Realizing specialist and advanced nursing practice: a typology of innovative nursing roles

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

Background  Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness. Objectives  This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors. Search Strategy  A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials. Selection Criteria  This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness. Results  Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions. Conclusions  While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

Stoma coloproctology nurse specialist: a case study

AIMS AND OBJECTIVES

The aim of this paper is to provide insight into the role of a Stoma Coloproctology Nurse Specialist. This paper presents the findings of an in-depth case study of a stoma coloproctology nurse specialist employed in one health board area in Northern Ireland. This case study was part of a larger study exploring innovative nursing and midwifery roles in Northern Ireland.

BACKGROUND

Specialist nursing roles have evolved and developed in response to changing health care needs, patient expectations, changes in professional regulation and government initiatives.

DESIGN

A case study approach was adopted.

METHOD

Semi-structured interviews with the post holder (PH), her line manager and the human resource manager were undertaken. Non-participant observation of the PH's practice was also carried out. Analysis was undertaken on secondary data such as job specification, annual reports and other documentation relating to the post.

RESULTS

Findings illustrate the PH's function and the impact of the role on patient care. Examples of innovative practices relating to providing care, support and guidance for patients and their families were identified; however, limitations to her role were also identified.

CONCLUSIONS

The PH provides an invaluable service to patients, demonstrating a positive impact on care. However, the findings suggest the importance of establishing clear role boundaries, which may lead to professional growth and practice development.

RELEVANCE TO CLINICAL PRACTICE

Although this study provides a valuable insight into the role of a Stoma Coloproctology Nurse Specialist a number of challenges exist, as the CNS role requires policy and appropriate educational preparation to practice at an advanced level. Further research investigating the development of the CNS role in the clinical setting and its relationship to members of the multi-professional team would be beneficial.

Evolution of practice nursing in Australia

AIM

This paper describes the evolution of Australian practice nursing and documents seminal events in crystallizing the importance of the nursing role in general practice.

BACKGROUND

Internationally, the potential for nurses to improve health in primary care settings is acknowledged. The general practice setting is a focal point for primary care in many health systems. Despite the important role played in the delivery of primary health care by nurses working in general practice in the United Kingdom and New Zealand, the role of nurses in Australian general practice is much less clearly defined, as reflected by the paucity of research and scholarship in this area. Fuelled by the increasing challenges of workforce shortages and the increasing need for multidisciplinary care, interest in the developing role of the Australian practice nurse among clinicians, researchers and policy makers is increasing.

DISCUSSION

Australian practice nursing has reached a critical point in its evolution. It is imperative for the promotion of nursing in general practice that knowledge from descriptive, exploratory research be used to inform strategic decision-making in terms of professional development issues, policy, research and scholarship. These data also need to inform systematic outcome studies. To date, the embryonic nature of practice nursing as a discrete professional entity in Australia has inhibited its representation in nursing curricula and professional bodies.

CONCLUSION

In order to advance the Australian practice nurse movement and demonstrate its important contribution to primary health care, nurses need to take the lead in strategic planning of this emerging specialty. As well as leadership from an academic, research and policy perspective, clinical leaders need to be fostered among the ranks of practice nurse clinicians to drive clinical practice development and the delivery of evidence-based primary care.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

BACKGROUND

Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness.

OBJECTIVES

This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors.

SEARCH STRATEGY

A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials.

SELECTION CRITERIA

This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness.

RESULTS

Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions.

CONCLUSIONS

While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

Advanced nursing practitioners in primary care settings: an exploration of the developing roles

Recent health care policies have resulted in patients having access to an integrated system of care that is quick and reliable. In concert with these changes, opportunities for professional development in nursing have increased, together with a reduction in the numbers of doctors. Advanced Nurse Practitioners (ANPs) have, therefore, developed to meet the complex demands of health care systems. This paper reports on a study that aimed to explore the current role of ANPs in primary care in the West Midlands region of the UK and how ANPs within three different nursing disciplines in primary care developed their roles over time. The study utilized a qualitative exploratory design incorporating a longitudinal element. Twenty-one ANPs were interviewed during phase one, 15 of whom were interviewed again during phase two, approximately 15 months later. Their managers (where appropriate) were also interviewed during phase one. The findings reveal that the nature and focus of practice varies between disciplines. At the extreme practice end of the practice-strategic continuum, Practice Nurse ANPs' expertise lies in their advanced practical assessment and diagnosis of individual patients, with little opportunity for strategic development. Health Visitor and District Nurse ANPs operate at the strategic end of the practice-strategic continuum, but operate differently at this level. Health Visitors, being community and public health focused are involved in multi-agency work, practice development and policy formulation. District Nurses work with individual patients/carers and the nursing team, thus their involvement in strategic developments tends to focus at the patient care level, such as protocol and practice developments, although their work also involves work in all three other domains. Overall, the findings reveal a unique role for all three with a potential career pathway for ANPs to become Nurse Consultants in the future.

Nursing roles and levels of practice: a framework for differentiating between elementary, specialist and advancing nursing practice

The recent profusion of new nursing roles in the UK has led to much confusion in the minds of health care consumers, employers, nursing practitioners and educationalists regarding the meaning, scope of practice, preparation for, and expectations of such roles. Titles such as Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), Advanced Nurse Practitioner (ANP), Higher Level Practitioner (HLP) and more recently Nurse Consultant (NC) are being adopted in a variety of care settings with little understanding or consensus as to the nature of or differences between such roles. Further, the former United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) initiative for extending the scope of professional practice allows for the prospect that nurses can adopt additional clinical tasks or alter the nature of service provision provided that they acquire the appropriate education or training, levels of competence and are prepared to be accountable for their new practices. Consequently, nursing practice is becoming more diverse than ever before and the boundaries of inter- and intraprofessional practices are becoming increasingly blurred. The UKCC (1999a) has recently contributed to an understanding of the levels of clinical practice undertaken at the specialist level but the situation at advanced or consultant levels remains unclear.

Skill mix, doctors and nurses: substitution or diversification?

This commentary surveys the current arguments for and against modifying the work of doctors and nurses by placing the main viewpoints - substitution and diversification - within the policy background, particularly that of the UK. We discuss the forces for modification: cost effectiveness, professional development, quality improvement and pragmatic management and how each provides a stand-point for evaluation of the issues. Policy makers and managers in the health sector should be aware of the rather fragmented evidence base for doctor-nurse substitution and should consider skill mix changes only when they are clear about: purpose, evidence base, acceptable risks, accountability and quality assurance. Doctor-nurse substitution is not necessarily cost effective, nor is it unfailingly a gain in nurse professionalism or in quality of care. Of the management perspectives available - advocacy, skepticism or pragmatism - the current evidence and policy base favours pragmatism over evaluations of the rightness or wrongness of a general policy.

Clinical role clarification: using the Delphi method to establish similarities and differences between nurse practitioners and clinical nurse specialists

This article is based on the Department of Health's (England) funded pluralistic evaluation of Nurse Practitioner preparation, 'Realizing Specialist & Advanced Nursing Practice: establishing the parameters of and identifying competencies for "Nurse Practitioner" roles and evaluating programmes of preparation' (RSANP). During this 27-month project, which began in 1996, one of the research methods used, the Delphi study, was aimed at reaching a consensus of views amongst nurses in clinical practice, educators, purchasers, providers and representatives of statutory and professional bodies on the parameters and competencies desirable for the Nurse Practitioner role. The agreed competencies were then used as one measure of the appropriateness of various programmes used to prepare Nurse Practitioners. Of the competencies required for the role, the majority are 'nursing' competencies and are the same as those required for the Clinical Nurse Specialist role. However, for both Clinical Nurse Specialists and Nurse Practitioners, these are practised at a 'higher level'. Other competencies needed for the Nurse Practitioner role relate to the knowledge and skills required to assess, diagnose and determine nursing and medical management of a patient and to evaluate that management. Data indicated, however, that even these competencies were being used by some Clinical Nurse Specialists. Final analysis enabled the identification of the two roles with the use of a 'Typology of Named Clinical Nursing Roles'.

Issues surrounding educational preparation for intensive care nursing in the 21st century

Major changes in intensive care provision, nursing and nurse education over the last ten years mean that it is a crucial time to take a look at the effectiveness of the post-registration intensive care nursing course [ENB 100]. This article examines whether nurse education is able to meet the current and future challenges. A call for more research regarding the effects of nurse education courses on participants' clinical practice is advocated. Key factors examined include teaching and learning strategies, the identification of common threshold core and specific competencies, and the assessment of practice. Post-registration assessment of practice within the writers' own educational institution is evaluated. Valid and reliable assessment which differentiates between the level of skills attainment of students and identifies the stage of development of the nurse (Benner 1984) is recommended. The question of who benefits from the current provision of ENB 100 courses is considered. It is argued that clinical and educational staff should work together to ensure nurses who undertake ENB 100 courses emerge 'fit for purpose' (DoH 1997a).

Identifying the practice characteristics of advanced practitioners in acute and critical care settings

This paper reports the results of a longitudinal, qualitative study into the role transition of advanced nurse practitioners (ANPs) in the UK. Following the completion of a Master's Degree in Health Studies programme, eleven ANPs working in high-dependency and acute care settings completed a purpose-designed 'role development diary' for the first six months they practised in their new role. In the diary, ANPs recorded the nature and focus of practice activities, identified the components of their practice perceived to be 'advanced', and documented the factors that influenced role implementation and development. Once completed, the diaries were subjected to a comparative analysis, which revealed that the level of patient dependency and the type of clinical environment had a direct bearing on the nature and extent of certain aspects of role performance. The findings also indicated that, whilst practitioners identified multiple components in their roles, priority was initially given to the acquisition and development of technical and diagnostic skills. It was concluded that variations in the performance of ANPs could be attributed not only to the nature of the clinical environment, but prevailing personal, political and organizational agendas.