Ahead of next month’s highly-anticipated EMJ Hepatology eJournal, we have provided an early taster of what is to come in this publication in the form of a feature from an interview we conducted with one of our distinguished Editorial Board members, Ms Fiona Fry. We hope you enjoy the article, which will be included in the journal alongside a review of the European Association of the Study of the Liver (EASL)’s annual International Liver Congress (ILC), peer-reviewed papers, and much more.
We recently spoke to one of the EMJ Hepatology Editorial Board members, Ms Fiona Fry, about a number of pertinent topics in the field, many of which will feature in the upcoming journal. Ms Fry is a very important voice in the liver nurses’ community, holding the position of Lead Hepatology Nurse at the Royal Devon and Exeter NHS Foundation Trust, Exeter, UK as well as being co-chair of the recently amalgamated British Liver Nurses Association (BLNA), a special interest group of the British Association for the Study of the Liver (BASL).
With a wealth of experience in this area of medicine, Ms Fry was able to provide us with excellent insights into the evolving role of nurses in hepatology and the crucial point of contact they have become for liver patients. We also talked about the importance of the recent establishment of the BLNA last year, a process Ms Fry was heavily involved in, and some of the vital work they are currently undertaking. Additionally, we analysed a number of challenges in the field and the ways they can be addressed to help improve care for these patients. These include combatting stigmatism of liver conditions such as hepatitis C and the work of outreach services in helping a patient group that is often difficult to treat via the usual methods.
Ms Fry firstly outlined how her own role and that of nurses in general has broadened over the years, requiring an increasingly greater skillset and knowledge than ever before. “I have been a hepatology nurse specialist for nearly 18 years and my role has developed significantly in this time. When I started in this role I just saw hepatitis C patients that were referred by the consultant for treatment,” she explained. “That has completely evolved and is now a truly nurse-led service, especially for viral hepatitis patients; My week is very busy with clinics in both the hospital and outreach settings, hepatocellular cancer (HCC) screening and also inpatient and telephone support (to patients; their family/carers and general practitioners). The complexity of patients seen has changed dramatically over the past 17 years, whereas as previously all complex liver patients would be seen solely by the consultants, they are now being seen in the nurse clinics, I now see anyone from a decompensated cirrhotic patient to a new hepatitis B patient in clinic.”
These multifaceted skills have had a significant impact in relieving the pressure on consultants, according to Ms Fry, who also explained how nurses tend to hold certain attributes that make them particularly suitable for such a prominent role in patient care. One of these is their organisational skills and systematic mode of operation that prevents people missing crucial stages of their care. “I think nurses are very good at putting in those systems,” she added.
Relationship with Patients
In addition, nurses are particularly adept at communicating with patients, something that is well-recognised as being crucial for ensuring the best possible outcomes. With consultants often constrained by time, nurses have a pivotal role in explaining each step of diagnosis and subsequent treatment to hepatology patients; for example, the reasons why they are undergoing a particular scan or procedure, which makes them more likely to turn up for appointments. Building relationships through familiarity with the nurses also enhances the trust patients have with the care they are receiving, and this improves adherence to management and treatment plans. “A good example is the establishment of really effective nurse-led services for the delivery of hepatitis C treatment. Adherence to treatment is essential to ensure the best outcomes and nurses have clearly proven their skills in delivering this,” stated Ms Fry.
Creation of the BLNA
With the aim of giving nurses a more unified and stronger voice in hepatology in the UK, Ms Fry, who was chair of BASL Nurse Forum, and Ms Michelle Clayton, previously chair of the British Liver Nurse Forum, merged the two organisations to set up the BLNA in September 2017. It is hoped that in addition to providing a more coherent message from liver nurses in the UK, unique knowledge and skills from both bodies will be brought together to engage in new projects that enhance the provision of care. One that has been embarked upon since the inception of the BLNA is a scoping exercise to establish a database of all the liver nurses working in the UK. Ms Fry explained that currently, many nurses are isolated in underfunded regions and not receiving sufficient support. They hope that a record of every liver nurse will ultimately ensure they each have access to full levels of support and educational opportunities.
Stigmatism in Liver Disease
Ms Fry was drawn to specialising in hepatology whilst working in gastroenterology wards during the early part of her career. Sadly she observed that some health care professionals tended to not treat liver patients with as much compassion as that being given to other gastroenterology patients. She quickly developed a lasting empathy and concern for these patients, finding that they didn’t always have as much of a voice as other patients and often relied on nurses to be their advocate. This is partly due to the complex issues many of these patients tend to have, such as alcohol misuse and mental health problems. These issues, as well as the commonly-held perception that liver disease is self-induced, has meant that stigmatism has always been a major problem in this area of medicine. Ms Fry believes these sorts of attitudes have improved over time with education, but there is clearly still a lot of work to be done.
Hepatitis C Testing
As part of an Operational Delivery Network (ODN) through which hepatitis C treatment is delivered, Ms Fry and her colleagues are playing a major part in the effort to implement the recent NHS England plan to eliminate hepatitis C in England by the year 2025. With massive strides being made in this direction, particularly treatment-wise over recent years, Ms Fry is confident of this being achieved; however, she sees the biggest challenge in this respect to be finding all the undiagnosed hepatitis C patients out there, believing a major advertising campaign that encourages more people to be tested would be highly beneficial. In particular, she feels that the ‘baby boom’ generation (born between 1946 and 1964) who may in the past have been exposed to hepatitis C after receiving blood transfusions or blood products, recreational drug use, tattoos with unsterilised equipment, etc., should be made aware of these risks and be offered testing. “We are seeing patients aged in their 50s and 60s that are presenting with cirrhosis or liver cancer that didn’t know they had hepatitis C,” commented Ms Fry. “I think we’re good at testing drug users and prisoners and all those at really high risk, but we also need to look at going back to people who may have had a risk many years ago.”
The liver nursing service at Royal Devon and Exeter NHS Trust currently delivers outreach services to both the local prison and GP surgery for the homeless and vulnerably housed. “We are now able to see and treat patients with hepatitis C in these outreach settings which has proved hugely successful in engaging with patients by offering a ‘one stop shop’, this has been made even more effective with the availability of a portable fibroscan. Patients can be assessed, monitored, and treated without the need to travel to the hospital for appointments and investigations which had previously often been a barrier to accessing care,” she explained. Another big step forward that she informed us about has been in obtaining the funding for an ultrasound machine to enable vascular access in the outreach clinics. Vascular access teams have provided best practice for taking bloods from people with poor venous access within the hospital setting for many years and by securing a portable ultrasound machine we have been able to remove another barrier to accessing treatment.
There are similar hepatitis C outreach services being delivered across the UK and these could be replicated to see patients with other types of liver disease such as fatty liver disease. Fatty liver disease is the condition that Ms Fry sees as being the next major area that needs addressing in hepatology. She believes nurses will have an important role in combatting this and other liver conditions by reaching out to at-risk patients in the community. This could be achieved by developing more outreach services in the community that enable education, monitoring, and treatment to take place in general practice surgeries rather than requiring patients to travel to local hospitals.
The next stage is to provide a business case for the creation of more outreach services, something Ms Fry is working towards. It is successes such as this that show the voice and positive influence on decisions that nurses can have in the field of hepatology.
Overall, there are undoubtedly grounds for optimism in regard to the care of liver disease patients. The efforts being put into the elimination of hepatitis C is highly positive for example, and Ms Fry reiterated that nurses are able to make a difference and help bring about changes that benefit patients, although she acknowledged this can be time-consuming and, at times, frustrating.
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