Nurses as substitutes for doctors in primary care

Nurse Managers' Perceptions of Family and Community Nurse Practitioners Joining Primary Care Teams in Spain: A Qualitative Study

The aim of this study was to explore and describe nurse managers' perceptions of family and community nurse practitioners' impact on primary care teams and public health. A descriptive qualitative study was carried out. The participants were recruited by means of convenience sampling during the months of April and May 2023. 20 nurse managers from different autonomous communities in Spain were interviewed. The data were analyzed following a thematic analysis method using ATLAS.ti nine software. Two main themes and sub-themes were drawn from the data analysis: (1) Nurse managers' view of primary care: (a) The driving force of primary care and (b) Resistance to the integration of family and community nurse practitioners; (2) Proposals for improvement in light of the Family and Community Nurse Practitioner's unique situation. These specialists are highly qualified professionals in primary care teams, whose expertise is evident in how they deliver community and health education activities, empower patients, and lead the training of new specialists.

Task shifting to improve practice efficiency: A survey among general practitioners in non-urban Baden-Wuerttemberg, Germany

BACKGROUND

Germany is challenged by an increasing shortage in general practice services, especially in non-urban areas. Task shifting from general practitioners (GPs) to other health professionals may improve practice efficiency to address this mismatch.

OBJECTIVES

Exploring GPs' motives and beliefs towards task shifting in non-urban Germany and identifying potential factors influencing these.

METHODS

The cross-sectional survey was disseminated by mail in three waves between July 2021 and August 2022 among all GPs in non-urban Baden-Wuerttemberg, Germany. It included items on demographics and practice characteristics as well as 15 Likert-scale items addressing motives and beliefs towards task shifting, based on the Theoretical Domain Framework. Likert-scale items were analysed descriptively, influencing factors on motives and beliefs were identified using multiple linear regression.

RESULTS

Response rate was 24.2% (281/1162), with respondents comparable in age and gender to all GPs in Baden-Wuerttemberg. GPs' motives and beliefs towards task shifting are positive overall. The majority expects task shifting to reduce their workload (87.9%) and increase practice efficiency (74.7%). They are open to shift additional tasks to other professionals (69.1%), even in the currently prohibited form of substitution (51.2%). Motives and beliefs were significantly more positive among younger GPs and those participating in the GP-centred care programme.

CONCLUSION

This study describes GPs' motives and beliefs towards task shifting in non-urban Germany. Identifying younger GPs and those participating in the GP-centred care programme as particularly endorsing may help design future interventions aiming to improve efficiency in general practice in non-urban Germany.

Task shifting in Dutch nursing practice: A repeated cross-sectional analysis of nurses' experiences

AIM

This study aims firstly to identify shifts in the execution of medical tasks by nurses in the past decade. Secondly, it aims to explore nurses' perspectives on task shifting: how they think task shifting affects the quality of care, the attractiveness of nursing practice and their collaboration with physicians.

DESIGN

A quantitative repeated cross-sectional study.

METHODS

A nationwide survey was conducted among Dutch registered nurses (RNs) working in hospitals and home care, first in 2012 and again in 2022, with sample sizes of 359 and 362, respectively. Analyses were based on descriptive statistics and logistic and linear regressions.

RESULTS

Between 2012 and 2022, there was a significant increase in the execution of only one medical task by nurses, namely prescribing over-the-counter medication. The majority reported in both years that task shifting has positive impact on their professional autonomy and the attractiveness of nursing practice. However, most nurses also reported that task shifting increased their workload (72.7% in 2022) could lead to conflicts in care teams (20.9% in 2022 compared to 14.7% in 2012) and may cause physicians to feel threatened (32.8% in 2022 and 29.9% in 2012). There were no significant changes in nurses' perception of the impact of task shifting on quality of care, the attractiveness of nursing practice and the nurse-physician relationship.

CONCLUSION

There was an increase in the execution of prescribing over-the-counter-medication by nurses between 2012 and 2022. However, both in 2012 and in 2022, as the majority of nurses reported that task shifting increased their workload, there is reason to worry about this negative consequence of task shifting, e.g. with regard to labour market issues. Further research, also among the medical profession, is needed to better understand and address the implications of task shifting for the nursing profession.

IMPLICATIONS FOR THE PROFESSION

Implications for the nursing profession include potential scope expansion with complex tasks, attracting more individuals to nursing careers, although an eye must also be kept on what that means for the workload of nurses and the relationship with physicians.

IMPACT

Nurse prescribing medicines was more executed in 2022 compared to 2012. Nurses had a predominantly positive perspective on task shifting, but still felt it can cause conflicts in care teams, high workload and physicians feeling threatened. These results can help during implementation of task shifting and in monitoring the perceived effects of task shifting among nurses.

REPORTING METHOD

This study followed the STROBE reporting guideline for cross-sectional studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution. This study focussed on the task shifting (perspectives) of nurses.

[Enhancing Chronic Pain Management: Exploring the Essential Contribution of Primary Care Nurses]

Introduction

L’expertise infirmière en soins primaires est cruciale pour répondre aux besoins des patients vivant avec une maladie chronique. Au Canada, une personne sur cinq vit avec de la de douleur chronique (DC), créant ainsi un fardeau socioéconomique majeur. Cependant, le rôle du personnel infirmier en soins primaires en DC reste sous-développé.

Objectifs

Cette revue narrative analyse l’adéquation du récent Plan d’action québécois en DC avec les modèles de soins reconnus pour la gestion des maladies chroniques et examine le rôle potentiel du personnel infirmier dans la mise en œuvre de ce plan.

Méthode

La synthèse de la littérature a été menée à partir de diverses bases de données (CINAHL, PubMed) et sources documentaires en français et en anglais. Les résultats ont été interprétés à travers le prisme du Chronic Care Model , un cadre reconnu pour améliorer les soins.

Résultats

Bien que le Plan d’action québécois en DC soit aligné sur les objectifs visés, sa mise en œuvre devra surmonter divers défis. Les constats indiquent des opportunités efficaces dans la gestion de la DC, comme le montrent des études sur la pratique infirmière en soins primaires. Elles révèlent que le personnel infirmier exerce déjà des activités de gestion des maladies chroniques applicables à la DC.

Conclusion

Il est important de reconnaître l’apport de l’expertise infirmière en soins primaires pour réévaluer les modèles d’organisation des soins, promouvoir un partage de responsabilités fondé sur les données probantes, et soutenir la recherche future ainsi que l’innovation clinique dans la gestion de la DC.

Nurses' work in relation to patient health outcomes: an observational study comparing models of primary care

BACKGROUND

Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into seven models of primary care: Traditional, Corporate, Health Care Home, Māori, Pacific, Trusts / Non-governmental organisations (Trust/NGOs) and District Health Board / Primary Care Organisations (DHB/PHO). We describe nurse work in relation to these models of care, populations with high health need and patient health outcomes.

METHODS

We conducted a cross-sectional study (at 30 September 2018) of data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥ 65 years), glucose control testing in adults with diabetes, immunisations (at 6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics.

RESULTS

Nurse clinical time, and combined nurse, nurse practitioner and general practitioner clinical time, were substantially higher in Trust/NGO, Māori, and Pacific practices than in other models. Increased patient clinical complexity was associated with more clinical input and higher scores on all outcome measures. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, depression screening, glucose control testing) were in Māori, Trust/NGO and Pacific practices. There was an eightfold difference, across models of care, in percentage of depression screening undertaken by nurses and a fivefold difference in cervical screening and glucose control testing. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree.

CONCLUSIONS

Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release general practitioner clinical time for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner clinical time is required, especially in practices with high volumes of complex patients.

Exploring factors associated with hypertension self-care in primary care: The role of nurse education levels and patient-related factors

AIM

To explore the association between nurse education levels and patient-related factors with hypertension self-care.

BACKGROUND

Although self-care development is recognized as a healthcare provider-patient encounter, the attribution of nurse education level to hypertension self-care is not well addressed.

DESIGN

A cross-sectional study.

METHODS

Hypertensive patients from 15 primary care facilities were sampled, and self-care was assessed using the Self-Care of Hypertension Inventory version 2.0, with standardized scores ≥70 indicating adequate self-care. Data on patient-related factors were obtained from electronic health records, self-reports and laboratory tests, while nurse education levels were categorized as standard (baccalaureate-prepared) or higher (post-baccalaureate specialty).

RESULTS

A total of 1493 participants were included in this study, with a median age of 66 years and 77.7% being female. Approximately 10% of participants had adequate self-care, and 66% received care from higher educated nurses. The study showed the relation between nurse education levels and the self-care of the patients. Adequate hypertension self-care was significantly associated with higher educated nurse providers and patient-related factors, including intermediate to higher education, non-overweight/obese and the absence of age-related comorbidities.

CONCLUSIONS

Hypertensive patients who had been provided care by higher educated nurses and their favourable sociodemographic, lower cardiometabolic risk and no concomitant disease were more likely to demonstrate adequate self-care.

Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis

BACKGROUND

Implementation strategies targeting individual healthcare professionals and teams, such as audit and feedback, educational meetings, opinion leaders, and reminders, have demonstrated potential in promoting evidence-based nursing practice. This systematic review examined the effects of the 19 Cochrane Effective Practice and Organization Care (EPOC) healthcare professional-level implementation strategies on nursing practice and patient outcomes.

METHODS

A systematic review was conducted following the Cochrane Handbook, with six databases searched up to February 2023 for randomized studies and non-randomized controlled studies evaluating the effects of EPOC implementation strategies on nursing practice. Study selection and data extraction were performed in Covidence. Random-effects meta-analyses were conducted in RevMan, while studies not eligible for meta-analysis were synthesized narratively based on the direction of effects. The quality of evidence was assessed using GRADE.

RESULTS

Out of 21,571 unique records, 204 studies (152 randomized, 52 controlled, non-randomized) enrolling 36,544 nurses and 340,320 patients were included. Common strategies (> 10% of studies) were educational meetings, educational materials, guidelines, reminders, audit and feedback, tailored interventions, educational outreach, and opinion leaders. Implementation strategies as a whole improved clinical practice outcomes compared to no active intervention, despite high heterogeneity. Group and individual education, patient-mediated interventions, reminders, tailored interventions and opinion leaders had statistically significant effects on clinical practice outcomes. Individual education improved nurses' attitude, knowledge, perceived control, and skills, while group education also influenced perceived social norms. Although meta-analyses indicate a small, non-statistically significant effect of multifaceted versus single strategies on clinical practice, the narrative synthesis of non-meta-analyzed studies shows favorable outcomes in all studies comparing multifaceted versus single strategies. Group and individual education, as well as tailored interventions, had statistically significant effects on patient outcomes.

CONCLUSIONS

Multiple types of implementation strategies may enhance evidence-based nursing practice, though effects vary due to strategy complexity, contextual factors, and variability in outcome measurement. Some evidence suggests that multifaceted strategies are more effective than single component strategies. Effects on patient outcomes are modest. Healthcare organizations and implementation practitioners may consider employing multifaceted, tailored strategies to address local barriers, expand the use of underutilized strategies, and assess the long-term impact of strategies on nursing practice and patient outcomes.

TRIAL REGISTRATION

PROSPERO CRD42019130446.

Effectiveness of comprehensive geriatric assessment adapted to primary care when provided by a nurse or a general practitioner: the CEpiA cluster-randomised trial

BACKGROUND

The benefits of comprehensive geriatric assessment (CGA) are well established for hospital care but less so for primary care. Our primary objective was to assess the effect of two multifaceted interventions based on a CGA adapted for primary care on a composite criterion combining all-cause mortality, emergency department visits, unplanned hospital admissions, and institutionalisation.

METHODS

This open-label, pragmatic, three-arm, cluster-randomised controlled trial involved 39 general practices in France. It included 634 patients aged 70 years or over with chronic health conditions and/or an unplanned hospital admission in the past 3 months, between 05/2016 and 08/2018. Interventions were in arm 1: a systematic nurse-led CGA; arm 2: a GP-led CGA, at the GP's discretion; arm 3: standard care. The primary composite endpoint was assessed at 12 months. The secondary endpoints included: components of the composite endpoint, health-related quality of life (Duke Health Profile), functional status (Katz Activities of Daily Living Index) and medications (number) at 12 months. Pairwise comparisons between the experimental groups and the control were tested. The main analysis was performed on the intention-to-treat (ITT) population, after imputing missing information and adjusting for baseline imbalances by mixed effects regressions.

RESULTS

For the primary composite outcome, no statistically significant difference was found between arm 1 and the control (adjusted odds ratio [aOR] = 0.81 [95%CI 0.54-1.21], P = 0.31), whereas arm 2 and the control differed significantly (aOR = 0.60 [0.39-0.93], P = 0.022). A statistically lower risk of unplanned hospital admission in arm 2 vs control (aOR = 0.57 [0.36-0.92], P = 0.020)) was observed, while no statistically significant differences were found for the other components and between arm 1 and the control. None of the other secondary endpoints differed between arms.

CONCLUSIONS

Our study led in community-dwelling older patients with chronic conditions found no significant effect of a CGA adapted for primary care on mortality, functional independence and quality of life, but suggests that a GP-led CGA may reduce the risk of unplanned hospital admission. Our study demonstrates the feasibility of incorporating CGA into clinical practice and highlights its potential benefits when applied on a case-by-case basis, guided by the GPs who develop the resulting PCP.

TRIAL REGISTRATION

NCT02664454.

Effects of nurse-led interventions on the physical and mental health among pre-frail or frail older adults: A systematic review

BACKGROUND

Globally, there is an increase in the number of older people living with frailty, thus effective strategies to prevent and manage frailty are of paramount importance. The effects of nurse-led interventions on the physical and mental health of (pre) frail people have not yet been systematically reviewed.

METHODS

We searched the PubMed, Web of Science, EMBASE, CINAHL, and the Cochrane Library from inception to 8 May 2024. Eligible studies included randomized controlled trials and quasi-experimental trials reporting the effects of nurse-led interventions on physical and mental health outcomes among (pre) frail people. Two researchers independently extracted trial data and assessed the risk of bias by using the risk of bias tool recommended by the Cochrane Back Review Group and the Methodological Index for Non-Randomized Studies.

RESULTS

14 randomized controlled trials and 6 quasi-experimental studies, encompassing 3943 participants, were included in the review. Nurse-led interventions included function-based care (cognitive behavioral therapy, exercise, and multi-domain intervention), personalized integrated care, and advance care planning. The reported outcomes were multiple with most results showing inconsistencies. Overall, function-based care showed more positive effects on physical outcomes (31/37, 84 %) and mental health (11/12, 92 %). However, the effectiveness of existing personalized integrated care and advance care planning might be limited.

CONCLUSIONS

Nurse-led interventions may effectively improve both physical and mental health among (pre) frail older adults, although effectiveness varies by intervention type. Nurses have the potential to play a leading role, both individually and within multidisciplinary teams, in alleviating the rising global burden of frailty. We need more well-designed randomized controlled trials to confirm the effectiveness of nurse-led interventions and identify the most effective type of interventions.

Positive PTSD Screening and Its Health Correlates in Patients With HIV in Urban Primary Care Settings

Posttraumatic stress disorder (PTSD) is underdiagnosed and undertreated in primary care, especially among African American individuals. The current study assessed documentation rates of PTSD and clinical health correlates among 135 predominantly African American patients with HIV and positive PTSD screens in a primary care unit. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) and a retrospective chart review of 135 patients with HIV were conducted. On the PCPTSD-5 (cut point of 3), approximately one half of patients (49.6%; n = 67) had probable PTSD; however, only 11.9% of patients (n = 16) had a chart diagnosis of PTSD. A positive PTSD screen was associated with higher rates of depression and insomnia, but not anxiety, alcohol use, drug use, or pain in patients with HIV. Multi-morbidity of HIV, major depression, and positive PTSD screens was associated with increased risk for asthma, number of medical diagnoses, depression, insomnia, and anxiety. Findings highlight the need for trauma-informed care in primary care settings for people with PTSD and HIV. Larger samples are warranted to further explore health correlates of PTSD. [Journal of Psychosocial Nursing and Mental Health Services, 62(8), 25-36.].

Exploring a pilot alcohol and other drug (AOD) nurse practitioner mentoring program: Empirical research mixed methods: A pilot nurse practitioner mentoring program

AIM

To explore the effectiveness and acceptability of a pilot mentoring program for alcohol and other drug (AOD) nurse practitioners (also known globally as addiction nurse practitioners).

DESIGN

Mixed method evaluation.

METHODS

Two-phase evaluation comprising survey (demographics, pre- and post-program perceived competency and confidence) with 15 participants completing the pre survey and 10 participants completing the post survey, and qualitative interviews after the program with 10 participants.

RESULTS

The quantitative results indicate statistically significant increases in some domains of perceived competence and confidence in treatment. Qualitative findings indicate that participants valued peer support and mentoring from experienced nurse practitioners. Where formal residency or internship programs for nurse practitioners do not exist, informal mentoring programs may address issues inherent in nurse practitioner transition that may impact retention. We recommend further exploration of mentoring programs with larger sample sizes to determine if self-reported clinical improvements are noted.

IMPLICATIONS FOR PROFESSION AND/OR PATIENT CARE

Nurse practitioners are a vital part of the healthcare system; their advanced skills and knowledge place them in an ideal position to address prescriber shortages and access to care for populations underserved by healthcare. However, literature indicates that they are often underutilised, and transition to autonomous practice remains a challenge. Our exploration of a pilot mentoring program for nurse practitioners shows that their knowledge and perceived skills are high, yet peer assistance is valued in transitioning from advanced practice registered nurse to autonomous nurse practitioner. We recommend further trialling and evaluation of nurse practitioner mentoring programs to both increase supply of nurse practitioners and provide greater access to quality healthcare for underserved populations.

IMPACT

What problem did the study address? The ability of nurse practitioners to offer advanced practice interventions such as diagnosis and medication management potentially provides a solution to healthcare resource shortages. However, current literature indicates that advanced nurses transitioning to nurse practitioner roles suffer transition shock, leading to burnout and poor retention. What were the main findings? Although this pilot mentoring program shows significant improvements in survey responses on confidence and capability, qualitative data shows that neophyte nurse practitioners value peer support and mentoring from more experienced practitioners. Participants described maintaining ongoing connections with both mentors and fellow mentees, which aided transition to the role of autonomous nurse practitioner. Where and on whom will the research have an impact? The results of this pilot mentoring program indicate that there is benefit to these programs for neophyte nurse practitioners in many specialties. This paper indicates that mentoring programs for nurse practitioners may provide a community of practice and may have a positive impact on transition shock.

REPORTING METHOD

Good Reporting of a Mixed Methods Study (GRAMMS) checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Nurse and midwife involvement in task-sharing and telehealth service delivery models in primary care: A scoping review

AIM

To synthesise and map current evidence on nurse and midwife involvement in task-sharing service delivery, including both face-to-face and telehealth models, in primary care.

DESIGN

This scoping review was informed by the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews.

DATA SOURCE/REVIEW METHODS

Five databases (Ovid MEDLINE, Embase, PubMed, CINAHL and Cochrane Library) were searched from inception to 16 January 2024, and articles were screened for inclusion in Covidence by three authors. Findings were mapped according to the research questions and review outcomes such as characteristics of models, health and economic outcomes, and the feasibility and acceptability of nurse-led models.

RESULTS

One hundred peer-reviewed articles (as 99 studies) were deemed eligible for inclusion. Task-sharing models existed for a range of conditions, particularly diabetes and hypertension. Nurse-led models allowed nurses to work to the extent of their practice scope, were acceptable to patients and providers, and improved health outcomes. Models can be cost-effective, and increase system efficiencies with supportive training, clinical set-up and regulatory systems. Some limitations to telehealth models are described, including technological issues, time burden and concerns around accessibility for patients with lower technological literacy.

CONCLUSION

Nurse-led models can improve health, economic and service delivery outcomes in primary care and are acceptable to patients and providers. Appropriate training, funding and regulatory systems are essential for task-sharing models with nurses to be feasible and effective.

IMPACT

Nurse-led models are one strategy to improve health equity and access; however, there is a scarcity of literature on what these models look like and how they work in the primary care setting. Evidence suggests these models can also improve health outcomes, are perceived to be feasible and acceptable, and can be cost-effective. Increased utilisation of nurse-led models should be considered to address health system challenges and improve access to essential primary healthcare services globally.

REPORTING METHOD

This review is reported against the PRISMA-ScR criteria.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

PROTOCOL REGISTRATION

The study protocol is published in BJGP Open (Moulton et al., 2022).

Community health services in European literature: A systematic review of their features, outcomes, and nursing contribution to care

BACKGROUND

To meet the population's needs, community care should be customized and continuous, adequately equipped, and monitored.

INTRODUCTION

Considering their fragmented and heterogeneous nature, a summary of community healthcare services described in European literature is needed. The aim of this study was to summarize their organizational models, outcomes, nursing contribution to care, and nursing-related determinants of outcomes.

METHODS

A systematic review was performed by searching PubMed, CINAHL, Scopus, and Embase in October 2022 and October 2023 (for updated results). Quantitative studies investigating the effects of community care, including nursing contribution, on patient outcomes were included and summarized. Reporting followed the PRISMA checklist. The review protocol was registered on PROSPERO (CRD42022383856).

RESULTS

Twenty-three studies describing six types of community care services were included, which are heterogeneous in terms of target population, country, interventions, organizational characteristics, and investigated outcomes. Heterogeneous services' effects were observed for access to emergency services, satisfaction, and compliance with treatment. Services revealed a potential to reduce rehospitalizations of people with long-term conditions, frail or older persons, children, and heart failure patients. Models are mainly multidisciplinary and, although staffing and workload may also have an impact on provided care, this was not enough investigated.

DISCUSSION

Community health services described in European literature in the last decade are in line with population needs and suggest different suitable models and settings according to different care needs. Community care should be strengthened in health systems, although the influence of staffing, workload, and work environment on nursing care should be investigated by developing new management models.

CONCLUSIONS AND IMPLICATIONS FOR HEALTH POLICY

Community care models are heterogeneous across Europe, and the optimum organizational structure is not clear yet. Future policies should consider the impact of community care on both health and economic outcomes and enhance nursing contributions to care.

Changes in location and number of nurse consultations as the supply of general practitioners decreases in primary health care: six-year register-based follow-up cohort study in the city of Vantaa, Finland

OBJECTIVE

To investigate whether the location and the number of nurse consultations have changed in response to the continuously decreasing number of GP consultations in the fourth-largest city in Finland. It has been suggested that nurse consultations are replacing GP consultations.

DESIGN

A retrospective register-based follow-up cohort study.

SETTING

Public primary health care in the City of Vantaa, Finland.

SUBJECTS

All documented face-to-face office-hour consultations with practical and registered nurses, and consultations with practical and registered nurse in the emergency department of Vantaa primary health care between 1 January 2009 and 31 December, 2014.

MAIN OUTCOME MEASURES

Change in the number of consultations with practical and registered nurses between 2009 and 2014 in primary health care both during office-hours and in the emergency department.

RESULTS

Over the follow-up period, the monthly median number of practical nurse consultations in the emergency department per 1000 inhabitants increased from 1.6 (interquartile range [IQR] 1.3-1.7) to 10.5 (10.3-12.2) (p < 0.001) and registered nurse consultations from a median of 3.6 (3.0-4.0) to 14.5 (13.0-16.6) (p < 0.001). However, there was no significant change in the median monthly number of office-hour consultations with practical or registered nurses.

CONCLUSIONS

It appears that in primary health care, medical consultations have shifted from GPs to nurses with lower education levels, and from care during office-hours to emergency care.

Evaluating the cost of NP-led vs. GP-led primary care in British Columbia

In 2020, British Columbia (BC) opened four pilot Nurse Practitioner Primary Care Clinics (NP-PCCs) to improve primary care access. The aim of this economic evaluation is to compare the average cost of care provided by Nurse Practitioners (NPs) working in BC's NP-PCCs to what it would have cost the government to have physicians provide equivalent care. Comparisons were made to both the Fee-For-Service (FFS) model and BC's new Longitudinal Family Physician (LFP) model. The analyses relied on administrative data, mostly from the Medical Services Plan (MSP) and Chronic Disease Registry (CDR) via BC's Health Data Platform. Results show the cost of NPs providing care in the NP-PCCs is slightly lower than what it would cost to provide similar care in medical clinics staffed by physicians paid through the LFP model. This suggests that the NP-PCC model is an efficient approach to increase accessibility to primary care services in BC and should be considered for expansion across the province.

Implementation of Full Practice Authority for Nurse Practitioners in Massachusetts: Impact of Organizational Climate on Practice Change

OBJECTIVE

The aim of this study was to examine the relationship between nurse practitioner (NP) organizational climate and the implementation of full practice authority (FPA) for NPs.

BACKGROUND

In 2021, Massachusetts passed FPA for NPs. Most NPs did not experience changes to their practice. It is unknown whether NP organizational climate impacts implementation of FPA.

METHODS

A Web-based survey was distributed to NPs in Massachusetts.

RESULTS

Response rate was 50.3% (N = 147). Practice remained unchanged for most. Organizations with more favorable climates experienced more rapid implementation of FPA, resulting in improved efficiency (P = 0.049) and timeliness (P = 0.007) of care. Nurse practitioners outside hospital systems were more likely to report favorable organizational climates and positive change to their practice after FPA.

CONCLUSIONS

Organizations that facilitate implementation of FPA are likely to experience improvement in efficiency and timeliness of patient care. Nursing leadership, especially within hospital-based organizations, can help achieve these benefits by improving the organizational climate for NPs.

Did the organization of primary care practices during the COVID-19 pandemic influence quality and safety? - an international survey

BACKGROUND

Changes in demographics with an older population, the illness panorama with increasing prevalence of non-communicable diseases, and the shift from hospital care to home-based care place demand on primary health care, which requires multiprofessional collaboration and team-based organization of work. The COVID-19 pandemic affected health care in various ways, such as heightened infection control measures, changing work practices, and increased workload.

OBJECTIVES

This study aimed to investigate the association between primary care practices' organization, and quality and safety changes during the COVID-19 pandemic.

DESIGN

Data were collected from 38 countries in a large online survey, the PRICOV-19 study. For this paper, the participating practices were categorized as "Only GPs", comprising practices with solely general practitioners (GPs) and/or GP trainees, without any other health care professionals (n = 1,544), and "Multiprofessional," comprising practices with at least one GP or GP trainee and one or more other health professionals (n = 3,936).

RESULTS

Both categories of practices improved in infection control routines when compared before and during the COVID-19 pandemic. A larger proportion of the multiprofessional practices changed their routines to protect vulnerable patients. Telephone triage was used in more "Multiprofessional" practices, whereas "Only GPs" were more likely to perform video consultations as an alternative to physical visits. Both types of practices reported that the time to review new guidelines and scientific literature decreased during the pandemic. However, both had more meetings to discuss directives than before the pandemic.

CONCLUSIONS

Multiprofessional teams were keener to introduce changes to the care organization to protect vulnerable patients. However, practices with only GPs were found to be more aligned with video consultations, perhaps reflecting the close patient-doctor relationship. In contrast, telephone triage was used more in multiprofessional teams.

Evolution of advanced practice nursing in acute care in Germany: A cross-sectional study of nurses' scope of practice

AIM

To describe activities and professional characteristics of nurses in expanded roles in acute care in Germany and achieve a greater understanding of the current situation of advanced practice nursing.

BACKGROUND

Advanced practice nursing plays an important role in meeting increased demands in healthcare and promoting high-quality care.

INTRODUCTION

In Germany, advanced practice nursing is still at an early stage with a lack of studies describing the scope of practice of nurses in expanded roles.

METHODS

We conducted a cross-sectional-study using a paper-and-pencil questionnaire. In a nationwide convenience sample, we surveyed nurses with an academic degree, who work in an acute care hospital and take over expanded roles in direct patient care. Reporting followed the STROBE checklist.

RESULTS

Of 108 eligible nurses, 84 (77%) completed the survey. The majority had a Master's degree (63.1%) and the average work experience was 18.2 years. Participants carried out activities in all the domains that were queried (direct clinical practice, guidance and coaching, consultation, leadership and research) with differences within and between domains. Foci were on direct clinical practice and coaching and guidance.

DISCUSSION

In Germany, qualifications are nearing the international standard of advanced practice nursing. Results suggest that participants partly undertake activities within the scope of registered nurses' practice that do not correspond fully to their formal qualifications.

CONCLUSION AND IMPLICATIONS FOR NURSING AND/OR HEALTH POLICY

In order to foster the role development of expanded practice nurses in Germany, political efforts are needed in terms of training (e.g. specific Master's programmes), funding of corresponding positions in practice and control mechanisms (e.g. professional registration).

APN nurses' core competencies for general clinical health assessment in primary health care. A scoping review

BACKGROUND

The field of Advanced Practice Nursing (APN) has developed over the past six decades. However, the definition of roles and responsibilities of APN nurses seem to be contested due to both a lack of a clear definition of the concept and to institutional and cultural barriers that restrict the nurses' opportunities to practise to the full extent of their competencies.

AIM

The objective of this scoping review was to identify, examine and conceptually map the available literature on APN nurses' core competencies for general health assessment in primary health care.

METHOD

We performed a scoping review, following the methodological guidance for reporting as it is described by the Joanna Briggs Institute (JBI). Furthermore, the PRISMA-ScR statement and checklist for reporting scoping reviews were followed. Guiding the initial process for the search, we used the Population, Concept and Context mnemonic (PCC) to clarify the focus and context of the review.

RESULTS

We found three areas of core competencies on which APN nurse draw in performing general health assessments in primary health care: (1) 'Collaborative, leadership and management skills' (2) 'Person-centred nursing care skills' and (3) 'Academic and educational skills'. Furthermore, we found that the three areas are interrelated, because it is crucial that APN nurses draw on collaborative competencies related to leadership and management to meet the service users' needs and deliver high-quality and person-centred care.

CONCLUSION

There is a need for a more specific investigation into how APN nurses' core competencies play a role during general health assessments of patients in primary care. We suggest an evaluation of what works for whom in what circumstances looking into the interrelation between competencies, skills and knowledge when an APN nurse performs a general health assessment in a primary healthcare setting.

Factors associated with registered nurses' academic performance in advanced practice nursing preparatory education: A retrospective cohort study

AIM

To explore factors associated with academic performance in the Master of Nursing programme.

BACKGROUND

Advanced practice nursing preparatory education generally involves completion of the Master of Nursing programme. While prior clinical experiences and on-the-job training are believed to underpin the preparation for such education, studies have suggested only weak or no associations between nurses' academic success in graduate schools and their clinical experiences.

METHODS

A retrospective cohort study was conducted in the nursing department of a university in Singapore. Academic and demographic data were extracted in February 2020 from a shared repository of anonymised teaching and learning data. R was used to select and merge data tables into a usable format for subsequent analysis. Students enrolled between 2010 and 2017 were included for the analysis (n = 246).

RESULTS

Age was statistically significantly associated with overall cumulative academic performance (p < 0.001). Younger students on average academically outperformed older students. Unmarried students were associated with better cumulative academic performance in the Clinical Practicum 2 module (p = 0.018).

CONCLUSION

Younger students have historically outperformed their older counterparts in the Master of Nursing programme. There is a need to reassess the requirement of five years of clinical experience as an admission criterion for the Master of Nursing programme in Singapore.

IMPLICATIONS FOR NURSING POLICY

There is a need to re-evaluate the admission criteria to better engage and retain younger nurses interested in advanced nursing practice. Nursing educators and leaders can partner with academics to develop advanced practice-specific education for pre-master nurses with the aptitude and interest in pursuing this track.

Healthcare utilization patterns of individuals with depression after national policy to increase the mental health workforce in primary care: a data linkage study

BACKGROUND

The deployment of the mental health nurse, an additional healthcare provider for individuals in need of mental healthcare in Dutch general practices, was expected to substitute treatments from general practitioners and providers in basic and specialized mental healthcare (psychologists, psychotherapists, psychiatrists, etc.). The goal of this study was to investigate the extent to which the degree of mental health nurse deployment in general practices is associated with healthcare utilization patterns of individuals with depression.

METHODS

We combined national health insurers' claims data with electronic health records from general practices. Healthcare utilization patterns of individuals with depression between 2014 and 2019 (N = 31,873) were analysed. The changes in the proportion of individuals treated after depression onset were assessed in association with the degree of mental health nurse deployment in general practices.

RESULTS

The proportion of individuals with depression treated by the GP, in basic and specialized mental healthcare was lower in individuals in practices with high mental health nurse deployment. While the association between mental health nurse deployment and consultation in basic mental healthcare was smaller for individuals who depleted their deductibles, the association was still significant. Treatment volume of general practitioners was also lower in practices with higher levels of mental health nurse deployment.

CONCLUSION

Individuals receiving care at a general practice with a higher degree of mental health nurse deployment have lower odds of being treated by mental healthcare providers in other healthcare settings. More research is needed to evaluate to what extent substitution of care from specialized mental healthcare towards general practices might be associated with waiting times for specialized mental healthcare.

Knowledge level and health information-seeking behavior of people with diabetes in rural areas: a multicenter cross-sectional study

Introduction

There is a lack of research on the current level of diabetes knowledge and health information-seeking behaviors among patients with diabetes in rural areas of China's economically underdeveloped regions during COVID-19, as well as a lack of up-to-date evidence on glycemic control and the incidence of complications among rural patients with diabetes.

Objectives

To investigate the prevalence of glycemic control and complications among patients with diabetes in rural areas, to explore the current status and correlation of diabetes knowledge level and health information-seeking behavior, and to analyze the factors affecting diabetes knowledge level.

Methods

From January 2022 to July 2022, we conducted a screening on diabetic complications and a questionnaire survey among 2,178 patients with diabetes in 15 county hospitals in rural areas of Guangxi Zhuang Autonomous Region. The patients' knowledge level and health information-seeking behavior were investigated. Spearman correlation analysis was used to assess the correlation between diabetes knowledge and health information-seeking behavior. Multiple linear regression analysis was used to test how demographic information and health information-seeking behavior influenced the level of diabetes knowledge.

Results

Of 2,178 patients with diabetes in rural areas, 1,684 (77.32%) had poor glycemic control, and the prevalence of diabetic complications was estimated to be 72.13%. Patients with diabetes had poor diabetes knowledge and health information-seeking behavior, and there is a strong positive correlation between them. Diabetes knowledge level was influenced by per capita household disposable income, occupational status, gender, age, ethnicity, family history of diabetes, insulin use, glycated hemoglobin, education level, number of complications and health information-seeking behavior.

Conclusion

Patients with diabetes in rural areas have poor glycemic control and a high incidence of diabetic complications. Patients with diabetes in rural areas have poor knowledge and inadequate health information-seeking behavior. Systematic and standardized education should be provided to improve patients' diabetes knowledge and thus improve their self-management ability.

Self-reported competence among advanced practice nursing students in Denmark, Finland and Norway: a cross-sectional multicentre study

BACKGROUND

The health care systems in the Nordic countries and worldwide are under pressure due to increased longevity and a shortage of nurses. Providing nurses with a high level of education, such as advanced practice nursing, is of great importance to ensure effective, safe and high-quality care.

AIM

The aim of this study was to investigate self-reported competence using the Nurse Professional Competence Scale Short-Form for the first time among master's students of advanced practice nursing in the Nordic countries and to relate the findings to age, work obligations, child-rearing responsibilities, level of education and clinical nursing experience.

METHODS

A multicentre, cross-sectional design was used in this study conducted at five universities in Denmark, Finland and Norway. The Nurse Professional Competence Scale Short-Form consisting of six competence areas was used with a maximum score of 7 per item for the analysis of single items and a transformed scale from 14.3 to 100 for analysing the competence areas (higher score equals higher self-reported competence). Descriptive and comparative statistics were used to analyse the data.

RESULTS

The highest mean score was found for the competence area 'Value-based nursing care'. Students living with home-dwelling children (≤ 18 years) reported significantly higher competence in 'Nursing care', while students ≥33 years reported significantly higher competence in 'Nursing care' and 'Value-based nursing care'. No significant differences were found between students working and those not working alongside their studies, between students with and without further nursing-related education, or between students with long and short experience as nurses.

CONCLUSIONS

The findings from this study might help to further develop curricula in advanced practice nursing master's programmes to ensure high-quality nursing and sustainable health care in the future. Future high-quality master's programmes might benefit from systematic collaboration between Nordic higher education institutions as also Sweden is planning master's programme. Higher age, having children at home and working while studying should not be considered causes for concern.

The process of nurses' role negotiation in general practice: A grounded theory study

AIM

To explain the process by which nurses' roles are negotiated in general practice.

BACKGROUND

Primary care nurses do important work within a social model of health to meet the needs of the populations they serve. Latterly, in the face of increased demand and workforce shortages, they are also taking on more medical responsibilities through task-shifting. Despite the increased complexity of their professional role, little is known about the processes by which it is negotiated.

DESIGN

Constructivist grounded theory.

METHODS

Semi-structured interviews were conducted with 22 participants from 17 New Zealand general practices between December 2020 and January 2022. Due to COVID-19, 11 interviews were via Zoom™. Concurrent data generation and analysis, using the constant comparative method and common grounded theory methods, identified the participants' main concern and led to the construction of a substantive explanatory theory around a core category.

RESULTS

The substantive explanatory theory of creating place proposes that the negotiation of nurse roles within New Zealand general practice is a three-stage process involving occupying space, positioning to do differently and leveraging opportunity. Nurses and others act and interact in these stages, in accordance with their conceptualizations of need-responsive nursing practice, towards the outcome defining place. Defining place conceptualizes an accommodation between the values beliefs and expectations of individuals and pre-existing organizational norms, in which individual and group-normative concepts of need-responsive nursing practice are themselves developed.

CONCLUSION

The theory of creating place provides new insights into the process of nurses' role negotiation in general practice. Findings support strategies to enable nurses, employers and health system managers to better negotiate professional roles to meet the needs of the populations they serve, while making optimum use of nursing skills and competencies.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Findings can inform nurses to better negotiate the complexities of the primary care environment, balancing systemic exigencies with the health needs of populations.

IMPACT

What Problem Did the Study Address? In the face of health inequity, general practice nurses in New Zealand, as elsewhere, are key to meeting complex primary health needs. There is an evidence gap regarding the processes by which nurses' roles are negotiated within provider organizations. A deeper understanding of such processes may enable better use of nursing skills to address unmet health need. What Were the Main Findings? Nurses' roles in New Zealand general practice are determined through goal-driven negotiation in accordance with individual concepts of need-responsive nursing practice. Individuals progress from occupying workspaces defined by the care-philosophies of others to defining workplaces that incorporate their own professional beliefs, values and expectations. Negotiation is conditional upon access to role models, scheduled dialogue with mentors and decision-makers, and support for safe practice. Strong clinical and organizational governance and individuals' own positive personal self-efficacy are enablers of effective negotiation. Where and on Whom Will the Research Have Impact? The theory of Creating Space can inform organizational and individual efforts to advance the roles of general practice nurses to meet the health needs of their communities. General practice organizations can provide safe, supported environments for effective negotiation; primary care leaders can promote strong governance and develop individuals' sense of self-efficacy by involving them in key decisions. Nurses themselves can use the theory as a framework to support critical reflection on how to engage in active negotiation of their professional roles.

REPORTING METHOD

The authors adhered to relevant EQUATOR guidelines using the COREQ reporting method.

PATIENT OR PUBLIC CONTRIBUTION

Researchers and participants currently working in general practice were involved in the development of this study. By the process of theoretical sampling and constant comparison, participants' comments helped to shape the study design. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: An understanding of the processes by which health professionals negotiate their roles is important to support them to meet the challenges of increased complexity across all health sectors globally.

Development of a competency framework for advanced practice nurses: A co-design process

AIMS

The aim of the study was to develop a comprehensive competency framework for advanced practice nurses in Belgium.

DESIGN

A co-design development process was conducted.

METHODS

This study consisted of two consecutive stages (November 2020-December 2021): (1) developing a competency framework for advanced practice nurses in Belgium by the research team, based on literature and (2) group discussions or interviews with and written feedback from key stakeholders. 11 group discussions and seven individual interviews were conducted with various stakeholder groups with a total of 117 participants.

RESULTS

A comprehensive competency framework containing 31 key competencies and 120 enabling competencies was developed based on the Canadian Medical Education Directions for Specialists Competency Framework. These competencies were grouped into seven roles: clinical expert and therapist, organizer of quality care and leader in innovation, professional and clinical leader, collaborator, researcher, communicator and health promoter.

CONCLUSION

The developed competency framework has resemblance to other international frameworks. This framework emphasized the independent role of the advanced practice nurse and provided guidance in a clear task division and delegation to other professionals. It can provide a solid foundation for delivering high-quality, patient-centred care by advanced practice nurses in the years to come.

IMPLICATIONS FOR THE PROFESSION

This competency framework can guide further development of advanced practice nursing education in Belgium and represents a starting point for future evaluation of its feasibility and usability in education and clinical practice. Advanced practice nurses and healthcare managers can also use the framework as an instrument for personal and professional development, performance appraisal, and further alignment of these function profiles in clinical practice. Finally, this framework can inform and guide policymakers towards legal recognition of advanced practice nursing in Belgium and inspire the development of advanced practice nursing profiles in countries where these profiles are still emerging.

IMPACT

What problem did the study address? The absence of a detailed competency framework for advanced practice nurses complicates legal recognition, role clarification and implementation in practice in Belgium. A rigorously developed competency framework could clarify which competencies to integrate in future advanced practice nursing education, mentorship programs and practice. What were the main findings? The competency framework outlined seven roles for advanced practice nurses: clinical expert and therapist, organizer of quality care and leader in innovation, professional and clinical leader, collaborator, researcher, communicator, and health promoter. Differentiation from other expert nursing profiles and clinical autonomy of advanced practice nurses were pivotal. Where and on whom will the research have impact? The comprehensive competency framework for advanced practice nurses and the collaborative methodology used can inspire other countries where these profiles are still emerging. The competency framework can be used as an instrument for role clarification, performance appraisals, continuous professional development, and professional (e-)portfolios. The competency framework can guide policymakers when establishing Belgian's legal framework for advanced practice nurses.

REPORTING METHOD

The authors have adhered to CONFERD-HP: recommendations for reporting COmpeteNcy FramEwoRk Development in health professions.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution in the design of the study. A patient advisory panel commented on the developed competency framework.

[Nursing skill levels and implementation of Advanced Nursing Practice in Austria: A cross-sectional study]

Nursing skill levels and implementation of Advanced Nursing Practice in Austria: A cross-sectional study Abstract: Background: New fields of practice are emerging under the concept of "Advanced Nursing Practice" (ANP) that offer specialised care provided by nurses who hold master's degrees. In Austria, nurses are currently being trained as Advanced Practice Nurses (APN). Aim: The project aimed to investigate which advanced nursing practice tasks according to the Hamric model are undertaken by nurses at different levels of qualification in Austria. Methods: Certified nurses did participate in a cross-sectional survey through an online questionnaire based on the Role Delineation Model and tailored to the Austrian context. The tasks were assigned based on the Hamric model and were tested and evaluated descriptively according to the qualification level through factor analysis. Results: Completed data was available from 105 participants, among them 80% with undergraduate education, 20% with a master's degree. A tendency in the results showed that the level of qualification was related to the activities carried out. The higher the academic degree, the more activities were performed in the field of leadership. The central ANP-competencies, research and education, are rather weak among all respondents. Conclusion: The results show that activities corresponding to the competencies of an ANP are performed by a heterogeneous group of nurses. Conditions and a standardized understanding of ANP need to be established in order to offer a professional practice that matches the competency profile.

Effects of task shifting from primary care physicians to nurses: a protocol for an overview of systematic reviews

INTRODUCTION

Task-shifting from primary care physicians (PCPs) to nurses is one option to better and more efficiently meet the needs of the population in primary care and to overcome PCP shortages. This protocol outlines an overview of systematic reviews to assess the effects of delegation or substitution by nurses of PCPs' activities regarding clinical, patient-relevant, professional and health services-related outcomes.

METHODS AND ANALYSIS

We will conduct a systematic literature search for secondary literature in PubMed/MEDLINE, EMBASE, CINAHL and Cochrane databases. Systematic reviews, meta-analyses and Health Technology Assessments in German and English comprising randomised controlled trials and prospective controlled trials will be considered for inclusion. Search terms will include Medical Subject Headings combined with free text words. At least one-third of abstracts and full-text articles are reviewed by two independent reviewers. Methodological quality will be assessed using the Overview Quality Assessment Questionnaire. We will only consider reviews if they include controlled trials, if the profession that substituted or delegated tasks was a nurse, if the profession of the control was a PCP, if the assessed intervention was the same in the intervention and control group and if the Overview Quality Assessment Questionnaire score is ≥5. The corrected covered area will be calculated to describe the degree of overlap of studies in the reviews included in the study. We will report the overview according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

ETHICS AND DISSEMINATION

The overview of secondary literature does not require the approval of an Ethics Committee and will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020183327.

Nurse-led lifestyle counseling in Polish primary care: the effect of current health status and perceived barriers

Introduction

Our study included counseling on diet and physical activity, smoking, e-cigarette use, and alcohol consumption. The aim was to examine the correlates of counseling provided by primary care nurses with the health status/health behaviors of nurses and the barriers in the advice provided.

Materials and methods

In 2022, we conducted a cross-sectional survey among 331 nurses employed in the primary care sector in Lodz. The questionnaire consisted of three sections: characteristics of the patient population receiving treatment and provided with healthy lifestyle counseling by nurses, barriers to the process of assessing, controlling, and guiding patients, and health status/health behaviors of nurses.

Results

Eighty percent of the nurses in our study provided advice on diet and physical activity to primary care patients. Over 70% of the survey participants performed minimal anti-smoking interventions forsmokers, 67.7% for alcohol drinkers, and 56.8% for e-cigarette users. The correlates of counseling in the field of diet and physical activity turned out to be the knowledge and skills, which enabled nurses to provide advice (OR = 2.57, p < 0.01). The correlates of the conducted minimal anti-smoking interventions in smoking patients were: subjective assessment of overweight and obesity in nurses, knowledge and skills in conducting counseling (OR = 1.92, p < 0.05), and measuring body weight, height and BMI (OR = 2.18, p < 0.01). Among the three most common barriers identified by the nurses in the process of assessing, monitoring, and guiding patients were the opinion that patients are not interested in improving their diet, physical activity, and weight loss (60.7%), lack of time (51.4%), as well as the belief that patients find it too difficult to change their current habits (54.1%).

Conclusion

The results of our survey indicate that nurses' participation in healthy lifestyle counseling in adult patients is unsatisfactory. Interventions in primary care should be designed considering the specific obstacles nurses may face in leading healthy lifestyles. Further training of nursing staff is required to increase their knowledge on healthy lifestyles.

A systematic integrative review of specialized nurses' role to establish a culture of patient safety: A modelling perspective

AIMS

To understand specialized nurses' role in the culture of patient safety and their ability to promote and enforce it within healthcare.

DESIGN

A systematic integrative review using the approach of Whittemore and Knafl.

METHODS

Systematic literature search for qualitative, quantitative and mixed-methods studies, followed by data evaluation, quality assessment, analysis and research synthesis with a narrative perspective. Findings were contextualized within a 'framework for understanding the development of patient safety culture'.

DATA SOURCES

Searches were conducted in PubMed [including MEDLINE], Scopus, CINAHL, Web of Science and EMBASE from Jan 2013 until Sep 2023.

RESULTS

Sixteen studies published in English from six different countries were selected and used for research synthesis. Diverse enabling factors and enacting behaviours influencing specialized nurses' roles to promote patient safety culture were identified, mainly focusing on nurses' workload, professional experiences and organizational commitment. Patient safety outcomes focused on medication management, infection prevention, surveillance process in critical care, oversight on quality and safety of nurses' practice, patient care management, continuity of care, adherence to the treatment plan and implementation of a specialized therapeutic procedure.

CONCLUSION

Specialized nurses can make a significant contribution to promote patient safety culture and support organizational initiatives to prevent adverse events.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Stronger participation and leadership of specialized nurses in initiatives to improve patient safety culture requires appropriate investments and support by policy makers and managers in terms of resources and training.

IMPACT

There is a gap in existing literature on the contribution that specialized nurses can make in promoting patient safety culture. Review results highlight the importance of interprofessional collaboration and teamwork by involving specialized nurses. They inform healthcare policy makers about recognizing their roles and competencies in patient safety culture. Preferred reporting items for systematic reviews and meta-analysis. No patient or public contribution.

The implementation and impact of an advanced practice recognition program

ABSTRACT

Meaningful job recognition is a pillar for sustaining healthy work environments and proven beneficial for job satisfaction and retention. However, few dedicated award recognition programs exist for advanced practice registered nurses (APRNs), and no available literature evaluates the impact on professional practice, sense of belonging, and job retention or satisfaction. The purpose of this study was to introduce a novel award recognition program for APRNs and physician associates (PAs) in a large academic medical system and evaluate it's impact on job satisfaction, retention, and sense of belonging. Five awards were created to recognize areas of achievement for clinically practicing APRNs or PAs within an academic health system. Nomination letters were collected, deidentified, and reviewed by an award committee. Winners were announced and received a plaque. A survey was sent to employed APRNs evaluating their response to the program. The survey was sent to both APRNs (83%) and PAs (17%). Survey end points included job satisfaction, willingness to stay in role for 1 and 5 years, sense of community, something to work toward, and increasing recognition of APRNs. Results showed statistical significance in three areas. Advanced practice registered nurses or PAs who were aware of award opportunities and/or nominated for an award showed higher job satisfaction, more likely to stay in job for 1 year, and felt a greater level of recognition. Dedicated APRN award programs may have a positive impact on job satisfaction and retention. This model may be extrapolated to provide greater opportunities for meaningful recognition among clinical APRNs.

Nurse-led intervention in the management of patients with cardiovascular diseases: a brief literature review

Coronary artery disease (CAD) is one among the major causes of mortality in patients all around the globe. It has been reported by the World Health Organization (WHO) that approximately 80% of cardiovascular diseases could be prevented through lifestyle modifications. Management of CAD involves the prevention and control of cardiovascular risk factors, invasive and non-invasive treatments including coronary revascularizations, adherence to proper medications and regular outpatient follow-ups. Nurse-led clinics were intended to mainly provide supportive, educational, preventive measures and psychological support to the patients, which were completely different from therapeutic clinics. Our review focuses on the involvement and implication of nurses in the primary and secondary prevention and management of cardiovascular diseases. Nurses have a vital role in Interventional cardiology. They also have major roles during the management of cardiac complications including congestive heart failure, atrial fibrillation and heart transplantation. Today, the implementation of a nurse-led tele-consultation strategy is also gaining positive views. Therefore, a nurse-led intervention for the management of patients with cardiovascular diseases should be implemented in clinical practice. Based on advances in therapy, more research should be carried out to further investigate the effect of nurse-led clinics during the long-term treatment and management of patients with cardiovascular diseases.

Exploring Frontline Shelter Staff Perspectives on the Healthcare Needs of Clients Experiencing Homelessness

PURPOSE

To examine healthcare service development needs for persons experiencing homelessness from the perspective of frontline staff at a homeless shelter in Montreal, Quebec.

DESIGN

Qualitative descriptive design.

METHODS

Purposive sampling, semi-structured interviews with frontline shelter staff (n = 8), and thematic analysis.

FINDINGS

Themes included: 1) Challenges meeting healthcare service needs in a shelter environment. 2) Visions for improving healthcare services while accounting for health issues and barriers to care. 3) Participants' own knowledge gaps around health and healthcare services.

CONCLUSIONS

Future research should emphasize this group's crucial role in homelessness healthcare services development.

Principles for the Physician-Led Patient-Centered Medical Home and Other Approaches to Team-Based Care: A Position Paper From the American College of Physicians

Team-based care models such as the Patient-Centered Medical Home are associated with improved patient health outcomes, better team coordination and collaboration, and increased well-being among health care professionals. Despite these attributes, hindrances to wider adoption remain. In addition, some health care professionals have sought to practice independent of the physician-led health care team, potentially undermining patient access to physicians who have the skills and training to deliver whole-person, comprehensive, and longitudinal care. In this paper, the American College of Physicians reaffirms the importance of the physician-led health care team and offers policy recommendations on professionalism, payment models, training, licensure, and research to support the expansion of dynamic clinical care teams.

Perceptions of general practitioners towards the services provided by advanced practice nurses: a cross-sectional survey in France

BACKGROUND

New healthcare professions are emerging due to scarce medical resources. The appearance of a new healthcare profession, advanced practice nurses (APNs), has raised questions about how general practitioners interrelate with them as primary care providers. The objective of this study was to explore the perceptions general practitioners have towards the services rendered by APNs to patients, to general practice and the role they play in the healthcare system.

METHODS

A survey-based, cross-sectional study was conducted throughout the Grand Est region of France which covers 57,333km2 and has a population of approximately 5,562,651. The survey was compiled using pre-existing questionnaires and was carried out from July to September 2022 via email. Variables collected were rate of acceptability and socio-demographic characteristics.

RESULTS

In total, 251 responses were included. The mean age of general practitioners was 41.7 years, most were women (58.2%) and worked in rural areas of the region (53.8%). Over 80% of respondents practiced in group structures (defined as either multi-professional health centers (n = 61) or in group practices (n = 143)). Most respondents (94.0%) were familiar with the APN profession and did not consider that APNs improved access to care (55.8%, percent of responders with score ≤ 3/10). Moreover, most did not believe that APNs were useful as a primary care provider for patients (61.8%). However, being a member of a territorialized healthcare community, known as Communautés Professionnelles Territoriales de Santé (CPTS), was associated with a positive appraisal of APNs' services (OR = 2.116, 95%CI: 1.223 to 3.712; p = 0.007).

CONCLUSIONS

Encouraging shared and networked practice within a healthcare community may promote a positive perception of new actors. Further studies need to be conducted to show whether the integration of APNs into healthcare networks improves quality of care.

Exploring the association between primary care efficiency and health system characteristics across European countries: a two-stage data envelopment analysis

BACKGROUND

Primary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance.

METHODS

We developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010-2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics.

RESULTS

Countries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider.

CONCLUSIONS

Our results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking.

Validation of the newly developed Advanced Practice Nurse Task Questionnaire: A national survey

AIM

To describe psychometric validation of the newly developed Advanced Practice Nurse Task Questionnaire.

DESIGN

Cross-sectional quantitative study.

METHODS

The development of the questionnaire followed an adapted version of the seven steps described in the guide by the Association for Medical Education in Europe. A nationwide online survey tested the construct and structural validity and internal consistency using an exploratory factor analysis, Cronbach's alpha coefficient and a Kruskal-Wallis test to compare the hypotheses.

RESULTS

We received 222 questionnaires between January and September 2020. The factor analysis produced a seven-factor solution as suggested in Hamric's model. However, not all item loadings aligned with the framework's competencies. Cronbach's alpha of factors ranged between .795 and .879. The analysis confirmed the construct validity of the Advanced Practice Nurse Task Questionnaire. The tool was able to discriminate the competencies of guidance and coaching, direct clinical practice and leadership across the three advanced practice nurse roles clinical nurse specialist, nurse practitioner or blended role.

CONCLUSION

A precise assessment of advanced practice nurse tasks is crucial in clinical practice and in research as it may be a basis for further refinement, implementation and evaluation of roles.

IMPACT

The Advanced Practice Nurse Task Questionnaire is the first valid tool to assess tasks according to Hamric's model of competencies independently of the role or the setting. Additionally, it distinguishes the most common advanced practice nurse roles according to the degree of tasks in direct clinical practice and leadership. The tool may be applied in various countries, independent of the degree of implementation and understanding of advanced nursing practice.

REPORTING METHOD

The STARD 2015 guideline was used to report the study.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

[Between New Responsibility and Daily Routines - The Role of the VERAH in GP Care: A Qualitative Secondary Data Case Study of the Introduction of Software-Based Case Management]

BACKGROUND

The concept of Care Assistant in General Practice (VERAH) was developed in order to integrate non-medical staff more strongly into primary care and thus to meet the increasing demand for care and the simultaneous shortage of medical staff. VERAHs are increasingly responsible for software-supported case management and are thus confronted with new tasks. The aim of this study was therefore to explore the role of the VERAH in primary care practices.

METHODS

The present study is a qualitative secondary data analysis; the data collection took place within the projects VESPEERA and TelePraCMan. Twenty individual interviews and two focus group meetings were conducted with a total of 30 physicians, VERAHs and medical assistants from primary care. The data were analysed qualitatively according to Emerson. Contextual and socio-demographic data were collected with an accompanying questionnaire.

RESULTS

The VERAHs of all primary care practices from which interview partners participated performed tasks within software-supported case management. Concerning the role of the VERAH, three themes were identified in the interviews: a) concrete tasks of the VERAH in software-supported case management within the practice team, b) relevance of software-supported case management within the activities of the VERAHS and c) relationship between VERAHs and patients.

CONCLUSION

Taking over tasks in software-supported case management can contribute to strengthening and expanding the role of the VERAH. In the future, more attention should be paid to a clear description of the new role, and the conditions of the VERAHs' task fulfilment should be considered.

[Attitudes of general practitioners and medical practice assistants towards the delegation of medical services: Results of a survey in Berlin, Brandenburg and Thuringia]

INTRODUCTION

The delegation of tasks and responsibilities from general practitioners (GPs) to medical practice assistants (MPAs) can contribute to ensuring primary care in Germany. The aim of the study was to collect and analyze attitudes and procedures of GPs and MPAs regarding the delegation of physician-related tasks and activities.

METHODOLOGY

A self-designed, piloted questionnaire was sent to all GPs listed within the regional Associations of Statutory Health Insurance Physicians (KV) in Thuringia, Berlin, and Brandenburg (n=5,516) and their MPAs. Participants were asked to indicate which physician-related activities were already delegated and on which occasions further delegations could be considered.

RESULTS

890 GPs (response rate: 16.1%) and 566 MPAs participated in the written survey. The participants were predominantly female and most of them worked in urban areas. Numerous activities, such as medical history taking, triage, Disease Management Program (DMP) controls, vaccinations and home visits, have already been delegated. The willingness to delegate further tasks (e. g., follow-up prescriptions and referrals, independent takeover of simple consultations, assessing the necessity of physician consultation) was high.

CONCLUSION

The survey showed a high level of willingness of both occupational groups to delegate physician-related activities to MFAs. An expansion seems possible under certain conditions. Many activities have already been delegated to MPAs in primary care practices. Our survey provides suggestions regarding further tasks suitable for delegation, some of which go beyond the delegation agreement valid in Germany.

An Interactive Educational Tool to Improve Human Papillomavirus Vaccine Knowledge and Recommendation Among Nurses

In United States, only 57% of  women and 53% of men in the recommended age groups have received all recommended doses of the human papillomavirus (HPV) vaccine. Healthcare provider education has been associated with strong vaccine recommendation and vaccination uptake. Our objective was to create a 7-min interactive online educational tool to improve knowledge and willingness to recommend the HPV vaccine among nurses. This is a prospective pre-test/post-test study to evaluate the effectiveness of the educational tool consisting of 10 flashcards in a question-answer format. Oncology nurses at our cancer center were invited to participate by email, which led them to the educational tool (i.e., intervention) along with pre- and post-test questions on HPV-associated cancers, vaccine-eligible age groups, dosing schedules, adverse events, and willingness to recommend. Of the 110 participants (mean age of 41.2 ± 11.4, 98% female, 64% >10 years of practice), there was improvement in knowledge after intervention in HPV-associated cancers (81% to 97%; p = 0.02), percentage of cervical caused by HPV (33% to 64%; p < 0.05), and dosing schedule (47% to 93%; p < 0.05). All participants correctly stated that continued screening is needed after vaccination both pre- and post-intervention. Eighty-five percent strongly agreed that the intervention improved their HPV knowledge, and 77% stated they were more likely to recommend the HPV vaccine after the intervention. While nurses are willing to recommend the vaccine, there remains persistent knowledge gaps. A brief 7-min self-administered online interactive flashcard educational intervention is effective in improving the HPV vaccine knowledge among nurses.

Nursing Development should Now Become a Priority for Health Systems in Europe

The vast majority of European countries are struggling to embrace nursing as a profession and as a science. There are still not enough nurses with bachelor's degrees and advanced practical skills, and clinical specialisations for nurses are being developed at the master's level. Attention should be paid to recognising nurses as an equal healthcare workforce who need to be empowered to advance their profession and be provided with professional development opportunities. Changes needed include improving pay and working conditions, providing opportunities to improve skills and professional recognition, empowering nurses to deliver care, and harnessing the power of technology to better support nurses. The declining interest in nursing education and the often stereotypical and condescending view of the role and work of nurses on the healthcare team should be a warning signal to all who are working on healthcare reform.

Patient perspective on task shifting from general practitioners to medical practice assistants - a quantitative survey in Germany

INTRODUCTION

Various developments result in increasing workloads in general practices. New models of care and a restructuring of the division of tasks could provide relief. One approach is to extend the delegation of medical tasks from general practitioners (GPs) to medical practice assistants (MPAs). So far, there has been a lack of information about specific situations in which patients are willing to be treated exclusively by MPAs.

METHODS

In three German federal states, patients who visited a general practice were surveyed exploratively and cross-sectionally with a self-designed, paper-based questionnaire. The data were analysed descriptively and multivariate. A mixed binary logistic regression model was calculated to account for cluster effects at practice level (random intercept model). The dependent variable was patients' acceptance of task delegation.

RESULTS

A total of 1861 questionnaires from 61 general practices were included in the analysis. Regarding the current problem/request, a total of 30% of respondents could imagine being treated only by MPAs. Regarding theoretical reasons for consultation, more than half of the patients agreed to be treated by MPAs. According to the regression model, MPAs were preferred when patients were younger (10-year OR = 0.84, 95%-CI [0.75, 0.93]) or had a less complicated issue (OR = 0.44, 95%-CI [0.26, 0.8]). For four current problems/requests ("acute complaints" OR = 0.27, 95%-CI [0.17, 0.45], "routine health check" OR = 0.48, 95%-CI [0.3, 0.79], "new problem" OR = 0.13, 95%-CI [0.06, 0.28], "known problem" OR = 0.16, 95%-CI [0.1, 0.27]) patients prefer to be treated by GPs instead of MPAs.

DISCUSSION

For the first time, statements could be made on patients' acceptance of task delegation in relation to current and theoretical reasons for treatment in general practices in Germany. The discrepancy in response behaviour on a theoretical and individual level could be explained by different contexts of questions and differences at practice level. Overall, patients seem to be open to increased delegation of medical tasks, depending on the reason for treatment. Selection and response biases should be considered in the interpretation.

CONCLUSION

The results are not completely opposed to an extension of task delegation. Further interventional studies could provide information on the possible effects of expansion of delegable tasks.

Introducing a triage and Nurse on Call model in primary health care - a focus group study of health care staff's experiences

BACKGROUND

With the increased demand for health care services and with simultaneous staff shortages, new work models are needed in primary health care. In November 2015, a Swedish primary health care centre introduced a work model consisting of a structured patient sorting system with triage and Nurse on Call. The aim of this study was to describe the staff's experiences of introducing the triage and Nurse on Call model at the primary health care centre.

METHODS

Five focus group discussions with staff (n = 39) were conducted 4 years after the introduction of the work model. Groups were divided by profession: medical secretaries, nursing assistants, physicians, primary health care nurses, and registered nurses. The transcribed text from the discussions was analysed using qualitative inductive content analysis.

RESULTS

The analysis generated one overarching theme: The introduction of triage and Nurse on Call addresses changed preconditions in primary health care, but the work culture, organization, and acquisition of new knowledge are lagging behind. The overarching theme had five categories: (1) Changed preconditions in primary health care motivate new work models; (2) The triage and Nurse on Call model improves teamwork and may increase the quality of care; (3) Unclear purpose and vague leadership make introducing the work model difficult; (4) Difficulties to adopt the work model as it challenges professional autonomy; and (5) The triage and Nurse on Call model requires more knowledge and competence from nurses in primary health care.

CONCLUSIONS

This study contributes with knowledge about implications of a new work model in primary health care from the perspective of health care staff. The work model using triage and Nurse on Call in primary health care was perceived by participants to increase availability and optimize the use of resources. However, before introduction of new work models, it is important to identify barriers to and facilitators for successful improvements in the local health care context. Additional education for the health care staff is important if the transition is to be successful. Complementary skills and teamwork, supported by a facilitator seems important to ensure a well-prepared workforce.

Pre-post analysis of the impact of British Columbia nurse practitioner primary care clinics on patient health and care experience

OBJECTIVE

This study aims to evaluate the impact of a primary care nurse practitioner (NP)-led clinic model piloted in British Columbia (Canada) on patients' health and care experience.

DESIGN

The study relies on a quasi-experimental longitudinal design based on a pre-and-post survey of patients receiving care in NP-led clinics. The prerostering survey (T0) was focused on patients' health status and care experiences preceding being rostered to the NP clinic. One year later, patients were asked to complete a similar survey (T1) focused on the care experiences with the NP clinic.

SETTING

To solve recurring problems related to poor primary care accessibility, British Columbia opened four pilot NP-led clinics in 2020. Each clinic has the equivalent of approximately six full-time NPs, four other clinicians plus support staff. Clinics are located in four cities ranging from urban to suburban.

PARTICIPANTS

Recruitment was conducted by the clinic's clerical staff or by their care provider. A total of 437 usable T0 surveys and 254 matched and usable T1 surveys were collected.

PRIMARY OUTCOME MEASURES

The survey instrument was focused on five core dimensions of patients' primary care experience (accessibility, continuity, comprehensiveness, responsiveness and outcomes of care) as well as on the SF-12 Short-form Health Survey.

RESULTS

Scores for all dimensions of patients' primary care experience increased significantly: accessibility (T0=5.9, T1=7.9, p<0.001), continuity (T0=5.5, T1=8.8, p<0.001), comprehensiveness (T0=5.6, T1=8.4, p<0.001), responsiveness (T0=7.2, T1=9.5, p<0.001), outcomes of care (T0=5.0, T1=8.3, p<0.001). SF-12 Physical health T-scores also rose significantly (T0=44.8, T1=47.6, p<0.001) but no changes we found in the mental health T scores (T0=45.8, T1=46.3 p=0.709).

CONCLUSIONS

Our results suggest that the NP-led primary care model studied here likely constitutes an effective approach to improve primary care accessibility and quality.

A situational analysis of human resource and non-communicable diseases management for community health workers in Chengdu, China: a cross-sectional study

BACKGROUND

Non-communicable diseases (NCDs) pose a major challenge to health economic cost and residents' health status. Community health workers (CHWs) are the gatekeeper of primary health care.

OBJECTIVE

This study aimed to conduct a situational analysis of current human resource and requirements of NCDs-related training among CHWs in Chengdu with regard to address to understand the suggestions for improvement of challenges and barriers.

METHODS

A descriptive online cross-sectional survey was conducted among CHWs (doctors and nurses) from 23 districts and counties in Chengdu. Sociodemographic and NCDs-related variables were collected. Univariate analysis and multiple response analysis were used to describe the characteristics of these variables.

RESULTS

711 doctors and 637 nurses completely responded. There were significant differences among gender, age, educational levels, professional title, working year, type of institution, urban circle and registration in general practice between doctors and nurses (P < 0.001). 60.6% of doctors were female, compared to 98.0% for nurses. 58.2% of doctors held a bachelor's degree compared with 45.4% of nurses, while 48.3% of nurses held a junior college degree compared with 25.7% of doctors. Higher levels of professional title and registration in general practice were found in doctors compared with nurses. The proportions of NCDs' category, NCDs-related roles and tasks, NCDs-related training contents and forms that CHWs have attend and hoped to gain more were significantly different between doctors and nurses (P < 0.001). In general, the proportions in nurses were much lower than those of doctors (P < 0.05). The top five diseases managed by CHWs were hypertension, diabetes, cerebrovascular disease, chronic respiratory diseases and mental diseases. The five most reported roles performed among doctors included the distribution of health education (91.4%), following up (85.9%), establishing archives (71.3%), medicine adjustment (64.7%) and treatment implementation (52.0%). The top three diseases managed by nurses were same with doctors. The top four and five tasks were contact with patients or health services (39.6%) and referral (16.6%) in nurses. Most CHWs had received primary and common diseases-related trainings, but they had few opportunities to study in a tertiary hospital (40.4% in doctors and 20.9% in nurses, respectively), attend domestic academic conferences (26.9% in doctors vs. 9.7% in nurses), and take part in training courses (44.9% in nurses). CHWs hoped that the above-discussed training contents and forms could be provided more in the future. Besides basic skills related trainings, some specific skills related trainings should be strengthened.

CONCLUSION

The qualifications in doctors were much better than those of nurses. The roles performed by CHWs in NCDs management are varied form common and frequent disease management to subsequent follow up and supervision. CHWs hope to receive more desired and oriented trainings. There is a need for building capacity of CHWs, optimizing and defining CHWs' role, facilitating postgraduate medical education support and strengthening multidisciplinary collaboration would be effective in NCDs management.

International comparison of professional competency frameworks for nurses: a document analysis

BACKGROUND

Nursing competency frameworks describe the competencies; knowledge, skills and attitudes nurses should possess. Countries have their own framework. Knowledge of the content of professional competency frameworks in different countries can enhance the development of these frameworks and international collaborations.

OBJECTIVE

This study examines how competencies and task divisions are described in the current professional competency frameworks for registered nurses (RNs with a Bachelor's degree) in the Netherlands, Belgium, the United Kingdom (UK), Canada and the United States (US).

METHODS

Qualitative document analysis was conducted using the most recently published professional competency frameworks for registered nurses in the above-mentioned five countries.

RESULTS

All the competency frameworks distinguished categories of competencies. Three of the five frameworks explicitly mentioned the basis for the categorization: an adaptation of the CanMEDS model (Netherlands), European directives on the recognition of professional qualifications (Belgium) and an adapted inter-professional framework (US). Although there was variation in how competencies were grouped, we inductively identified ten generic competency domains: (1) Professional Attitude, (2) Clinical Care in Practice, (3) Communication and Collaboration, (4) Health Promotion and Prevention, (5) Organization and Planning of Care, (6) Leadership, (7) Quality and Safety of Care, (8) Training and (continuing) Education, (9) Technology and e-Health, (10) Support of Self-Management and Patient Empowerment. Country differences were found in some more specific competency descriptions. All frameworks described aspects related to the division of tasks between nurses on the one hand and physicians and other healthcare professionals on the other hand. However, these descriptions were rather limited and often imprecise.

CONCLUSIONS

Although ten generic domains could be identified when analysing and comparing the competency frameworks, there are country differences in the categorizations and the details of the competencies described in the frameworks. These differences and the limited attention paid to the division of tasks might lead to cross-country differences in nursing practice and barriers to the international labour mobility of Bachelor-educated RNs.

Provision of evaluation and management visits by nurse practitioners and physician assistants in the USA from 2013 to 2019: cross-sectional time series study

OBJECTIVE

To examine the proportion of healthcare visits are delivered by nurse practitioners and physician assistants versus physicians and how this has changed over time and by clinical setting, diagnosis, and patient demographics.

DESIGN

Cross-sectional time series study.

SETTING

National data from the traditional Medicare insurance program in the USA.

PARTICIPANTS

Of people using Medicare (ie, those older than 65 years, permanently disabled, and people with end stage renal disease), a 20% random sample was taken.

MAIN OUTCOME MEASURES

The proportion of physician, nurse practitioner, and physician assistant visits in the outpatient and skilled nursing facility settings delivered by physicians, nurse practitioners, and physician assistants, and how this proportion varies by type of visit and diagnosis.

RESULTS

From 1 January 2013 to 31 December 2019, 276 million visits were included in the sample. The proportion of all visits delivered by nurse practitioners and physician assistants in a year increased from 14.0% (95% confidence interval 14.0% to 14.0%) to 25.6% (25.6% to 25.6%). In 2019, the proportion of visits delivered by a nurse practitioner or physician assistant varied across conditions, ranging from 13.2% for eye disorders and 20.4% for hypertension to 36.7% for anxiety disorders and 41.5% for respiratory infections. Among all patients with at least one visit in 2019, 41.9% had one or more nurse practitioner or physician assistant visits. Compared with patients who had no visits from a nurse practitioner or physician assistant, the likelihood of receiving any care was greatest among patients who were lower income (2.9% greater), rural residents (19.7%), and disabled (5.6%).

CONCLUSION

The proportion of visits delivered by nurse practitioners and physician assistants in the USA is increasing rapidly and now accounts for a quarter of all healthcare visits.

Outcomes of Patient Education in Nurse-led Clinics: A Systematic Review

Introduction

Patient education is an independent role of nurses performed in nurse-led clinics (NLCs). The measurement of patient education outcomes validates whether nursing educational interventions have a positive effect on patients, which helps determine whether changes in care are needed. Standardized nursing terminologies facilitate the evaluation of educational outcomes. We aimed to explore the outcomes of patient education in NLCs based on the Nursing Outcome Classification (NOC) system.

Methods

The review was conducted according to PRISMA guidelines. We searched "Medline", "Embase", "Web of Science", and "Scopus" databases for articles published between 2000 and 2022. Based on the search strategy, 1157 articles were retrieved from PubMed, Scopus, Web of Science, and Embase databases. After excluding the duplicates, 978 articles were appraised. 133 articles remained after reading the titles and abstracts of the articles. In the next step, the articles were evaluated regarding methodology, research population, and exclusion criteria, after which 112 articles were omitted, and finally, 21 articles were included in the full-text review. We assessed all included studies using the Quality Assessment of Controlled Intervention Studies checklist.

Results

A total of 21 randomized controlled trials met the inclusion criteria. "Physiologic health", "functional health", "psychosocial health", "health knowledge and behavior", and "perceived health" were the domains of nursing outcomes investigated as Patient Education Outcomes in NLCs.

Conclusion

Most of the outcomes were linked to lifestyle-related chronic diseases and, further studies are needed to determine the effects of patient education provided in NLCs in terms of family/society health outcomes.

How does the quality of care for type 2 diabetic patients benefit from GPs-nurses' teamwork? A staggered difference-in-differences design based on a French pilot program

In many countries, policies have explicitly encouraged primary care teams and inter-professional cooperation and skill mix, as a way to improve both productive efficiency gains and quality improvement. France faces barriers to developing team working as well as new and more advanced roles for health care professionals including nurses. We aim to estimate the impact of a national pilot experiment of teamwork between general practitioners (GPs) and advance practitioners nurses (APN)-who substitute and complement GPs-on yearly quality of care process indicators for type two diabetes patients (T2DP). Implemented by a not-for-profit meso-tier organisation and supported by the Ministry of Health, the pilot relied on the voluntary enrolment of newly GPs from 2012 to 2015; the staffing and training of APNs; skill mixing and new remuneration schemes. We use latent-response formulation models, control for endogeneity and selection bias by using controlled before-after and quasi-experimental design combining coarsened exact matching-prior to the treatment, at both GPs (435 treated vs 973 control) and T2DP levels -, with intention to treat (ITT; 18,310 in each group) and per protocol (PP, 2943 in each group) perspectives, as well as difference-in-differences estimates on balanced panel claims data from the National Health Insurance Fund linked to clinical data over the period 2010-2017. We show evidence of a positive and significant positive impact for T2DP followed-up by newly enrolled GPs in the pilot compared to the pretreatment period and the control group. The effect magnitudes were larger for PP than for ITT subsamples.

Developing modern primary care nursing in North Macedonia

BACKGROUND

Nurses have the potential to make a real impact on the health and well-being of people and populations and contribute to the realisation of delivery of Universal Health Coverage. However, in many parts of the world, the education and practice of nursing and nurses' position in health care and society are restricted by a range of social, cultural, economic and political factors. In North Macedonia, the Ministry of Health in partnership with the WHO Country Office launched a primary healthcare strategy supporting the development of nurses in primary care to fulfil their full scope of service.

AIMS

To present information on the education, practice and position of nursing, in particular primary care nursing, in North Macedonia and to describe the ongoing initiatives to support the further development of nursing.

APPROACH

Background documents reviewed, and visits to healthcare settings, organisations, interviews with individuals and groups and workshops undertaken in 2019-2020.

FINDINGS

Three key areas of development were identified: education of nurses, their service delivery and practice in primary care, and their position in health care and society, all underpinned by the need for workforce planning. The findings formed the basis of a 10-year plan: Making Change Happen: The Nursing and Midwifery Development Roadmap.

DEVELOPMENTS

To support the proposed primary care pilots, during the 2020/2021 COVID-19 pandemic, an on-line modular programme for primary care nurses was developed and delivered with the support of members drawn from The National Working Group for Moving Primary Care Nursing Forward in North Macedonia. Further work is planned to develop initial nurse education and to pilot changes in primary care.

CONCLUSIONS

The launch of the primary healthcare strategy stimulated initiatives to improve the education, position and practice of primary care nursing. The COVID-19 pandemic required flexibility and changes to the original plans.

An international comparison of student nurse practitioner diagnostic reasoning skills

BACKGROUND

Nurse practitioners (NPs) play a pivotal role in health care provision. Diagnostic reasoning is an important core skill of advanced practice.

PURPOSE

The purpose of this study was to compare diagnostic reasoning skills of NP students. It also identified the variability in clinical teaching components of a sample of international NP curricula.

METHODS

An international group of NP students completed an online survey using a validated diagnostic reasoning scale during the first year of their NP program. Program faculty surveyed provided data on core curricula.

RESULTS

The NP students' ( n = 152) mean diagnostic thinking inventory (DTI) score was 142, flexibility in thinking subscale score mean of 73 with a knowledge structure in memory of 69. The programs surveyed required bioscience courses. Most programs provided opportunities for students to practice diagnostic thinking using individual precepted clinical hours (range 500-950) and objective structured clinical examinations.

CONCLUSION

The lower scores of this group of NP students were similar to other NP students and first-year medical residents. Higher mean scores in the DTI reflect expertise and are developed over time. Courses providing a foundation of biomedical knowledge were identified in each program, with opportunities for the NP students to practice diagnostic thinking using objective structured clinical examinations and clinical practice hours.

IMPLICATIONS

The use of the diagnostic reasoning inventory is a useful tool for evaluating student NP's diagnostic reasoning during their NP program. Nurse practitioner programs should consider the provision of dedicated clinical hours, including supervised clinical practice experiences and objective structured clinical examinations to improve diagnostic reasoning.