Coping with itch, a nurse-led intervention

Abstract

The aim of this thesis is to provide insight into the psychosocial morbidity and itch cognitions of patients with chronic pruritic skin disease and to develop, test and implement a nursing programme, to help patients to cope with itch. In a study of 168 patients, it became clear that patients with a pruritic skin disease often have a high level of psychosocial morbidity. The most important predictor of psychosocial morbidity is catastrophizing and helpless coping strategies; frequency and intensity of itching and scratching and the demographic variables age and sex were also significant, but less important predictors. The nursing programme 'Coping with Itch', which supplements dermatological treatment as usual, is intended to reduce itch and psychosocial morbidity related to itch, and to help the patient to cope with his or her itch. The programme consists of dermatological education and cognitive behavioural interventions. A randomized controlled study (RCT) was carried out, showing that the programme led to a faster reduction in the frequency of itching and scratching and to a faster reduction in catastrophizing and helpless coping in patients with chronic pruritic skin diseases as compared to a control group receiving usual dermatological treatment. Implementation of innovative programs in health care is difficult: therefore we evaluated the feasibility of the program. The programme proved to be feasible in a dermatology outpatient department. A tailored implementation approach was used to solve discrepancies between the (structural, human resource, political and cultural) characteristics of the organizations and the requirements of the innovative nursing intervention. This approach has led to the successful implementation of the nursing programme in five hospitals in the Netherlands. Nurses are able to carry out the programme and all five hospitals continued the itch clinic after completion of the implementation study. Cost and cost effectiveness of the programme were also explored. Most of the costs of the nursing programme 'Coping with itch' were incurred during the first three months of the study. The point-estimate of the incremental effectiveness ratio for the first three months of study was € 129.91 per gained day with little itch. Benefits in terms of days with little itch persisted and increased beyond three months, thus leading to a more favourable incremental cost effectiveness ratio of € 1.02 per day with little itch. The current findings suggest that the 'Coping with itch' programme is worthwhile on the short term. The period of effectiveness with regard to the reduction of itching and scratching may be lengthened by a longer follow-up to the itch clinic, and making use of telephone contact or E-health. Research to investigate which patients with regard to diagnosis of skin disease and level of itching and scratching, benefit most from the 'Coping with Itch' programme is recommended as a next step in research.