The safety and effectiveness of a nurse-led anticoagulant service

Nursing self-efficacy for oral anticoagulant therapy management: Development and initial validation of a theory-grounded scale

AIM

This study aimed to develop and validate a nursing self-efficacy scale for OAC management (SE-OAM).

BACKGROUND

Oral anticoagulant therapy (OAC) requires specific nursing competencies. Given that self-efficacy acts as a proxy assessment of nursing competence, its measurement is pivotal for addressing educational programs to enhance nursing competence in managing OAC. Thus far, the measurement of self-efficacy in OAC is undermined by the unavailability of valid and reliable tools.

METHODS

A multi-method and multi-phase design was adopted: Phase one was a methodological study encompassing developmental tasks for generating items. Phase two comprised the validation process for determining the content validity, construct and concurrent validity, and internal consistency through two cross-sectional data collections.

RESULTS

In total, 190 nurses were enrolled for determining the psychometric structure of the SE-OAM through an exploratory approach, and 345 nurses were subsequently enrolled to corroborate its most plausible factor structure derived from the exploratory analysis. The SE-OAM showed evidence of face and content validity, adequate construct, concurrent validity, good internal consistency, and stability. The final version of the scale encompassed 21 items kept by five domains: clinical management, care management, education, clinical monitoring, and care monitoring.

CONCLUSIONS

The SE-OAM showed evidence of initial validity and reliability, fulfilling a current gap in the availability of tools for measuring nursing self-efficacy in managing OAC. SE-OAM could be strategic for performing research to improve the quality of OAC management by enhancing nursing self-efficacy.

Variation in warfarin prescribing and dosing in the UK: a national survey of anticoagulation clinics

WHAT IS KNOWN AND OBJECTIVE

Clinical practice in the initiation, prescribing, dosing and monitoring of warfarin in the UK varies, but this has not been adequately documented. The objective was to undertake a survey on current clinical practice in this area, and how it compares with national guidelines that have been developed by the British Committee for Standards in Haematology.

METHODS

A national online survey of anticoagulation clinics was performed using Survey Monkey(®) . The survey was designed to capture data for prescribing, dosing and monitoring of anticoagulation with warfarin.

RESULTS

Of 85 clinics who responded to the survey, most were run by secondary care (68%), facilitated by specialist nurses (58%) and followed standard guidelines for the management of warfarin (87%). The majority of clinics indicated their target international normalized ratio (INR) for patients with atrial fibrillation (AF) (69/73; 94·5%) was between 2·0 and 3·0, but the indicated target INR for mechanical heart valves was more variable. Initiation and loading dosing regimens were a major source of variability with uncertainty surrounding individual patient factors such as age, ethnicity and BMI.

WHAT IS NEW AND CONCLUSIONS

Current practice amongst UK anticoagulation clinics largely follows current national guidelines but better guidance on dosing, taking into account factors that determine interindividual variability in daily warfarin dose requirements would improve and standardize oral anticoagulation with warfarin.

Anticoagulation management in the ambulatory surgical setting

Many people receiving maintenance anticoagulation therapy require surgery each year in ambulatory surgery centers. National safety organizations focus attention toward improving anticoagulation management, and the American College of Chest Physicians has established guidelines for appropriate anticoagulation management to balance the risk of thromboembolism when warfarin is discontinued with the risk of bleeding when anticoagulation therapy is maintained. The guidelines recommend that patients at high or moderate risk for thromboembolism should be bridged with subcutaneous low-molecular-weight heparin or IV unfractionated heparin with the interruption of warfarin, and low-risk patients may require subcutaneous low-molecular-weight heparin or no bridging with the interruption of warfarin. The guidelines recommend the continuation of warfarin for patients who are undergoing minor dermatologic or dental procedures or cataract removal. The literature reveals, however, that there is not adequate adherence to these recommendations and guidelines. Management of anticoagulation therapy by a nurse practitioner may improve compliance and safety in ambulatory surgery centers.

From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management

Throughout the world, countries are experiencing shortages of health care workers. Policy-makers and system managers have developed a range of methods and initiatives to optimise the available workforce and achieve the right number and mix of personnel needed to provide high-quality care. Our literature review found that such initiatives often focus more on staff types than on staff members' skills and the effective use of those skills. Our review describes evidence about the benefits and pitfalls of current approaches to human resources optimisation in health care. We conclude that in order to use human resources most effectively, health care organisations must consider a more systemic approach--one that accounts for factors beyond narrowly defined human resources management practices and includes organisational and institutional conditions.

A randomised controlled trial of structured nurse-led outpatient clinic follow-up for dyspeptic patients after direct access gastroscopy

Background

Dyspepsia is a common disorder in the community, with many patients referred for diagnostic gastroscopy by their General Practitioner (GP). The National Institute of Clinical Excellence (NICE) recommends follow-up after investigation for cost effective management, including lifestyle advice and drug use. An alternative strategy may be the use of a gastro-intestinal nurse practitioner (GNP) instead of the GP. The objective of this study is to compare the effectiveness and costs of systematic GNP led follow-up to usual care by GPs in dyspeptic patients following gastroscopy.

Results

Direct access adult dyspeptic patients referred for gastroscopy; without serious pathology, were followed-up in a structured nurse-led outpatient clinic. Outcome measurement used to compare the two study cohorts (GNP versus GP) included Glasgow dyspepsia severity (Gladys) score, Health Status Short Form 12 (SF12), ulcer healing drug (UHD) use and costs. One hundred and seventy five patients were eligible after gastroscopy, 89 were randomised to GNP follow-up and 86 to GP follow-up. Follow-up at 6 months was 81/89 (91%) in the GNP arm and 79/86 (92%) in the GP arm. On an intention to treat analysis, adjusted mean differences (95%CI) at follow-up between Nurse and GP follow-up were: Gladys score 2.30 (1.4–3.2) p < 0.001, SF12 140.6 (96.5–184.8) p =< 0.001 and UHD costs £39.60 (£24.20–£55.10) p =< 0.001, all in favour of nurse follow-up.

Conclusion

A standardised and structured follow-up by one gastrointestinal nurse practitioner was effective and may save drug costs in patients after gastroscopy. These findings need replication in other centres.

Anticoagulation in Ambulatory Care

PURPOSE OF THE MANUSCRIPT: Anticoagulation is warranted for the treatment of various disorders including cardiac, vascular, and postsurgical causes. Many centers have nurse case managers to coordinate care for patients on anticoagulation. This increases the demand for specific guidelines to assist nurse case managers to ensure quality of care. This review will address guidelines for nurse case managers and providers regarding initiating anticoagulation treatment and monitoring prothrombin time and international normalized ratio. Information will also be provided regarding when the nurse case manager should notify the providers to establish target international normalized ratio. This review will also provide educational tools to serve as standards for patient teaching, including drug and food interactions.

PRIMARY PRACTICE SETTING(S)

This article applies to adult ambulatory practice that includes primary care, cardiology, and vascular and surgical settings.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The complexity of managing anticoagulation in ambulatory practice warrants case management. The nurse case manager will establish a rapport with patients to improve compliance, providing patient education about diet, dosages, and drug interactions to reduce medication errors and bleeding complications. This review on anticoagulation management will assist nurse case managers and providers to provide better quality of care.

Establishing a definition for a nurse-led clinic: structure, process, and outcome

AIM

This paper reports a study to define a nurse-led clinic by exploring the domains of structure, process and outcome.

BACKGROUND

Nurse clinics have been introduced as a measure to support intermediate care after the acute phase of disease. Previous studies have been mainly descriptive, or have only addressed a particular aspect of clinic service.

METHODS

This exploratory study was conducted in two phases. In the first phase, nurses from 34 clinics were interviewed. In the second phase, 162 clinic sessions were observed, and 162 patients and 16 physicians were interviewed. The data were collected in 2001-2003.

RESULTS

The nurses who ran the clinics were very experienced, and resources were available to support their work. Over 80% of their work was independent or interdependent, involving skills such as adjusting medications, and initiating therapies and diagnostic tests according to protocols. The principal interventions were assessments and evaluations, and health counselling. The nurses rated 'management of symptoms', 'prevention of complications', and 'client satisfaction' as the top three key indicators of their success. All patients studied showed improvement after the nurse clinic consultation, but the best rates were found in wound and continence clinics. Satisfaction scores for both nurses and clients were high. Physicians valued their partnership in care with the nurses, but were concerned about possible legal liability resulting from the advanced roles assumed by these nurses.

CONCLUSIONS

A nurse clinic is an effective alternative model of ambulatory healthcare delivery that uses a holistic framework.

Long-term follow-up of survivors of childhood cancer in the UK

BACKGROUND

Childhood cancer is rare, but there are now good survival prospects and in the UK approximately 1 in 1,000 young adults is a survivor of childhood cancer. There are many adverse health outcomes associated with the treatment of childhood cancer often arising several years after completion of treatment. The aim of this study was to quantify the long-term clinical follow-up practices concerning survivors of childhood cancer.

PROCEDURE

A cross-sectional postal survey of 22 treatment centres of the United Kingdom Children's Cancer Study Group (UKCCSG) clinicians was carried out as well as a cross-sectional postal survey of general practitioners of most adult survivors of childhood cancer in Britain.

RESULTS

Subsequent to 5 years after the end of treatment: 52% of UKCCSG clinicians follow-up all survivors for life, while 45% discharge some patients. Of those clinicians discharging: over 50% discharged benign, stage I or tumors treated with surgery alone, in contrast 16% reported discharging all or most patients; almost all (97%) clinicians discharged to a general practitioner. Only 14% of clinicians reported nurses undertook a specialist role. Sixty-five percent of the 10,979 general practitioners reported that their patient was not on regular hospital follow-up.

CONCLUSIONS

There are wide variations in the extent to which survivors of childhood cancer are discharged from hospital follow-up. There is a need for regularly updated national guidelines concerning the levels of follow-up required for specific groups of survivors defined principally by the treatment they received.