Información de la revista
Vol. 105. Núm. 3.
Páginas 213-215 (Abril 2014)
Vol. 105. Núm. 3.
Páginas 213-215 (Abril 2014)
Opinion Article
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Is Collaboration With Nursing Staff Necessary for the Management of Patients With Psoriasis?
La enfermería: ¿una colaboración necesaria para el control de nuestros pacientes afectos de psoriasis?
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R.F. Lafuente-Urrez
Autor para correspondencia
, M.C. Martin de Aguilera Moro
Servicio de Dermatología, Hospital Reina Sofia, Tudela, Spain
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Given recent developments in the treatment of psoriasis, a chronic disease with stigmatizing effects in which quality-of-life measures are important for guiding therapy and ensuring its success, it has become essential to manage the disease through individualized, holistic, and multidisciplinary approaches. We therefore believe that appropriately trained nurses must become involved in patient management and follow-up.

Nurses administer phototherapy in most dermatology departments,1 but very few centers have organized a system through which patients can consult nurses directly. One center with a psoriasis-specific nursing clinic that has been in operation since 2003 is Hospital Universitario de Gran Canaria Doctor Negrín, a 450-bed facility that serves a population of 400 000 inhabitants. The dermatology department has 7 specialists working inside the hospital, 1 dermatologist assigned to an off-site clinic, 4 residents, 2 nurses and 2 assistant nurses on the ward, and 2 administrative assistants. This facility has the potential to serve as an example for other hospitals, and in fact nurses from several other parts of Spain have been enthusiastically welcomed into the department to learn the more nuanced skills needed for participating in the care of these patients.

Another differently organized service that can also provide an example for nurse collaboration in this setting is located in Hospital Reina Sofía de Tudela. The nursing clinic there is not specific to psoriasis, but it does attend patients with this disease. The hospital is a regional 161-bed facility serving a population of approximately 100 000 inhabitants. The department has 3 dermatologists and 3 nurses on staff. The dermatology nurse consultancy was created in 2002 to provide ongoing care for the department's patients. The idea of referring patients with psoriasis to the service was suggested in 2004–2005, as the new biologic therapies were being introduced.2 Initially, only patients on biologics were referred so that they or a relative could be properly instructed in how to administer the treatments and take note of its effects. Later, it was thought that other psoriasis patients might also benefit from closer monitoring.

In this article our main objective is to describe the patients with psoriasis who are appropriate candidates for ongoing care by a dermatology nurse consultant. We will analyze the results of such care to evaluate whether psoriasis patients benefit from nurse follow-up or not. Secondary aims are to define the current role of nurses in the management of psoriasis in order to analyze problems and plan an approach. The nurse consultant seeks to motivate patients to manage their illness encouraging independence and self-care while also promoting the adoption of healthful habits. Other aims of these nursing clinics are to prevent complications, answer questions, or resolve skin or medication problems that arise. Changes in symptoms and behaviors are assessed and patients are shown ways to improve their condition.

With these interests in mind, the dermatology department of Hospital Reina Sofía de Tudela decided that all patients with psoriasis who were in treatment would be followed through the nursing clinic. Patients who had been diagnosed by a dermatologist and whose treatment was being monitored or who experienced an exacerbation were candidates for nurse consultation; the nurse would refer the patient to a dermatologist when necessary.

A computerized system for scheduling nursing clinic visits and keeping records, similar to medical charts, were created for recording information about the patient's condition and health-related behaviors. These records help the nurse identify factors and situations relevant to an individual's problems.

During a visit, the nurse calculates the Psoriasis Area and Severity Index and the body surface area affected by the disease; the Dermatology Life Quality Index is also sometimes recorded.

Written information and instruction are given in the following cases: a) if a knowledge gap or mistaken idea about the disease or treatment is detected; b) if the patient expresses low self esteem or altered perception of physical appearance related to the disease or if signs of social isolation are detected; c) if comorbid conditions, such as hypertension or diabetes mellitus, are poorly controlled; and d) if the treatment is poorly tolerated related to lack of understanding and/or adverse effects.

The dermatology nurse consultant is responsible for explaining how the patient should manage and administer systemic, biologic, and nonbiologic therapies as well as how side effects are detected and managed.

The number of patients being followed by nurses has increased over the past 8 years. In 2012, the service's caseload reached 167 patients, 22 of them on biologics.

The response of the nursing staff has been highly satisfactory, not only because their understanding of psoriasis and its treatment has grown but because their collaboration has enabled the department to pinpoint habits and life styles that have a negative effect on treatment and factors that lead to treatment failure or nonadherence. The nurses work with the dermatologist on diagnostic evaluation and follow-up.

Most patients evaluate the nurses’ participation in their care positively, reporting that they understand their disease and its treatment better, undertake more effective self care, and notice factors that might improve or worsen their condition, thus helping them to adopt healthful habits. Above all, the patients feel more confident because specialist care is more accessible to them, since they are not subject to placement on wait lists that can delay starting or continuing treatment in case of flare-ups. Adherence to treatment has also improved under this system. Response to therapy is thereby improved and adverse events are fewer, helping to reduce the number of medical visits. Some patients have also reported less anxiety and greater self-esteem under this type of follow-up.

Although our observations are consistent with reports in the literature,3–7 a certain proportion of the medical and nursing staff are reluctant to accept the practice of transferring to nurses responsibilities traditionally assigned to dermatologists, arguing that this approach is not risk-free.4 Nurse follow-up of patients with psoriasis does involve a certain degree of autonomy. However, while nurses are assuming this responsibility, showing initiative and making and implementing decisions and choices, they never hesitate to contact the dermatologist when problems arise. Nurse competence, the availability of support from the dermatologist and ongoing supervision as well as treatment protocols should allay fears about using this approach, although the threat of possible legal consequences should not be forgotten.3–5 Implementing a program for nurse follow-up care in psoriasis also requires good relations among physicians, nurses, and patients. All members of the team must know each other, the disease, and the institution's rules. It is necessary to explain the project to medical and nursing colleagues and staff supervisors, who must understand how it will be implemented and responsibilities distributed. The actual functioning of these programs is often driven by demographic factors (e.g., the distance of certain populations from the health care facility) or by nurses’ progress in acquiring the required skills because of limited training resources3 due to recent cutbacks in health care funding. The organization of a psoriasis nursing clinic requires planning. Protocols must be established8 and adapted to the specific characteristics and circumstances of the organizing hospital.

We conclude that the results support the usefulness of nurse consultants’ involvement in the care of patients with psoriasis. We also conclude that nurses are ready and willing to undertake professional development to increase their knowledge and skills for handling the new responsibilities. More effective care of psoriasis patients is not the only outcome of making nursing clinics available to patients. Additional benefits are more efficient care and greater patient cooperation and participation in the care process. We believe that the potential of therapy rests on more than the doctor-patient relationship alone.9 The patient, nurse, and doctor are all involved.

References
[1]
P.M. Farr, B.L. Diffey.
PUVA treatment of psoriasis in the United Kingdom.
Br J Dermatol, 124 (1991), pp. 365-367
[2]
M.C. Martin de Aguilera, M.P. Hernández, R.F. Lafuente, R. Matheu.
Tratamientos biológicos en la consulta de enfermería: control e información.
Enf Dermatol, 2 (2007), pp. 12-18
[3]
M. Courtenay, N. Carey.
Nurse-led care in dermatology: A review of the literature.
Br J Dermatol, 154 (2006), pp. 1-6
[4]
N.H. Cox, Y. Walton.
Prescribing for out-patients by nursing staff in a dermatology department.
Br J Dermatol, 139 (1998), pp. 77-80
[5]
N.H. Cox, J. Bowman.
An evaluation of educational requirements for community nurses treating dermatological patients.
Clin Exp Dermatol, 25 (2000), pp. 12-15
[6]
C. Gradwell, K.S. Thomas, J.S. English, H.C. Williams.
A randomized controlled trial of nurse follow-up clinics: Do they help patients and do they free up consultants¿ time?.
Br J Dermatol, 147 (2002), pp. 513-517
[7]
N.H. Cox.
The expanding role of nurses in surgery and prescribing in British departments of dermatology. Therapy guidelines and audit subcomittee of the British Association of Dermatologists.
Br J Dermatol, 140 (1999), pp. 681-684
[8]
P. Mota López, G. Carretero Hernández.
Manual de la consulta de enfermería dermatológica (CEDER).
1st ed., Farmalia Comunicación S.L., (2007),
[9]
L. Rojas Marcos.
Claves para un mejor control de la psoriasis.
1st ed., Laboratorios LEO Pharma S.A., (2012),

Please cite this article as: Lafuente-Urrez R.F. Martin de Aguilera Moro M.C. La enfermería: ¿una colaboración necesaria para el control de nuestros pacientes afectos de psoriasis?. Actas Dermosifiliogr. 2014;105:213–215.

Copyright © 2013. Elsevier España, S.L. and AEDV
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