Providing group consultations for children with viral-induced wheeze

Introduction

Asthma is the most common long-term medical condition in children; it cannot be cured but, with appropriate management, quality of life can be improved (NHS, 2016). The paediatric respiratory team at Whittington Health NHS Trust reviews children aged under five years with viral-induced wheeze for whom any of the following apply:

• Two or more attendances at the emergency department within a year;
• Previous admission to the children’s ward;
• Previous admission to a paediatric intensive care or high-dependency unit;
• A food allergy;
• Safeguarding concerns.

The purpose of the review is to develop preventative strategies to avoid future hospital admission; it involves taking the child’s history and performing a physical examination, followed by teaching and testing as required. We had been experiencing a number of challenges and decided to introduce a new service model.

Historically, two specialist nurses saw each child separately. This made it difficult for us to join up care and support each other as a team, and was also very repetitive. Often families did not attend their appointment, which meant clinic time was wasted while both nurses waited between appointments. Clinics often overran, which added to the stress of the working day as it already took up a half-day session for each nurse. There was also sometimes pressure on clinic waiting times, meaning patients were waiting more than six weeks for an appointment.

We wanted to address these challenges by finding a solution that would help us see more patients in less time.

What were our aims?

We had several aims to improve the service:

• Improve outcomes for families;
• Join up assessment and care planning;
• Reduce the clinic time from a half day to two hours;
• Reduce nurses’ wasted time caused by families failing to attend;
• Stop the clinic overrunning and reduce waiting list pressure;
• Reduce the repetitive nature of consultations;
• Re-energise the nurses.

How did we go about it?

Inspired by evidence from group clinics for adults living with long-term conditions (Kessels, 2003), we hypothesised that running a group clinic, where five families are seen together, could help us achieve our aims.

Members of our team attended group-consultation development training. They then created a prototype clinic design.Changes included a new group clinic room layout, an improved patient summary record and a self-complete questionnaire to elicit information that parents may not wish to talk about openly in a group.

The team ran two trial sessions with a parent advisor and student nurses, then carried out a six-month pilot. Under the new system, the clinic administrator checks parents in and asks them to complete paperwork that captures key information the nurses need to know about the home environment and symptom control. The children’s heights and weights are taken, then a band 6 asthma specialist nurse runs the group, beginning by creating an agenda based on questions the parents share. Parents are encouraged to answer each other’s questions and, where necessary, the nurse adds information.

After this a band 7 nurse undertakes individual consultations with each family, involving a physical examination and a discussion about the child’s history and atopy. The nurses work together, creating a personalised wheeze plan for each family. The band 6 nurse encourages the parents to reflect on their learnings, performs allergy tests for any children who need it, then closes the clinic.

“An innovative, family-centred approach to asthma care in which the drive and passion of the team was apparent” (Judges’ feedback)

What did we achieve?

We asked parents to complete a questionnaire at the end of the group clinic that elicited personal outcomes and provided space for qualitative feedback; 24 families participated in the pilot, and there was a 100% response rate. Respondents were given a list of statements and asked to indicate which they agreed with, as well as space to write down anything else they wanted to share. The statements “I learnt something new from the nurses” and “I learnt something new from my peers”, were each agreed with by 58% of parents, while “I understand the health condition better” and “I built my confidence to take control of my child’s health condition” were each agreed with by 50%. Parents also reported that they found the atmosphere relaxed and child-friendly. They said they felt safe and had time to talk about their concerns and things that mattered to them.

Research shows that people immediately forget 40-80% of a one-to-one encounter with a health professional. Recall is a key variable in managing a long-term condition, and is improved by active patient engagement (Kessels, 2003). The highly interactive nature of the group consultations means it is likely the parents learned and retained more than they would from a one-to-one consultation.

The nurses observed that reassurance from a peer with lived experience was more credible than advice and encouragement from a nurse. This bodes well for the children’s future health outcomes in this high-risk group and suggests group clinics can help parents learn more and gain confidence to manage their child’s condition.

Group clinics offer a social model of care that connects people in the same situation. For parents supporting a child with a long-term health condition, having a support network of other parents who understand and empathise reduces social isolation and builds confidence and resilience. Group clinics help build community in a similar way to NHS initiatives such as social prescribing, and this can happen at no additional cost.

The group clinic increased efficiency in a number of ways. It took the band 7 nurse 66% less time to see families and the band 6 nurse 45% less time. Clinics also finished on time, and in total nearly 50% of a half-day session was freed up for other work. Efficiency gains of this magnitude within specialist nursing could be transformative.

The new system also saw a 31% reduction in families failing to attend appointments. Every missed appointment in a one-to-one clinic costs the NHS £289, so this had a financial benefit as well as reducing waiting times for all patients. All trusts are under pressure to reduce the number of missed appointments, and group clinics could offer a solution.

Finally, group clinics improved nurse wellbeing by:

• Reducing repetition;
• Supporting integrated working;
• Reducing lone working;
• Finishing on time, which improved their work-life balance.

Nurse wellbeing leads to good patient experience and has been linked to patient safety. Caring for staff is also a key part of the NHS Long Term Plan (National Health Service, 2019).

What are our future plans?

The team’s next steps are to secure suitable premises – ideally in a community venue –and to obtain additional support from volunteers to help keep the children entertained during the clinic. In addition,we want to start running group clinics for different age ranges, including teenagers.

We also want to continue to improve nurses’ group consultation skills so they feel more confident, and plan to undertake motivational interviewing training as a team to ensure we achieve the best outcomes for families during consultations. We also aim to incorporate learning from patient self-management training into the sessions.

Overall, we plan to continue and expand evaluation of the impact of this way of working. This will inform our business case and help us support other teams at the hospital trust who could consider running group consultations.