recognise this type of work, collaborated with the Hewlett Packard Company to develop an award which would celebrate some of these successes. The Golden Helix Award was inaugurated in 1991 to mark the contribution of healthcare teams to the development of innovative services (Hewlett Packard, 1994). An example of the evidence needed in service development was seen in the presentation given by the Spinal Assessment Clinic (SAC) team as one of the finalists in the Golden Helix Award of 1997 (Greenough et al., 1997). Working in new ways to develop services is challenging, but the initial audit and research conducted by the SAC demonstrated that both innovation and vision is needed. This, however, must be supported organisationally with resources for training/development for modernisation of healthcare delivery to be successful. The initial results from the audit and research conducted by the SAC on clinical effectiveness summarised how the SAC functioned and were initially presented in London in 1997 and subsequently at further meetings regionally, nationally and internationally. In modernising the NHS there has been some ‘blurring’ of roles and increasing Multi-Disciplinary Team (MDT) working. The value of working collaboratively is that the expertise of each individual team member is used but the overall outcome has more impact. This has been identified as beneficial in managing back pain (Koes et al. 2001). It has now become accepted both in primary and secondary care that the first point of contact for the person with back pain does not have to be a medically qualified practitioner. Whilst new services have been developed and provide safe high quality care, there is a need to provide evidence that these
M.M. Murray services make a difference. Consequently inauguration of such services has required commitment to audit, research and outcome evaluation, with data collected from patients, professionals and organisationally to enable monitoring of progress. In the field of orthopaedics this concept is one that has been embraced with a number of new ‘Nurseled’ or ‘Allied Health Professional (AHP)-led’ outpatient services along with diversification of roles in the ward setting and relevant development of educational preparation. Development of these services has enhanced the patient’s journey with a significant impact on the provision of optimum care in the modern NHS. In some cases developments have been in response to an identified problem in the system or as a means to re-shape and deliver patient services. It had become obvious that the different skills of team members could be used in alternative ways to optimise patient outcomes. In the case of Low Back Pain (LBP) there was recognition that only a small number of patients need surgery (Ehrlich 2003; Waddell 1998) yet many were waiting months to be seen by a surgeon. There was increasing acknowledgment that this condition was best managed by embracing traditional and complementary medicine within a multidisciplinary service (Waddell 1998). This was an activity of high volume and high cost for the NHS with estimates that it consumed £6,000million annually (Underwood 1998). Altering provision was perceived to be potentially beneficial providing it was underpinned by collated evidence of clinical and organisational effectiveness. The aim of this paper is to describe the steps taken to develop the first nurse-led triage clinic for back pain management in response to the issues raised above. It will then discuss the data gathered over a number of years which demonstrates how the development of the service has helped to alter patient pathways and demonstrate clinical effectiveness.
Back pain management Over the years many different treatments have been advocated for back pain, some of which could be labelled as traditional but often emerging under the umbrella of complimentary medicine (Cueller et al., 2003). The evaluation of these treatments has often indicated that for some the treatment effect was short-lived or had no impact on sustaining an improved quality of life. Whilst this wealth of information and research was readily available, questions were raised about which options were
Reflections on the development of nurse-led backpain triage clinics in the UK most likely to optimise patient care? Waddell (1998) undertook a review of the various treatments with a focus on quality of research, clinical effectiveness and outcomes. Earlier recommendations (Waddell 1998) were considered by some at the time to be radical, because of the increased emphasis on MDT working and moving focus from secondary to primary care. It was recommended that management of back pain should use a MDT approach including discussion with patients regarding realistic options. This placed an emphasis on controlling the condition and enabling improved lifestyle. The approach avoided a focus on a ‘cure’ and emphasised the value of exercise. The potential effect this could have on resource distribution from secondary to primary care, and subsequent impact on budgets was noted.
Service development South Tees Trust in the North-East of England had a problem with managing some aspects of its LBP referrals and, as an organisation, made a commitment to alter orthopaedic services in attempts to resolve this. In 1992 an orthopaedic surgeon had been appointed with a specific remit to develop a ‘Back Pain Service’ with a dedicated weekly clinic for back pain patients. At the time of his appointment his waiting list was zero weeks. By the time he had been in post for twelve months the waiting time was 64 weeks. This was unacceptable to all concerned. A working group was created that included all stakeholders from both primary and secondary care, embracing the MDT concept and with commitment from managers and commissioners. The aim was to inaugurate a new style of triage clinic that became known as the Spinal SAC and which would use a Nurse-led approach. The purpose of the clinic was to triage patients within six weeks of referral letter from a General Practitioner (GP). As this was the first time in the UK that such an approach had been used, careful arrangements were made at the outset for monitoring of outcomes using research and audit data. Time and resources were committed to the training and development of the nurse who would undertake extended scope practice. As there were no formal education programmes to meet such needs in 1993, in the first instance training and education were conducted using the ‘shadow training method’. This required the nurse to observe, take a history and examine the patient. Using knowledge of anatomy, physiology and pathology there would be an analysis of the history presented and the find-
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ings from the examination, comparing this to the norm in order to arrive at a nursing diagnosis. The nurse would then clinically present this to the orthopaedic surgeon, providing written and verbal evidence of the logical process undertaken and including recommendations for intervention. This facilitated development of protocols which acted as a baseline standard to open the clinic, thus enabling the first patients to be triaged.
Nurse led clinics In the UK healthcare system nurse-led clinics in a number of specialities have often evolved driven by the need to deliver more timely services through the development of ‘‘multifaceted’’ roles (Lucas 2009). Part of the nurse’s role is gathering data about patient outcomes which allows progress to be monitored objectively. Another aspect of the role is undertaking a thorough history and physical examination so that a nursing diagnosis can be made which informs intervention decisions. Such role development reflects aspects of practice described in the study by Drozd et al. (2007) in which ‘‘partner/guide, risk manager, comfort enhancer and technician’’ were identified and which can be seen in the role of the nurse in the SAC. The nurse needs to be competent at taking history, examining patients, providing education, arranging investigation, follow up appointments and discussing options for intervention. This is a complex role requiring the nurse to act autonomously. During the initial development of the SAC this was acknowledged, with time identified to enable professional development.
Monitoring The SAC commenced in March 1993 and continuous monitoring of interventions and outcomes has demonstrated clinical effectiveness. As part of routine appointments in SAC patients are asked to complete a Low Back Outcome Score (LBOS) questionnaire (Greenough and Fraser 1992). This is a method used to measure the functional capacity of patients. It includes assessment of Activities of Daily Living (ADLs) and distress levels, allowing measurement of objective data. This tool has been used sequentially in subsequent appointments and as part of long-term follow-up providing outcome scores that can be compared. One aim of the clinic was to provide a method to ‘‘fast track’’ any patients potentially requiring surgery, so that the surgeon could arrange access to operation more quickly. This has been shown, in
116 the small percentage of patients who need surgery, to be important. In the case of patients’ not needing surgery, a diagnosis was provided and followed up with information, advice and education about how LBP could be managed with increased selfmanagement. These monitoring arrangements have allowed a consistent approach to be taken from the outset and the clinic has extended its practice with the impact demonstrated through a number of audit and research projects.
Demonstrating success in back pain triage As with any research or audit, evaluating the service takes time and resources. For the purpose of this paper a summary of key points will be made, these include various audit or research projects conduct by the SAC which were approved by the relevant audit and research committees prior to being conducted. This demonstrates the natural progression needed to build evidence of how the SAC has impacted on service development and identifies involvement of professionals and patients in the process. The results of these projects have been reported to the Trauma and Orthopaedic division and management group to provide information for evaluation and business planning. Mention is made above of the ‘natural progression’ of building the evidence, this in essence means that careful steps were taken to ensure the work of the SAC was providing clinical effectiveness in a safe environment. The nature of the triage appointment meant that the patient was being seen by a nurse for diagnosis, so it was appropriate to assess this aspect first. The first audit conducted was a retrospective chart audit on patients seen wherein the nurse had identified potential for surgical intervention. This included a cohort of 178 patients seen in the first eighteen months that the clinic operated and was conducted by an orthopaedic registrar attached to the team, but who had no contact with the patients included in the study (Short et al. 1996). On comparing the nursing documentation/diagnosis to that of the consultant orthopaedic surgeon a correlation of 78% agreement on diagnosis was demonstrated. The next stage of audit was to evaluate the diagnostic agreement in non-surgical patients. This proved to be logistically more difficult. Following clinical discussion it was felt important that patients should be seen and examined by the nurse and orthopaedic surgeon on the same day so that the history and examination was presented in the
M.M. Murray same ‘Time-frame’. To enable this, five clinics were identified where triage patients would be seen by both staff members and a comparison of history and examination would be made at the end of the sessions. This included a cohort of 50 patients and at the end of this audit there was a 92% agreement between the nurse and the surgeon. These results from a professional perspective indicated clinically effective care. It was also felt important to evaluate this from a ‘customer perspective’. The next stage of audit, therefore, was to write to patients who had been triaged and treated wholly under the remit of Nurse-led care, discharged to their GP and had not seen the surgeon. This project was conducted with two cohorts of patients; 100 in each group seen in two consecutive years, who were asked for their opinion of the clinic, of the class sessions they had attended and they were also asked to complete another LBOS questionnaire. This was undertaken using a postal survey. Although there are critics of this method, it is acknowledged that it is a way to monitor progress and gather a large amount of data. The return rate in these surveys was over 80% which was accepted as satisfactory. Indeed De-Vaus (2002) identifies 60% as an acceptable response level in research, so this return rate provided powerful evidence. The results showed that the LBOS had improved from 29 at triage to 35 on review (P < 0.01). In both cohorts the patients rated the clinic as ‘Very Good ‘ 76% and 87% or ‘Fairly Good’ 18% and 11%, respectively on each of the two occasions. Only 6% in audit one and 2% in audit two finding it of little or no help. When asked for the opinion of education classes the satisfaction rate decreased to 67%. It is well known, however, that changing health beliefs can be complex (Telford et al. 2006). At this stage perhaps part of the problem was recognition by patients of the increased need to actively participate to impact upon their ADLs and the time commitment needed to maximise outcomes. At this time the other aspect evaluated from a ‘customer’s’ perspective, was to canvass the opinion of GPs as the team were keen to identify if the service met their needs and if patients, having attended the clinic, were more able, in primary care, to manage their own LBP. We therefore wrote to the GPs of the same patients who had been included in the previous audits to ask for information about the use of prescribed medication for back pain in the year prior to the first appointment in SAC and in the year following discharge. This showed the same levels of 30% and 18%, respectively, more in 14% in both audits but less in 48%
Reflections on the development of nurse-led backpain triage clinics in the UK and 45%, with some records incomplete. Thus it appeared that patients who had attended the SAC were more able to manage a flare-up of pain in long-term control of the back pain problem. In the second audit we also asked about visits to the GP for LBP in the year prior to and the year after SAC intervention. It was noted that 82% went less often to the GP after attending the SAC. The above audits have taken place over a number of years and provide the basis for continued development of the concept of the SAC which inevitably has required expansion of the team at South Tees.
Capacity of sac ‘fast track’ surgical cases As previously stated only a small number of patients with LBP need surgery (Ehrlich 2003; Waddell 1998) but it is acknowledged that in such cases patients need to see the surgeon more quickly and this was a key result required by the organisation at inauguration of the SAC. As the initial audits on diagnosis had noted efficient co-relation, plotting the patient pathway from referral to time of surgery enabled identification of delays in the system and evaluation and alteration of the surgical pathway could be considered. The main delays were in patients having to be seen by the surgeon for a scan to be requested and in providing results of the scan. Thus this part of service needed to be altered. A first step was taken by enabling a scan to be requested based on the Nurse Practitioner (NP) assessment. In 1996 this could not be requested by the NP writing the scan request, although this has now changed. It was also felt that educationally this would provide continued opportunity for clinical support if the NP did a case presentation with recommendations on scans and intervention at the weekly clinical meeting. This system was implemented and audited in two consecutive years demonstrating 84% and 82% of scans being positive. The audit also showed that waiting time for surgery had been reduced by this step. The delay in having a results appointment had also been addressed by arranging for an associate specialist orthopaedic surgeon to provide extra sessions for these patients. This coincided with the provision of perioperative care by a Spinal NP with increased emphasis on pre-operative teaching and post-operative follow-up by nurses in the SAC. This has shown increased satisfaction of patients with this style of care (Holmes et al. 2002). This groundwork in altering provision for this group of patients in the SAC has demonstrated benefit to patients and to the organisation.
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This development has enabled the surgical pathway to be changed, creating a ‘fast track’ for surgical patients and providing an opportunity for increased collaboration across departments, especially with radiology services. This increase in collaboration developed when national recommendations were being made by the Royal College of Radiologists (2003) on new ways of working and safety aspects including awareness of radiation training for non-medical staff. In South Tees this has provided an opportunity to develop robust protocols, so written requests are now accepted from non-medical practitioners who have completed the relevant training, thus establishing new ways of working. Further evaluation of the pathway continued to demonstrate a delay between the date of the scan and the date of results. Hence, from 2007, in collaboration with the radiology services, appointments were identified in both radiology and SAC so that patients could be seen on the same day for a scan and results. As with all NHS appointments, there is opportunity for patients to have a choice as to when they want to attend an appointment by using the ‘Choose and Book’ system (2006). In practical terms, this meant that to have a scan and results appointment on the same day was not possible seven days a week. However, at the triage appointment, when it is decided to proceed to arrange a scan, the options are carefully explained by the nurse including scan availability Monday to Friday or availability of scan and results on the same day. The patient then has all information prior to choosing scan appointments. This increased the options available to patients and has had a definite impact on ‘fast tracking’ of patients. Within the South Tees Trust health screening and pre-assessment occur at the same appointment when the patient is put on the waiting list for surgery. The impact of this can be seen in Table 1 below which is taken from the NHS Spinal Top Tips 18 week
Table 1
Typical surgical pathway SAC.
General practitioner referral
(1) SAC triage clinic (NP) (2) MRI scan + results same day with wait listing for discectomy (3) Pre-op education session (NP) (4) Day case disc surgery (5) 1st Post-op (NP) (6) 2nd Post-op and discharge to GP (NP)
Time from clock start (weeks) 3 5 10 14 16 20
118 pathway (Department of Health, 2008) and shows the pathway taken by one of the patients seen in the SAC in 2007 with stages 1, 3, 5 and 6 being conducted by NP. Simultaneously the patients are provided with a ‘helpline card’ so that if more advice or support is needed between formal appointments, there is an easy way to access help. Thus the SAC has been able to deliver on this key point identified at service inauguration and the development has been underpinned by EBP with patient and organisational benefit.
Organisational impact At inauguration of the service one nurse was employed with two hours clerical support. The SAC was based in the Trauma and Orthopaedic Division and clinical supervision/support was provided by the named orthopaedic surgeon. As stated, there was commitment to develop the evidence of how this service would impact. This was a challenge, but it had been identified in planning and discussed at the interview stage so there was an expectation of the post-holder (NP). It was obvious that this style of development would have resource implications as audit and research evidence takes time and money to gather, but as it was a means of demonstrating clinical effectiveness, it was also acknowledged as an important step. Organisationally, this type of development provided opportunities for new ways of working with increased collaboration across the MDT and facilitated improved links with colleagues in primary care. As part of the development would see staff working in different ways and extending roles, it was also clear that this would impact on the educational preparation of staff. To this end, the organisation has worked very closely with the local university on course provision at undergraduate and post-graduate level (Madhok and Stothard 2002) across the MDT sector. As roles and services in the NHS have altered over the years, the need to use EBP has been widely accepted but the reality and resource implications of the appropriate educational preparation has not always been so clearly defined. The collaboration in Teesside between the Trust and the University was a welcome example of creative ways to optimise orthopaedic service provision underpinned by educational preparation. Once the initial evidence from the SAC demonstrating clinical effectiveness had been generated and referral rates monitored, it was obvious that staffing needed to be increased. At the end of the second year a further nurse was recruited. Clerical
M.M. Murray support was expanded and team dynamics have varied over the intervening years, depending on work-loads but based on EBP. As previously identified results of the initial work had been presented at a number of meetings and colleagues from other organisations have requested the opportunity to visit and observe in the SAC. The team was asked to develop a course so that nurses from other trusts could develop competency in this speciality and staff have now been able to access training in this way. Similar services based on the South Tees model, but adapted to local needs, have been developed and this style of service has become an accepted norm in the UK. There is, of course, a commitment in the NHS to share practice, identified by Robertson (2005) who gives an outline of why this should happen. Such visits, sharing of practice and provision of training were a natural progression in development, although this involved considerable time commitment. However, the overall benefit is seen by increased numbers of patients in the NHS accessing triage appointments more quickly, ensuring longer term benefits directly to the patient. The efficiency of any service and the impact of collaborative practice were monitored for outcome which has been considered an important aspect of work within South Tees. There were five main entry points for OPD appointments in back pain – Pain Management, Neurosurgery, Rheumatology, Orthopaedics and SAC. A cross sectional group of professionals from these divisions, including medical, nursing, physiotherapy and audit personnel, started meeting to discuss ways that back pain services might be streamlined. This demonstrated similarities and variances in practice with some of the information being anecdotal. However, it was also possible to compare data generated previously in divisional service evaluations. One of the difficulties encountered with audit is funding. In 2000 the group were successful in gaining a grant via the Health Action Zone (HAZ) route, which enabled a wider audit project to evaluate efficiency. This study chose an index period of six months in 1998. At this time South Tees had eight hundred patients for whom the main reason for referral was that the GP had requested an appointment for assessment of back pain. These patients were referred to the five specialty groups. The audit tracked patients for 2 years after their first appointment as well as the six months before the index period to evaluate hospital service provision for LBP. This included timing from referral to first appointment. Hospital outpatient department (OPD) allowed for evaluation of the re-referral rates seen in Table 2. This audit demonstrated
Reflections on the development of nurse-led backpain triage clinics in the UK Table 2
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Efficiency of hospital services.
Results
SAC
Neurosurgery
Ortho
Rheumatology
Pain
Pt’s seen Mean wait/days Surgery (%) Intra hospital (%) GP re-refer
597 42 8 4.9 3.7
95 78 19 33.7 3.2
45 103 11 26.7 11.1
35 82 0 8.6 2.9
29 77 0 10.3 17.2
effective triage of patients attending the SAC previously reported by Plant et al. (2005) showing efficiency of hospital services for LBP.
Conclusion This paper has explored the drivers for the development of a new nurse led service in the NHS for Back Pain Triage. It has identified the careful arrangements made to monitor impact and outcomes and it has noted how evidence from audit and research can be used to provide information to service users and organisationally. This commitment to provision of high quality data and information has enabled business planning to take place. Although the style and resources of the service are different to when it was inaugurated, this is based on evaluation of impact and value. The service is provided using extended scope practice with protocol based care and the development has provided the staff involved with the opportunity to use clinical judgement and EBP. As the NHS Implementation Plan (2000 1.7) states, there is a need to ‘‘improve the quality and overall experience of the patient’’. In the context of safe governance, this nurse-led style underpinned by evidence is an important contribution that has impacted positively on the quality of service for this group of patients.
Ethical statement Not applicable.
Role of funding source None to disclose.
Conflict of interest No conflict of interest as the article is a report of work completed when a full time member of staff at South Tees.
Acknowledgment The work completed in the developing the concept of the SAC and the commitment to the principles of evidenced based practice would not have been possible without the vision, clinical support and direction of Professor Charles Greenough. The close professional working relationships that have developed over this time within the SAC and external links created in a MDT remit are a testament to his leadership, which at times challenged but provided an environment of mutual respect and growth.
References Cueller, N.G., Cahill, B., Ford, J., Aycock, T., 2003. The development of an educational workshop on complementary and alternative medicine: what every nurse should know. Journal of Continuing Education in Nursing 34 (3), 128–135. De-Vaus, D.A., 2002. Surveys in Social Research, 3rd ed. UCL press limited, Gower St., London. Department of Health, 1992. The Health of the Nation. DoH, London. Department of Health, 1998. A First Class Service. DoH, London. Department of Health, 2000a. The NHS Plan. DoH, London. Department of Health, 2000b. NHS Implementation Plan. DoH, London. Department of Health, 2008. Top Ten Tips 18 Week Spinal Surgical Pathway. DoH, London. Department of Health (2010) Liberating the NHS Equity and Excellence. Drozd, M., Jester, R., Santy, J., 2007. The inherent components of the orthopaedic nursing role: an exploratory study. Journal of Orthopaedic Nursing 11, 43–52. Ehrlich, G.E., 2003. Bulletin of World Health Organisation [WHO]. Low Back Pain Policy and Practice 81 (9). Greenough, C.G., Fraser, R.D., 1992. Assessment of outcome in patients with low back pain. Spine 17, 36–41. Greenough, C.G., Murray, M.M., Holmes, M., 1997. Golden Helix Quality Award Whitehall London ‘‘The Spinal Assessment Clinic’’. Hewlett Packard, 1994. The Golden Helix Award System Development, Google accessed 2009. Holmes, M., Basu, P., Pratt, D., Greenough, C.G., 2002. Nurse practitioner led management of lumbar spine surgery patients – A prospective randomised study. Journal of Bone and Joint surgery British 84-B (Supp. 1), 95. Koes, B.W., Van Tulder, M.W., Ostelo, R., Burton, A.K., Wadell, G., 2001. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 26, 2504–2513.
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M.M. Murray
Lucas, B., 2009. The emergence of specialist orthopaedic nurses and nurse-led pre-operative assessment in the 1990’s. Journal of Orthopaedic Nursing 13, 204–207. Madhok, R., Stothard, J., 2002. Promoting evidence based orthopaedic surgery – An English experience. Acta orthopaedica Scandinavica (Suppl. 305), 73. National Service Frameworks and strategies, (last review 2010). www.nhs.uk/nhsengland/NSF accessed 11/11/2010. Plant, M., Chadwick, R., Greenough, C.G., Murray, M.M., Strachan, R., Milligan, K., Hughes, J., Carter, E., Puttick, S., Robertson, J., 2005. Hospital services for low back pain – Are they efficient?. Journal of Bone and Joint Surgery 87-B. Robertson, S., 2005. NHS EVIDENCE – Knowledge ManagementIdentifying and Sharing Best Practice (Access 11/08/09). Royal College of Radiologists, 2003. Making the best use of a department of clinical radiology: guidelines for doctors, 5th ed. London Royal College of Radiologists.
Sackett, D.L., Rosenburg, W.M.C., Gray, J.A.M., Hynes, R.B., 1996. Evidence based medicine what it is and what it isn’t. BMJ 312, 71–72. Smith, P., 1991. Where is the wisdom? The poverty of medical evidence. BMJ 303, 798–799. Short, R.M., Murray, M.M., Greenough, C.G., 1996. The implementation of a nurse-led spinal assessment clinic. Journal of Bone and Joint Surgery 78-B (Supp. 1), 61. Telford, K., Kralik, D., Koch, T., 2006. Acceptance and denial: implications for people adapting to chronic illness: literature review. Journal of Advanced Nursing 55 (4), 457–464. Underwood, M.R., 1998. Crisis: what crisis?. European Spine Journal 7 2–5. Waddell, G., 1998. The Back Pain Revolution, 2th ed. (2004). Churchill Livingston, London.
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