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nursing standard: clinical research education

Continuing professional development Blood and the classification of anaemia 45-53 Multiple-choice self-assessment Practice profile assessment 54 55 Author guidelines If you want to write for Nursing Standards art&science section, visit the website at www.nursing-standard.co.uk Coughs and colds: nurse management of upper respiratory tract infection 33-35 Empowerment for adults with chronic mental health problems and obesity 37-42

Coughs and colds: nurse management of upper respiratory tract infection

Rees M, Butler C (2001) Coughs and colds: nurse management of upper respiratory tract infection. Nursing Standard. 15, 39, 33-35. Date of acceptance: February 19 2001. Abstract Background Nurses in general practice are increasingly managing minor illness. This literature review examines the management of upper respiratory tract infection (URTI) as one area of patient care where nurses can make a major contribution. Conclusion The challenge for nurses is to respond to the changing healthcare environment creatively and in collaboration with doctors and patients. ANY PEOPLE with upper respiratory tract infection (URTI) seek medical help, despite the fact that medicine does not offer a cure for these illnesses. Traditionally, patients with these symptoms who consult a health professional usually choose a GP. As boundaries of workload and responsibilities between doctors and nurses are being redefined in this area, nurses in general practice are increasingly managing minor illness (Marsh and Dawes 1995, Rees and Kinnersley 1995). Recent randomised controlled trials show that nurses manage acute illness in primary care safely (Kinnersley et al 2000, Shum et al 2000). This boundary shift has been acceptable and patients are able to choose which practitioner they consult (Luker et al 1998). Innovative ways of managing minor illness and patient education are developing, albeit slowly. The few studies of the work done by both practice nurses and nurse practitioners all cite management of minor illness as part of that role. However, few studies describe the actual nature and management of these minor illnesses. The management of URTI is considered here as one area of patient care where nurses can make a major contribution. Increasing interest is being shown in the management of URTI. The media, the medical profession and the government are working towards informing the public on the natural course and effective self-management of such illnesses. This activity has been generated by anxieties about inappropriate use of antibiotics and their consequences, misplaced patient expectations, a growing problem of antibiotic resistance and workload for the primary healthcare team (PHCT). What is URTI? Upper respiratory tract infection usually involves coryza (acute rhinitis) and/or inflammation of the pharynx. It can also include otitis media, quinsy, epiglottitis, croup and sinusitis, and can precipitate exacerbation of asthma. Some sore throats are caused by a streptococcal infection (approximately 20 per cent depending on age group and season). High fever, no cough, absence of coryza and swollen and/or exudating tonsils are suggestive of streptococcal infection (McIsaac et al 1998). Antibiotics can shorten the duration of symptoms in that subgroup with streptococcal infection. However, in the absence of high fever and exudate or swollen tonsils and in the presence of a cough or coryza, active streptococcal infection is unlikely. Most URTIs, therefore, are caused by viruses, the most common pathogen being the rhinovirus (Carter 1991) and antibiotics are of no curative benefit for these infections. In practice, however, antibiotics are frequently prescribed for viral illnesses (McIsaac For related articles visit our online archive at: www.nursing-standard.co.uk and search using the key words below. Mags Rees MSc, RN, RM, is Nurse Practitioner, Taff Riverside Practice, Riverside Health Centre, Cardiff. Christopher Butler MD, is Associate Professor of Family Medicine, McMaster University, Hamilton, Canada.

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Key words

I Nurse-patient relations I Respiratory disorders I Respiratory system and disorders

These key words are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review.

art&scienceliterature review
nursing standard: clinical research education

et al 1998). It is generally accepted that children will experience up to five to eight episodes of URTI in one year, and adults only two to four (Carter 1991). Smokers are more at risk of URTI because of impaired function of the ciliary mucosa (Carter 1991). Antibiotic prescribing for URTI Despite increasing evidence that antibiotics have little effect in treating sore throats, otitis media, maxillary sinusitis and acute bronchitis (Butler et al 1998a), antibiotic prescribing for URTI is still common. A systematic review found no evidence that giving children antibiotics for uncomplicated URTI has any value (Fahey et al 1998). Butler et al (1998a) examined the research evidence for reducing antibiotic prescribing for URTI in primary health care. The studies they considered examined outcomes such as the rate of resolution of symptoms, complications prevented, work days lost, and side effects of antibiotic treatment. The emerging message was unequivocal: '... for most people in developed countries with these infections, antibiotics do not significantly shorten the duration of acute symptoms or prevent complications'. That doctors continue to prescribe antibiotics for URTI is an indication that the problem of URTI management is more complex than it might seem. Maintaining a good doctor-patient relationship and avoiding confrontation are important considerations. Doctors cite patients' expectations of 'something to cure the illness', and lack of time to explain why patients do not need antibiotics as reasons for giving medication. However, they also thought that interventions by other members of the PHCT to enhance patient self-care would help (Butler et al 1998b). The consequences of antibiotic prescribing at the current level for URTI are serious. Disturbing evidence is now emerging regarding the development of bacterial resistance and it is suggested that 75 per cent of antibiotic use is of questionable value (Wise et al 1998). The House of Lords Select Committee on Science and Technology has issued advice on the judicious use of antibiotics (House of Lords Select Committee on Science and Technology 1998). The effect on patients' help-seeking behaviour by prescribing antibiotics for patients with URTI reinforces their belief that antibiotics are necessary and effective and increases the probability that they will consult for future episodes (Little et al 1997, Mainous et al 1997). The cost of consultations for sore throat alone in the UK is about 60 million a year (Little and Williamson 1995). Antibiotics can have potentially harmful side effects for the individual diarrhoea and rashes are common with broad spectrum penicillins and anaphylaxis can occur (Arroll and

Kenealy 1998). Indeed: ' ...like benzodiazepines, antibiotics are yesterday's wonder-drug that have become today's problem' (Audit Commission 1994). Management of URTI While no immediate cure is available for URTI, management should involve working with the patient to increase his or her understanding of symptomatic relief, preventing transmission and complications, and sharing the facts that antibiotics are usually ineffective and can have harmful effects. Viral infections cause unpleasant symptoms and patients can do much on their own to alleviate symptoms and hasten the healing process. Symptomatic relief involves drinking fluids to prevent dehydration, discomfort of dry mucosa and reduce fever. Steam inhalation gives temporary relief for congested nasal passages (the addition of volatile applications such as menthol has not been shown to be of benefit). Resting allows optimal immune system response. Pharmacological remedies include antipyretics and analgesia such as aspirin or paracetamol. Cough remedies are not thought to be greatly effective and homemade honey and lemon drink is as soothing as a proprietary syrup. Prevention of transmission is often a neglected area of education. Traditionally it is held that coughing and sneezing without covering the nose and mouth in the process, spreads infection by droplet release into the air, which is then inhaled. However, transmission by the infected person touching secretions and passing it on by touching another person or an intermediary object (Carter 1991) is probably just as common. Parents with young children are often concerned about recurrent URTI. While explaining that children normally have more frequent URTI, it is also an opportunity to discuss the benefits of a smoke-free environment, adequate ventilation and a balanced diet including fruits, vegetables and exercise. It is assumed that people who consult a doctor or nurse about a URTI expect to be given a prescription for antibiotics. While this is often the case, many patients might be coming to be reassured that they do not have a serious illness or for advice on management (Virji and Britten 1991), particularly when it comes to children. Parents often only want advice on how to care for their children and to rule out serious illness (Mayefsky et al 1991). Parents have legitimate concerns about their children's health and health carers should respond accordingly and not necessarily focus just on prescribing. Patient satisfaction with URTI consultation does not always depend on whether a prescription was given (Cowan 1987, Mangione-Smith et al 1999).

REFERENCES Arroll B, Kenealy T (1998) Antibiotics versus placebo in the common cold. The Cochrane Library of Systematic Reviews. 1. Oxford, Update Software. Audit Commission (1994) A Prescription for Improvement. Towards More Rational Prescribing in General Practice. London, HMSO. Butler C, Rees M (2001) A quality assurance: case study of nurse management of upper respiratory tract infections in general practice. Journal of Advanced Nursing. 33, 3, 328-333. Butler C et al (1998a) Reducing antibiotics for respiratory tract symptoms in primary care: consolidating 'why' and considering 'how'. British Journal of General Practice. 48, 437, 1865-1870. Butler C et al (1998b) Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats. British Medical Journal. 317, 7159, 637-642. Carter S (1991) Upper respiratory infections: the common cold and its complications. Physician Assistant. December, 18-35. Cowan P (1987) Patient satisfaction with an office visit for the common cold. Journal of Family Practice. 24, 4, 412-413. Crawford M (1998) Limit prescribing of 'cure all' antibiotics. Practice Nurse. 16, 6, 339. Fahey T et al (1998) Systematic review of the treatment of upper respiratory tract infection. Archives of Diseases in Childhood. 79, 3, 225-230. House of Lords Select Committee on Science and Technology (1998) Resistance to Antibiotics and Other Antimicrobial Agents. London, The Stationery Office. Kinnersley P et al (2000) Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting same day consultations in primary care. British Medical Journal. 320, 7241, 1043-1048. Kitson A (1999) The essence of nursing: part 2. Nursing Standard. 13, 24, 34-36. Little P, Williamson I (1995) Sore throat management in general practice. Family Practice. 13, 3, 317-321.

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Patients generally want to be taken seriously and not to be rushed (Butler et al 1998b). The results of one study (Mainous et al 1997) suggest that people do not have a good understanding of the normal course of URTI. There was incongruity between their actions and words. While they said that there was no need to consult a doctor about a common cold, they consulted often for uncomplicated URTI and had a strong belief that antibiotic treatment was effective for colds, especially if there was discoloured nasal discharge (Mainous et al 1997). Good patient education could mean that if people understood the normal course of uncomplicated URTI, they would consult less. Such interventions have been shown to be effective in decreasing consultations for URTI (Roberts et al 1983). Upper respiratory tract infection management involves understanding and working with patients' expectations, informing and educating them about the nature of the illness, how to care for themselves and the appropriate use of antibiotics. In the context of general practice, this approach will be most effective by a consistent message delivered across the disciplines. Conflicting messages from different practitioners are confusing for patients. The experience of having antibiotics prescribed for URTI reinforces the belief that antibiotics are effective (Little et al 1997). Some doctors say they prescribe because they know that if they refuse, the patient would get them from another doctor in the practice or from a nearby practice. This kind of disparity of advice could apply between a doctor and a nurse. Nurse management of URTI Evidence is emerging that nurses are making inroads into URTI education and management. Catherine Baraniack, a Derby nurse practitioner, has found that patients do not always expect a consultation to end with a prescription and that, provided a little time is spent in explaining, they are happy to accept advice and recommendation for symptomatic treatment (Crawford 1998). A case management study of nurse management of URTI in a general practice in Cardiff has also shown that patients' threshold for future consulting was not lowered and there was a significant reduction in the number of prescriptions for antibiotics in the group who consulted the nurse (Butler and Rees 2001). Health promotion is a complex series of interactions that is more than simply information and advice giving. How a nurse interacts with a patient and the philosophy on which that interaction is based, can have a profound effect on the outcome. The traditional 'sick nursing perspective', where care is 'done to the patient', is often determined according to the

diagnosis or problem and characterised by a prescriptive, directive, reassuring approach. This usually results in decision making being in the hands of the nurse. However, nursing founded on a health perspective, building on the patient's expectations and existing knowledge, leads to a more collaborative relationship and changes the process and outcome of the encounter (Macleod Clark 1993). The process of change to health nursing involves a rethink about nurse/patient relationships and the interventions we use. What is most effective in helping patients might not be 'the way we have always done it'. Kitson (1999) talked about nurses having a pivotal role in improving people's ability to care for themselves. Nurses can transfer their own nursing skills to promote people's basic self-care skills, by giving them the right information, support and confidence in their ability to cope: 'Innovations in nursing care should centre around new partnerships with carers and patients' (Kitson 1999). This, of course, assumes that nurses have the right information, skills and knowledge to impart. Kitson's emphasis is on a broad health education role in the communitywide setting. Part of informing communities is getting the message across to individuals in the hope of influencing the wider community. In this case, the message is about URTI self-care and appropriate use of antibiotics. What interventions can be offered? Nurses should promote an understanding of the natural history of URTI, an awareness of the clinical evidence for the management of URTI, and appropriate use of antibiotics. A clear and consistent message must be given work with other colleagues in this. Patients' expectations and concerns should be elicited and patients should be provided with the means to cope with the illness. Conclusion The healthcare environment is constantly evolving and with it, patients' perceptions and expectations of health care change. Perpetuating ineffective treatments is costly. Turning the tide of dependence on antibiotics as the cureall is difficult. The challenge for nurses is to respond to this in creative ways, in collaboration with both doctors and patients

Implications for practice Moving away from over-dependence on antibiotics is difficult The challenge for nurses is to respond to this creatively and in collaboration with doctors and patients

Little P et al (1997) Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. British Medical Journal. 315, 7104, 350-352. Luker K et al (1998) Nurse-patient relationships: the context of nurse prescribing. Journal of Advanced Nursing. 28, 2, 235-242. Macleod Clark J (1993) From sick nursing to health nursing: evolution or revolution? In Wilson Barnett J, Macleod Clark J (Eds) Health Promotion Research in Nursing. London, Macmillan. Mainous A et al (1997) Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. Journal of Family Practice. 45, 1, 75-83. Mangione-Smith R et al (1999) The relationship between perceived parental expectations and paediatrician antimicrobial prescribing behaviour. Pediatrics. 103, 4, 711-718. Marsh G, Dawes M (1995) Establishing a minor illness nurse in a busy general practice. British Medical Journal. 310, 6982, 778-780. Mayefsky J et al (1991) Families who seek care for the common cold in a pediatric emergency department. Journal of Pediatrics. 119, 6, 933-934. McIsaac W et al (1998) A clinical score to reduce unnecessary antibiotic use in patients with sore throat. Canadian Medical Association Journal. 158, 1, 75-83. Rees M, Kinnersley P (1995) Nurse-led management of minor illness in a GP surgery. Nursing Times. 92, 6, 32-33. Roberts CR et al (1983) Reducing physician visits for colds through consumer education. Journal of the American Medical Association. 250, 15, 1986-1989. Shum C et al (2000) Nurse management of patients with minor illness in general practice: multicentre, randomised controlled trial. British Medical Journal. 320, 7241, 1038-1043. Virji A, Britten N (1991) A study of the relationship between patients' attitudes and doctors' prescribing. Family Practice. 8, 4, 314-319. Wise R et al (1998) Antimicrobial resistance is a major threat to public health. British Medical Journal. 317, 7159, 609-610.