Advanced Practice Nurses Globally: Responding to Health Challenges, Improving Outcomes

The development of advanced practice nurses in Singapore

The development of advanced practice nursing has evolved globally over the past decades and has become an important component in the contemporary healthcare system. The term 'advanced practice nurse' is used to refer to nurses practising at a higher level than traditional nurses and is defined as a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice. In 2003, Singapore embarked on the development of advanced practice nurses as an initiative to improve the nursing professional image, retain excellent clinical nurses and fill the gaps in the provision of healthcare services for the ageing population. This paper documents Singapore's journey of advanced practice nursing development and shares our unique learning experience in the aspects of education, certification, registration and scope of practice.

Intensive Primary Care Nursing: Exploring the Impact of a Nurse-Led Model for Medically and Social Complex Patients

Lack of access to primary care contributes to health inequities. Treatment settings that utilize the full experience and training of nurses, both registered nurses (RNs) and advanced practice registered nurses (APRNs), can expand in primary care and successfully address health inequities. This small study describes the implementation of a model of primary care called intensive primary care (IPC), which has eight elements that support the full utilization of a nurse's experience and training. This is a mixed method qualitative study, which reports the observations of the implementation and pre- and post-intervention measures. The IPC model was implemented at a free clinic, which targeted underserved population between 2020 and 2023. Participants were selected as a convenience sample. Participants were to have two or more chronic health problems The participants received primary care using the IPC model, which included setting self-management goals, and meeting with RN or APRN on a monthly basis (face to face, via phone or zoom) to monitor progress toward goals. Twenty-two people were approached, and 19 completed the intervention. Pre- and Post-intervention measures (Patient Assessment of Chronic Illness Care [PACIC]-20); Functional, Communicative, Critical Thinking Health Literacy; Perceived Stress; Patient Activation; Perceived Self Efficacy for Chronic Disease; EuroQo- 5 Dimension (EQ-5D); Trust in Provider; Emotional Support-Patient Reported Outcome Measure Information System (PROMIS); and Patient Health Questionnaire-9) were obtained and analyzed with paired T test (α < .05). Nurses involved meet weekly to share observations recorded in free form notes. These observations were summarized by two of the authors (MD and KF) at the end of the study. All patients had improved physical health outcomes, but more importantly, there were significant improvements in measures known to impact health and health outcomes, specifically, patient activation, self-efficacy for chronic illness, PACIC, and trust in provider. Time spent with patients, both duration and frequency of contact, was observed to have significant impacts.

Response and innovations of advanced practice nurses during the COVID-19 pandemic: A scoping review

AIM

Identify and map international evidence regarding innovations led by or involving advanced practice nurses in response to COVID-19.

BACKGROUND

COVID-19 necessitated unprecedented innovation in the organization and delivery of healthcare. Although advanced practice nurses have played a pivotal role during the pandemic, evidence of their contributions to innovations has not been synthesized. Evidence is needed to inform policies, practices, and research about the optimal use of advanced practice nurses.

METHODS

A scoping review was conducted and reported using the PRISMA-ScR checklist. Electronic databases were searched for peer-reviewed articles published between January 2020 and December 2021. Papers were included that focused on innovations emerging in response to COVID-19 and involved advanced practice nurses.

RESULTS

Fifty-one articles were included. Four themes were identified including telehealth, supporting and transforming care, multifaceted approaches, and provider education. Half of the articles used brief and mostly noncomparative approaches to evaluate innovations.

CONCLUSION

This is the first synthesis of international evidence examining the contributions of advanced practice nurses during the pandemic. Advanced practice nurses provided leadership for the innovation needed to rapidly respond to healthcare needs resulting from COVID-19. Innovations challenged legislative restrictions on practice, enabled implementation of telehealth and new models of care, and promoted evidence-informed and patient-centered care.

IMPLICATIONS FOR PRACTICE

Advanced practice nurses led, designed, implemented, and evaluated innovations in response to COVID-19. They facilitated the use of telehealth, supported or transformed models of care, and enabled health providers through education, mentorship, and mental health support.

IMPLICATION FOR POLICY

Advanced practice nurses are a critical resource for innovation and health system improvement. Permanent removal of legislative and regulatory barriers to their full scope of practice is needed.

[Practice and challenges of delegating medical tasks in the interprofessional everyday work of inpatient healthcare in Germany - An exploratory survey]

BACKGROUND

The delegation of medical tasks (DMT) plays a significant role in the everyday practice of inpatient care but also presents a potential challenge in interprofessional collaboration. Assessing the conditions of DMT in everyday work is crucial to identify areas for optimization.

METHODS

In a nationwide exploratory study, physicians, nursing and allied health professionals working for inpatient care facilities were surveyed regarding various aspects of DMT using a standardized online questionnaire.

RESULTS

The majority of the 757 participants (64.9% physicians), perceived DMT to be both economically and time-efficient (88.5% agreement) and in the best interest of patients (74%). For 78.7% of the respondents, DMT represents a potential conflict in their daily work, depending on the quality of interprofessional communication. Inadequate staffing was identified as a barrier to a broader implementation of DMT by 83.8% of participants. 63.2% of the participants considered their knowledge of legal aspects related to DMT to be at least good (participants with less than 5 years of professional experience: 52.6%). Physicians primarily acquire relevant knowledge through professional practice (71.3% vs. non-physicians 39.5%).

CONCLUSION

Across the different professional groups DMT was considered beneficial and serving the interests of patients. Targeted promotion of safe and cost-effective DMT should be incorporated into medical education. Achieving greater benefits from DMT requires explicit legal frameworks, effective communication within the team and, in particular, adequate staffing among the professional groups responsible for delegated tasks.

Stepping outside national borders: International active learning educational collaboration events

AIM

This paper discusses the benefits of international collaborations for advanced practice nursing education. It identifies new perspectives and innovative practices to enhance cultural competency.

BACKGROUND

Competent, well-trained advanced practice nurses (APNs) are necessary to provide high-quality and safe patient care, improve access to care, and address health disparities that are no longer geographically bound. In 2021, an international network of advanced practice educators established an active learning program to teach students their role in global citizenship and increase awareness of health disparities. APN students from Scotland, Wales, Minnesota, Houston, and Rotterdam participated in presentations, online discussions, and in-country scholarships.

SOURCES OF EVIDENCE

Growing health disparities have created the need for efficient international collaboration to develop new concepts, approaches, and bidirectional exchange of experiences, culture, and knowledge. Integrating global health into curricula engages students' curiosity and integrates education, research, practice, and leadership while improving cultural competency.

DISCUSSION

Forty-two students participated in the international presentations. The students strongly believed in the benefit of international collaboration and the need for a universal role for the advanced practice nurse. They responded positively to sharing cultural and clinical experiences.

CONCLUSION

The recent global health challenge supported the development of innovative methods to deliver education and created an opportunity for advanced practice students to develop cultural competence and critical thinking. Collaborative solutions are essential to education and healthcare as we move forward in the 21st century.

IMPLICATIONS FOR NURSING PRACTICE

Robust international collaborations have enabled the development of cultural competence and critical thinking. These are crucial elements for advanced practice roles.

Models of care with advanced practice nurses in the emergency department: A scoping review

INTRODUCTION

Emergency departments play a critical role in healthcare systems internationally. Visits for emergency care continue to increase, related to poor access to primary care, the COVID-19 pandemic, and health human resource issues. International literature shows similar stressors in the emergency department. Extended wait times to see health providers lead to poor outcomes, and innovative models of care are needed to address emergency department overcrowding and to meet the needs of patients. Advanced practice nurses have the expertise and scope of practice to optimize and address primary and acute care needs and could be further integrated into the emergency healthcare systems. It is unclear what and how advanced practice nurses are functioning in emergency departments to improve patient and organization outcomes.

METHODS

This scoping review was a comprehensive search of MEDLINE, EMCARE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and gray literature. Authors developed inclusion and exclusion criteria, performed title and abstract screening, and full text screening using review software. Data about models of care with advanced practice nurses were extracted and organized to understand patient, provider, and organizational outcomes. We also extracted information about the development and implementation of roles.

RESULTS

Of the 6780 records identified, 76 met inclusion criteria. Emergency department models of care, mainly using nurse practitioners, include fast-track, generalized emergency, minor injury, orthopedics, pediatrics, geriatrics, specific populations, and triage. Reported patient outcomes include improvement in key metrics specific to emergency departments, such as total length of stay, wait times to be seen by a provider, left without being seen rates, treatment for pain, costs, and resource use. When comparing nurse practitioners to other providers, outcomes were similar or better for patient and organizational outcomes.

DISCUSSION

Various models of care utilizing advanced practice nurses in emergency departments are present internationally and information about how they are developed, integrated, and utilized provides practical information to support and sustain new roles. There is an opportunity to expand the use of these roles into emergency departments as the nurse practitioner scope of practice grows. Given the current crisis across healthcare systems, there is need for innovation, and improving delivery of emergency services with these advanced practice nursing models of care can help to address important health policy priorities in Canada and other countries.

TWEETABLE ABSTRACT

Advanced Practice Nurse models of care in emergency - Improved outcomes for patients and organizations - A review of the literature. @SamanthaH_RN.

Advancement of research on nurse practitioners: Setting a research agenda

BACKGROUND

Primary care delivered by nurse practitioners (NPs) helps to meet the United States' growing demand for care and improves patient outcomes. Yet, barriers impede NP practice. Knowledge of these barriers is limited, hindering opportunities to eliminate them.

PURPOSE

We convened a 1.5-day conference to develop a research agenda to advance evidence on the primary care NP workforce.

METHODS

Thirty experts gathered in New York City for a conference in 2022. The conference included plenary sessions, small group discussions, and a prioritization process to identify areas for future research and research questions.

DISCUSSION

The research agenda includes top-ranked research questions within five categories: (a) policy regulations and implications for care, quality, and access; (b) systems affecting NP practice; (c) health equity and the NP workforce; (d) NP education and workforce dynamics, and (e) international perspectives.

CONCLUSION

The agenda can advance evidence on the NP workforce to guide policy and practice.

Teaching strategies of clinical reasoning in advanced nursing clinical practice: A scoping review

AIM/OBJECTIVE

To report and synthesize the main strategies for teaching clinical reasoning described in the literature in the context of advanced clinical practice and promote new areas of research to improve the pedagogical approach to clinical reasoning in Advanced Practice Nursing.

BACKGROUND

Clinical reasoning and clinical thinking are essential elements in the advanced nursing clinical practice decision-making process. The quality improvement of care is related to the development of those skills. Therefore, it is crucial to optimize teaching strategies that can enhance the role of clinical reasoning in advanced clinical practice.

DESIGN

A scoping review was conducted using the framework developed by Arksey and O'Malley as a research strategy. Consistent with the nature of scoping reviews, a study protocol has been established.

METHODS

The studies included and analyzed in this scoping review cover from January 2016 to June 2022. Primary studies and secondary revision studies, published in biomedical databases, were selected, including qualitative ones. Electronic databases used were: CINAHL, PubMed, Cochrane Library, Scopus, and OVID. Three authors independently evaluated the articles for titles, abstracts, and full text.

RESULTS

1433 articles were examined, applying the eligibility and exclusion criteria 73 studies were assessed for eligibility, and 27 were included in the scoping review. The results that emerged from the review were interpreted and grouped into three macro strategies (simulations-based education, art and visual thinking, and other learning approaches) and nineteen educational interventions.

CONCLUSIONS

Among the different strategies, the simulations are the most used. Despite this, our scoping review reveals that is necessary to use different teaching strategies to stimulate critical thinking, improve diagnostic reasoning, refine clinical judgment, and strengthen decision-making. However, it is not possible to demonstrate which methodology is more effective in obtaining the learning outcomes necessary to acquire an adequate level of judgment and critical thinking. Therefore, it will be necessary to relate teaching methodologies with the skills developed.

Relationships between self-efficacy, coping-style and quality of work-life among nursing managers in China: A cross-sectional study

AIM

To investigate the quality of work-life among nursing managers in China and analyze the relationships between self-efficacy, coping-style, and quality of work-life.

BACKGROUND

Self-efficacy, coping-style, and quality of work-life play significant roles in the stability of nursing teams, the quality of clinical care, and patient safety. Although some factors influencing quality of work-life have been identified, there is no large-scale study of the relationships among self-efficacy, coping-style, and quality of work-life of nursing managers. Strategies to strengthen the quality of work-life of nursing managers should be developed by exploring the relationships between the three variables.

METHODS

A nationwide cross-sectional study was conducted. A total of 1498 nursing managers from 51 tertiary general hospitals in 20 provinces in China were selected for the study using multistage stratified proportional sampling. Registered full-time nursing managers with more than one year of management experience were eligible for the study. The participants completed online questionnaires to assess their self-efficacy, coping-style, and work-related quality of life. The data were analyzed using descriptive analysis, Pearson's correlation, hierarchical multiple linear regression, and structural equation modelling to verify the relationships between variables.

RESULTS

The quality of work-life score for the nursing managers surveyed was 3.74 ± 0.56 out of a possible five. Self-efficacy was positively correlated with quality of work-life (β = 0.484, P < 0.01) over all demographic variables. Positive coping was also positively associated with quality of work-life (β = 0.404, P < 0.01). Self-efficacy and positive coping explained 22.7% and 14.2% of the variance in the quality of work-life, respectively. Structural equation modelling indicated that self-efficacy positively and directly predicted the quality of work-life (β = 0.395, P < 0.001), and indirectly affected quality of work-life via positive coping (β = 0.186, P < 0.001), but not via negative coping (β = 0.005, P > 0.05). The final model could explain 44% of the variance in the quality of work-life.

CONCLUSION

Self-efficacy was positively correlated with quality of work-life among Chinese nursing managers, and positive coping partially mediated this relationship. The results suggest that self-efficacy and positive coping are pivotal facilitators for improving the quality of work-life and need to be taken into account in measures to improve the quality of work-life of nursing managers.

IMPLICATIONS FOR NURSING MANAGEMENT

Hospital administrators should recognize the importance of nursing managers' work-life quality to promote both the stability of nursing teams and the quality of clinical care and safety provided. They should help nursing managers foster self-efficacy and active coping abilities through incentive measures and provide positive coping training courses to enhance their quality of work-life.