An evaluation of the implementation of Advanced Nurse Practitioner (ANP) roles in an acute hospital setting

Strategies for knowledge mobilization by advanced practice nurses in three hospitals in Spain: a qualitative study

BACKGROUND

Evidence-based practice, in conjunction with optimum care quality, improves patients' clinical outcomes. However, its implementation in daily clinical practice continues to present difficulties. The aim of this study was to identify the strategies applied by Advanced Practice Nurses (APNs) to foster adherence to clinical practice guideline recommendations.

METHODS

An exploratory qualitative study was conducted with six focus groups at three public hospitals belonging to the Balearic Islands Health Care Service (Spain). The study participants were 32 ward nurses and 5 advanced practice nurses working routinely with inpatients at these hospitals. The study was conducted from November 2020 to January 2021, using thematic analysis, based on the COREQ checklist.

RESULTS

Four major themes related to the facilitation process were identified either by RNs and APNs: the context of the project, APN contribution to nursing team management, healthcare provision on the ward, and the acquisition and application of knowledge.

CONCLUSIONS

The APNs adapted their actions to the characteristics and needs of the local context, employing strategies aimed at improving teamwork, healthcare, and knowledge management. Each of these contributions enhanced the sustainability of the changes made.

Advanced practice nurses' experiences of patient safety: a focus group study

BACKGROUND

Patient harm from unsafe care is an increasingly global phenomenon leading to death or disability. Drawing on their expertise, Advanced Practice Nurses provide the opportunity to improve care quality and safety.

AIM

To explore Nurse Practitioners and Clinical Nurse Consultants' experiences in patient safety.

DESIGN

A qualitative design was used involving six audio-visually recorded focus group interviews. Participants working in an acute or community adult nursing speciality were involved.

METHODS

Twenty-eight Advanced Practice Nurses (female 82.1%, mean age 47.5 ± 10 years) were recruited by convenience and snowball sampling. After transcription of interview data, qualitative content analysis was conducted.

RESULTS

Six categories were identified: patient safety as the highest priority (1), special contribution to patient safety (2), patients/relatives role in safety (3), multidisciplinary team approach (4), government regulation in safety (5), and further needs to improve safety (6). Advanced Practice Nurses saw themselves as role models and leaders for other healthcare staff through their expertise and professional experience and thus able to see the bigger picture in health. They identified as change agents at the system-level due to their decision-making ability and multi-professional team connectivity.

CONCLUSIONS

This study emphasises the key position of extended nursing roles and the need for future development of patient safety strategies in hospitals and community care. As influential leaders, Advanced Practice Nurses are best placed to identify improvements. They play a central role in guiding the multi-professional team, the patient and their family, educating nursing staff, and identifying and addressing system-wide safety gaps to improve patient safety.

Career Considerations in Nurse-Led Traditional Chinese Medicine Clinics: a Two-Center Qualitative Study

Background

Growing demand exists for high-quality Traditional Chinese Medicine (TCM) care, particularly through Nurse-led TCM clinics (TCM-NLCs). Nurses with extensive experience in TCM departments represent a potential workforce for this healthcare model. This qualitative study aims to investigate the willingness of these candidates to engage in TCM-NLCs, with a specific focus on their main concerns and apprehensions when facing new challenges.

Methods

Individual semi-structured face to face interviews were conducted with senior nurses from two TCM hospitals in Shanghai. Each participant had a minimum of three years of work experience in a TCM related department. Conventional qualitative content analysis was utilized.

Results

Fourteen participants were interviewed and data saturation was achieved. Nurses exhibited strong interest in practicing in TCM-NLCs. They believed that such innovative TCM nursing service model not only extends nursing role, provides greater empowerment and opportunities for professional development but also meets patients' diverse healthcare needs, reduces reliance on other healthcare providers such as doctors, and increases hospital revenue. However, challenges such as deficiencies in evidence-based TCM nursing education, the absence of standardized practice guidelines, and limited prescriptive privileges were identified as primary obstacles to engaging in TCM-NLCs practice, potentially undermining the specialization of this advanced nursing practice model.

Conclusion

Although the nurses interviewed were highly motivated, they generally lacked confidence to practice independently in TCM-NLCs. A pressing priority is to address their concerns by providing appropriate resources as well as education and policy support to enhance their competency and ensure their practice autonomy, therefore building a more qualified pool of professionals for advanced TCM nursing practice.

Patient perspectives on the role of orthopedic nurse practitioners: a cross-sectional study

BACKGROUND

The inclusion of nurse practitioners (NPs) specializing in orthopedics shows potential for improving the quality of care for orthopedic patients. A critical aspect of assessing the feasibility and acceptance of introducing NPs into orthopedic settings involves understanding patients' perspectives on this role. This study aims to explore the receptiveness of orthopedic patients to treatment by orthopedic Nurse Practitioners (NPs). Additionally, it investigates potential associations between patients' willingness to engage with NPs, their familiarity with the NPs role, perceptions of nursing, and satisfaction with orthopedic nursing care.

METHODS

This cross-sectional study involved patients admitted to an orthopedic department in a central Israeli hospital between January and February 2023. Data was collected using a questionnaire consisting of five sections, validated by content experts. Statistical analyses, performed using SPSS, included descriptive statistics, independent samples t-tests, Pearson correlations, and linear regression.

RESULTS

Orthopedic patient participants demonstrated a moderate willingness to undergo treatment by orthopedic NPs, with over two-thirds expressing strong openness. Patients displayed a high willingness for NPs to engage in various clinical tasks, albeit showing lesser enthusiasm for medication management and preoperative evaluation. Positive attitudes towards nurses and familiarity with the NP's role emerged as significant predictors of patient receptiveness to NPs' treatment.

CONCLUSION

Patient acceptance of orthopedic NPs varies across different aspects of care. While there is overall willingness to receive care from NPs, these nuanced preferences should be considered when implementing NPs in orthopedic settings. Awareness and positive perceptions play crucial roles in shaping patients' willingness to receive care from these NPs.

TRIAL REGISTRATION

The research doesn't report the results of a health care intervention.

Patient experience during their joint replacement journey: The role of the Orthopaedic Nurse Practitioner

BACKGROUND

The benefits of the Nurse Practitioner role in acute care are known however, the patient's experience of having an Orthopaedic Nurse Practitioner involved in their joint replacement care is unknown.

AIM

This study aimed to explore the experience of patients undergoing a hip or knee joint replacement who had an Orthopaedic Nurse Practitioner involved in their care.

METHODS

This study used a qualitative descriptive design using semi-structured interviews with eleven participants. Data were analysed using Braun and Clark's six step reflexive thematic analysis framework.

RESULTS

Four themes emerged from the thematic analysis: 1) Information sharing and education; 2) Support throughout the journey; 3) Coordination of care, and 4) Reassurance.

CONCLUSION

The role of the Orthopaedic Nurse Practitioner in supporting participants throughout their joint replacement journey provided benefits for the patient's health and recovery.

Experiences and attitudes of task-shifting and task-sharing of physicians, nurses, and nursing assistants in hospitals: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to explore the experiences and attitudes of physicians, nurses, and nursing assistants regarding task-shifting and task-sharing in hospitals.

INTRODUCTION

Despite multiple health care professionals performing overlapping tasks, the need for effective task-shifting and task-sharing remains a concern. Understanding task-shifting and task-sharing experiences, as well as the attitudes of health care providers in hospitals, is essential for providing safe and patient-appropriate care with limited human resources.

INCLUSION CRITERIA

Qualitative studies that examine the experiences and attitudes of physicians, nurses, and nursing assistants in hospitals regarding task-shifting and task-sharing will be included. The review will include physicians, advanced practice nurses who are nurse practitioners or clinical nurse specialists, registered nurses, and nursing assistants. Midwives, pharmacists, occupational therapists, physical therapists, and students will be excluded.

METHODS

PubMed, MEDLINE, CINAHL, PsycINFO, Cochrane Database, and Web of Science will be searched as part of a 3-step search strategy. We will search for unpublished research and gray literature using Google Scholar and ProQuest Dissertations and Theses. Studies published in English or Japanese from the time each database was established to the present will be considered for inclusion. The methodological quality of all studies will be evaluated by screening against the inclusion criteria and by at least 2 critical evaluations using the standardized JBI checklist. Synthesized results will be pooled by meta-aggregation and published as a ConQual Summary of Findings.

REVIEW REGISTRATION

PROSPERO CRD42023409612.

Evaluation of the implementation of advanced practice nursing roles in France: A multiple case study

AIMS

The aims of the study were to describe the processes used to introduce advanced practice nursing roles and factors that facilitated or hindered role implementation, examine the time advanced practice nurses (APNs) spend in role activities and how these activities relate to domains of advanced practice nursing and examine how implementation processes influenced APN integration within healthcare teams.

DESIGN

A multiple case study was conducted.

METHODS

Five cases were included, representing the four population areas approved for advanced practice nursing in France. Data were collected from January to March 2021 using observation, interview and document analysis methods. Data were examined using thematic analysis.

RESULTS

Participants included APNs (n = 5), nurses/allied health providers (n = 5), physicians (n = 5), managers (n = 4) and decision-makers (n = 4). Stakeholder engagement and leadership provided by decision-makers, managers, physicians and APNs facilitated role implementation. Poor stakeholder role understanding, uncertain role funding, and the COVID-19 pandemic hindered role implementation. APNs spent the most time in clinical activities. Participants perceived the integration of APNs within the healthcare team and their impact on patient care to be positive.

CONCLUSION

Stakeholder engagement and organizational and APN leadership facilitated the implementation of the roles, especially related to team-based patient care. Further efforts are needed to strengthen APN involvement in non-clinical activities and address role barriers.

IMPLICATIONS FOR NURSING AND PATIENT CARE

Systematic and system-wide approaches are needed to improve role clarity, role autonomy and health systems integration of APNs. Research should examine patient perspectives about APNs in France.

IMPACT

The results highlight how policies can create favourable conditions for advanced practice nursing role implementation in France. Internationally, this study serves as a reminder to APNs and nurse leaders about the strategies for and importance of implementation evaluation to support the optimal development of advanced practice nursing roles.

REPORTING METHOD

The study reporting followed the Consolidated Criteria for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Staff perspectives of a nurse practitioner-led orthogeriatric model of care in a large academic hospital: A mixed methods study

BACKGROUND

Research has shown that models of care involving geriatric care in orthopedics decrease hospitalizations, mortality, length of stay and post-operative complications. This article presents an example of a nurse practitioner-led orthogeriatric model of care in a large academic hospital in Ontario. The overall goal was to explore staff perspectives regarding the nurse practitioner-led orthogeriatric model of care.

METHODS

We conducted a mixed methods approach consisting of an online questionnaire, semi-structured interviews, and a focus group with staff.

RESULTS

Questionnaire of staff showed overall support for functions of the NP within the model. Interviews with healthcare providers, and leadership as well as one focus group with orthopedic surgeons showed that despite the lack of formal awareness of the NP-led orthogeriatric model of care, staff felt that the model provided better care for the geriatric hip fracture population.

CONCLUSION

In the current context of geriatricians' shortages to provide post-surgical care to geriatric patients, the staff described that geriatric care of hip fracture patients can be well accomplished by a NP. Further improvement efforts to create better awareness of the NP-led orthogeriatric model among the care team is needed.

Nurse practitioner in Swedish municipal elderly care: A Delphi study of challenges and opportunities

INTRODUCTION

Worldwide, countries are struggling with strained healthcare systems, especially due to the growing number of frail elderly. Developing the role of nurse practitioner in the care of the frail elderly is therefore of interest to make the care chain more efficient. In Sweden, the role is in an early development phase, but more research is needed.

AIM

The aim was to investigate how stakeholders at the national level express the challenges and opportunities of the evolving nurse practitioner role in Swedish municipal elderly care.

METHOD

A Delphi survey technique with three rounds of electronic questionnaires was used. Twenty-seven experts responded to the first questionnaire, containing two open questions; what opportunities respectively challenges do you see in developing and implementing the nurse practitioner role in municipal elderly care? The following questionnaires consisted of statements to rate using a four-grade Likert scale, and 20 and 17 responded to the second and third, respectively. The first round was analysed using content analysis, and the other two with descriptive statistics.

RESULTS

Thirty-four statements about challenges and opportunities related to the nurse practitioner role in municipal elderly care were identified and rated as important.

CONCLUSION

The findings provide knowledge that can contribute to discussions and decisions to refine the nurse practitioner role in Swedish municipal elderly care. The nurse practitioner role may contribute with much-needed competence to the elderly care. However, it is important to consider the challenges that need to be overcome before the development of the role. To solve this, it is necessary to have clear national guidelines concerning issues of education, title protection and the mandate and authority of the NP role.

[Role understanding of expert nurses in primary and acute care in Germany: A descriptive cross-sectional study]

Role understanding of expert nurses in primary and acute care in Germany: A descriptive cross-sectional study Abstract. Background: Innovative care concepts are necessary to cope with the increase in complex care situations due to a rising number of older people with chronic diseases and a simultaneous shortage of nursing and medical staff. In the context of the implementation and development of new, innovative nursing roles, an unclear role understanding is considered a barrier. Aim: Description of expert nurses' (EN) role understanding in primary and acute care in Germany. Method: Using questionnaires, EN are asked cross-sectionally about role clarity, competencies and performance as well as perceived autonomy and interprofessional collaboration. Results are analysed descriptively. Results: A total of eight (primary care) and 14 (acute care) EN completed the questionnaires. The majority of EN often/very often perform both the clinical (77.5% and 85.7%, respectively) and the expert role (75% and 78.6%, respectively) and indicate that they can explain their role to patients (75% and 92.9%, respectively) and physicians (87.5% and 90.9%, respectively). Having a high degree of autonomy is more likely to be perceived by EN working in acute care. Conclusion: Although there are similarities in terms of role understanding, EN working in acute care can apparently benefit from already established structures, which is reflected, among other things, in their perceived autonomy.

Impact of advanced practice nurses in hospital units on compliance with clinical practice guidelines: a quasi-experimental study

BACKGROUND

Incorporating the best available evidence into clinical practice is a determining challenge for healthcare professionals and organisations. The role of advanced practice nurses is viewed as a facilitator to adapt guideline recommendations to suit specific contexts and to overcome barriers to implementation. In this study, we evaluate the impact of advanced practice nurses on clinical indicators of hospitalised patients and on adherence to recommendations derived from two clinical practice guidelines (pressure ulcer prevention and treatment and vascular access device management).

METHODS

Quasi-experimental study in five intervention (IU) and five control (CU) hospital units at three hospitals in Spain (period 2018-19). Five advanced practice nurses were incorporated into IU, with the intention that would produce attitudinal changes and enhance the skills and knowledge of the nursing team regarding 18 clinical practice recommendations. In this study, 41 indicators were evaluated through direct observation of all patients admitted, at monthly intervals for 1 year. Outcomes were assessed by means of a descriptive, multi-line regression and association analysis.

RESULTS

The study population was composed of 3742 inpatients admitted for pressure ulcer assessment and 2631 fitted with vascular access devices. By the end of the study period, all variables had improved in the IU, where average compliance with recommendations was statistically significantly higher (pressure ulcer guidance 7.9 ± 1.9 vs 6.0 ± 1.7. OR 1.86, 95% CI 1.67-2.05; vascular access devices guidance 5.4 ± 1.4 vs 4.4 ± 1,6. OR 1.06, 95% CI 0.95-1.17). The prevalence of pressure lesions and catheter-related adverse events decreased statistically significantly in the IU compared to the CU. The prevalence of pressure ulcers decreases (5.7% in IU vs 8.7% in CU p < 0.005) as well as the prevalence of adverse events related to the catheter (14% In IU vs 21.6% in CU p < 0.005). The unnecessary catheters decressed in IU 10.9% VS CU 15.8% (p < 0.005).

CONCLUSIONS

The incorporation of an advanced practice nurse statistically significantly improves clinical indicators related to the prevention and treatment of pressure ulcers and to the management of vascular access devices.

TRIAL REGISTRATION

ISRCTN18259923 retrospectively registered on 11/02/2022.

Focused Cardiac Ultrasound Training for Non-cardiologists: An Overview and Recommendations for a Lower Middle-Income Country

Poor outcomes among the critically ill in low- and middle-income countries (LMICs) have been attributed in part to the challenge of diagnostic delays caused by lack of skilled personnel. Focused cardiac ultrasound (FoCUS) by non-cardiologists may mitigate the shortage of echocardiography experts to perform emergency echocardiography at the point of care in these settings. It is however crucial that FoCUS training for non-cardiologists in LMICs be based on robust evidence to support training delivery if diagnostic accuracy is to be assured.

Parent Satisfaction With Pediatric Nurse Practitioner Care in Specialty Services

INTRODUCTION

This study examined parent satisfaction with care provided to their children by Pediatric Nurse Practitioners (PNPs) in specialty areas at a tertiary care pediatric hospital.

METHOD

A convenience sample of parents of children cared for by 19 PNPs in different specialty settings completed a confidential survey consisting of demographic information and the Parents' Perception of Satisfaction with Care from the Pediatric Nurse Practitioners Instrument (PPSC-PNP). Data were analyzed using SPSS (IBM, Armonk, NY).

RESULTS

The overall PPSC-PNP mean score was 129.82/140. Mean subscale scores ranged from 27.15 to 28.51/30. The general satisfaction score showed a mean score of 18.31/20. No statistical difference was found in parental satisfaction when scores were analyzed by the child's age, parent participant, or patient setting.

DISCUSSION

These findings indicate that parents are highly satisfied with the care their children receive from PNPs across various subspecialties regardless of the child's age and clinical setting.

Nationwide evaluation of the advanced clinical practitioner role in England: a cross-sectional survey

BACKGROUND AND STUDY OBJECTIVE

In response to growing pressures on healthcare systems, the advanced clinical practice (ACP) role has been implemented widely in the UK and internationally. In England, ACP is a level of practice applicable across various healthcare professions, who exercise a level of autonomy across four domains, referred to as the four pillars of practice (education, leadership, research and clinical practice). A national framework for ACP was established in 2017 to ensure consistency across the ACP role, however current ACP governance, education and support is yet to be evaluated. This study aimed to analyse data from a national survey of the ACP role to inform the development and improvement of policies relating to ACP in the National Health Service (NHS) in England.

DESIGN

A cross-sectional survey with free-text comments.

SETTING

The survey was distributed across primary and secondary levels of care to three distinct groups in England, including individual ACPs, NHS provider organisations and Trusts and primary care settings.

PARTICIPANTS

A total of 4365 surveys were returned, from ACP staff (n=4013), NHS provider organisations and Trusts (n=166) and primary care organisations (n=186).

RESULTS

Considerable variation was found in role titles, scope of practice, job descriptions and educational backgrounds of ACPs. Differing approaches to governance were noted, which led to inconsistent ACP frameworks in some organisations. A further challenge highlighted included committing time to work across the four pillars of advanced practice, particularly the research pillar. ACPs called for improvements in supervision and continuing professional development alongside further support in navigating career pathways.

CONCLUSIONS

A standardised approach may support ACP workforce development in England and enable ACPs to work across the four pillars of practice. Due to the wide uptake of ACP roles internationally, this study has relevance across professions for global healthcare workforce transformation.

Constructing the advanced nurse practitioner identity in the healthcare system: A discourse analysis

AIMS

To explore how Advanced Nurse Practitioners (ANP) are positioned within current nursing and health system structures in Ireland by making explicit the discourses that construct ANPs' identities and how they both enable and constrain their roles.

BACKGROUND

Ambiguity and confusion characterize debates about the ANP role having a profound impact on ANP identity and how they realize their roles. Without clear definitions, boundaries are difficult to ascertain, the full potential of the ANP is not realized and, consequently, ANPs are underutilized. Although this study is relevant outside Ireland's borders, it is of particular concern in the Irish setting as current policy aims to increase ANP numbers.

DESIGN

A qualitative discourse analysis using Gee's Tools of Inquiry.

METHOD

Data were collected between April 2019 and January 2020 through seven in-depth interviews and four focus groups and analysed using Gee's Tools of Inquiry. Participants included ANPs, nurses, doctors and allied healthcare professionals.

FINDINGS

Five key discourses emerged. Language-in-use established, first, that ANPs add value to the healthcare system and, second, highlighted the centrality of nursing to ANPs' identity. The third discourse builds an educated and skilled identity for ANPs, one that, however, lacked the expertise and influence of their medical colleagues. The fourth discourse constructs an identity for ANPs as medical substitutes, lesser roles, yet innovative additions to the system and a threat to existing structures. The final discourse constructs tensions between independence and autonomy, on the one hand, and control, on the other.

CONCLUSION

This study alerts healthcare professionals to ways in which discourses influence opinion and frame ANPs' identity. Healthcare professionals should challenge Conversations and Discourses that disparage the ANP role. ANPs need to clearly articulate their role, the value that it adds to the healthcare system and demonstrate how it aligns with and complements other healthcare professionals' roles.

IMPACT

By identifying and critiquing extant Discourses and Conversations, healthcare professionals, and health system leaders and managers will gain a better understanding of the issues that both enable and constrain the ANP role.

Patient-reported experiences of consultation with an advanced nurse practitioner: Factor structure and reliability analysis of the patient enablement and satisfaction survey

AIM

The aim was to analyse the psychometric properties of a patient-reported-experience measure, the Patient Enablement and Satisfaction Survey (PESS), when used to evaluate the care provided by Advanced Nurse Practitioners (ANPs) in terms of factor structure and internal consistency. The PESS is a 20-item, patient-completed data collection tool that was originally developed to measure patient experience and enablement following consultation with nurses in general practice.

DESIGN

Cross-sectional survey; validity and reliability analysis.

METHODS

The sample in this study consisted of 178 patients who consulted with 26 ANPs working in four different specialities. Data were collected between June and December 2019. An exploratory factor analysis of the PESS was conducted to determine convergent validity which was supported by parallel analysis and the traditional Kaiser criterion. The internal consistency of individual PESS items was determined via Cronbach's alpha, McDonald's omega, the Average Variance Extracted tests and item-subscale/total score correlations.

RESULTS

A three-factor structure (PESS-ANP) was found through exploratory factor analysis and this was supported by parallel analysis, the traditional Kaiser criterion and the percentage of variance explained criterion. A high degree of internal consistency was reported across all factors. One question was omitted from the analysis ('Overall Satisfaction') following the identification of problematic cross-loadings. The three factor solution was identified as: patient satisfaction, quality of care provision and patient enablement.

CONCLUSION

The findings of this study propose a three-factor model that is sufficiently reliable for analysing the experience and enablement of patients following consultation with an ANP.

IMPACT

Increasingly, patient-reported experience measures are being used to evaluate patients' experience of receiving care from a healthcare professional. The PESS was identified to be reliable in evaluating the experience of patients who receive care from an ANP while a three-factor structure was proposed that can capture specific attributes of this care.

Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review

OBJECTIVES

In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK.

DESIGN

A scoping review was undertaken following JBI methodological guidance.

METHODS

13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative.

RESULTS

191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway.

CONCLUSION

This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.

Perceptions of competency in advanced clinical practice

BACKGROUND

Historically, there has been limited research carried out on the competency of individuals undertaking advanced clinical roles.

AIMS

To research advanced clinical practitioner (ACP) perceptions of the term competency, and how they evidence their competency in practice.

METHODS

A cross-sectional, qualitative study used semi-structured interviews, which were analysed by content analysis. Six participants were recruited to the study.

FINDINGS

There is disparity in the definitions of 'trainee' and 'qualified' ACP in clinical practice as well as disparity and ambiguity regarding being able to work in a supernumerary capacity during training and master's level study. There is a lack of agreement over the benchmark for qualified ACP status and the road to getting there.

CONCLUSION

ACPs should be employed in a supernumerary capacity while training and work towards a full MSc in advanced clinical practice. They should maintain a portfolio of their competency. Work must also be carried out nationally to identify both generic and specialist curricula for ACPs to benchmark against.

Skills, competencies, and policies for advanced practice critical care nursing in Europe: A scoping review

OBJECTIVES

Management of critically ill patients is changing due a rise in population age, comorbidity and complexity. To accommodate these changes, the demand is increasing for advanced practice nurses. More knowledge is needed regarding the role of advanced practice critical care nurses in European countries. The aim of the study was to review the literature describing skills and competencies required for advanced practice critical care nursing in Europe and to investigate related policy.

REVIEW METHOD

We performed a scoping review including papers published in 1992-2019 targeting policy and the intersection of advanced practice nursing (level of practice), critical care nursing (specialty area) and Europe (geographical origin).

DESIGN AND DATA SOURCES

Main sources of evidence were PubMed, EMBASE, PsycINFO, CINAHL, Cochrane Library, SweMed+, Scopus, ERIC and Social Sciences Citation Index. We also searched grey literature, webpages, reference lists and performed hand-search.

RESULTS

The search identified 11,478 papers/references of which 42 were included. Four levels of practice were identified with unclear boundaries: professional nurse, specialized nurse, advanced practice nurse and advanced critical care practitioner (nurse or other). Most skills and competencies described in the literature were generic to advanced practice and only few were area specific to critical care. Advanced practice critical care nurses were often unable to fulfil their role because education, supportive policy and legislation were lacking.

CONCLUSIONS

This scoping review informs the policy makers and the INACTIC study of existing advanced practice in critical care nursing in Europe. The advanced role in critical care nursing is characterized by inconsistency regarding policy, education, titles, roles, scope of practice, skills and competencies. Levels of practice and areas of specialization need to be clarified. Most skills and competencies identified were generic for advanced practice nursing and many were generic for any profession. Task-shifting from physician to nurse needs to be more clearly defined and patient outcomes described. Given the scarcity of papers in our target area, we believe it might be too early to conduct a systematic review at this time.

Comparison of Japan nurse practitioner-led care and physician trainee-led care on patients' length of stay in a secondary emergency department: A retrospective study

Aim

We compared Japan nurse practitioner‐led care and physician trainee‐led care in terms of patients' length of stay in a secondary emergency department in Japan.

Methods

This was a retrospective observational study, utilizing medical records. Participants (n = 1419; mean age = 63.9 ± 23.4 years; 52.3% men) were patients transferred to the emergency department by ambulance between April 2016 and March 2018 in western Tokyo. Multiple linear regression analyses were performed, with length of stay as the dependent variable and factors related to the length of stay, including medical care leaders, as the independent variable.

Results

Approximately half of the patients (n = 763; 53.8%) received Japan nurse practitioner‐led care. Patients' length of stay was significantly shorter, by 6 min, in the Japan nurse practitioner‐led care group, compared with the physician trainee‐led care group (unstandardized coefficient: −6.81; 95% confidence interval: −13.35 to −0.26; p < 0.05).

Conclusion

Patients' shorter length of stay in the Japan nurse practitioner group, compared with the physician trainee group, suggests that Japan nurse practitioners are not inferior to physician trainees in terms of the time spent to manage patients.

Has the introduction of an advanced practitioner led service had an impact on radiation dose for fluoroscopy guided lumbar punctures? A service review

INTRODUCTION

Historically, procedures requiring fluoroscopic guidance such as myelography; barium and video swallows; and fluoroscopy guided lumbar punctures (LP) have been performed by radiologists with the assistance of radiographers. As the National Health Service (NHS) evolves, more responsibilities are being disseminated to specifically trained radiographers to relieve workload due to a national shortage of radiologists. One step taken by the trust was to train an Advanced Practitioner (AP) in fluoroscopy to perform fluoroscopy guided LPs. Clinical audit and service evaluations are required to ensure there is no impact on patient care as a result of changes in practice. Regardless of occupation, healthcare workers undertaking procedures must ensure the same standards of care for patients. Minimising radiation dose is a duty of all radiological professionals.

METHODS

This retrospective review evaluated and compared examinations performed by a group of radiologists and an AP in terms of dose area product (DAP) and fluoroscopy screening time. A total of 300 X-ray guided LPs doses were reviewed and comparison between the radiation exposure data sets was performed to determine whether there was a significant difference between the two operator groups.

RESULTS

The study revealed that AP-performed LPs had a statistically significant lower DAP and fluoroscopy time (a mean of 4.21Gycm2 and 0.74min) compared to the radiologist-performed LPs (a mean of 5.72Gycm2 and 0.94min).

CONCLUSION

The review demonstrates that patient dose is not detrimentally affected by the introduction of an advanced practitioner. It establishes that dose and screening time was significantly lower. It also highlights the effectiveness of APs in an evolving radiology department.

IMPLICATIONS FOR PRACTICE

These outcomes propose advanced practitioners in this area of expertise can expand their role from neuroradiographer with no detriment to patient dose. Despite the results, it is recognised that continuous appraisal is required to ensure that competencies are maintained, and high levels of care are sustained.

Content in nurse practitioner education - A scoping review

OBJECTIVE

Globally, the role of nurse practitioner is evolving to meet increased healthcare demands. Nevertheless, there are factors hindering the development of this role, one of which involves differences in nurse practitioner education worldwide. Therefore, the objective of the present study is to identify what is known in the research field on the content of nurse practitioner educational programmes.

DESIGN AND DATA SOURCES

The literature scoping review follows a six-stage methodological framework including: i) formulate research questions, ii) identify relevant studies, iii) select studies, iv) chart data, v) collate, summarize and report the results, vi) consultations. Data bases searched included CINAHL, PubMed and ERIC and were followed by manual searching of reference list in the included papers. Of the 1553 papers identified, 16 met the aim of this study.

REVIEW METHODS

To answer the research questions 'what is the content of curricula in nurse practitioner education?' a deductive content analysis was used.

RESULTS

Two main categories emerged. The first was related to the professional nurse practitioner role and includes research and nursing theories, leadership and collaboration, and organizational, political, economic, regulatory and legislative issues. The second is related to becoming an autonomous practitioner and includes health promotion and disease prevention, and other medically oriented content.

CONCLUSIONS

The content identified is consistent with the core competencies that nurse practitioners are expected to have after graduation, which have been described by the International Council of Nurses and by other researchers. Given the lack of recent research in nurse practitioner education, the results of the present study advance knowledge in this research field. Additionally, this study may be of practical value in developing new nurse practitioner educational programmes.

An evaluation of the role of the advanced nurse practitioner on an elective orthopaedic ward from the perspective of the multidisciplinary team

AIM

To evaluate the role of the advanced nurse practitioner on an elective orthopaedic ward from the perspective of the multidisciplinary team.

BACKGROUND

The development of advanced practice roles worldwide has been influenced by an ageing population with complex needs. There is evidence that these roles can have a positive impact in hospital settings, but little is known about the role of the ANP in an elective orthopaedic ward.

DESIGN

A qualitative evaluation study (n = 10).

METHODS

A purposive sample of 4 junior doctors and 6 nurses working on an elective orthopaedic ward was recruited. Participants were interviewed individually using semi-structured interviews.

FINDINGS

There were three overarching themes found from the analysis: 1) role identity, 2) a valued member of the team, and value-added care. The ANPs were identified as being part of the medical team, while their nursing background was valued. They provided continuity and clinical expertise to the ward team. They were perceived as being supportive and as working closely with the ward team.

CONCLUSIONS

The ANPs were perceived to deliver effective, person-centred care. The evaluation adds to the recognition that the ANP has a unique identity. The study adds to the limited literature on ANPs working on elective orthopaedic wards.

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.

The orthopaedic nurse practitioner: Breaking tradition to fill gaps in care delivery through varied scopes of practice

BACKGROUND

Musculoskeletal conditions are the world's fourth largest burden of disease, accounting for more than 50% of chronic health conditions in the population aged >50 years (Briggs et al., 2016). This increasing burden is due to a progressively overweight, sedentary and ageing population and is often poorly recognised as a priority globally in an under-resourced health care system. This article reviews the current literature to identify where Orthopaedic Nurse Practitioners (ONPs) currently fill gaps in care delivery through varied scopes of practice in musculoskeletal trauma, degenerative disease, tumour and bone health. The varied scopes of practice include, fracture management, surgical assisting, performing surgical and/or advanced clinical procedures, prescribing treatment for bone health, conducting home visits and managing ONP led outpatient clinics. The article will outline current ONP roles in orthopaedic trauma, pain management, fragility hip fractures, osteoporosis, bone and soft tissue sarcoma and surgical assisting which effectively address long waiting lists, gaps in care delivery and reduce costs currently being managed by the health care system.

METHOD

A brief search of the literature published from January 2008-January 2020 on CINAHL, Cochrane Library, MEDLINE, Joanna Briggs Institute, Ovid, PubMed, Embase and Pro Quest databases was undertaken using key words Orthopaedic Nurse Practitioner, Advanced Practice Nurse (APN), musculoskeletal health, bone health, nurse-led and nurse specialist.

CONCLUSION

ONPs offer an innovative, viable and cost-effective solution to providing comparable, effective and efficient care with varied scopes of practice and valuable experience in both the inpatient and outpatient settings.

Workforce experience of the implementation of an advanced clinical practice framework in England: a mixed methods evaluation

BACKGROUND

This study aims to understand how the implementation of the advanced clinical practice framework in England (2017) was experienced by the workforce to check assumptions for a national workforce modelling project. The advanced clinical practice framework was introduced in England in 2017 by Health Education England to clarify the role of advanced practice in the National Health Service.

METHODS

As part of a large-scale workforce modelling project, a self-completed questionnaire was distributed via the Association of Advanced Practice Educators UK aimed at those studying to be an Advanced Clinical Practitioner or who are practicing at this level in order to check assumptions. Semi-structured phone interviews were carried out with this same group. Questionnaires were summarised using descriptive statistics in Excel for categorical responses and interviews and survey free-text were analysed using thematic analysis in NVivo 10.

RESULTS

The questionnaire received over 500 respondents (ten times that expected) and 15 interviews were carried out. Advanced clinical practice was considered by many respondents the only viable clinical career progression. Respondents felt that employers were not clear about what practicing at this level involved or its future direction. 54% (287) thought that 'ACP' was the right job title for them. 19% (98) of respondents wanted their origin registered profession to be included in their title. Balancing advanced clinical practice education concurrently with a full-time role was challenging, participants underestimated the workload and expectations of employer's training. There is an apparent dichotomy that has developed from the implementation of the 2017 framework: that of advanced clinical practice as an advanced level of practice within a profession, and that of Advanced Clinical Practitioner as a new generic role in the medical model.

CONCLUSIONS

Efforts to establish further clarity and structure around advanced clinical practice are needed for both the individuals practising at this level and their employers. A robust evaluation of the introduction of this role should take place.

Quality of Life and Dependence Degree of Chronic Patients in a Chronicity Care Model

Background: The complex chronic patient is a person with one or several long-term diseases, the clinical management of which are considered difficult and related to cognitive or functional impairment. The chronicity care model deeply affects the quality of life and degree of dependence. Objectives: The objective of this study was to analyse the perceived quality of life and dependence degree in complex chronic patients within a chronicity care model in the Autonomous Communities of Cantabria and the Balearic Islands (Spain). Design: This was a multicentred, transversal, descriptive, and observational study on a cohort of 206 chronic patients included in a chronicity care program. Methods: Patients’ sociodemographic variables, integral valuation, nurse follow-up records, nursing outcomes classification (NOC)/nursing interventions classification (NIC), nurse diagnoses, and hospitalization data were analysed. A descriptive analysis of all data was carried out. The bivariate analysis assessed the relation between covariables and the overall scoring in European Quality of Life Scale (EuroQuol-5D), Barthel, Braden, and Chronic Patient eXperience Assessment Instrument (IEXPAC in the Spanish abbreviation). A multivariate linear regression analysis was conducted. Results: The mean age was 79.4 years (standard deviation (SD) = 9.12; range: 39–94). A percentage of 79.3% of the study population shows functional impairment in one or more activities of daily life. A percentage of 83.3% of patients showed a physical dependence. There is a significant relationship between the gender and kinship degree of the caregiver (χ2 = 18.2; p = 0.001). An overall mean score of 55.38 points in EuroQuol-5D was obtained, along with a 36.87-point satisfaction with the care given in IEXPAC. The overall score correlated positively and significantly with Barthel, Braden, and IEXPAC. The dependence levels improved slightly in the observed patients, which was a very significant outcome in statistical terms (t = 2.08; p = 0.039). A percentage of 66% (R2 = 0.66) of the score variability at the Barthel index could be predicted from Braden scale scoring. Conclusions: Dependence is not only affected by the related pathology, but also by the effect on mobility and daily-life activities, which cause a worse perception of the quality of life. The health-care model based on the case management nurse is having positive effects, especially on dependence and patients with ulcer issues.

Quality of Life and Dependence Degree of Chronic Patients in a Chronicity Care Model

BACKGROUND

The complex chronic patient is a person with one or several long-term diseases, the clinical management of which are considered difficult and related to cognitive or functional impairment. The chronicity care model deeply affects the quality of life and degree of dependence.

OBJECTIVES

The objective of this study was to analyse the perceived quality of life and dependence degree in complex chronic patients within a chronicity care model in the Autonomous Communities of Cantabria and the Balearic Islands (Spain).

DESIGN

This was a multicentred, transversal, descriptive, and observational study on a cohort of 206 chronic patients included in a chronicity care program.

METHODS

Patients' sociodemographic variables, integral valuation, nurse follow-up records, nursing outcomes classification (NOC)/nursing interventions classification (NIC), nurse diagnoses, and hospitalization data were analysed. A descriptive analysis of all data was carried out. The bivariate analysis assessed the relation between covariables and the overall scoring in European Quality of Life Scale (EuroQuol-5D), Barthel, Braden, and Chronic Patient eXperience Assessment Instrument (IEXPAC in the Spanish abbreviation). A multivariate linear regression analysis was conducted.

RESULTS

The mean age was 79.4 years (standard deviation (SD) = 9.12; range: 39-94). A percentage of 79.3% of the study population shows functional impairment in one or more activities of daily life. A percentage of 83.3% of patients showed a physical dependence. There is a significant relationship between the gender and kinship degree of the caregiver (χ2 = 18.2; p = 0.001). An overall mean score of 55.38 points in EuroQuol-5D was obtained, along with a 36.87-point satisfaction with the care given in IEXPAC. The overall score correlated positively and significantly with Barthel, Braden, and IEXPAC. The dependence levels improved slightly in the observed patients, which was a very significant outcome in statistical terms (t = 2.08; p = 0.039). A percentage of 66% (R2 = 0.66) of the score variability at the Barthel index could be predicted from Braden scale scoring.

CONCLUSIONS

Dependence is not only affected by the related pathology, but also by the effect on mobility and daily-life activities, which cause a worse perception of the quality of life. The health-care model based on the case management nurse is having positive effects, especially on dependence and patients with ulcer issues.

Advanced Nursing Practice in Austria under consideration of outcome measurement

BACKGROUND

Internationally, Advanced Practice Nurses (APN) are associated with improvements when measuring results in health care. Advanced Nursing Practice (ANP) refers to an extended nursing care with the aim of meeting the changing conditions in health care systems by providing evidence-based practice. APN outcomes are the endpoints of nursing interventions based on clinical experience, scientific knowledge, and practical skills. Due to the challenges in health care systems, Advanced Practice Nurses have become well established internationally in various fields.

PROBLEM

In Austria, the first nurses are currently trained in Advanced Nursing Practice on a master's level according to the International Council of Nurses core curriculum (ICN). However, national implementation and evaluation strategies are still missing.

OBJECTIVE

The aim of this short report is (i) to show the current situation of APNs in Austria, and (ii) to underline the importance of measuring APN outcomes in implementing this role for future developments in health care.

METHOD

A literature search was conducted in CINAHL (Cumulative Index to Nursing and Allied Health), PubMed, and the Cochrane Library in the period 09/2019 to 01/2020.

RESULTS

With the help of APNs and coordinated, holistic, patient-centered care, a higher quality of care for different patient groups is clearly evident. The cost-effectiveness and the positive experience of both patients and nursing staff have been demonstrated in international studies. In particular, the guidance and educational skills of APNs have been shown to improve health outcomes in vulnerable population groups.

CONCLUSION

With regard to the implementation of APNs in the health care system, more focus is needed on the measurement of outcomes in nursing research. Outcome research has been shown to help identify the unique effect of APNs in patient care and to highlight the health-related improvements through Advanced Nursing Practice for health policy and further developments in the health care system.

The role of the future physician: building on shifting sands

The role of the future physician in the NHS is of interest to current doctors, patients, policymakers and the wider public. Amid the COVID-19 pandemic, it has never been more clear that the healthcare needs of the population, and the technical and scientific advances with which to solve them, are rapidly evolving and the medical workforce must adapt to these changes to deliver personalised healthcare. This article considers the current challenges that need to be addressed to deliver a future physician-led healthcare service that works for its patients. Key themes are expanded upon, including the changing healthcare workforce, digital and technological innovation, service delivery, complex conditions and changing patient demographics. The impact and challenges of the ongoing COVID-19 pandemic on these factors are highlighted. Avenues for development are suggested, both in postgraduate medical training and the health service as a whole. These changes will be required to deliver the physicians of the future, imbued with the skills and attributes they will need to provide a high standard of care in the mid-21st century.

Implementation of a new cardiology hospital service leveraging nurse practitioners to improve patient access and outcomes

BACKGROUND

Delays in patient access due to excessive wait times for clinic consult appointments impair timely diagnosis and treatment, resulting in worse outcomes.

LOCAL PROBLEM

Average days wait (ADW) for clinic consult appointments for the cardiology group of a regional managed care organization was too long. A quality improvement project (QIP) was undertaken to improve efficiency/efficacy of patient coverage and reduce ADW by implementing a new cardiology hospital service with expanded roles for nurse practitioners (NPs).

METHODS AND INTERVENTION

The QIP used the Institute for Healthcare Improvement's Model for Improvement. The new cardiology hospital service deployed a group of 11 cardiologists and three cardiology NPs who rotated between hospital and clinic service. Two cardiologists and one NP covered all cardiology inpatients, alleviating the need for clinic-assigned cardiologists to also see hospitalized patients, thus improving capacity. The primary measure was ADW, whereas secondary measures included patient satisfaction with access, hospital readmissions, clinic cancellations, and provider job satisfaction.

RESULTS

All measures were assessed on pre/post 6-month averages. Average days wait reduced from 28 to 14; patient satisfaction improved from 39% to 52%; readmissions reduced from 13.2% to 9.7%, and provider job satisfaction with the intervention was 91% positive. There were no significant changes in potential confounding factors and no identified negative consequences.

CONCLUSIONS

Implementation of a cardiology hospital service leveraging NPs was feasible, increased capacity to improve patient access and associated outcomes, and did not manifest any known adverse impacts.

The UK haemophilia specialist nurse: Competencies fit for practice in the 21st century

Introduction

Nurses play a central co‐ordinating role in delivering comprehensive care for people with haemophilia and allied bleeding disorders, for which they need a broad range of competencies. The UK Haemophilia Nurses Association (HNA) published a role description in 1994 which was developed into a competency framework in 2014. This has now been updated to reflect current educational and clinical practice.

Aim

To summarize the evidence supporting the nurse's advanced role within haemophilia care and develop new competencies to deliver comprehensive care within a multidisciplinary team.

Methods

Systematic reviews were identified by PubMed literature search. The HNA conducted workshops to consult its membership, and the authors incorporated this input to update its competency framework within the structure outlined by Health Education England in multiprofessional framework for advanced clinical practice in England (2017).

Results

The proposed framework includes five domains (Clinical knowledge, Clinical/direct care, Communication and support, Collaborative practice and Research) supported by indicators for four levels of practice (beginner, competent, proficient and expert). The framework is a tool which nurses and their managers can use to assess skills and knowledge, and identify learning needs appropriate to personal development and improve patient care and outcomes.

Conclusion

The HNA has developed a new competency framework to provide a strong foundation for haemophilia specialist nurses to continue improving services for people living with bleeding disorders and their families, as well as supporting personal development alongside new therapeutic options, models of care and follow‐up.

Advanced Nurse Practitioners' (Emergency) perceptions of their role, positionality and professional identity: A narrative inquiry

AIMS

To explore Advanced Nurse Practitioners' (ANP) (Emergency) perceptions of their role, positionality and professional identity.

BACKGROUND

Advanced nursing practice was formally established in the Republic of Ireland in 2001 with 336 ANPs currently registered, projection increasing to a critical mass of 750 by 2021. Advanced practitioners (Emergency) give full emergency care for a specific cohort of clients with unscheduled, undifferentiated and undiagnosed conditions.

DESIGN

Qualitative narrative inquiry using Bourdieu's concepts of habitus, field and capital as the theoretical framework was undertaken.

METHODS

Data were collected in 10 in-depth interviews and thematic analysis applied.

RESULTS

Five key themes emerged: participants' career pathways, personal and professional transitions, role dimensions and core concepts, and position in the organization and emergent professional identity. Role transitioning and a change in habitus, field and capital revealed the uniqueness of their nursing role. Minimizing waiting times, timely patient care and patient satisfaction were key performance indicators. A heightened awareness regarding higher-level decision-making, autonomy and accountability is integral to advanced practice.

CONCLUSION

This study presents unique insights into the ANP role covering recruitment, organizational culture changes required and support to ease transition emerged.

IMPACT

Better understanding the motivation to undertake the role, the transition experience and use of advanced practice skills sets will inform the targets for the future recruitment and retention of ANPs are met nationally and internationally. Dissatisfaction with previous management roles and wanting to be clinically close to patients were motivations to follow an advanced practice clinical career trajectory. Positionality and emergent professional identity are key enablers ensuring that advanced practitioners' roles demonstrate the attributes of advanced practice. Educators could use the findings to develop recruitment, retention and progression strategies. Disseminating the role and scopes of practice could positively influence collaborative models of service delivery and policy development.

Advanced Practice Nursing in Primary Health Care in the Spanish National Health System

The primary health care in the Spanish National Health System is organised in health centres with multi-professional teams, composed of doctors and nurses specialised in family and community health, in addition to other professionals. This article analyses the role of primary health care nurses in the Spanish National Health System. In the last decade, new concepts of task sharing between doctors and nurses as well as advanced nursing roles have been evolved in the health centres that focus on improving care for chronically ill patients and access to primary care. With shared responsibility, nurses are responsible for chronic patients in stable conditions, health prevention and promotion. The scaling up of advanced nursing tasks is limited by uncertainties of roles, disparities between states, and legislations that do not cover the full extent of advanced nursing tasks. The case study of Spain indicates that a strong multi-professional model of primary health care teams is a crucial basis for the evolvement of advanced nursing practice and its acceptance in daily routines. However, advantageous education structures and legislations are needed to allow nurses to develop their contribution in the full potential.

Evidence characterising skills, competencies and policies in advanced practice critical care nursing in Europe: a scoping review protocol

INTRODUCTION

The management of critically ill patients is challenged by increasing population age and prevalence of comorbid diseases. High-quality intensive care nursing practice is imperative to accommodate these issues. The roles of the nurse practitioner (NP) and the acute care NP have existed for decades in the USA, Canada and Australia but are still evolving in Europe. Some European countries have introduced the advanced practice nurse (APN), but the current standard of the advanced level of nursing is variable and consensus regarding the framework, role and definition is lacking. Literature and evidence are sparse as well. Identification of skills and competencies required for the APN is warranted. Mapping skills and competencies will enable future educational harmonisation and facilitate mobility of the advanced-level intensive care nursing workforce across Europe. The aim of our scoping review is to identify literature describing skills, competencies and policies characterising advanced nursing practice in intensive care across Europe.

METHODS AND ANALYSIS

We will apply a five-stage scoping review methodology with a comprehensive systematic literature search as outlined by Arksey and O'Malley. In collaboration with a research librarian, we will search nine interdisciplinary databases and grey literature for publications originating in European countries in 1992-2018. Using a two-stage screening process with Covidence to remove duplicates, we will first scan the title and abstract and then perform full-text review to determine the eligibility of the papers. Qualitative content analysis will be used to chart the data.

ETHICS AND DISSEMINATION

Our study is a part of the European Union-funded INACTIC project (International Nursing Advanced Competency-based Training for Intensive Care) with the overall aim of developing a common European curriculum for advanced practice critical care nursing. Results from this scoping review mapping the evidence of APNs in Europe will be presented at national and international conferences and published in a peer-reviewed journal.

Ward staff perceptions of the role of the advanced nurse practitioner in a 'hospital at day' setting

AIM

to examine ward staff perceptions on the role of the 'hospital at day' advanced nurse practitioner (ANP). This term is used locally to refer to a model first introduced into 'hospital at night' teams, in response to changes in working patterns of junior doctors, where an advanced nurse practitioner is based on the ward-the model was subsequently rolled out to daytime teams.

METHODS

a qualitative descriptive phenomenological approach was adopted to carry out this study with a purposive sample of ten participants. Participants were interviewed individually using semi-structured interviews to gain insights into their perceptions on the role of the ANP, following Colaizzi's analytical model of data analysis.

FINDINGS

four major themes were identified. The first overarching theme was effectiveness of the ANP role. There was evidence that the role was not only clinically effective in the ward but also in relation to organisational priorities such as impact on patient flow. Secondly it was acknowledged that having an ANP based on the ward and as a 'constant' in the ward area, when medical teams rotate, provides team stability and improves the functioning of the ward area. Despite the positivity recognised, the third theme identified that having a ward-based ANP may affect skill acquisition and development and may lead to the 'de-skilling' of staff. Lastly it was acknowledged that there remains an overall confusion about the role of the ANP.

CONCLUSION

the themes identified reflect what is already known about the wider perceived role of the ANP. Moreover, this study adds to the limited literature available specifically on the benefits of the ANP within 'hospital at day' roles.

The framework for developing nursing specialist roles in the health care system of Iran

BACKGROUND

A key step to the development of a roadmap for developing nursing specialist roles is to create its framework based on the immediate context.

PURPOSE

This study aimed to create the framework for developing nursing specialist roles in the health care system of Iran.

METHODS

This was a descriptive qualitative study. A purposeful sample of 81 nursing and nonnursing experts was recruited. The directed content analysis approach was used for data analysis.

FINDINGS

The framework for developing nursing specialist roles in the health care system include eight main categories. These categories are role titles, prioritization of the necessary specialties, the necessary competencies of nurses at specialist level, the scope of nursing specialist practice, expected authorizations, requirements for role development, and its barriers and facilitators.

DISCUSSION

Creating a context-based framework for nursing specialist role development based on the characteristics of each country is recommended.

Exploring nursing competence to care for older patients in municipal in-patient acute care: A qualitative study

AIM

To identify critical aspects of nursing competence to care for older patients in the context of municipal in-patient acute care.

BACKGROUND

An increasingly complex and advanced primary healthcare system requires attention to the extent of nursing competence in municipal services. However, competence in complex and advanced care settings must be explored using perspectives which acknowledge the complexity of nurses' performance.

DESIGN

A phenomenological hermeneutic, qualitative approach with individual in-depth interviews was used. COREQ reporting guidelines have been applied.

METHODS

A sample of eight nurses and two physicians employed in municipal in-patient acute care units (MAUs) were purposively recruited to participate. Data were collected between May and June of 2017. Analysis and interpretation were conducted systematically in three steps: naïve reading, structural analysis and comprehensive understanding.

FINDINGS

Two main themes were revealed. The first was the following: "The meaning of the individual nursing competence" including the themes "Having competence in clinical assessments, decision-making, and performing interventions"; "Having competence to collaborate, coordinate and facilitate"; and "Being committed." The second was the following: "The meaning of environmental and systemic factors for nursing competence," included the themes "Having professional leadership"; "Having a sufficiently qualified staff"; and "Working in an open, cooperative and professional work environment."

CONCLUSION

Individual nursing competence in MAUs should include the capability to detect patient deterioration and to care for older patients in a holistic perspective. In addition, the professional environmental culture, supportive leadership and systemic factors seemed to be crucial to success.

RELEVANCE TO CLINICAL PRACTICE

This study illustrates the nurses' responsibility for older patients' safety and quality of care in the MAUs. These findings can act as a foundation for the development and adaptation of educational programmes to accommodate requirements for nursing competence in MAUs. The broad perspective of nursing competence can give directions for quality improvements in MAUs.

Patient-reported perceptions of care after the introduction of a new advanced cancer nursing role in Sweden

PURPOSE

Extensive research results show quality improvements associated with advanced cancer nursing roles. Despite this, these roles are not implemented in many countries. The aim of this cross-sectional, population-based study was to compare patients' perception of care, before and after the introduction of a new advanced nursing role, the coordination contact nurse (CCN), in a region in Sweden.

METHOD

All patients (with gynaecological, haematological, Head & Neck, upper gastrointestinal cancers) diagnosed in the region the year prior and one-year post introducing the new CCN role were identified from the Swedish Cancer Register. Data were collected using the European Organization of Research and Treatment of Cancer [EORTC] Quality of Life Questionnaire (QLQ-C30 and QLQ-INFO25) and a study specific questionnaire.

RESULT

The results, based on baseline (n = 869) and follow-up data (n = 1003), show statistically significant patient-reported improvements after the introduction of the CCN role, regarding health-related patient information (EORTC QLQ- INFO25 global mean score increased from 41.23 to 44.16, p = 0.0006). We found statistically significant improvements related to availability of supportive care resources, e.g. increased reported access to contact nurse (from 53% to 66%, p ≤ 0.0001) and individual written care plans (from 40% to 54%, p < 0.0001). We also found some improvements related to patient involvement and care coordination, but also room for further developments.

CONCLUSION

The implementation of the new advanced cancer nursing role may have contributed to important improvements, but it has also identified areas in need of development. Further research with long-term evaluations of CCN roles in other contexts, are both needed and on-going.

Nurse Practitioners in Orthopaedic Surgical Settings: A Review of the Literature

PURPOSE:

The purpose of this article was to conduct an extensive literature review of nurse practitioners (NPs) in orthopaedic surgical settings to delineate whether a need exists for NPs in these settings.

BACKGROUND:

Due to physician shortages and changes in healthcare, patients are experiencing difficulty accessing orthopaedic surgeons. To meet this need, NPs are becoming an essential part of the multidisciplinary orthopaedic team in Level 1 trauma hospitals.

RESULTS:

Nurse practitioners are qualified and competent to work in a variety of orthopaedic settings including preoperative clinics, primary care orthopaedic clinics, and pre-/postoperative care within the hospital. The benefits of NPs in orthopaedic surgical settings includes increased access to care, improved team communication, decreased length of stay, improved quality of care, and improved patient satisfaction. Moreover, NPs meet patient needs while surgeons are operating, and have a positive impact on resident surgeon education.

CONCLUSION:

A need exists for NPs in orthopaedic surgical settings to both improve access to healthcare for patients and reduce the burden on orthopaedic surgeons.

A study of macro-, meso- and micro-barriers and enablers affecting extended scopes of practice: the case of rural nurse practitioners in Australia

BACKGROUND

Shortages of skills needed to deliver optimal health care in rural and remote locations raises questions about using extended scopes of practice or advanced practice models in a range of health professions. The nurse practitioner (NP) model was introduced to address health service gaps; however, its sustainability has been questioned, while other extended scope of practice roles have not progressed in Australia. This study aimed to explore the experiences and perceptions of NPs and their colleagues about barriers to and enablers of extended scope of practice and consider the relevance of the findings to other health professions.

METHODS

Semi-structured, in-depth interviews were conducted with primary, nurse practitioner informants, who were also invited to nominate up to two colleagues, as secondary informants. Data analysis was guided by a multi-level, socio-institutional lens of macro-, meso- and micro-perspectives.

RESULTS

Fifteen primary informants and five colleagues were interviewed from various rural and remote locations. There was a fairly even distribution of informants across primary, aged, chronic and emergency or critical care roles. Key barriers and enablers at each level of analysis were identified. At the macro-level were legal, regulatory, and economic barriers and enablers, as well as job availability. The meso-level concerned local health service and community factors, such as attitudes and support from managers and patients. The micro-level relates to day-to-day practice. Role clarity was of considerable importance, along with embedded professional hierarchies and traditional role expectations influencing interactions with individual colleagues. Given a lack of understanding of NP scope of practice, NPs often had to expend effort promoting and advocating for their roles.

CONCLUSIONS

For communities to benefit from extended scope of practice models of health service delivery, energy needs to be directed towards addressing legislative and regulatory barriers. To be successful, extended scope of practice roles must be promoted with managers and decision-makers, who may have limited understanding of the clinical importance. Support is also important from other members of the interprofessional health care team.

Evidence-based practice among epilepsy specialist nurses in the Republic of Ireland: Findings from the SENsE study

AIM

To describe how epilepsy specialist nurses in Ireland enact the evidence-based practice dimension of their role.

BACKGROUND

The importance of epilepsy specialist nurses (ESNs) delivering evidence-based care to people experiencing epilepsy is unquestionable, yet research into this aspect of the role is relatively sparse.

METHODS

A qualitative design was used, involving 12 epilepsy specialist nurses working in five units in Ireland, 24 multidisciplinary team members working with them and 35 people with epilepsy and their family members. Data were collected using individual and focus group interviews, observation and documentary analysis.

RESULTS

These ESNs were active in accumulating, translating, applying, generating and disseminating evidence. All were actively involved in, or leading audit and service evaluations, and used findings to improve practice. Their research activity mainly consisted of small-scale unfunded research projects.

CONCLUSIONS

These ESNs acted as opinion leaders and role models in relation to evidence-based practice, including the generation of new knowledge through audit and research.

IMPLICATIONS FOR NURSING MANAGEMENT

Organisations and managers need to support ESNs by ensuring that they have the necessary resources and competencies to accumulate, translate, apply, generate and disseminate relevant evidence. Future research should explore the impact of ESNs' evidence-based practice on patient outcomes.

Experience of the impact of physician associates on -postgraduate medical training: A mixed methods -exploratory study

The introduction of new professional roles to the multidisciplinary team has been heralded as a way to facilitate medical education in the face of increasing service pressures. However, concerns have been raised that the training of new healthcare professionals will dilute the availability of learning opportunities, thereby detracting from postgraduate medical education. As part of a mixed methods exploratory study, the experienced impact of newly qualified physician associates on medical training was explored. Within 6 months of newly qualified physician associates being introduced, half of junior doctors reported no overall impact on their training and a third felt that their training was enhanced by the presence of physician associates. A minority of trainees experienced dilution of training opportunities. The findings support the notion that new healthcare professionals do not detract from medical training and suggest that roles such as the physician associate have potential to enhance postgraduate medical education.

Relevance of a specialised nurse in thoracic surgery

This review of the development of a specialist nursing service within a thoracic surgery centre looks at the implementation of a specialist nursing role. An analysis of the needs of the service allowed identification of areas where specialist nursing input could have a positive impact on the patient pathway: (I) a nurse-led clinic for review of patients who require early review after discharge, in particular those discharged home with chest drains, was developed; (II) improvements to the patient pathway such as day of surgery admission were introduced along with a reduction in the number of patients who require admission to intensive care after surgery; (III) the specialist nurse leads on the introduction of new technology such as electronic chest drains. The specialist nurse works in the follow-up clinic, seeing patients autonomously, with a particular emphasis on patients under long-term follow-up after thoracic surgery. A telephone clinic has been introduced for patients on long-term CT follow-up. These are well received by patients; (IV) specialist nurses also work on in-patient wards, providing specialist input to the patient pathway, and can also take on work traditionally undertaken by junior medical staff. To be successful the specialist nursing role needs to be supported by the multidisciplinary team (MDT). These roles are developed to meet the needs of each unit and can have a very positive impact on the patient pathway.

What are the motivating and hindering factors for health professionals to undertake new roles in hospitals? A study among physicians, nurses and managers looking at breast cancer and acute myocardial infarction care in nine countries

BACKGROUND

Many European countries experience health workforce skill-mix changes due to population ageing, multimorbidity and medical technology. Yet, there is limited cross-country research in hospitals.

METHODS

Cross-sectional, observational study on staff role changes and contributing factors in nine European countries. Survey of physicians, nurses and managers (n = 1524) in 112 hospitals treating patients with breast cancer or acute myocardial infarction. Group differences were analysed across country clusters (skill-mix reform countries [England, Scotland and the Netherlands] versus no reform countries [Czech Republic, Germany, Italy, Norway, Poland and Turkey]) and stratified by physicians, nurses and managers, using Chi-squared, Mann-Whitney U and Kruskal Wallis tests.

RESULTS

Nurses in countries with major skill-mix reforms reported more frequently being motivated to undertake a new role (66.5%) and having the opportunity to do so (52.4%), compared to nurses in countries with no reforms (39.2%; 24.8%; p < .001 each). Physicians and nurses considered intrinsic motivating factors (personal satisfaction, use of qualifications) more motivating than extrinsic factors (salary, career opportunities). Reported barriers were workforce shortages, facilitators were professional and management support. Managers' recruitment decisions on choice of staff were mainly influenced by skills, competences and experience of staff.

CONCLUSION

Managers need to know the motivational factors of their employees and enabling versus hindering factors within their organisations to govern change effectively.