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Substitution of general practitioners by nurse practitioners in out-of-hours primary care home visits: A quasi-experimental study. Int J Nurs Stud 2020; 104:103445. [DOI: 10.1016/j.ijnurstu.2019.103445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 09/20/2019] [Accepted: 09/24/2019] [Indexed: 11/20/2022]
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Garrard JW, Cox NJ, Dodds RM, Roberts HC, Sayer AA. Comprehensive geriatric assessment in primary care: a systematic review. Aging Clin Exp Res 2020; 32:197-205. [PMID: 30968287 PMCID: PMC7033083 DOI: 10.1007/s40520-019-01183-w] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/23/2019] [Indexed: 11/29/2022]
Abstract
Background Comprehensive geriatric assessment (CGA) involves the multidimensional assessment and management of an older person. It is well described in hospital and home-based settings. A novel approach could be to perform CGA within primary healthcare, the initial community located healthcare setting for patients, improving accessibility to a co-located multidisciplinary team. Aim To appraise the evidence on CGA implemented within the primary care practice. Methods The review followed PRISMA recommendations. Eligible studies reported CGA on persons aged ≥ 65 in a primary care practice. Studies focusing on a single condition were excluded. Searches were run in five databases; reference lists and publications were screened. Two researchers independently screened for eligibility and assessed study quality. All study outcomes were reviewed. Results The authors screened 9003 titles, 145 abstracts and 97 full texts. Four studies were included. Limited study bias was observed. Studies were heterogeneous in design and reported outcomes. CGAs were led by a geriatrician (n = 3) or nurse practitioner (n = 1), with varied length and extent of follow-up (12–48 months). Post-intervention hospital admission rates showed mixed results, with improved adherence to medication modifications. No improvement in survival or functional outcomes was observed. Interventions were widely accepted and potentially cost-effective. Discussion The four studies demonstrated that CGA was acceptable and provided variable outcome benefit. Further research is needed to identify the most effective strategy for implementing CGA in primary care. Particular questions include identification of patients suitable for CGA within primary care CGA, a consensus list of outcome measures, and the role of different healthcare professionals in delivering CGA. Electronic supplementary material The online version of this article (10.1007/s40520-019-01183-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James W Garrard
- Radcliffe Department of Medicine, University of Oxford, Oxford, OX1 2JD, UK.
| | - Natalie J Cox
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard M Dodds
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- AGE Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Helen C Roberts
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Wessex, University of Southampton, Southampton, UK
| | - Avan A Sayer
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- AGE Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
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Holm Hansen E, Bomann E, Bing-Jonsson P, Fagerstrom LM. Introducing Nurse Practitioners Into Norwegian Primary Healthcare-Experiences and Learning. Res Theory Nurs Pract 2020; 34:21-34. [PMID: 31937634 DOI: 10.1891/1541-6577.34.1.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Nurse practitioners (NPs) are well established internationally, and Norway is now in the first phase of implementing their role. The aim of this study was to describe the reflections of nurse leaders and general practitioners (GPs) on the establishment of the new NP role in primary healthcare. METHODS This study was qualitative and longitudinal. Written reports and audio recordings from 11 meetings with nurse leaders and GPs during 3 years in 3 municipalities were analyzed by a thematic analysis. RESULTS Four themes were identified: the need for enhanced clinical competence among registered nurses, the need for reorganization of advanced practice, the need for negotiating professional barriers, and demanding economic situations. Nurse leaders and GPs were generally positive toward NPs, but they had difficulty in clarifying their roles and how to organize them in the existing work models. This was due to economic pressures, different needs in departments, and shift work. Nurse leaders and GPs agreed that NPs should not replace physicians but perform the tasks of advanced practice nursing in a more expert way. Nurse leaders also wanted NPs to be a resource for registered nurses. It was important to gain trust in the new role not only of GPs but also of registered nurses. IMPLICATIONS FOR PRACTICE It is extremely important that an implementation group is proactive in finding a suitable model for the implementation process. Clarification of the roles, tasks, and responsibilities of NPs at an early implementation stage could make the process easier.
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Abraham CM, Norful AA, Stone PW, Poghosyan L. Cost-Effectiveness of Advanced Practice Nurses Compared to Physician-Led Care for Chronic Diseases: A Systematic Review. NURSING ECONOMIC$ 2019; 37:293-305. [PMID: 34616101 PMCID: PMC8491992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Globally, advanced practice nurses (APNs) provide high-quality chronic disease care to patients, yet the cost-effectiveness of their services is minimally explored. This review aims to determine the cost-effectiveness of chronic disease care provided by APNs compared to physicians globally.
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Johnson D, Ouenes O, Letson D, de Belen E, Kubal T, Czarnecki C, Weems L, Box B, Paculdo D, Peabody J. A Direct Comparison of the Clinical Practice Patterns of Advanced Practice Providers and Doctors. Am J Med 2019; 132:e778-e785. [PMID: 31145882 DOI: 10.1016/j.amjmed.2019.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/22/2019] [Accepted: 05/08/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Rising health care costs, physician shortages, and an aging patient population have increased the demand and utilization of advanced practice providers (APPs). Despite their expanding role in care delivery, little research has evaluated the care delivered by APPs compared with physicians. METHODS We used clinical patient simulations to measure and compare the clinical care offered by APPs and physicians, collecting data from 4 distinct health care systems/hospitals in the United States between 2013 and 2017. Specialties ranged from primary care to hospital medicine and oncology. Primary study outcomes were to 1) measure any differences in practice patterns between APPs and physicians, and 2) determine whether the use of serial measurement and feedback could mitigate any such differences. RESULTS At baseline, we found no major differences in overall performance of APPs compared with physicians (P = .337). APPs performed 3.2% better in history taking (P = .013) and made 10.5% fewer unnecessary referrals (P = .025), whereas physicians ordered 17.6% fewer low-value tests per case (P = .042). Regardless of specialty or site, after 4 rounds of serial measurement and provider-specific feedback, APPs and physicians had similar increases in average overall scores-7.4% and 7.6%, respectively (P < .001 for both). Not only did both groups improve, but practice differences between the groups disappeared, leading to a 9.1% decrease in overall practice variation. CONCLUSIONS We found only modest differences in quality of care provided by APPs and physicians. Importantly, both groups improved their performance with serial measurement and feedback so that after 4 rounds, the original differences were mitigated entirely and overall variation significantly reduced. Our data suggest that APPs can provide high quality care in multiple clinical settings.
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Affiliation(s)
| | | | | | | | | | | | | | - Brent Box
- AdventHealth, Altamonte Springs, Fla
| | | | - John Peabody
- QURE Healthcare, San Francisco, Calif; University of California, Los Angeles; Institute for Global Health Sciences, University of California, San Francisco.
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van den Brink GTWJ, Kouwen AJ, Hooker RS, Vermeulen H, Laurant MGH. An activity analysis of Dutch hospital-based physician assistants and nurse practitioners. HUMAN RESOURCES FOR HEALTH 2019; 17:78. [PMID: 31665010 PMCID: PMC6819603 DOI: 10.1186/s12960-019-0423-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/24/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management. STUDY DESIGN A descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated. METHODS The patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system. FINDINGS In total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care. CONCLUSIONS NPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.
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Affiliation(s)
- G T W J van den Brink
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
- Department of Master Programs, HAN University of Applied Sciences, PO box 6960, 6503 GL, Nijmegen, The Netherlands.
| | - A J Kouwen
- Radboud University Medical Center, PVI, Nijmegen, The Netherlands
| | - R S Hooker
- Health Policy Analyst, Ridgefield, WA, United States of America
| | - H Vermeulen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M G H Laurant
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, Institute of Nursing Studies, Nijmegen, The Netherlands
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Acting in the Public Interest: Learnings and Commentary on the Occupational Licensure Literature. JOURNAL OF NURSING REGULATION 2019. [DOI: 10.1016/s2155-8256(19)30120-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gigli KH, Beauchesne MA, Dirks MS, Peck JL. White Paper: Critical Shortage of Pediatric Nurse Practitioners Predicted. J Pediatr Health Care 2019; 33:347-355. [PMID: 30878267 DOI: 10.1016/j.pedhc.2019.02.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/11/2019] [Accepted: 02/18/2019] [Indexed: 11/29/2022]
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Smith T, McNeil K, Mitchell R, Boyle B, Ries N. A study of macro-, meso- and micro-barriers and enablers affecting extended scopes of practice: the case of rural nurse practitioners in Australia. BMC Nurs 2019; 18:14. [PMID: 30976197 PMCID: PMC6444450 DOI: 10.1186/s12912-019-0337-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Shortages of skills needed to deliver optimal health care in rural and remote locations raises questions about using extended scopes of practice or advanced practice models in a range of health professions. The nurse practitioner (NP) model was introduced to address health service gaps; however, its sustainability has been questioned, while other extended scope of practice roles have not progressed in Australia. This study aimed to explore the experiences and perceptions of NPs and their colleagues about barriers to and enablers of extended scope of practice and consider the relevance of the findings to other health professions. METHODS Semi-structured, in-depth interviews were conducted with primary, nurse practitioner informants, who were also invited to nominate up to two colleagues, as secondary informants. Data analysis was guided by a multi-level, socio-institutional lens of macro-, meso- and micro-perspectives. RESULTS Fifteen primary informants and five colleagues were interviewed from various rural and remote locations. There was a fairly even distribution of informants across primary, aged, chronic and emergency or critical care roles. Key barriers and enablers at each level of analysis were identified. At the macro-level were legal, regulatory, and economic barriers and enablers, as well as job availability. The meso-level concerned local health service and community factors, such as attitudes and support from managers and patients. The micro-level relates to day-to-day practice. Role clarity was of considerable importance, along with embedded professional hierarchies and traditional role expectations influencing interactions with individual colleagues. Given a lack of understanding of NP scope of practice, NPs often had to expend effort promoting and advocating for their roles. CONCLUSIONS For communities to benefit from extended scope of practice models of health service delivery, energy needs to be directed towards addressing legislative and regulatory barriers. To be successful, extended scope of practice roles must be promoted with managers and decision-makers, who may have limited understanding of the clinical importance. Support is also important from other members of the interprofessional health care team.
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Affiliation(s)
- Tony Smith
- Department of Rural Health, The University of Newcastle, 69A High Street, Taree, NSW 2430 Australia
| | - Karen McNeil
- Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
| | - Rebecca Mitchell
- Faculty of Business and Law, University of Newcastle, Callaghan, Australia
| | - Brendan Boyle
- Faculty of Business and Law, University of Newcastle, Callaghan, Australia
| | - Nola Ries
- Faculty of Law, University of Technology Sydney, Ultimo, Australia
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Barry E, Greenhalgh T. General practice in UK newspapers: an empirical analysis of over 400 articles. Br J Gen Pract 2019; 69:e146-e153. [PMID: 30642907 PMCID: PMC6355271 DOI: 10.3399/bjgp19x700757] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/07/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the context of the biggest GP workforce crisis since the NHS began, the alleged negative portrayal of UK general practice in the media is often cited as a reason for falling recruitment. AIM To explore how general practice and GPs are depicted in UK national newspapers. DESIGN AND SETTING A thematic analysis of all newspaper articles mentioning GPs or general practice published in the UK from late October 2016 to early October 2017 was undertaken, along with a sample of articles on hospital medicine. METHOD Articles were identified through the Lexin UK search engine; relevant titles were tabulated and data extracted. A preliminary coding scheme was developed through discussion and used to categorise data; additional codes and categories were added iteratively as the analysis progressed. RESULTS In total, 403 articles on general practice or GPs were identified, and 100 on hospital specialists or specialties were sampled. Articles depicted UK general practice as a service in crisis, with low morale and high burnout, and leaving gaps in patient care. The traditional family doctor service was depicted as rapidly eroding through privatisation and fragmentation, with GPs portrayed as responsible for the crisis and the resulting negative impact on quality of care. Hospital specialties were also illustrated as under pressure, but this crisis was depicted as being the fault of the government. GP leaders interviewed in the press were usually defending their specialty; hospital doctors were usually sharing their expertise. CONCLUSION Newspaper portrayals of general practice are currently very negative. Efforts to influence the media to provide a more balanced perspective of general practice should continue.
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Affiliation(s)
- Eleanor Barry
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Trish Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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Barnes H, Richards MR, McHugh MD, Martsolf G. Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners. Health Aff (Millwood) 2019; 37:908-914. [PMID: 29863933 DOI: 10.1377/hlthaff.2017.1158] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The use of nurse practitioners (NPs) in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. We found increasing NP presence in both rural and nonrural primary care practices in the period 2008-16. At the end of the period, NPs constituted 25.2 percent of providers in rural and 23.0 percent in nonrural practices, compared to 17.6 percent and 15.9 percent, respectively, in 2008. States with full scope-of-practice laws had the highest NP presence, but the fastest growth occurred in states with reduced and restricted scopes of practice. State Medicaid expansion status was not associated with greater NP presence. Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.
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Affiliation(s)
- Hilary Barnes
- Hilary Barnes ( ) is an assistant professor in the School of Nursing, University of Delaware, in Newark
| | - Michael R Richards
- Michael R. Richards is an assistant professor of health policy at Vanderbilt University, in Nashville, Tennessee
| | - Matthew D McHugh
- Matthew D. McHugh is a professor of nursing; the Independence Chair for Nursing Education, Center for Health Outcomes and Policy Research; and a senior fellow at the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania, in Philadelphia
| | - Grant Martsolf
- Grant Martsolf is a professor in the Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, and an adjunct policy researcher at the RAND Corporation in Pittsburgh, both in Pennsylvania
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Maier CB, Batenburg R, Birch S, Zander B, Elliott R, Busse R. Health workforce planning: which countries include nurse practitioners and physician assistants and to what effect? Health Policy 2018; 122:1085-1092. [PMID: 30241796 DOI: 10.1016/j.healthpol.2018.07.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND An increasing number of countries are introducing new health professions, such as Nurse Practitioners (NPs) and Physician Assistants (PAs). There is however limited evidence, on whether these new professions are included in countries' workforce planning. METHODS A cross-country comparison of workforce planning methods. Countries with NPs and/or PAs were identified, workforce planning projections reviewed and differences in outcomes were analysed, based on a review of workforce planning models and a scoping review. Data on multi-professional (physicians/NPs/PAs) vs. physician-only models were extracted and compared descriptively. Analysis of policy implications was based on policy documents and grey literature. RESULTS Of eight countries with NPs/PAs, three (Canada, the Netherlands, United States) included these professions in their workforce planning. In Canada, NPs were partially included in Ontario's needs-based projection, yet only as one parameter to enhance efficiency. In the United States and the Netherlands, NPs/PAs were covered as one of several scenarios. Compared with physician-only models, multi-professional models resulted in lower physician manpower projections, primarily in primary care. A weakness of the multi-professional models was the accuracy of data on substitution. Impacts on policy were limited, except for the Netherlands. CONCLUSIONS Few countries have integrated NPs/PAs into workforce planning. Yet, those with multi-professional models reveal considerable differences in projected workforce outcomes. Countries should develop several scenarios with and without NPs/PAs to inform policy.
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Affiliation(s)
- Claudia B Maier
- Department of Healthcare Management, Technische Universität Berlin, H 80, Straße des 17. Juni 135, 10623 Berlin, Germany.
| | - Ronald Batenburg
- Netherlands Institute for Health Services Research (NIVEL), P.O. Box 1568, 3500 BN Utrecht, The Netherlands; Radboud University Nijmegen, Department of Sociology P.O. Box 9104, 6500 HE Nijmegen, The Netherlands.
| | - Stephen Birch
- Centre for Health Economics, University of Manchester Centre for the Business and Economics of Health, United Kingdom; University of Queensland, Brisbane, Australia.
| | - Britta Zander
- Department of Healthcare Management, Technische Universität Berlin, H 80, Straße des 17. Juni 135, 10623 Berlin, Germany.
| | - Robert Elliott
- Health Economics Research Unit, University of Aberdeen, Aberdeen AB25 2ZD, United Kingdom.
| | - Reinhard Busse
- Department of Healthcare Management, Technische Universität Berlin, H 80, Straße des 17. Juni 135, 10623 Berlin, Germany.
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Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJAH. Nurses as substitutes for doctors in primary care. Cochrane Database Syst Rev 2018; 7:CD001271. [PMID: 30011347 PMCID: PMC6367893 DOI: 10.1002/14651858.cd001271.pub3] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005. OBJECTIVES Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'. SELECTION CRITERIA Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis. MAIN RESULTS For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low. AUTHORS' CONCLUSIONS This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.
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Affiliation(s)
- Miranda Laurant
- Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical CenterPO Box 9101NijmegenNetherlands6500 HB
- HAN University of Applied SciencesFaculty of Health and Social StudiesNijmegenNetherlands
| | - Mieke van der Biezen
- Radboud Institute for Health Sciences, IQ healthcareRadboud University Medical CenterPO Box 9101NijmegenNetherlands6500 HB
| | | | - Kanokwaroon Watananirun
- Faculty of Medicine, Siriraj Hospital, Mahidol UniversityDepartment of Obstetrics and GynaecologyMahidolThailand
| | - Evangelos Kontopantelis
- The University of ManchesterCentre for Health Informatics, Institute of Population HealthWilliamson Building, 5th FloorOxford RoadManchesterGreater ManchesterUKM13 9PL
| | - Anneke JAH van Vught
- HAN University of Applied SciencesFaculty of Health and Social StudiesNijmegenNetherlands
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Estimating the association between burnout and electronic health record-related stress among advanced practice registered nurses. Appl Nurs Res 2018; 43:36-41. [PMID: 30220361 DOI: 10.1016/j.apnr.2018.06.014] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/19/2018] [Accepted: 06/23/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Health information technology (HIT), such as electronic health records (EHRs), is a growing part of the clinical landscape. Recent studies among physicians suggest that HIT is associated with a higher prevalence of burnout. Few studies have investigated the workflow and practice-level predictors of burnout among advanced practice registered nurses (APRNs). AIM Characterize HIT use and measure associations between EHR-related stress and burnout among APRNs. METHODS An electronic survey was administered to all APRNs licensed in Rhode Island, United States (N = 1197) in May-June 2017. The dependent variable was burnout, measured with the validated Mini z burnout survey. The main independent variables were three EHR-related stress measures: time spent on the EHR at home, daily frustration with the EHR, and time for documentation. Logistic regression was used to measure the association between EHR-related stress and burnout before and after adjusting for demographics, practice-level characteristics, and the other EHR-related stress measures. RESULTS Of the 371 participants, 73 (19.8%) reported at least one symptom of burnout. Among participants with an EHR (N = 333), 165 (50.3%) agreed or strongly agreed that the EHR added to their daily frustration and 97 (32.8%) reported an insufficient amount of time for documentation. After adjustment, insufficient time for documentation (AOR = 3.72 (1.78-7.80)) and the EHR adding to daily frustration (AOR = 2.17 (1.02-4.65)) remained predictors of burnout. CONCLUSIONS Results from the present study revealed several EHR-related environmental factors are associated with burnout among APRNs. Future studies may explore the impact of addressing these EHR-related factors to mitigate burnout among this population.
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Maier CB, Köppen J, Busse R. Task shifting between physicians and nurses in acute care hospitals: cross-sectional study in nine countries. HUMAN RESOURCES FOR HEALTH 2018; 16:24. [PMID: 29801452 PMCID: PMC5970499 DOI: 10.1186/s12960-018-0285-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 04/20/2018] [Indexed: 05/28/2023]
Abstract
BACKGROUND Countries vary in the extent to which reforms have been implemented expanding nurses' Scopes-of-Practice (SoP). There is limited cross-country research if and how reforms affect clinical practice, particularly in hospitals. This study analyses health professionals' perceptions of role change and of task shifting between the medical and nursing professions in nine European countries. METHODS Cross-sectional design with surveys completed by 1716 health professionals treating patients with breast cancer (BC) and acute myocardial infarction (AMI) in 161 hospitals across nine countries. Descriptive and bivariate analysis on self-reported staff role changes and levels of independence (with/without physician oversight) by two country groups, with major SoP reforms implemented between 2010 and 2015 (Netherlands, England, Scotland) and without (Czech Republic, Germany, Italy, Norway, Poland, Turkey). Participation in 'medical tasks' was identified using two methods, a data-driven and a conceptual approach. Individual task-related analyses were performed for the medical and nursing professions, and Advanced Practice Nurses/Specialist Nurses (APN/SN). RESULTS Health professionals from the Netherlands, England and Scotland more frequently reported changes to staff roles over this time period vs. the other six countries (BC 74.0% vs. 38.7%, p < .001; AMI 61.7% vs. 37.3%, p < .001), and higher independence in new roles (BC 58.6% vs. 24.0%, p < .001; AMI 48.9% vs. 29.2%, p < .001). A higher proportion of nurses and APN/SN from these three countries reported to undertake tasks related to BC diagnosis, therapy, prescribing of medicines and information to patients compared to the six countries. Similar cross-country differences existed for AMI on prescribing medications and follow-up care. Tasks related to diagnosis and therapy, however, remained largely within the medical profession's domain. Most tasks were reported to be performed by both professions rather than carried out by one profession only. CONCLUSIONS Higher levels of changes to staff roles and task shifting were reported in the Netherlands, England and Scotland, suggesting that professional boundaries have shifted, for instance on chemotherapy or prescribing medicines. For most tasks, however, a partial instead of full task shifting is practice.
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Affiliation(s)
- Claudia B. Maier
- Department of Healthcare Management, Technische Universität Berlin, H 80, Straße des 17. Juni 135, 10623 Berlin, Germany
- Center for Health Outcomes and Policy Research, University of Pennsylvania, School of Nursing, Claire Fagin Hall, 418 Curie Blvd., Philadelphia, PA 19104 United States of America
| | - Julia Köppen
- Department of Healthcare Management, Technische Universität Berlin, H 80, Straße des 17. Juni 135, 10623 Berlin, Germany
| | - Reinhard Busse
- Department of Healthcare Management, Technische Universität Berlin, H 80, Straße des 17. Juni 135, 10623 Berlin, Germany
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Determining geographic accessibility of family physician and nurse practitioner services in relation to the distribution of seniors within two Canadian Prairie Provinces. Soc Sci Med 2017; 194:96-104. [DOI: 10.1016/j.socscimed.2017.10.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/30/2017] [Accepted: 10/17/2017] [Indexed: 11/19/2022]
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Woo BFY, Lee JXY, Tam WWS. The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review. HUMAN RESOURCES FOR HEALTH 2017; 15:63. [PMID: 28893270 PMCID: PMC5594520 DOI: 10.1186/s12960-017-0237-9] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/31/2017] [Indexed: 05/05/2023]
Abstract
BACKGROUND The prevalence of chronic illness and multimorbidity rises with population aging, thereby increasing the acuity of care. Consequently, the demand for emergency and critical care services has increased. However, the forecasted requirements for physicians have shown a continued shortage. Among efforts underway to search for innovations to strengthen the workforce, there is a heightened interest to have nurses in advanced practice participate in patient care at a great extent. Therefore, it is of interest to evaluate the impact of increasing the autonomy of nurses assuming advanced practice roles in emergency and critical care settings on patient outcomes. OBJECTIVES The objectives of this study are to present, critically appraise, and synthesize the best available evidence on the impact of advanced practice nursing on quality of care, clinical outcomes, patient satisfaction, and cost in emergency and critical care settings. REVIEW METHODS A comprehensive and systematic search of nine electronic databases and a hand-search of two key journals from 2006 to 2016 were conducted to identify studies evaluating the impact of advanced practice nursing in the emergency and critical care settings. Two authors were involved selecting the studies based on the inclusion criteria. Out of the original search yield of 12,061 studies, 15 studies were chosen for appraisal of methodological quality by two independent authors and subsequently included for analysis. Data was extracted using standardized tools. RESULTS Narrative synthesis was undertaken to summarize and report the findings. This review demonstrates that the involvement of nurses in advanced practice in emergency and critical care improves the length of stay, time to consultation/treatment, mortality, patient satisfaction, and cost savings. CONCLUSIONS Capitalizing on nurses in advanced practice to increase patients' access to emergency and critical care is appealing. This review suggests that the implementation of advanced practice nursing roles in the emergency and critical care settings improves patient outcomes. The transformation of healthcare delivery through effective utilization of the workforce may alleviate the impending rise in demand for health services. Nevertheless, it is necessary to first prepare a receptive context to effect sustainable change.
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Affiliation(s)
- Brigitte Fong Yeong Woo
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore, 117597 Singapore
| | - Jasmine Xin Yu Lee
- National University Heart Centre Singapore, National University Hospital, 5 Lower Kent Ridge Road, Main Building 1, Level 2, Singapore, 119074 Singapore
| | - Wilson Wai San Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore, 117597 Singapore
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van der Biezen M, Wensing M, Poghosyan L, van der Burgt R, Laurant M. Collaboration in teams with nurse practitioners and general practitioners during out-of-hours and implications for patient care; a qualitative study. BMC Health Serv Res 2017; 17:589. [PMID: 28830410 PMCID: PMC5568365 DOI: 10.1186/s12913-017-2548-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 08/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasingly, nurse practitioners (NPs) are deployed in teams along with general practitioners (GPs) to help meet the demand for out-of-hours care. The purpose of this study was to explore factors influencing collaboration between GPs and NPs in teams working out-of-hours. METHODS A descriptive qualitative study was done using a total of 27 semi-structured interviews and two focus group discussions. Data was collected between June, 2014 and October, 2015 at an out-of-hours primary care organisation in the Netherlands. Overall, 38 health professionals (GPs, NPs, and support staff) participated in the study. The interviews were audio-taped and transcribed verbatim. Two researchers conducted an inductive content analysis, involving the identification of relevant items in a first phase and clustering into themes in a second phase. RESULTS The following four themes emerged from the data: clarity of NP role and regulation, shared caseload and use of skills, communication concerning professional roles, trust and support in NP practice. Main factors influencing collaboration between GPs and NPs included a lack of knowledge regarding the NPs' scope of practice and regulations governing NP role; differences in teams in sharing caseload and using each other's skills effectively; varying support of GPs for the NP role; and limited communication between GPs and NPs regarding professional roles during the shift. Lack of collaboration was perceived to result in an increased risk of delay for patients who needed treatment from a GP, especially in teams with more NPs. Collaboration was not perceived to improve over time as teams varied across shifts. CONCLUSION In out-of-hours primary care teams constantly change and team members are often unfamiliar with each other or other's competences. In this environment, knowledge and communication about team members' roles is continuously at stake. Especially in teams with more NPs, team members need to use each other's skills to deliver care to all patients on time.
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Affiliation(s)
- Mieke van der Biezen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, IQ Healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, IQ Healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Health Services Research and Implementation Science, Heidelberg University, Marsilius Arkaden-Turm West, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Lusine Poghosyan
- Columbia University School of Nursing, 168th St., Suite 219, New York, NY 10032 USA
| | - Regi van der Burgt
- Foundation for Development of Quality Care in General Practice, Tilburgseweg-West 100, 5652 NP, Eindhoven, The Netherlands
| | - Miranda Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, IQ Healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, P.O. BOX 6960, Nijmegen, 6503 GL The Netherlands
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van der Biezen M, Wensing M, van der Burgt R, Laurant M. Towards an optimal composition of general practitioners and nurse practitioners in out-of-hours primary care teams: a quasi-experimental study. BMJ Open 2017; 7:e015509. [PMID: 28559458 PMCID: PMC5730011 DOI: 10.1136/bmjopen-2016-015509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To gain insights into the ability of general practitioners (GPs) and nurse practitioners (NPs) to meet patient demands in out-of-hours primary care by comparing the outcomes of teams with different ratios of practitioners. DESIGN Quasi-experimental study. SETTING A GP cooperative (GPC) in the Netherlands. INTERVENTION Team 2 (1 NP, 3 GPs) and team 3 (2 NPs, 2 GPs) were compared with team 1 (4 GPs). Each team covered 35 weekend days. PARTICIPANTS All 9503 patients who were scheduled for a consultation at the GPC through a nurse triage system. OUTCOME MEASURES The primary outcome was the total number of consultations per provider for weekend cover between 10:00 and 18:00 hours. Secondary outcomes concerned the numbers of patients outside the NPs' scope of practice, patient safety, resource use, direct healthcare costs and GPs' performance. RESULTS The mean number of consultations per shift was lower in teams with NPs (team 1: 93.9, team 3: 87.1; p<0.001). The mean proportion of patients outside NPs' scope of practice per hour was 9.0% (SD 6.7), and the highest value in any hour was 40%. The proportion of patients who did not receive treatment within the targeted time period was higher in teams with NPs (team 2, 5.2%; team 3, 8.3%) compared with GPs only (team 1 3.5%) (p<0.01). Team 3 referred more patients to the emergency department (14.7%) compared with team 1 (12.0%; p=0.028). In teams with NPs, GPs more often treated urgent patients (team 1: 13.2%, team 2: 16.3%, team 3: 21.4%; p<0.01) and patients with digestive complaints (team 1: 11.1%, team 2: 11.8%, team 3: 16.7%; p<0.01). CONCLUSIONS Primary healthcare teams with a ratio of up to two GPs and two NPs provided sufficient capacity to provide care to all patients during weekend cover. Areas of concern are the number of consultations, delay in patient care and referrals to the emergency department. TRIAL REGISTRATION NCT02407847.
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Affiliation(s)
- Mieke van der Biezen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Regi van der Burgt
- Foundation for Development of Quality Care in General Practice, Eindhoven, The Netherlands
| | - Miranda Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, The Netherlands
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Betlehem J, Pek E, Banfai B, Olah A. Current Characteristics of the Hungarian Nurses’ Workforce. TEACHING AND LEARNING IN NURSING 2017. [DOI: 10.5772/intechopen.68383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Wilberforce M, Abendstern M, Tucker S, Ahmed S, Jasper R, Challis D. Support workers in community mental health teams for older people: roles, boundaries, supervision and training. J Adv Nurs 2017; 73:1657-1666. [PMID: 28122155 DOI: 10.1111/jan.13264] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2017] [Indexed: 11/28/2022]
Abstract
AIMS The aim of this study was to explore the support worker functions in community mental health teams for older adults in relation to roles, boundaries, supervision and training. BACKGROUND Support workers in community mental health teams provide important help to older people with complex mental and physical health needs in their own homes. Their numbers have grown substantially in recent years, but without professional registration there is concern that boundaries with qualified practitioners are insufficiently clear and that they do not receive the support they require. DESIGN Qualitative research using interview data and thematic framework analysis investigated support workers' and registered practitioners' perspectives on roles, boundaries, supervision and training. METHODS Semi-structured face-to-face interviews were undertaken in 2011, with 42 members of nine teams spread across England, including support workers and community mental health nurses. Coding of transcribed audio-recordings and subsequent analysis was undertaken by four researchers. RESULTS Support workers undertook diverse roles and had considerable autonomy over their duties. Participants agreed about what tasks support workers should not undertake, yet there was evidence of 'negotiated' boundaries and examples of these being breached. Lines of authority were complex, yet support workers were supported through open communication with the wider team. Training was problematic, with few courses tailored for support workers and efforts towards formal qualification hindered by low pay and time pressures. CONCLUSION Local and national attention is needed to prevent 'drift' into activities that both support workers and registered practitioners consider outside their remit. Barriers to training and further qualification need to be addressed.
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Affiliation(s)
- Mark Wilberforce
- Personal Social Services Research Unit, University of Manchester, UK
| | | | - Sue Tucker
- Personal Social Services Research Unit, University of Manchester, UK
| | - Saima Ahmed
- Personal Social Services Research Unit, University of Manchester, UK
| | - Rowan Jasper
- Personal Social Services Research Unit, University of Manchester, UK
| | - David Challis
- Personal Social Services Research Unit, University of Manchester, UK
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