Consensus on an Australian Nurse practitioner specialty framework using Delphi methodology: results from the CLLEVER 2 study

Practice pathways, education, and regulation influencing nurse practitioners' decision to provide primary care: a rapid scoping review

BACKGROUND/OBJECTIVE

Initially established to improve access to healthcare, particularly for primary care, the full potential of the nurse practitioner role is yet to be realised in most countries. Despite this, most countries are working to meet an ageing population's increasing healthcare needs and reduce healthcare costs and access disparities. Achieving these outcomes requires reform at multiple levels, including nurse practitioner practice pathways, education and regulation, and identifying the barriers and facilitators to optimising their primary care role.

METHODS

A rapid scoping review of nurse practitioner practice pathways, education and regulation inclusive of: (1) a systematic search of Medline and CINAHL for peer-reviewed English language articles, including opinion pieces published between January 2015 and February 2022; and (2) a web-based search of nurse practitioner program entry requirements of International Nurse Regulator Collaborative country members with a protected nurse practitioner title and prescribing rights, plus the Netherlands. The individually summarised search data was integrated and synthesised using Popay's narrative approach.

RESULTS

Emerging evidence from the included nurse practitioner courses (n = 86) and articles (n = 79) suggests nurse practitioners working in primary care provide safe, effective care and improve healthcare efficiencies. However, different regulatory and educational models are required if the primary care nurse practitioner is to meet growing demand.

CONCLUSIONS

International variations in entry criteria, curriculum, and regulation shape the global profile of the nurse practitioner primary care workforce and their practice setting. For countries to grow their primary care nurse practitioner workforce to meet unmet needs, different entry requirements, program content and accredited post-registration transitional programs must be urgently considered.

Nurse practitioner and midwife antibiotic prescribing in Australia

INTRODUCTION

Antimicrobial resistance is of global significance. To reduce the risk of harm associated with antibiotic prescribing in Australia, a recent strategy to tackle antimicrobial resistance has included non-medical prescribers. Traditionally, antibiotic prescribing has been the domain of the medical profession but, more recently, nurse practitioners and endorsed midwives have been authorized to prescribe antibiotics. This study describes the antibiotic prescribing practices by nurse practitioners and endorsed midwives in Australia, with clinical implications for international settings.

METHODS

This was a retrospective analysis of routinely collected aggregated data of anonymous individuals. Data on dispensed prescriptions of antibiotics were obtained from the Australian Department of Human Services, for the period 2005-2016. All antibiotics were allocated to a spectrum class (narrow, moderate, broad). Analysis using descriptive statistics was undertaken to determine the antibiotic prescribing patterns of nurse practitioners and endorsed midwives.

RESULTS

Nurse practitioners have been prescribing within Australia since 2000, and midwives since 2012. Nurse practitioner antibiotic written scripts increased from 3143 during 2005-2011 to 34615 in 2012-2016, while antibiotic written scripts by midwives increased from 2012 (n=2) to 2016 (n=469). Nurse practitioners and midwives prescribed similar classes of antibiotics. These professionals are important non-medical prescribers and are increasingly writing antibiotic prescriptions.Both nursing and midwifery cohorts complete accredited education programs, albeit with some differences in structure.

CONCLUSIONS

When prescribing antibiotics, nurse practitioners and midwives are following evidenced-based therapeutic guidelines. They are increasingly relevant clinicians prescribing antibiotics, particularly in acute and primary care settings, which has relevance in global antimicrobial strategies.

Bridging the gap: Study protocol for development of an implementation strategy for evidence-informed reablement and rehabilitation for community-dwelling people with dementia

BACKGROUND

Extensive research supports the use of goal-directed reablement and rehabilitation interventions to address a range of physical, functional, cognitive and behavioural needs of people living with dementia. Despite this, evidence-informed multidisciplinary reablement and rehabilitation interventions are not being offered in usual dementia care across Australia. An examination is needed of how best to implement reablement and rehabilitation interventions within the community-based dementia care sector.

METHODS

Drawing on implementation science, this study uses a four-phase mixed-methods retrospective and prospective approach: (1) clinical audit to evaluate current clinical practice, and through focus groups with practitioners, identify practitioner-led goals and targets for practice change; (2) Delphi survey to converge opinions from the diverse stakeholders involved in reablement in dementia, to reach national consensus around an implementation strategy; (3) hybrid pragmatic effectiveness-implementation pilot will facilitate testing of the implementation strategy in parallel with exploring effectiveness of the reablement intervention specifically within a real-world Australian community aged care context; (4) implementation capacity building.

DISCUSSION

This study will result in a freely available, nationally relevant implementation protocol, designed and tailored via input from key stakeholders over a series of iterative project activities. By testing this protocol via a pilot implementation-effectiveness study, we will generate national information about effectiveness of evidence-informed reablement programs for people living with dementia across various community aged care settings. Outcomes have potential to influence policy and drive widespread practice change, increasing access to evidence-informed reablement and rehabilitation for people living with dementia across Australia.

Identifying the core competencies of backup nurses in the acute care hospital through a modified Delphi process†

Background

The backup nurses are created to meet emergencies in the case of inadequate nursing staff and emergency circumstances, and there are no clear definitions of the core competencies for training and evaluation of backup nurses in the acute care hospitals in China.

Methods

This study used a modified Delphi process where an initial list of potential competencies is established following a framework of training need analysis (TNA), literature review, and focus groups. This process generated as a list of 47 core competencies, which is presented to an expert panel (n = 20) for consideration in two rounds.

Results

As determined by the survey, a combination of 26 core competencies in three specified categories is identified: professional practice ability, critical thinking ability, and interpersonal skills. A total of 154.99 h is required to complete all 26 core competencies, and each item has a corresponding evaluation method.

Conclusions

The core competencies provide a scientific basis for the hospital nursing managers to train and evaluate backup nurses, and it may ensure consistency in standards across the country.

Practice expectations for Australian graduate emergency nursing programs: A Delphi study

BACKGROUND

Practice standards in nursing provide minimum expectations to enable the provision of high quality and safe care. There are currently no practice standards for post-registration graduate emergency nursing programs in Australia, leading to variation in graduate attributes and clinical expectations on completion of their program.

OBJECTIVES

The aim of this study was to establish consensus-based practice standards for graduate emergency nursing programs in Australia.

DESIGN

Delphi approach.

PARTICIPANTS

Australian nurses who identified as an emergency nurse and currently worked, or previously worked, in an emergency care environment.

METHODS

A modified two-round Delphi method was used. The survey was divided into four sections of data collection, including demographics, graduate emergency nursing course entry requirements, graduate expectations, and clinical care capabilities. Data were analysed using descriptive statistics including calculation of content validity index (CVI).

RESULTS

There were 204 respondents in Round One and 153 respondents in Round Two. Respondents agreed that nurses wanting to undertake graduate studies in emergency nursing require prior experience in the emergency care environment and should be working a minimum of 0.5 full time equivalent (FTE) whilst completing their studies. Thirty-nine statements presented under graduate attributes achieved a CVI of >0.8. All 70 clinical care capability statements presented in Round Two achieved a CVI of >0.8.

CONCLUSION

This study generated the evidence to establish minimum practice standards for Australian graduate emergency nursing programs. The standards centre around three key areas: graduate entry requirements, graduate attributes and clinical care capabilities. The standards provide a clear guide for employers, educators and clinicians, and inform capabilities for early career emergency nurses.

Exploring healthcare professionals' perceptions of artificial intelligence: Validating a questionnaire using the e-Delphi method

Objective

The aim of this study was to draw upon the collective knowledge of experts in the fields of health and technology to develop a questionnaire that measured healthcare professionals' perceptions of Artificial Intelligence (AI).

Methods

The panel for this study were carefully selected participants who demonstrated an interest and/or involvement in AI from the fields of health or information technology. Recruitment was accomplished via email which invited the panel member to participate and included study and consent information. Data were collected from three rounds in the form of an online survey, an online group meeting and email communication. A 75% median threshold was used to define consensus.

Results

Between January and March 2019, five healthcare professionals and three IT experts participated in three rounds of study to reach consensus on the structure and content of the questionnaire. In Round 1 panel members identified issues about general understanding of AI and achieved consensus on nine draft questionnaire items. In Round 2 the panel achieved consensus on demographic questions and comprehensive group discussion resulted in the development of two further questionnaire items for inclusion. In a final e-Delphi round, a draft of the final questionnaire was distributed via email to the panel members for comment. No further amendments were put forward and 100% consensus was achieved.

Conclusion

A modified e-Delphi method was used to validate and develop a questionnaire to explore healthcare professionals' perceptions of AI. The e-Delphi method was successful in achieving consensus from an interdisciplinary panel of experts from health and IT. Further research is recommended to test the reliability of this questionnaire.

Development of nurse practitioner metaspecialty clinical practice standards: A national sequential mixed methods study

AIM

To achieve profession-wide consensus on clinical practice standards for six broad Australian nurse practitioner specialty areas (termed metaspecialties).

DESIGN

Sequential mixed methods with initial interpretive study (Interpretive Phase) followed by modified three-round Delphi study (Survey Phase).

METHODS

Participants from all Australian jurisdictions were recruited. Main eligibility criterion was current endorsement as a nurse practitioner for 12 or more months. Interpretive Phase comprised in-depth interviews of purposeful sample of nurse practitioners to identify clinical care activities and practice processes. Six sets of draft clinical practice standards relevant to six previously identified metaspecialties were developed. Outcome informed Round 1 of Survey Phase (six nested web-based Delphi surveys), with draft standards reviewed profession-wide. Responses comprised scoring using Likert scales to calculate content validity indexes for individual standards with qualitative responses supporting decision-making. For Rounds 2 and 3, participants rated relevancy of original or revised standards after consideration of individual and group feedback. The study was conducted 2014-2017.

RESULTS

Interpretive Phase: Analysis of interview data with 16 nurse practitioners provided 75 draft standards. Survey Phase: 221 nurse practitioners completed Round 1 (20% of then eligible Australian nurse practitioners). Weighted respondent retention was 92%. Seventy-three standards were validated, with final content validity indices of 92-100%. Scale-level indices were 98%, strongly validating metaspecialty taxonomy.

CONCLUSION

A research-derived, professionally endorsed suite of nurse practitioner clinical practice standards was developed. This provides a broad clinical learning structure with metaspecialties guiding nurse practitioner student clinical education.

IMPACT

The clinical practice standards and metaspecialty taxonomy strengthen nurse practitioner clinical education and professional development nationally and internationally. These novel study methods and findings are applicable to advanced specialty roles in other health professions.

Use of the Delphi method to generate guidance in emergency nursing practice: A systematic review

AIM

To examine the application and methodological quality of the Delphi method used in developing guidance for emergency nursing practice.

BACKGROUND

Emergency nursing scope of practice has rapidly expanded in response to increasing patient acuity, complexity and technological innovation. Determining best practice is crucial for delivering high quality, safe and effective emergency nursing care. The Delphi method has been used to identify, prioritise complex issues and develop evidence-driven guidance in emergency nursing practice. The use and quality of the Delphi method in emergency nursing practice has not been examined.

DESIGN

Systematic literature review.

DATABASES AND DATA TREATMENT

A systematic literature search was conducted using the following databases: SCOPUS, EMBASE, Medline and ProQuest from date of inception to August 2019. The database search was limited to scholarly articles or peer-reviewed journals. No language restrictions were applied. The Cochrane Collaboration method and PRISMA checks were utilized to conduct the review.

RESULTS

Of 246 records identified 22 (8.9%) studies met the inclusion criteria. A modified Delphi method was commonly used (n = 15; 68.2%) and often conducted online (n = 11; 50.0%). Eight practice guidance themes were identified. Overall study quality was high (score 12/14; range 4-13), transparency of reporting varied.

CONCLUSION

Based on this review, the Delphi method is an appropriate method for exploring emergency nursing practice. The studies reviewed demonstrated that knowledge, skills and clinical expertise has progressively expanded in the specialty of emergency nursing. Variation in the application, conduct and transparency of reporting in Delphi studies developing guidance for emergency nursing practice is discussed.

Are service and patient indicators different in the presence or absence of nurse practitioners? The EDPRAC cohort study of Australian emergency departments

OBJECTIVES

To evaluate the impact of nurse practitioner (NP) service in Australian public hospital emergency departments (EDs) on service and patient safety and quality indicators.

DESIGN AND SETTING

Cohort study comprising ED presentations (July 2013-June 2014) for a random sample of hospitals, stratified by state/territory and metropolitan versus non-metropolitan location; and a retrospective medical record audit of ED re-presentations.

METHODS

Service indicator data (patient waiting times for Australasian Triage Scale categories 2, 3, 4 and 5; number of patients who did not-wait; length of ED stay for non-admitted patients) were compared between EDs with and without NPs using logistic regression and Cox proportional hazards regression, adjusting for hospital and patient characteristics and correlation of outcomes within hospitals. Safety and quality indicator data (rates of ED unplanned re-presentations) for a random subset of re-presentations were compared using Poisson regression.

RESULTS

Of 66 EDs, 55 (83%) provided service indicator data on 2 463 543 ED patient episodes while 58 (88%) provided safety and quality indicator data on 2853 ED re-presentations. EDs with NPs had significantly (p<0.001) higher rates of waiting times compared with EDs without NPs. Patients presenting to EDs with NPs spent 13 min (8%) longer in ED compared with EDs without NPs (median, (first quartile-third quartile): 156 (93-233) and 143 (84-217) for EDs with and without NPs, respectively). EDs with NPs had 1.8% more patients who did not wait, but similar re-presentations rates as EDs with NPs.

CONCLUSIONS

EDs with NPs had statistically significantly lower performance for service indicators. However, these findings should be treated with caution. NPs are relatively new in the ED workforce and low NP numbers, staffing patterns and still-evolving roles may limit their impact on service indicators. Further research is needed to explain the dichotomy between the benefits of NPs demonstrated in individual clinical outcomes research and these macro system-wide observations.

The use of advanced web-based survey design in Delphi research

AIM

A discussion of the application of metadata, paradata and embedded data in web-based survey research, using two completed Delphi surveys as examples.

BACKGROUND

Metadata, paradata and embedded data use in web-based Delphi surveys has not been described in the literature. The rapid evolution and widespread use of online survey methods imply that paper-based Delphi methods will likely become obsolete. Commercially available web-based survey tools offer a convenient and affordable means of conducting Delphi research. Researchers and ethics committees may be unaware of the benefits and risks of using metadata in web-based surveys.

DESIGN

Discussion paper.

DATA SOURCES

Two web-based, three-round Delphi surveys were conducted sequentially between August 2014 - January 2015 and April - May 2016. Their aims were to validate the Australian nurse practitioner metaspecialties and their respective clinical practice standards. Our discussion paper is supported by researcher experience and data obtained from conducting both web-based Delphi surveys.

IMPLICATIONS FOR NURSING

Researchers and ethics committees should consider the benefits and risks of metadata use in web-based survey methods. Web-based Delphi research using paradata and embedded data may introduce efficiencies that improve individual participant survey experiences and reduce attrition across iterations. Use of embedded data allows the efficient conduct of multiple simultaneous Delphi surveys across a shorter timeframe than traditional survey methods.

CONCLUSION

The use of metadata, paradata and embedded data appears to improve response rates, identify bias and give possible explanation for apparent outlier responses, providing an efficient method of conducting web-based Delphi surveys.