The work of nurse practitioners

Implementing care-related services in care units - an interview study

BACKGROUND

The growing concern about a dwindling healthcare workforce, exacerbated by demographic changes, calls for innovative solutions. One viable approach involves implementing new professional roles and restructuring existing healthcare teams within hospital care units.

OBJECTIVES

To evaluate the implementation of an innovative task-shifting concept, care-related services (CRS), from the managers' perspective in somatic care units across the hospitals in a region in Sweden.

METHODS

The qualitative study was conducted in 2022, after the implementation of CRS. Individual interviews were conducted with 24 key stakeholders, including 14 care unit managers, six CRS managers, and four process managers. A qualitative content analysis was performed, utilizing the Consolidated Framework of Implementation Research (CFIR).

RESULTS

The implementation of CRS involved collaboration between care unit managers, CRS managers, and project managers, alongside CRS staff, registered nurses (RNs), and licensed vocational nurses (LVNs). In particular, their roles encompassed defining boundaries, establishing routines, and managing personnel. Throughout the implementation process, challenges emerged, stemming from undefined goals, difficulties in recruiting qualified CRS staff, and issues associated with seamlessly integrating CRS into existing work routines. These challenges arose due to a constrained timeframe, widespread team apprehension, shortcomings in the training of CRS staff, unclear task allocation, and an increased workload for care unit managers. Factors associated with successful CRS implementation included effective cooperation among managers and an open-minded approach.

CONCLUSIONS

Our findings highlight the crucial role of clear communication, effective recruitment, integration of CRS staff, clarification of roles, responsibilities, and defined goals for successful CRS implementation.

Work time allocation at primary health care level in two regions of Albania

Introduction

Although well-performing workforce is essential to equitable and efficient health service delivery, few countries have systematically addressed performance improvements. How health workers use their work time and what tasks they accomplish is here an important starting point. Therefore, a time motion study was conducted to assess the work time allocation patterns of primary health care doctors and nurses in two regions of Albania.

Methods

We used observation tool to record the time allocation along eight predefined main categories of activities. Conditional to presence at work, 48 health workers were continuously observed in early 2020 before start of the Covid-19 pandemic over five consecutive working days.

Results

The observed health workers spent 40.7% of their overall working time unproductively (36.8% on waiting for patients and 3.9% on breaks), 25.3% on service provision to users, 18.7% on administrative activities, 12.7% on outreach activities, 1.6% on continuous medical education and 1% on meetings. The study found variations in work time allocation patterns across cadres, with nurses spending more time unproductively, on administrative activities and on outreach and less on all other activities than doctors. Further, the work time allocation patterns were similar between urban and rural settings, except for nurses in rural settings spending less time than those in urban settings on administrative work.

Conclusion

This study found that primary health care workers in Albania devote a substantial amount of work time to unproductive, service provision to users and administrative activities. Consequently, there is possibility for productivity, respectively efficiency gains in how health workers use their time.

A survey of nurse practitioner perceptions of integration into acute care organisations across one region in Ireland

Aim

The purpose of the study was to explore nurse practitioner perceptions of integration practices in acute hospitals across one health care region in Ireland.

Background

A recent Department of Health National policy towards developing a critical mass of nurse practitioners was implemented across Ireland. Successful integration of nurse practitioner roles is integral to the success of the service and sustainability of the roles for the long term.

Method

An electronic survey was circulated to a convenience sample of 85 nurse practitioners across a single, acute health care region in Ireland.

Results

Sixty‐six (78%) of nurse practitioners participated. A standardized governance structure was reported by 24 (36%) participants. Thirty‐two (48%) participants expressed their job description clearly defined their role. Consultant physicians were identified as the most supportive stakeholder by participants.

Conclusions

This research identifies that nurse practitioner integration is not currently structured. A framework to support nurse practitioner integration is required to ensure ongoing support for the role. This research identifies that integration is not currently optimized.

Implications for Nursing Management

Failure to successfully integrate the nurse practitioner role risks the long‐term sustainability of the role and is a missed opportunity to demonstrate the success of advanced clinical leadership to health care.

Job performance in healthcare: a systematic review

BACKGROUND

Healthcare organisations face major challenges to keep healthcare accessible and affordable. This requires them to transform and improve their performance. To do so, organisations must influence employee job performance. Therefore, it is necessary to know what the key dimensions of job performance in healthcare are and how these dimensions can be improved. This study has three aims. The first aim is to determine what key dimensions of job performance are discussed in the healthcare literature. The second aim is to determine to which professionals and healthcare organisations these dimensions of job performance pertain. The third aim is to identify factors that organisations can use to affect the dimensions of job performance in healthcare.

METHODS

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The authors searched Scopus, Web of Science, PubMed, and Google Books, which resulted in the identification of 763 records. After screening 92 articles were included.

RESULTS

The dimensions - task, contextual, and adaptative performance and counterproductive work behaviour - are reflected in the literature on job performance in healthcare. Adaptive performance and counterproductive work behaviour appear to be under-researched. The studies were conducted in different healthcare organisations and pertain to a variety of healthcare professionals. Organisations can affect job performance on the macro-, meso-, and micro-level to achieve transformation and improvement.

CONCLUSION

Based on more than 90 studies published in over 70 journals, the authors conclude that job performance in healthcare can be conceptualised into four dimensions: task, contextual and adaptive performance, and counterproductive work behaviour. Generally, these dimensions correspond with the dimensions discussed in the job performance literature. This implies that these dimensions can be used for further research into job performance in healthcare. Many healthcare studies on job performance focus on two dimensions: task and contextual performance. However, adaptive performance, which is of great importance in constantly changing environments, is under-researched and should be examined further in future research. This also applies to counterproductive work behaviour. To improve job performance, interventions are required on the macro-, meso-, and micro-levels, which relate to governance, leadership, and individual skills and characteristics.

Nurse practitioner led model of after-hours emergency care in an Australian rural urgent care Centre: health service stakeholder perceptions

Background

The challenges of providing and accessing quality health care in rural regions have long been identified. Innovative solutions are not only required but are also vital if effective, timely and equitable access to sustainable health care in rural communities is to be realised. Despite trial implementation of some alternative models of health care delivery, not all have been evaluated and their impacts are not well understood. The aim of this study was to explore the views of staff and stakeholders of a rural health service in relation to the implementation of an after-hours nurse practitioner model of health care delivery in its Urgent Care Centre.

Methods

This qualitative study included semi-structured individual and group interviews with professional stakeholders of a rural health service in Victoria, Australia and included hospital managers and hospital staff who worked directly or indirectly with the after-hours NPs in addition to local GPs, GP practice nurses, and paramedics. Thematic analysis was used to generate key themes from the data.

Results

Four themes emerged from the data analysis: transition to change; acceptance of the after-hours nurse practitioner role; workforce sustainability; and rural context.

Conclusions

This study suggests that the nurse practitioner-led model is valued by rural health practitioners and could reduce the burden of excessive after-hour on-call duties for rural GPs while improving access to quality health care for community members. As pressure on rural urgent care centres further intensifies with the presence of the COVID-19 pandemic, serious consideration of the nurse practitioner-led model is recommended as a desirable and effective alternative.

Factors supporting career pathway development amongst advanced practice nurses in Thailand: A cross-sectional survey

BACKGROUND

Thailand has recently reformed its health care system and this change has contributed to the rapidly increasing need for skilled and experienced specialist nurses and in 2003 a new Advanced Practice Nursing role was formally introduced. While Advanced Practice Nursing is now accepted as a clinical career option, there is little understanding of the factors conducive to successful career development. This study offers the first examination of factors associated with successful career progression for Advanced Practice Nurses in Thailand.

OBJECTIVES

1. To provide a description of the Advanced Practice Nurse population in Thailand, as represented by a purposive stratified national sample. 2. To examine the factors influencing successful career pathway development of Advanced Practice Nurses in Thailand. 3. To examine the factors which influence the extent to which Advanced Practice Nurses in Thailand engage in evidence-based practice and research.

DESIGN

National cross-sectional survey.

SETTING

Thailand.

PARTICIPANTS

333 currently practicing Advanced Practice Nurses.

METHODS

A national cross-sectional survey was conducted in Thailand in order to identify and examine key influencing factors on the successful development of Advanced Practice Nurses. The research tool was a specifically designed questionnaire in the Thai language, informed by international academic literature on the development of the Advanced Practice Nurse role, validated and piloted with 30 Advanced Practice Nurses to assess its reliability using Cronbach's alpha. The data were analysed in SPSS (version 21). Initial parametric testing was done using the Kolmogorov-Smirnov test and Pearson's correlation analysis was performed to examine the relationship between the independent variables (those measuring demographic and support factors) and the dependent variables (measuring career pathway development).

RESULTS

A response rate of 90% was achieved. A lack of clear progression routes in the Advanced Practice Nurse structure was identified along with inconsistent patterns of working including variation in the number of days per week (range: 1-5 days) that nurses dedicated to the Advanced Practice Nurse role and the amount of autonomy achieved in this role. The study highlighted a lack of research productivity in and production of outputs (59% had never published) and given the expectation of Advanced Practice Nurses to both produce and utilise research evidence, this constitutes a significant gap in current practice. Other factors reported as important for career pathway development of Advanced Practice Nurses related to the environment, peer networks, institutional (hospitals) and external (government and the Thai Nursing Council) support.

CONCLUSIONS

Our study offers insights for national and local policymakers and highlights the need to firmly establish, standardised career pathways in Advanced Practice Nursing to support career progression and the implementation of evidence into practice. These findings also have implications for clinical departments which have a responsibility to ensure they provide an enabling environment for Advanced Practice Nurses to fully carry out their roles. Tweetable abstract: Our study reports findings from a first national survey in Thailand investigating the factors which support career development in Advanced Practice Nurses.

An integrative review to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes

AIMS

This study aimed to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes.

BACKGROUND

Changing health-care delivery is synonymous with the nurse practitioner role. The literature is critical of the lack of research by nurse practitioners, reporting the effects of a change to health-care delivery.

DESIGN

This study used a systematic integrative review by using Torraco's approach.

DATA SOURCES

Databases Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Web of Science and SCOPUS were searched for peer-reviewed publications from 2000 to 2019.

REVIEW METHODS

A systematic approach was used to screen and analyse the literature. Inclusion/exclusion criteria were applied, and quality appraisal was undertaken by two reviewers.

RESULTS

Eighteen articles were selected. The research projects were across the community and acute care settings. Research methodologies varied including preintervention and postintervention studies, evaluation of quality improvement projects, randomized controlled trial and descriptive studies. Multiple data collection tools were used. Two major themes were identified including evidence-based practice champions and improved patient outcomes.

CONCLUSION

The nurse practitioner role is pertinent toward improving evidence-based practice in clinical settings. Positive patient outcomes and praise for clinical leadership are evident in the literature. Research by nurse practitioners to date has focused on individual services.

A survey identifying leadership and research activities among Nurse Practitioners

Background: Nurse Practitioners are identified as the ideal conduit to transform healthcare delivery internationally. Healthcare transformation requires the application of leadership and research skills. Current literature has limited information on NPs as leaders or researchers in the nursing profession.Objectives: Determine if Nurse Practitioners identify themselves as leaders in nursing. Identify the leadership and research activities and influencing characteristics of Nurse Practitioners in Ireland and Australia. Establish similarities in leadership and research activities between Nurse Practitioners in Ireland and Australia. To identify if there is a relationship between leadership and research activities.Design: A quantitative electronic survey.Methods: A survey instrument was developed by combining two previously validated instruments. Nurse Practitioners in Ireland or Australia that had practiced within the last five years, and members of the respective professional association were included. Descriptive statistics were used to describe the findings and explore relationships in the data.Results: 14% (n = 96) of Nurse Practitioners responded to the survey. Nurse Practitioners in Ireland and Australia identified themselves as leaders of the nursing profession. Nurse Practitioners work practices, leadership and research activities are similar in Ireland and Australia. The majority (n = 55, 57%), of participants reported being research active. There was an association between perceived leadership and research activities among participants.Conclusion: Nurse Practitioners in both Ireland and Australia identify themselves as leaders of the nursing profession. There is no difference in reported work practices, leadership or research activities of Nurse Practitioners in both Ireland and Australia. There is an association between perceived leadership and research activity.Impact Statement: Nurse Practitioners in Ireland and Australia percieved themselves as leaders in nursing and this perception increases with research activity.

Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model

The American College of Surgeons (ACS) mandates all trauma centers conduct individual case reviews of nonsurgical admissions when rates of allocation to this service exceed 10% of all inpatient traumas. Nonsurgical admission rates at the study institution, which is a Level I trauma center, historically exceeded this ACS criterion. In an effort to decrease nonsurgical admissions, the study institution recruited trauma nurse practitioners (TNPs) who began managing low acuity patients with oversight from trauma attending physicians. This study examines the impact of TNPs on the rate of nonsurgical admissions. A retrospective cohort study was conducted with 1,400 patients between January 2017 and October 2018. Two cohorts examined in this study included trauma patients whose care was managed by the TNPs versus those admitted under the care of hospitalists. The rate of admission to nonsurgical services (NSS) was 19.6% in 2017 and 13.9% in 2018, which yielded a significant decrease from previous years' percentages (p < .001). The average hospital length of stay was 1.17 days shorter in the TNP group, which translated into a savings of approximately $876,330 in hospital charges for the study period. Additional significant findings noted in favor of the TNP cohort were for discharge orders placed prior to noon, discharge location, and reduced time to the operating room. This TNP model proved to be successful in significantly reducing admissions to NSS and substantiated the quality of patient care provided by TNPs. Hospitals struggling to meet the ACS criterion for NSS admissions may consider implementing a similar TNP model.

Perceptions of the scope of practice of nurse practitioners caring for older adults: level of agreement among different healthcare providers

BACKGROUND

Globally, new nurse practitioner roles have been introduced into interdisciplinary teams. Research indicates that agreement among the different healthcare providers regarding one another's role and scope of practice is important for establishing interdisciplinary teamwork. Lack of agreement regarding a new nurse practitioner's scope of practice may hinder collaboration.

AIM

To investigate the level of agreement among advanced geriatric nurses (AGNs), their colleagues and their leaders regarding which activities related to direct and indirect care, teaching/supervision, coordination and research and development work are perceived as appropriate for AGNs.

DESIGN

A cross-sectional descriptive survey.

METHODS

The total population of AGNs in Norway (n = 26) and a sample of their colleagues, including leaders (n = 465), were invited to answer an online questionnaire. Twenty-three (88.5%) AGNs and 195 (42%) colleagues answered the questionnaires. A series of cross-tabulations were conducted to identify the respondents reporting on the appropriateness of different activities.

RESULTS

The respondents identified all of the activities related to coordination, teaching/supervision and research and development work as appropriate for AGNs. Although the respondents considered several of the direct and indirect care activities as appropriate, there were conflicting views on the activities that traditionally fall within the medical field vs. those that traditionally fall within the nursing field. The AGNs saw most of the nursing and medical activities as appropriate, but their colleagues and leaders saw only some of the nursing activities as appropriate. The results also showed that there was high disagreement among the leaders regarding appropriate activities.

CONCLUSION

The results indicate that healthcare providers agree on which activities related to teaching/supervision, coordination, and research and development work are appropriate to include in AGNs' scope of practice, but that there are conflicting views regarding activities related to direct and indirect care.

The integration of new nurse practitioners into care of older adults: A survey study

AIMS AND OBJECTIVES

To assess Norwegian advanced geriatric nurses' (AGNs) use of their knowledge and skills, and factors that may influence AGNs' opportunities to use their knowledge and skills to reach their full potential.

BACKGROUND

Despite the need for nurses with advanced knowledge and skill in the care of older adults, the introduction of new advanced nursing roles has been challenging. Countries in the process of establishing advanced roles need to monitor and identify possible implementation issues.

DESIGN

A cross-sectional descriptive survey.

METHODS

We invited the total population of AGNs in Norway (n = 26) and some of their colleagues (n = 465) to answer an online questionnaire. Twenty-three (88.5%) of the AGNs and 195 (42.0%) of the invited colleagues completed and submitted the questionnaires. The data were analysed with descriptive statistics. STROBE guidelines were used in reporting this study.

RESULTS

Of the AGNs, 16 (69.6%) used their knowledge and skills to their full potential when providing direct care. However, a minority used their knowledge and skills to their full potential when proving indirect care (n = 11, 47.8%), teaching/supervision (n = 11, 47.8%) and coordination (n = 5, 21.8%). A total of 47 (24.1%) colleagues experienced the AGNs' scope of practice as completely clear, and 52 (26.6%) collaborated with the AGNs several times a week. Of the colleagues, 131 (67.2%) considered the AGNs' role and scope of practice contributed positively to a high degree to health service for older adults.

CONCLUSION

The results indicate the need for greater focus on organisational adjustment for the AGNs to utilise their knowledge and skills to their full potential.

RELEVANCE TO CLINICAL PRACTICE

There is a need for greater focus on organisational adjustment to integrate AGNs at the workplace, as complete integration may improve the AGNs' use of their knowledge and skills.

Clinical staff work sampling in a neurorehabilitation hospital and its relationship to severity of disease

Aim

Study aimed to analyse how rehabilitation staff spends working time on specific activities in a neurorehabilitation hospital and to determine the number of direct activities received by patients with different levels of disease severity.

Background

Few studies have investigated how clinical staff spends their time on activities in rehabilitation hospitals without considering at the same time all working categories and without reporting the number of direct activities received by patients with respect to their disease severity.

Design

Self‐reported observational study.

Method

Work Sampling Technique was used to record direct, indirect, unit‐related and personal activities every 5 min for 2 days.

Results

Total of 6,974 activities were recorded over 581 working hours. Physiotherapists and nurses spent 75.2% and 54.8% of their time in direct activities and medical doctors only 25.4%. Total time of direct activities was significantly different among worker categories (p = 0.001) and depended on patients’ disease severity (p = 0.020) in a different manner among worker categories (interaction: p = 0.010). This time ranged from almost 4 hr up to 6½ hr for the most severely affected patients.

Conclusion

Type of work differed among professionals. Workload greatly depended on degree of patients’ disability.

Implications for Nursing Management

Nurses and therapists spent most of their time in direct activities with patients. Economic burden of neurorehabilitation may vary greatly depending on disease severity.

Increasing value-adding patient care by applying a modified TCAB program

Purpose The purpose of this study is to evaluate a development process aimed at increasing registered nurses' (RNs) working time use in value-adding patient care by applying a modified Transforming Care at the Bedside (TCAB) program at inpatient units of two tertiary hospitals. Design/methodology/approach Basic data for the development process were collected on RNs' working time use via external observation in 2011 (RNs = 113). Nursing work was redesigned and implemented by 12 multi-professional teams during 2012-2013. The development process was evaluated by repeating the collection of RNs' working time use data in 2013 (RNs = 95) and by analyzing the memos of the development teams via deductive content analysis ( N = 64). Findings RNs' working time use showed statistically significant increases in value-adding care and direct patient care but decreases in non-value-added work and miscellaneous work. Changes in the nursing work model, division of labor and the nursing work environment all affected RNs' working time use. Practical implications The development process progressed distinctively in each unit, as shown by the results of the development work. Clinical RNs had key roles as innovators and change agents, yet the engagement of nursing managers was most essential for the success of the development work. Originality/value Even minor changes in nurses' daily work profile can have considerable effects on RNs' work. The TCAB program was shown to be a useful method in developing RNs' work also in psychiatric units.

Practice activities of privately-practicing nurse practitioners: Results from an Australian survey

To facilitate expansion of privately-practicing nurse practitioners in community and primary care settings, a legislative amendment in 2010 made privately-practicing nurse practitioners eligible to provide services subsidised through the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. To evaluate their practice activities, a national survey of privately-practicing nurse practitioners in Australia was conducted, and data analysed using descriptive statistics and thematic analysis (n = 73). As part of their role, 96% (n = 70) participants reported undertaking direct patient care, 95% (n = 69) patient education and health promotion, 95% (n = 69) prescribed medications, 92% (n = 67) referred patients for diagnostic investigations, and 88% (n = 64) reported making a diagnosis. Over 50% of participants saw up to 15 patients daily, and 80% (n = 58) treated the same patients on a regular basis. Of the participants, 59% (n = 43) perceived that they worked to their full scope of practice. The mainstay of privately-practicing nurse practitioner services is provision of direct patient care in community and primary healthcare settings, suggesting they have emerging potential in addressing the ever-increasing demand for healthcare in Australia.

Implementing two nurse practitioner models of service at an Australian male prison: A quality assurance study

AIMS AND OBJECTIVES

To examine the quality and safety of nurse practitioner services of two newly implemented nurse practitioner models of care at a correctional facility.

BACKGROUND

Nurse practitioners could help to meet the physical and mental health needs of Australia's growing prison population; however, the nurse practitioner role has not previously been evaluated in this context.

DESIGN

A quality assurance study conducted in an Australian prison where a primary health nurse practitioner and a mental health nurse practitioner were incorporated into an existing primary healthcare service. The study was guided by Donabedian's structure, processes and outcomes framework.

METHODS

Routinely collected information included surveys of staff attitudes to the implementation of the nurse practitioner models (n = 21 staff), consultation records describing clinical processes and time use (n = 289 consultations), and a patient satisfaction survey (n = 29 patients). Data were analysed descriptively and compared to external benchmarks where available.

RESULTS

Over the two-month period, the nurse practitioners provided 289 consultations to 208 prisoners. The presenting problems treated indicated that most referrals were appropriate. A significant proportion of consultations involved medication review and management. Both nurse practitioners spent more than half of their time on individual patient-related care. Overall, multidisciplinary team staff agreed that the nurse practitioner services were necessary, safe, met patient need and reduced treatment delays.

CONCLUSIONS

Findings suggest that the implementation of nurse practitioners into Australian correctional facilities is acceptable and feasible and has the potential to improve prisoners' access to health services. Structural factors (e.g., room availability and limited access to prisoners) may have reduced the efficiency of the nurse practitioners' clinical processes and service implementation.

RELEVANCE TO CLINICAL PRACTICE

Results suggest that nurse practitioner models can be successfully integrated into a prison setting and could provide a nursing career pathway.

Integration of nurse practitioners using a change management framework: the way forward

Objective The aim of the present study was to investigate and describe the application of a change management theoretical framework in relation to nurse practitioner (NP) role integration. Methods A survey formed Phase 1 of a broader mixed-methods study to explore perceptions of the change process involved with integrating NPs into Australian health care settings. The stakeholder participants were NPs, nurse managers and nurse policy advisers. Results Key themes were identified adding information about how NPs, nurse managers and nurse policy advisers perceive the integration of NPs into Australian healthcare. The themes correlate to the components of organisational change management necessary to embed NPs into the healthcare workforce. Conclusions Healthcare reform is a complex organisational change. Alignment of several key elements is required for the process to be successful. A change management proposal for reframing organisations provides an apt framework for use in the Australian context of reforming workforce to integrate NPs into healthcare teams. The theoretical framework proposes that multiple lenses be applied to change processes, to integrate NPs into the workforce and highlights the need for exceptional leadership throughout such endeavours. What is known about the topic? NPs provide safe and efficient care to patients, often in settings where access to health care is limited. NPs have been identified as a key strategic workforce reform initiative to address some of the known healthcare gaps. What does this paper add? This paper adds information about how NPs, nurse managers and nurse policy advisers perceive progress of the integration of NPs into healthcare settings. The findings are contextualised within an organisational change framework and highlight the complexity of healthcare reform. What are the implications for practitioners? The findings provide a novel approach for managing workforce reform and identify the components of change management necessary to embed NPs into the healthcare workforce.

Differences in the working pattern among wound, ostomy, and continence nurses with and without conducting the specified medical act: a multicenter time and motion study

Background

To overcome the shortage of medical care delivery in the rapidly aging Japanese society, the Ministry of Health, Labour and Welfare in 2010 started to train the nurses to be able to conduct the specified medical acts. The Japanese Nursing Association conducted the educational program to train the wound, ostomy, and continence nurses for the specified medical act of wound care. However, the difference between wound, ostomy, and continence nurses who conducted the medical act and those who did not was not clear. The aim of this study was to determine how trained wound, ostomy, and continence nurses spend their time during their entire shift in an acute hospital setting.

Methods

In this prospective observational study, we selected those wound, ostomy, and continence nurses who received advanced training in the wound management program (T-WN) in 2011–2012. Wound, ostomy, and continence nurses who did not receive the training (N-WN) were also recruited as controls. We conducted a time and motion study during subject's day shifts for 1 week. We calculated the time spent on tasks based on a task classification code that was created to facilitate a two-group comparison.

Results

Six T-WNs and five N-WNs were our analysis subjects. T-WNs spent significantly more time on direct care than did N-WNs (p = 0.00). Moreover, in the sub-categories s of direct care, T-WN spent significantly more time on “treatment” than did N-WN (p = 0.01). T-WN spent significantly more time on treatment with (p = 0.03) or without (p = 0.01) physicians than did N-WN. In the treatment activities, T-WN performed significantly more time on foot care (p = 0.01), wound cleansing (p = 0.01) and conservative sharp wound debridement (p = 0.01) than did N-WN. Frequencies of direct care interventions for the patients was significantly different between T-WN and N-WN (p = 0.04).

Conclusions

T-WNs frequently engaged in direct care provided treatment for patients with chronic wounds.

What keeps nurses busy in the mental health setting?

ACCESSIBLE SUMMARY

Recent evidence suggests that the interactional work of mental health nursing has been eroded and redirected to the task-based roles of medicine. This study utilized work sampling methodology to observe the proportion of time nurses working in a mental health setting spend in direct care, indirect care and service-related activities. Nurses spent 32% of their time in direct care, 52% in indirect care and 17% in service-related activities. Mental health nurses need to re-establish their therapeutic availability to maximize consumer experiences and outcomes.

ABSTRACT

The foundation of mental health nursing has historically been grounded in an interpersonal, person-centred process of health care, yet recent evidence suggests that the interactional work of mental health nursing is being eroded. Literature emphasizes the importance of person-centred care on consumer outcomes, a model reliant upon the intimate engagement of nurses and consumers. Yet, the arrival of medical interventions in psychiatry has diverted nursing work from the therapeutic nursing role to task-based roles delegated by medicine, distancing nurses from consumers. This study used work sampling methodology to observe the proportion of time nurses working in an inpatient mental health setting spend in the activities of direct care, indirect care and service-related activities. Nurses spent 32 of their time in direct care, 52% in indirect care and 17% in service-related activities. Mental health nurses need to re-establish their therapeutic availability to maximize consumer experiences and outcomes.

Financial viability, benefits and challenges of employing a nurse practitioner in general practice

This case study examines the financial viability, benefits and challenges of employing a primary healthcare (PHC) nurse practitioner (NP) in a bulk-billing healthcare cooperative in the Australian Capital Territory. There are few empirical case reports in the Australian literature that demonstrate financial sustainability of this type of healthcare professional in primary healthcare. This case study demonstrates that the costs of employing a PHC-NP in general practice are offset by direct and indirect Medicare billings generated by the PHC-NP, resulting in a cost-neutral healthcare practitioner. The success of this model relies on bidirectional collaborative working relationships amongst general practitioners and NPs. PHC-NPs should have a generalist scope of practice and specialist expertise in order to maximise their utility within the general practice environment. What is known about the topic? NPs represent a growing workforce of highly trained and educated advanced practice nurses that aims to improve access to timely and affordable healthcare for underserviced populations. Recent legislation has allowed for greater exploration of innovative models of care using NPs in Australian primary healthcare. What does this paper add? This case study provides practical information on the financial and logistical implications of employing an NP in a bulk-billing general practice. It demonstrates the broad capability of this workforce in Australian primary healthcare, and gives an overview of the facilitators and barriers to their use in private practice. What are the implications for practitioners? Employment of a PHC NP in general practice requires careful consideration of the direct and indirect benefits associated with the complimentary care they offer. NP access to the Medicare Benefits Schedule is severely restricted, which impairs their ability to achieve a full scope of practice and may contribute to increased health system costs and inefficiencies. There are opportunities for integration and facilitation of this emerging role in general practice with existing nursing workforce. Further research into this evolving area would be of benefit.

Scoping study into wound management nurse practitioner models of practice

OBJECTIVES

The primary objective of this research was to investigate wound management nurse practitioner (WMNP) models of service for the purposes of identifying parameters of practice and how patient outcomes are measured.

METHODS

A scoping study was conducted with all authorised WMNPs in Australia from October to December 2012 using survey methodology. A questionnaire was developed to obtain data on the role and practice parameters of authorised WMNPs in Australia. The tool comprised seven sections and included a total of 59 questions. The questionnaire was distributed to all members of the WMNP Online Peer Review Group, to which it was anticipated the majority of WMNPs belonged.

RESULTS

Twenty-one WMNPs responded (response rate 87%), with the results based on a subset of respondents who stated that, at the time of the questionnaire, they were employed as a WMNP, therefore yielding a response rate of 71% (n=15). Most respondents (93%; n=14) were employed in the public sector, with an average of 64 occasions of service per month. The typical length of a new case consultation was 60 min, with 32 min for follow ups. The most frequently performed activity was wound photography (83%; n=12), patient, family or carer education (75%; n=12), Doppler ankle-brachial pressure index assessment (58%; n=12), conservative sharp wound debridement (58%; n=12) and counselling (50%; n=12). The most routinely prescribed medications were local anaesthetics (25%; n=12) and oral antibiotics (25%; n=12). Data were routinely collected by 91% of respondents on service-related and wound-related parameters to monitor patient outcomes, to justify and improve health services provided.

CONCLUSION

This study yielded important baseline information on this professional group, including data on patient problems managed, the types of interventions implemented, the resources used to accomplish outcomes and how outcomes are measured.

Nurse practitioners in aged care: documentary analysis of successful project proposals

Meeting the primary health care needs of an aging population is an increasing challenge for many Western nations. In Australia, the federal government introduced a program to develop, test, and evaluate nurse practitioner models in aged care settings. In this article, we present a documentary analysis of 32 project proposals awarded funding under the Nurse Practitioner-Aged Care Models of Practice Program. Successfully funded models were diverse and were operated by a range of organizations across Australia. We identified three key priorities as underlying the proposed models: "The right care," "in the right place," and "at the right time." In this article, we explore how these priorities were presented by different applicants in different ways. Through the presentation of their models, the program's applicants identified and proposed to address current gaps in health services. Applicants contrasted their proposed models with available services to create persuasive and competitive applications for funding.

Development and interrater reliability testing of a telephone interview training programme for Australian nurse interviewers

BACKGROUND

The final phase of a three phase study analysing the implementation and impact of the nurse practitioner role in Australia (the Australian Nurse Practitioner Project or AUSPRAC) was undertaken in 2009, requiring nurse telephone interviewers to gather information about health outcomes directly from patients and their treating nurse practitioners. A team of several registered nurses was recruited and trained as telephone interviewers. The aim of this paper is to report on development and evaluation of the training process for telephone interviewers.

METHODS

The training process involved planning the content and methods to be used in the training session; delivering the session; testing skills and understanding of interviewers post-training; collecting and analysing data to determine the degree to which the training process was successful in meeting objectives and post-training follow-up. All aspects of the training process were informed by established educational principles.

RESULTS

Interrater reliability between interviewers was high for well-validated sections of the survey instrument resulting in 100% agreement between interviewers. Other sections with unvalidated questions showed lower agreement (between 75% and 90%). Overall the agreement between interviewers was 92%. Each interviewer was also measured against a specifically developed master script or gold standard and for this each interviewer achieved a percentage of correct answers of 94.7% or better. This equated to a Kappa value of 0.92 or better.

CONCLUSION

The telephone interviewer training process was very effective and achieved high interrater reliability. We argue that the high reliability was due to the use of well validated instruments and the carefully planned programme based on established educational principles. There is limited published literature on how to successfully operationalise educational principles and tailor them for specific research studies; this report addresses this knowledge gap.

Nurse practitioners: an insight into their integration into Australian community pharmacies

BACKGROUND

Nurse practitioners (NPs) are independent health professionals with prescribing rights, and have recently established primary care roles in pharmacies.

OBJECTIVE

To describe the roles of pharmacy-based NPs in Australia.

METHODS

Semi-structured interviews were undertaken onsite or by telephone, with 28 staff of all 9 Revive NP Clinics in Western Australia. Participants comprised NPs representing 6 practices and pharmacy staff of all 9 practices. Questions explored the NPs' scope of practice and staff collaboration. Data are descriptively reported.

RESULTS

The NPs undertook a range of services, including medication prescribing according to clinical guidelines, provision and ordering of diagnostic services, vaccine administration and provision of medical certificates. Community pharmacists reported to continue ensuring the safe and quality use of medicines and to counsel clients. Both pharmacists and NPs provided consumer medicine information leaflets. NPs are authorized to write prescriptions for Pharmacist-Only (S3) Medicines.

CONCLUSIONS

NPs' primary healthcare roles appear to complement roles of community pharmacists. Potential exists for further collaboration and interdisciplinary care in health promotion and screening services. Clarification is needed with respect to prescribing and provision of Pharmacist-Only Medicines, and offering consumer medicines leaflets.

How nurse practitioners implement their roles

OBJECTIVE

This is a report of a qualitative health research study examining how nurse practitioners construct and implement their roles.

METHODS

In-depth interviews and a focus group discussion were conducted to obtain narrative data from nurse practitioners from a variety of clinical backgrounds. Data were analysed utilising the principles of grounded theory. Subjects. Seven nurse practitioners participated in face-to-face interviews and six participated in a focus group discussion.

RESULTS

The central process of 'developing legitimacy and credibility' is achieved through the processes of: 'developing Clinical Practice Guidelines', 'collaborating with the multidisciplinary team', 'communicating', and 'transitioning to practice'.

CONCLUSION

Policy makers and those responsible for operationalising nurse practitioner roles need to support the central process of developing legitimacy and credibility vital for successful implementation. First, this involves enabling a supportive and informed process of Clinical Practice Guideline development. Second, key inter-disciplinary relationships need to be identified to facilitate collaboration and sources of mentorship for nurse practitioners. Finally, an identified period of transition will facilitate identification, development and implementation of the above processes.

Suboptimal reporting of adverse medical events to the FDA Adverse Events Reporting System by nurse practitioners and physician assistants

OBJECTIVES

The Adverse Events Reporting System (AERS) of the FDA is used to identify toxicities of drugs that are on the market. Nurse practitioners (NP) and physician assistants (PA), having an increasing role in the delivery of medical care, are also needed to participate in post-marketing pharmacovigilance. This study was performed to assess awareness and use of the AERS in voluntary reporting of drug toxicities by NPs and PAs.

METHODS

A cluster sample survey was issued at the Principles of Gastroenterology for the Nurse Practitioner and Physician Assistant course in August 2010. The survey assessed familiarity with the AERS, the number of adverse events seen and the frequency of reports sent to the AERS. NP and PA responses were compared using the two-tailed Fisher's exact.

RESULTS

Of the 92 respondents, 67 (72%) were NPs and 24 (26%) PAs. Of the 50 (54%) respondents that reported being familiar with the AERS system, 20 (40%) incorrectly identified the methods to report using the AERS. Overall reporting of adverse events was low, particularly in respondents seeing 5-12 adverse events per year.

CONCLUSION

The study suggests that improved education regarding the importance of using AERS for pharmacovigilance is suggested for NPs and PAs. Due to the small size of the study, these data should be viewed as preliminary, pending a larger confirmatory study.

The Experience and Effectiveness of Nurse Practitioners in Orthopaedic Settings: A Comprehensive Systematic Review

REVIEW QUESTION/OBJECTIVE

This review asks "What is the experience and effectiveness of nurse practitioners in orthopaedic settings"?The objective of the quantitative component of this review is to synthesise the best available evidence on effectiveness of orthopaedic nurse practitioner specific care on patient outcomes and process indicators.The objective of the qualitative component of this review is to synthesise the best available evidence on the experience of becoming or being an orthopaedic nurse practitioner in relation to role development, role implementation and (ongoing) role evaluation.The objective of the text and opinion component of this review is to synthesise the best available evidence of the contemporary discourse on the effectiveness and experience of nurse practitioners in orthopaedic settings.

BACKGROUND

Nurse practitioner roles have emerged in response to areas of unmet healthcare needs in a variety of settings. Nurse practitioners first evolved in the United States 40 years ago in response to a shortage of primary health care physicians. Nurse practitioners filled the void by providing access to primary health care services where otherwise there was none. Nurse practitioners comprise one branch of advanced nursing practice in the US along with Nurse Anaesthetists (NA), Clinical Nurse Specialists (CNS) and Nurse Midwives (NM). Canada soon followed America's lead by establishing the nurse practitioner role in 1967. Canada has two areas of advanced nursing practice, namely nurse practitioner and clinical nurse specialist; they are moving towards introducing nurse anaesthetists currently. The nurse practitioner role was introduced into the United Kingdom 20 years ago.There is commonality amongst the definition and characteristics of Nurse Practitioner (NP)/Advanced Practice Nurse (APN) role and practice internationally in terms of education, practice standards and regulation; operationally there is variability however. Australia's progress with nurse practitioners is very much informed by the experiences of the United States and United Kingdom and for the most part there exists a parallel between the international experience and the Australian experience of nurse practitioners.This review will focus on orthopaedic nurse practitioners in an international context. However the local context of the primary reviewer which informs this review is Australian. Australia has mirrored the trends around nurse practitioner practice found elsewhere. In the last 20 years (post implementation of the 1986 Australian nursing career structure), the debate around advanced nursing practice and nurse practitioners, in an Australian context, has developed. The inaugural 'legal & policy' nurse practitioner framework was developed in New South Wales (NSW) in 1998, with the first Australian nurse practitioner authorised to practise in NSW in 2000. It is posited that evaluation of emerging roles began to be seen in the research literature from 1990 onwards. In response to a need for creative workforce re-engineering and against a context of limited health resources, nurse practitioners in Australia over the last 20 years have emerged as an alternative model of health care delivery. For the last 10 years there has been a proliferation of influential 'reports' written by nurse researchers, generated to review the progress of Australia's nurse practitioners, commissioned by the health departments of respective state governments and other service planners to guide health workforce planning.In a national context the Australian Nursing & Midwifery Council (ANMC) as the peak national nursing body, defines a nurse practitioner as a Registered Nurse (RN) who is educated and authorised to practice autonomously and collaboratively in an advanced and extended clinical role. The ANMC Competency Standards for the Nurse Practitioner encompass three generic standards which are further defined by nine competencies. The competency standards provide a framework for practice and licensure of nurse practitioners in Australia. In order for the nurse practitioner to be endorsed by the Australian Health Practitioner Regulation Agency (AHPRA) to practise as a nurse practitioner they must have met the competency standards and be endorsed to practise by the Nursing and Midwifery Board of Australia (NMBA) as a nurse practitioner under section 95 of the National Law. The nurse practitioner's endorsement in Australia is contextualised by their scope of practice, as is the case internationally.At September 2011, 450 endorsed nurse practitioners were nationally registered with AHPRA; 54 of these were endorsed to practise in South Australia. The first orthopaedic nurse practitioner was authorised in South Australia in 2005. To date there are eight endorsed orthopaedic nurse practitioners in Australia authorised to practise in a diverse range of orthopaedic settings that include acute care, community care, outpatient settings, rehabilitation, private practice and rural settings. The current scope of practice for Australian orthopaedic nurse practitioners spans the clinical range of trauma, arthroplasty, fragility fracture and ortho-geriatric care, surgical care: spinal/neurology and paediatric care. Orthopaedic nurse practitioners work within contemporary orthopaedic/musculoskeletal client disease models. These clinical models of care articulate the health care needs of populations living with musculoskeletal conditions, disorders and disease. Osteoarthritis and osteoporosis are 'highly prevalent long term [musculoskeletal] conditions known to predominantly affect the elderly and comprise the most common cause of disability in Australia'. Musculoskeletal trauma or injury as a result of an 'external force' such as vehicle accident, a fall, industrial or home environment accident or assault comprises a leading cause of hospital admission that requires orthopaedic management and care.There is some evidence to suggest that orthopaedic nursing is a 'specialty under threat' as orthopaedic-specific hospital wards are increasingly being absorbed into general surgical units; a trend observed in the United States in the mid 1990's in response to the American experience of 'downsizing' orthopaedic nursing services. Despite a limited evidence base, early citations with specific reference to orthopaedic nurses in the American context in particular started to populate the literature on or around this time. Several proponents of the specialty began to refer to a core nursing skill set that was 'highly orthopaedic' when describing 'specialist' orthopaedic nursing practice. More recently commentators point to differences in certain variables when patients are 'outlied' or managed in a non-orthopaedic ward environment by non-orthopaedic nurses.Despite 'in-principle' support for expanded scopes of practice for various health practitioner roles, the observation exists from within the specialty of orthopaedic nursing that progress in establishing the orthopaedic nurse practitioner role for this group of specialist clinicians has been slow and their journey has not been without challenge. The majority of orthopaedic nurse practitioners in Australia at least have emerged from extended practice roles similar to the generally well established experience of other nurse practitioners emerging from their own practice interest. The orthopaedic nurse practitioner is considered a 'pioneer' as they fill a 'gap' in clinical need and develop an orthopaedic nurse practitioner role. An emerging evidence base suggests that barriers such as a lack of role understanding, lack of 'team' support and a lack of resources at a system, organisational and practice level, constrain nurse practitioner practice and integration of the role into practice settings. Nurse practitioners function in an advanced clinical role. Some attempts have been made at quantifying the work of nurse practitioners. For example, Gardner et al in 2010 divided the work of nurse practitioners into three domains of practice: direct care, indirect care and service-related activities. Within these domains nurse practitioners perform a variety of tasks. Reporting on such activity by way of performance outcome measures is a variable practice amongst nurse practitioners however numbers seen/occasions of service, waiting times, effectiveness of interventions, referral patterns, patient/client satisfaction, clinical quality of care indicators are typical of the data maintained and reported by nurse practitioners to either justify their existence, embed their role service wide and/or contribute to workforce planning. Furthermore the orthopaedic nurse practitioner must effectively define and characterise the patient population to which they deliver care within the nurse practitioner's own scope of practice, ultimately to form an 'indicator' for the nurse practitioner role.The international literature pertaining to nurse practitioners or advanced practice nurses resonates with the many challenges faced by these nurses when it comes to role development and role implementation. Furthermore there is a body of evidence that validates the effectiveness of these roles. This becomes increasingly important in a context of building the health workforce of the future: a redefined workforce that must ensure adequate numbers of suitably qualified health workers who provide 'care the first time and every time'.A search of the Joanna Briggs Institute (JBI) Library of Systematic Reviews, Cochrane Library, PubMed and CINAHL has shown there are no existing or systematic reviews underway on this topic. The JBI undertook a systematic review commissioned by the Department of Health South Australia on Advanced Practice in Nursing and Midwifery and recommended a framework for advanced practice in a report released in early 2008. The framework defined advanced practice, levels of advanced practice, scope of practice, credentialing, education, preparation and regulation of advanced practitioners. The search identified a published systematic review protocol in the JBI Library for a qualitative systematic review by Ramis looking broadly at the experience of advanced practice nurses working in acute settings. The JBI Library of Systematic Reviews also contains a systematic review examining the effectiveness of nurse practitioners in residential aged care. Whilst these publications provide valuable context to this review neither specifically examines the clinical practice of orthopaedic nurse practitioners.Similarly a search of the Cochrane Library revealed a review on the topic of substitution of doctors by nurses in primary care. The focus of this particular intervention review was neither specific to nurse practitioners nor the acute care setting, but the topic of 'doctor substitution' complements the practice of nurse practitioners and may be a consideration in this review. Doctor substitution or care provided by a nurse other than an orthopaedic nurse practitioner is a natural comparator when examining the role and practice of orthopaedic nurse practitioners.Given the breadth of this topic a comprehensive approach has been chosen to systematically review the evidence as it relates to orthopaedic nurse practitioner role and practice.