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Local steroid injections have traditionally been given by doctors in rheumatology practice, with varying accuracy and success.1–3 The first joint injection course for nurses approved by the English National Board (ENB) was established at Cannock Chase Hospital in 1995, jointly led by a rheumatology consultant and nursing sister, and has run annually since then (ENB-N78).4 Over 50 nurses have completed the course, including many from this unit. They now give an increasing proportion of these injections at this hospital (following medical prescription), releasing doctors for other activities. Our audit assessed this service increasingly provided by nurses, measuring the frequency and type of nurse injection and patient satisfaction. Injections given by nurses and doctors at this unit were compared, as we required a standard of service from the nurses at least equal to that of the doctors.
The audit included all patients who underwent an intra-articular or soft tissue cortiocosteroid injection at this hospital over one calendar month. Injectors recorded their professional background and the site of injection(s). After the injection, the patient completed an anonymous questionnaire in their home within 3–7 days for return by prepaid envelope. This also recorded the injector's professional background; the patient's opinion of the adequacy of the information given before and after the injection (on a four point scale, from “no information” to “very detailed information”); the comfort (on a four point scale, from “very comfortable” to “very uncomfortable”) and efficacy (on a four point scale, from “very helpful” to “made worse”) of the procedure; their overall satisfaction (marked on a 10 cm visual analogue scale (VAS)); and the professional group from whom they would prefer to receive any future injections. The approval of the local research ethics committee was given for this audit.
In one month, 170 corticosteroid injections were given to 103 patients: trained nurses gave 114 (67%) of these injections to 63 patients. Nurses gave a mean (range) of 1.8 (1–8) injections to each patient compared with 1.4 (1–4) given by doctors. Nurses gave most of the ankle, knee, wrist, elbow, glenohumeral, and subacromial injections (table 1). Doctors gave all subtalar and carpometacarpal joint injections. Ninety three (90%) completed questionnaires were returned by patients. Almost all (96%) described preinjection information as “adequate” or “very detailed”, but more described it as “very detailed” when given by a nurse (48%) than when given by a doctor (32%) (fig 1). A greater proportion also described postinjection information as “very detailed” when given by a nurse (47% v 34%) (fig 1). Most (93%) described the injection as “fairly comfortable” or “very comfortable” but were more likely to have described the injection given by a nurse as “very comfortable” (61% v 43%). Almost all the injections given by both nurses and doctors were described as “helpful” or “very helpful” (93% and 88%, respectively). Overall satisfaction of injections given by nurses and doctors was similar (mean (range) VAS 8.0 (1.1–10.0) cm and 7.8 (0.6–10) cm, respectively). Only one patient injected by a nurse expressed a preference for any future injections to be given by a doctor; the rest preferred a nurse (38%) to give any future injections or had no preference.
This audit confirmed that trained nurses were performing the vast majority of local corticosteroid injections at this unit and that their standards were at least as good as those of doctors. Patients felt well informed by nurse injectors, found their injections were effective, were highly satisfied with their treatment, and were willing to have further treatment from nurses, if necessary. The results show that trained nurses can deliver a service previously provided by doctors in training, whose working hours are now greatly restricted.
There might be concerns about the experience acquired by such doctors during their rheumatology attachment, but further audit has shown that they now learn the techniques of steroid injection largely from trained nursing staff (results not shown). Rheumatology nurses now fulfil a wide range of roles in education, counselling, monitoring, and giving treatment.5 Debate continues over whether such developments represent progress or a dilution of the nurturing role traditionally ascribed to nurses.6,7 The cost effectiveness of an injection service provided by nurses was not considered by this audit and would be influenced by salary and patient throughput. The length of time spent with patients during this audit was not recorded, but it is worth noting that nursing staff were performing multiple intra-articular injections on some patients, which is time-consuming in itself and certainly does not represent “cherry picking” the easy cases.
The authors acknowledge and thank Dr A Hassell, consultant rheumatologist, for his foresight and determination in establishing the ENB-N78 joint injection course.
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