The feasibility and acceptability of nurse-led chronic disease management interventions in primary care: An integrative review

Nurse led models of care for outpatient substance use disorder treatment: A scoping review

AIM

To map key characteristics and describe nurse led models of care for the treatment of persons with substance use disorders (SUDs) in the outpatient setting.

DESIGN

A scoping review.

METHODS

Conducted in accordance with the JBI methodology. The PRISMA-ScR checklist was used.

DATA SOURCES

Pubmed, CINAHL Complete (EBSCOhost), Cochrane Library, APA PsycNet and Scopus were searched from 1999 to May 2022 and updated on 28 November 2023. A handsearch and a grey literature search was conducted.

RESULTS

Title and abstract screening was performed on 774 articles resulting in 88 articles for full text screening. Full text screening yielded 13 articles that met inclusion criteria.

CONCLUSION

Existing nurse-led models of care for SUDS are scarce and limited in scope, with the majority focused on treating opioid use disorder. Additional research is needed to develop, test, and implement efficacious nurse-led models of care for the treatment and management of SUDs.

IMPLICATIONS TO CLINICAL PRACTICE

Nurse led models of care have demonstrated their efficacy and quality in the management of other chronic diseases. As we move forward with innovative solutions for individuals with addiction, nurse led models of care can be a mechanism to deliver high quality, evidence-based care for SUDs.

IMPACT

SUDs are chronic diseases that impact individuals, families, and communities. SUDs require a biopsychosocial approach to treatment. Globally, nurses are well positioned to provide high quality care to mitigate the impact of SUDs. This scoping review mapped the extant literature on nurse led models of care for substance use disorder treatment in the outpatient setting finding that additional research is needed to develop, test and implement evidence-based interventions to care for individuals, families, and communities experiencing SUDs.

REPORTING METHOD

PRISMA checklist for scoping reviews. No patient or public contribution were part of this study.

PROTOCOL REGISTRATION

Open Science Framework accessible at: https://doi.org/10.17605/OSF.IO/NSW7V.

The effect of consultations performed by specialised nurses or advanced nurse practitioners on patient and organisational outcomes in patients with complex health conditions: An umbrella review

BACKGROUND

Policymakers and researchers often suggest that nurses may play a crucial role in addressing the evolving needs of patients with complex conditions, by taking on advanced roles and providing nursing consultations. Nursing consultations vary widely across settings and countries, and their activities range from complementing to substituting traditional physician-led consultations or usual care.

OBJECTIVE

This study was aimed at describing the effects of nursing consultations with patients with complex conditions in any setting on patient outcomes (quality of life, physical status, psychosocial health, health behaviour, medication adherence, mortality, anthropometric and physiological outcomes, and patient satisfaction) and organisational outcomes (health resource use and costs).

DESIGN

Umbrella review.

METHODS

We followed the Joanna Briggs Institute method for umbrella reviews. We searched PubMed, Embase, Cochrane Database of Systematic Reviews and CINAHL to identify relevant articles published in English, Dutch, French, Spanish or German between January 2013 and February 2023. We included systematic literature reviews, with or without meta-analyses, that included randomised controlled trials conducted in high-income countries. Reviews were eligible if they pertained to consultations led by specialised nurses or advanced nurse practitioners. Article selection, data extraction and quality appraisal were performed independently by at least two reviewers.

RESULTS

We included 50 systematic reviews based on 473 unique trials. For all patient outcomes, nursing consultations achieved effects at least equivalent to those of physician-led consultations or usual care (i.e., non-inferiority). For quality of life, health behaviour, medication adherence, mortality and patient satisfaction, more than half the meta-analyses found statistically significant effects in favour of nursing consultations (i.e., superiority). Cost results must be interpreted with caution, because very few and heterogeneous cost-related data were extracted, and the methodological quality of the cost analyses was questionable. Narrative syntheses confirmed the overall conclusions of the meta-analyses.

CONCLUSIONS

The effects of nursing consultations on patients with complex health conditions across healthcare settings appear to be at least similar to physician-led consultations or usual care. Nursing consultations appear to be more effective than physician-led consultations or usual care in terms of quality of life, health behaviour, mortality, patient satisfaction and medication adherence. Further analysis of the primary data is necessary to determine the patient populations and settings in which nursing consultations are most effective. Moderate study quality, diversity amongst and within systematic reviews, and quality of reporting hamper the strength of the findings.

Feasibility of conducting a cohort randomized controlled trial assessing the effectiveness of a nurse-led package of care for knee pain

OBJECTIVE

To evaluate the feasibility of conducting a cohort randomized controlled trial (RCT) of a nurse-led package of care for knee pain and determining a treatment sequence for use in a future trial.

METHODS

This study was an open-label, three-arm, single-centre, mixed-methods, feasibility cohort RCT. Adults aged ≥40 years with moderate-to-severe knee pain for ≥3 months were eligible. Participants were randomized into group A (non-pharmacological treatment first), group B (pharmacological treatment first), or group C (usual care). The intervention was delivered over 26 weeks. Outcomes were dropout rate, recruitment rate, intervention fidelity, ability to collect outcome data, and treatment acceptability.

RESULTS

Seventeen participants were randomized and enrolled into each of groups A and B (5.2% recruitment rate), and 174 participants were randomized to group C. The participant characteristics at randomization were comparable across the three arms. Coronavirus disease (COVID-19) paused the study from March-November 2020. Participants enrolled in groups A and B before March 2020 were withdrawn at the restart. Of the 20 participants enrolled after the restart, 18 completed the study (10% dropout). The nurse reported delivering most aspects of the intervention with high fidelity. The participants viewed the package of care as structured, supportive and holistic, they learnt about self-managing knee pain, and they could engage with and follow the non-pharmacological treatment. Most found the non-pharmacological treatment more useful than the pharmacological treatment, preferring to receive it before or alongside analgesia. Many self-report questionnaires were not fully completed.

CONCLUSION

The nurse-led package of care for knee pain was acceptable, with low dropout, although the cohort RCT design may not be feasible for a definitive trial.

TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT03670706.

General practice nurse perceptions of barriers and facilitators to implementation of best-practice dementia care recommendations-a qualitative interview study

INTRODUCTION

With an aging population and a growing prevalence of people living with dementia, the demand for best-practice dementia care in general practice increases. There is an opportunity to better utilise the nurse role within the primary care team to meet this increasing demand in the provision of care for people living with dementia. However, general practice nurses have limited knowledge in the provision of best-practice care for people living with dementia and their carer(s). A number of best-practice dementia care recommendations contained in the Australian Clinical Practice Guidelines and Principles of Care for People with Dementia have been identified as highly relevant to the role of the general practice nurse.

AIMS

To explore general practice nurses' perspectives on published best-practice dementia care recommendations relevant to their role and identify barriers and facilitators to their implementation into clinical practice.

METHODS

Thirteen Australian general practice nurses took part in this qualitative interview study. The research questions for this study were addressed within a paradigmatic framework of social constructionism. Data were transcribed verbatim and thematically analysed.

RESULTS

There was a high level of agreement between general practice nurses that the recommendations were important, reflected best-practice dementia care and were relevant to their role. However the recommendations were perceived as limited in their usefulness to nurses' clinical practice due to being too vague and lacking direction. Four main themes were identified describing barriers and facilitators to operationalising best-practice dementia care.: creating a comfortable environment; changing approach to care; optimising the general practice nurse role and working collaboratively. Nine sub-themes were described: physical environment; social environment; complexity of care; care planning for the family; professional role and identity, funding better dementia care, education, networking and resources; different roles, one team; and interagency communication.

CONCLUSION

This study identified several factors that need addressing to support general practice nurses to integrate best-practice dementia care recommendations into daily clinical practice. The development of interventions needs to include strategies to mitigate potential barriers and enhance facilitators that they perceive impact on their delivery of best-practice care for people living with dementia and their carer(s). The knowledge gained in this study could be used to develop multi-faceted interventions informed by theoretical implementation change models to enable the general practice nurse to operationalise best-practice dementia care recommendations.

Nurses' experiences of competence in lifestyle counselling with adult patients in healthcare settings: A qualitative systematic literature review

AIMS AND OBJECTIVES

To identify and synthesise nurses' experiences of competence in lifestyle counselling with adult patients in healthcare settings.

BACKGROUND

Modifiable lifestyle risk behaviours contribute to an increased prevalence of chronic diseases worldwide. Lifestyle counselling is part of nurses' role which enables them to make a significant contribution to patients' long-term health in various healthcare contexts, but requires particular competence.

DESIGN

Qualitative systematic literature review and meta-aggregation.

METHOD

The review was guided by Joanna Briggs Institute's methodology for conducting synthesis of qualitative studies. PRISMA-checklist guided the review process. Relevant original studies were search from databases (CINAHL, PubMed, Scopus, Medic and Psych Articles, Ebscho Open Dissertations and Web of Science). After researcher consensus was reached and quality of the studies evaluated, 20 studies were subjected to meta-aggregation.

RESULTS

From 20 studies meeting the inclusion criteria, 75 findings were extracted and categorised into 13 groups based on their meaning, resulting in the identification of 5 synthesised findings for competence description: Supporting healthy lifestyle adherence, creating interactive and patient-centred counselling situations, acquiring competence through clinical experience and continuous self-improvement, collaborating with other professionals and patients, planning lifestyle counselling and managing work across various stages of the patient's disease care path.

CONCLUSION

The review provides an evidence base that can be used to support nurses' competence in lifestyle counselling when working with adult patients in healthcare settings. Lifestyle counselling competence is a complex and rather abstract phenomenon. The review identified, analysed and synthesised the evidence derived from nurses' experience which shows that lifestyle counselling competence is a multidimensional entity which relates to many other competencies within nurses' work.

IMPLICATIONS FOR THE PROFESSION

Recognising the competencies of nurses in lifestyle counselling for adult patients can stimulate nurses' motivation. The acquisition of these competencies can have a positive impact on patients' lives and their health.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

IMPACT

The research may enhance nurses' competence in lifestyle counselling, leading to improved health outcomes, better adherence to recommendations and overall well-being. It may also drive the development of interventions, improving healthcare delivery in lifestyle counselling.

REPORTING METHOD

The review was undertaken and reported using the PRISMA guidelines.

PROTOCOL REGISTRATION

Blinded for the review.

Barriers and strategies for primary health care workforce development: synthesis of evidence

BACKGROUND

Having a sufficient and well-functioning health workforce is crucial for reducing the burden of disease and premature death. Health workforce development, focusing on availability, recruitment, retention, and education, is inseparable from acceptability, motivation, burnout, role and responsibility, and performance. Each aspect of workforce development may face several challenges, requiring specific strategies. However, there was little evidence on barriers and strategies towards comprehensive health workforce development. Therefore, this review explored barriers and strategies for health workforce development at the primary health care level around the world.

METHODS

A scoping review of reviews was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews. The article search was performed in Google Scholar, PubMed, Web of Science, and EMBASE. We used EndNote x9 for managing the collected articles, screening processes, and citation purpose. The scoping review included any kind of review articles on the application of health workforce development concepts, such as availability, recruitment, retention, role and responsibility, education and training, motivation, and burnout, with primary health care and published in English anywhere in the world. Based on the concepts above, barriers and strategies for health workforce development were identified. The findings were synthesized qualitatively based on the building blocks of the health system framework. The analysis involved specific activities such as familiarization, construction of the thematic framework, indexing, charting, and interpretation. The results were presented in texts, tables, and figures.

RESULTS

The search strategies yielded 7,276 papers were found. Of which, 69 were included in the scoping review. The most frequently cited barriers were financial challenges and issues related to health care delivery, such as workloads. Barriers affecting healthcare providers directly, including lack of training and ineffective teamwork, were also prominent. Other health system and governance barriers include lack of support, unclear responsibility, and inequity. Another notable barrier was the shortage of health care technology, which pertains to both health care supplies and information technology. The most common cited effective strategies were ongoing support and supervision, engaging with communities, establishing appropriate primary care settings, financial incentives, fostering teamwork, and promoting autonomous health care practice.

CONCLUSIONS

Effective leadership/governance, a robust health financing system, integration of health information and technology, such as mobile health and ensuring a consistent supply of adequate resources are also vital components of primary health care workforce development. The findings highlight the importance of continuous professional development, which includes training new cadres, implementing effective recruitment and retention mechanisms, optimising the skill mix, and promoting workplace wellness. These elements are essential in fostering a well-trained and resilient primary health care workforce.

A comprehensive analysis concerning eating behavior associated with chronic diseases among Romanian community nurses

Introduction

Lifestyle factors, including inadequate eating patterns, emerge as a critical determinant of chronic disease. Apart from caring for patients, nurses should also take an active role in monitoring and managing their own health. Understanding the intricate relationship between nurses' eating behavior and managing their own health is crucial for fostering a holistic approach to healthcare, therefore our study aimed to evaluate eating behavior and demographic factors influencing chronic disease prevalence in a sample of community nurses from Romania.

Methods

Between October-November 2023, 1920 community nurses were invited to answer an online survey, using an advertisement in their professional network. Of them, 788 responded. In the survey, which included a semi-quantitative food frequency questionnaire with 53 food items, the Intuitive Eating Survey 2 (IES-2), and demographic items were used.

Results

A multivariate model was built for the prediction of the association between eating behavior and other factors associated with chronic diseases. The majority of participants were females (95.1%), with the largest age group falling between 40 and 49.9 years (48.2%). Regarding the EFSA criteria for adequate carbohydrate and fat intake, 20.2% of the group have a high intake of carbohydrates, respectively, 43.4% of the group have a high intake of fat. Analysis of chronic diseases indicated that 24.9% of individuals reported at least one diagnosis by a physician. The presence of chronic disease was associated with a low level of perceived health status, with an OR = 3.388, 95%CI (1.684-6.814), compared to those reporting excellent or very good perceived health status. High stress had an OR = 1.483, 95%CI (1.033-2.129). BMI had an OR = 1.069, 95%CI (1.032-1.108), while low carbohydrate diet score had an OR = 0.956, 95%CI (0.920-0.992). Gender and IES-2 did not significantly contribute to the model, but their effect was controlled.

Discussion

By unraveling the intricate interplay between nutrition, lifestyle, and health outcomes in this healthcare cohort, our findings contribute valuable insights for the development of targeted interventions and support programs tailored to enhance the well-being of community nurses and, by extension, the patients they support.

Nurse-led lifestyle counseling in Polish primary care: the effect of current health status and perceived barriers

Introduction

Our study included counseling on diet and physical activity, smoking, e-cigarette use, and alcohol consumption. The aim was to examine the correlates of counseling provided by primary care nurses with the health status/health behaviors of nurses and the barriers in the advice provided.

Materials and methods

In 2022, we conducted a cross-sectional survey among 331 nurses employed in the primary care sector in Lodz. The questionnaire consisted of three sections: characteristics of the patient population receiving treatment and provided with healthy lifestyle counseling by nurses, barriers to the process of assessing, controlling, and guiding patients, and health status/health behaviors of nurses.

Results

Eighty percent of the nurses in our study provided advice on diet and physical activity to primary care patients. Over 70% of the survey participants performed minimal anti-smoking interventions forsmokers, 67.7% for alcohol drinkers, and 56.8% for e-cigarette users. The correlates of counseling in the field of diet and physical activity turned out to be the knowledge and skills, which enabled nurses to provide advice (OR = 2.57, p < 0.01). The correlates of the conducted minimal anti-smoking interventions in smoking patients were: subjective assessment of overweight and obesity in nurses, knowledge and skills in conducting counseling (OR = 1.92, p < 0.05), and measuring body weight, height and BMI (OR = 2.18, p < 0.01). Among the three most common barriers identified by the nurses in the process of assessing, monitoring, and guiding patients were the opinion that patients are not interested in improving their diet, physical activity, and weight loss (60.7%), lack of time (51.4%), as well as the belief that patients find it too difficult to change their current habits (54.1%).

Conclusion

The results of our survey indicate that nurses' participation in healthy lifestyle counseling in adult patients is unsatisfactory. Interventions in primary care should be designed considering the specific obstacles nurses may face in leading healthy lifestyles. Further training of nursing staff is required to increase their knowledge on healthy lifestyles.

Nurse-led models of care for metabolic syndrome in primary care: A scoping review

AIM

To identify and map out existing nurse-led models of care for treatment and prevention of metabolic syndrome in primary care settings.

DESIGN

A scoping review.

METHODS

Conducted in accordance with the JBI methodology.

DATA SOURCES

A search of the databases PubMed, CINAHL Complete, Cochrane Library, Scopus, handsearch and a grey literature search was conducted in June 2022 and updated in March 2023.

RESULTS

Title and abstract screening was performed on 926 articles resulting in 40 articles for full text screening. Full text screening yielded seven articles that met inclusion criteria.

CONCLUSION

Additional research is needed on nursing models of care to prevent and treat metabolic syndrome. Future studies should concentrate on rigour with clearly defined objective inclusion criteria.

IMPLICATIONS TO CLINICAL PRACTICE

This review contributes a synthesis of the evidence on nurse-led models for metabolic syndrome in primary care.

IMPACT

This scoping review addresses metabolic syndrome, the precursor to non-communicable disease. The review mapped the evidence for nurse-led models of care for metabolic syndrome in the primary care setting. These findings promote the development and evaluation of novel nurse-led models of care which can mitigate the effect of the current epidemic.

REPORTING METHOD

PRISMA checklist for scoping reviews. No patient or public contribution was part of this study.

PROTOCOL REGISTRATION

Open Science Framework accessible at: https://osf.io/jfpw7/.

Examining nursing processes in primary care settings using the Chronic Care Model: an umbrella review

BACKGROUND

While there is clear evidence that nurses can play a significant role in responding to the needs of populations with chronic conditions, there is a lack of consistency between and within primary care settings in the implementation of nursing processes for chronic disease management. Previous reviews have focused either on a specific model of care, populations with a single health condition, or a specific type of nurses. Since primary care nurses are involved in a wide range of services, a comprehensive perspective of effective nursing processes across primary care settings and chronic health conditions could allow for a better understanding of how to support them in a broader way across the primary care continuum. This systematic overview aims to provide a picture of the nursing processes and their characteristics in chronic disease management as reported in empirical studies, using the Chronic Care Model (CCM) conceptual approach.

METHODS

We conducted an umbrella review of systematic reviews published between 2005 and 2021 based on the recommendations of the Joanna Briggs Institute. The methodological quality was assessed independently by two reviewers using the AMSTAR 2 tool.

RESULTS

Twenty-six systematic reviews and meta-analyses were included, covering 394 primary studies. The methodological quality of most reviews was moderate. Self-care support processes show the most consistent positive outcomes across different conditions and primary care settings. Case management and nurse-led care show inconsistent outcomes. Most reviews report on the clinical components of the Chronic Care Model, with little mention of the decision support and clinical information systems components.

CONCLUSIONS

Placing greater emphasis on decision support and clinical information systems could improve the implementation of nursing processes. While the need for an interdisciplinary approach to primary care is widely promoted, it is important that this approach not be viewed solely from a clinical perspective. The organization of care and resources need to be designed to support contributions from all providers to optimize the full range of services available to patients with chronic conditions.

PROSPERO REGISTRATION

CRD42021220004.

Family Medicine and Primary Healthcare: The Past, Present and Future

As defined by the World Health Organisation in the conference held in Alma Ata, Kazakhstan, in 1978, "Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination" [...].

Implementation of Self-Care Deficits Assessment and a Nurse-Led Supportive Education Program in Community Hospitals for Behavior Change and HbA1c Reduction: A Cluster Randomized Controlled Trial

BACKGROUND

The prevalence of uncontrolled type 2 diabetes has been increasing, and the nurse is a primary healthcare provider to patients when health professionals are scarce in the community setting. A feasible intervention delivered by nurses is necessary to fulfill patients' needs to help them achieve glycemic control.

AIM

To investigate whether Thai adults with uncontrolled diabetes in community hospitals lack self-care competency and whether a nurse-led supportive education program can enhance their self-care skills, change behavior, and control HbA1C levels.

METHODS

We employed a multi-community hospital cluster randomized controlled trial design. Participants were randomly selected in the experimental group (2 hospitals) and control group (2 hospitals), with 30 patients from each hospital. One hundred twenty adults with HbA1c 7-10% treated by oral glycemic medication were recruited. Using Orem's Theory as a framework, nurses implemented self-care deficit assessments and supportive-educative nursing programs into their work. Participants in the control group received usual care, and those in the experimental group underwent a nurse assessment and supportive education measures. Data were collected at baseline, with 4-week and 12-week follow-ups. Data analysis were a repeated measures ANOVA with post hoc analysis, and Independent t-test.

RESULTS

One hundred three patients completed the trial (51 in the experimental group and 52 in the control group). At 12 weeks, there were statistically significant improvements in HbA1c (P < .001), fasting plasma glucose (P = .03), knowledge (P < .001), diabetes self-care agency (P < .001), diet consumption (P < .001), physical activity (P < .001), and medical adherence (P = .03) in the experimental group significantly greater than those in the control group. Also, the between-group effect sizes were 0.49 or greater.

CONCLUSION

The self-care deficit assessment and supportive education program were essential to the nursing intervention that effectively improved knowledge, changed behavior, and HbA1c levels among adults with uncontrolled blood glucose.

Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: A qualitative exploration using the Theoretical Framework of Acceptability

Introduction

Medication errors are an important cause of morbidity and mortality. The pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) intervention was shown to reduce medication errors when tested in a cluster randomised controlled trial and when implemented across one region of England. Now that it has been rolled out nationally, and to enhance findings from evaluations with staff and stakeholders, this paper is the first to report patients’ perceived acceptability on the use of PINCER in primary care and proposes suggestions on how delivery of PINCER related care could be delivered in a way that is acceptable and not unnecessarily burdensome.

Methods

A total of 46 participants living with long-term health conditions who had experience of medication reviews and/or monitoring were recruited through patient participant groups and social media. Semi-structured, qualitative interviews and focus groups were conducted face-to-face or via telephone. A thematic analysis was conducted and findings mapped to the constructs of the Theoretical Framework of Acceptability (TFA).

Results

Two themes were identified and interpreted within the most relevant TFA construct: Perceptions on the purpose and components of PINCER (Affective Attitude and Intervention Coherence) and Perceived patient implications (Burden and Self-efficacy). Overall perceptions on PINCER were positive with participants showing good understanding of the components. Access to medication reviews, which PINCER related care can involve, was reported to be limited and a lack of consistency in practitioners delivering reviews was considered challenging, as was lack of communication between primary care and other health-care providers. Patients thought it would be helpful if medication reviews and prescription renewal times were synchronised. Remote medication review consultations were more convenient for some but viewed as a barrier to communication by others. It was acknowledged that some patients may be more resistant to change and more willing to accept changes initiated by general practitioners.

Conclusions

Participants found the concept of PINCER acceptable; however, acceptability could be improved if awareness on the role of primary care pharmacists is raised and patient-pharmacist relationships enhanced. Being transparent with communication and delivering streamlined and consistent but flexible PINCER related care is recommended.

Australian general practice experiences of implementing a structured approach to initiating advance care planning and palliative care: a qualitative study

OBJECTIVES

Initiation of advance care planning (ACP) and palliative care (PC) assessments in general practice is key to quality end-of-life care. The Advance Project promotes a team-based approach to initiating ACP and PC needs assessment in general practices through training, resources and practical support for implementation from local primary health networks (PHNs). This paper aims to understand: (1) general practice participants' experiences of undertaking Advance Project training and implementing the Advance Project resources in their practices; (2) barriers and facilitators to implementation of Advance Project resources; and (3) PHN staff experiences of supporting general practices through training and practical support for implementation of the Advance Project resources.

DESIGN

Qualitative study using semistructured interviews and thematic analysis.

SETTING

Twenty-one general practices and four PHNs from three Australian states were recruited between June 2019 and May 2020.

PARTICIPANTS

General practitioners (GPs), general practice nurses, practice managers (PMs) and PHN staff.

RESULTS

45 participants comprising 13 GPs, 13 general practice nurses, 9 PMs, 3 allied health staff and 7 PHN staff were interviewed. The general practice participants generally agreed that the Advance Project training/resources led to changes in their own behaviour and increased their awareness of the importance of ACP/PC discussion with their patients. Participants reported the following benefits for patients: increased awareness of ACP; engagement with families/carers and peace of mind. Key facilitators for successful implementation were a team-based approach, the role of the PHN, the role of practice champions, training facilitators' ability to influence peers and facilitate change, and mentoring support. Barriers to implementation included issues related to workplace culture, cost, time/workload, patients and health system.

CONCLUSION

Findings suggest that the Advance Project approach facilitated successful implementation of ACP and PC needs assessment into usual care in general practices that encouraged teamwork among GPs and general practice nurses. The ability of the practice to make the best use of practical support and guidance available to them through their local PHN both before and during implementation was a key factor in integration of Advance Project resources into routine practice.

Barriers and facilitators to nurse-led advance care planning and palliative care practice change in primary healthcare: a qualitative study

Primary care settings are ideal for initiating advance care planning (ACP) conversations and assessing palliative and supportive care needs. However, time constraints and a lack of confidence to sensitively and efficiently initiate such discussions are noted barriers. The Advance Project implemented a national multicomponent training package to support Australian general practice nurses (GPNs) to work with GPs to initiate ACP and palliative care conversations in their practice. This paper reports on semistructured interviews conducted with 20 GPNs to explore barriers and facilitators to implementing the Advance Project model. Participants identified a range of factors that affected implementation, including lack of time, limited support from colleagues, lack of knowledge about systems and funding processes in general practice and a need for better alignment of the Advance Project resources and practices with general practice information management platforms. Barriers related to professional roles, particularly the lack of clarity and/or limitations in the scope of practice of GPNs, highlighted the importance of defining and supporting the roles that different primary health practice staff could play to support implementation of the model. The findings underline the need for complementary training in the Advance Project model for GPs and practice managers to enable a team-based approach to implementation.

Implementability of healthcare interventions: an overview of reviews and development of a conceptual framework

Background

Implementation research may play an important role in reducing research waste by identifying strategies that support translation of evidence into practice. Implementation of healthcare interventions is influenced by multiple factors including the organisational context, implementation strategies and features of the intervention as perceived by people delivering and receiving the intervention. Recently, concepts relating to perceived features of interventions have been gaining traction in published literature, namely, acceptability, fidelity, feasibility, scalability and sustainability. These concepts may influence uptake of healthcare interventions, yet there seems to be little consensus about their nature and impact. The aim of this paper is to develop a testable conceptual framework of implementability of healthcare interventions that includes these five concepts.

Methods

A multifaceted approach was used to develop and refine a conceptual framework of implementability of healthcare interventions. An overview of reviews identified reviews published between January 2000 and March 2021 that focused on at least one of the five concepts in relation to a healthcare intervention. These findings informed the development of a preliminary framework of implementability of healthcare interventions which was presented to a panel of experts. A nominal group process was used to critique, refine and agree on a final framework.

Results

A total of 252 publications were included in the overview of reviews. Of these, 32% were found to be feasible, 4% reported sustainable changes in practice and 9% were scaled up to other populations and/or settings. The expert panel proposed that scalability and sustainability of a healthcare intervention are dependent on its acceptability, fidelity and feasibility. Furthermore, acceptability, fidelity and feasibility require re-evaluation over time and as the intervention is developed and then implemented in different settings or with different populations. The final agreed framework of implementability provides the basis for a chronological, iterative approach to planning for wide-scale, long-term implementation of healthcare interventions.

Conclusions

We recommend that researchers consider the factors acceptability, fidelity and feasibility (proposed to influence sustainability and scalability) during the preliminary phases of intervention development, evaluation and implementation, and iteratively check these factors in different settings and over time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01171-7.

Practices of nurses in monitoring Chronic Non-communicable Diseases in Primary Health Care

Abstract Objective to analyze the Primary Health Care nurses' practices for monitoring the four main Chronic Non-communicable Diseases (circulatory system diseases, cancer, diabetes, and chronic respiratory diseases) in a city in the interior of Santa Catarina State. Method single case study, qualitative approach. Data was collected through triangulation of techniques: focused interviews, document analysis, and online database, from January to July 2019. The analysis techniques were given by means of theoretical propositions and the construction of explanation regarding the nurses' practices. Results the nurse's practices for monitoring chronic diseases identified were: HiperDia Group; health education; tele-monitoring; welcoming; home visits; nursing consultation; care plan; self-monitoring and protocols. Conclusion and implications for the practice the nurses in the studied context perform several practices for the monitoring of chronic diseases, contributing to the effectiveness of policies for this condition and, possibly, with the drop in the mortality indicator for these causes.

Health care network model for older adults: a co-creation and participatory action research approach

Objective: To develop a collaborative, multidisciplinary care model for older adults that improves interdisciplinary teamwork and increases access to specialized services for frail patients, helping solve management problems in the Brazilian Unified Health System. In the state of Bahia, the health care network for older adults requires better interaction and integration with the Unified Health System and the Unified System of Social Assistance to improve patient flow in the network. Methods: We used a co-creation and participatory action research approach based on reflection, data collection, interaction, and feedback with participants and stakeholders. Data was collected from health professionals, representatives of health agencies, and older adults through collective and individual interviews, reflective diaries, and direct communication. Results: An action plan involving members of the older adult care network was developed to put the new model into practice. A pilot study with a multidisciplinary team allowed adjustments and implementation of the model at our institution. Conclusions: The new model improved both the internal management of the State Reference Center for Older Adult Health Care (Centro de Referência Estadual de Atenção à Saúde do Idoso - CREASI) and its interaction with primary care, optimizing patient flow and establishing rules for shared management between CREASI and primary care institutions. In view of this, restructuring the care model reorganized relations between the agencies, expanding CREASI’s role in the management and systematization of older adult health.

Práticas do enfermeiro no monitoramento das Doenças Crônicas Não Transmissíveis na Atenção Primária à Saúde

Resumo Objetivo analisar as práticas do enfermeiro da Atenção Primária à Saúde para o monitoramento das quatro principais Doenças Crônicas Não Transmissíveis (doenças do aparelho circulatório, câncer, diabetes e doenças respiratórias crônicas) em um município do interior do Estado de Santa Catarina. Método estudo de caso único, de abordagem qualitativa. Os dados foram coletados por meio de triangulação de técnicas: entrevistas focadas, análise documental e banco de dados on-line, de janeiro a julho de 2019. As técnicas de análise deram-se por meio de proposições teóricas e da construção da explicação relativas às práticas dos enfermeiros. Resultados as práticas do enfermeiro para o monitoramento das doenças crônicas identificadas foram: Grupo HiperDia; educação em saúde; telemonitoramento; acolhimento; visita domiciliar; consulta de Enfermagem; plano de cuidados; automonitoramento e protocolos. Conclusão e implicações para a prática os enfermeiros do contexto estudado realizam práticas diversas para o monitoramento das doenças crônicas, contribuindo para a efetividade das políticas para esta condição e, possivelmente, com a queda no indicador de mortalidade por essas causas.

Evaluation of metabolic monitoring practices for mental health consumers in the Southern District Health Board Region of New Zealand

WHAT IS KNOWN ON THIS SUBJECT?: The physical health of people with serious mental illness (SMI) is an issue of growing concern in New Zealand and internationally. Metabolic syndrome is prevalent among people with severe mental illness and increases the likelihood of developing cardiovascular disease and diabetes. No previous international research has investigated rates of metabolic monitoring in specialist mental health services and in primary care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Rates of metabolic monitoring are low in this specialist mental health service and in primary care. Primary care nurses are positive in their views of their role in providing care for people with mental illness, and would value further education in this area. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Services need to consider ways in which nurses can be supported to improve rates of metabolic monitoring. Guidelines may have a role to play in improved monitoring but need service-level support in order to be effective. ABSTRACT: Introduction People with serious mental illness experience significant disparities in their physical health compared with the general population. One indicator of health impairment is metabolic syndrome, which increases the likelihood of developing cardiovascular disease and diabetes. No international studies have reported both primary care and mental health nurses' rates of metabolic monitoring among people with serious mental illness, and no New Zealand studies have investigated rates of metabolic monitoring. Aim To evaluate metabolic monitoring practices within one of New Zealand's 20 district health board regions. Method An audit of clinical records in primary care (n = 46) and secondary care (n = 47) settings and a survey of practice nurses were conducted. A survey was sent to 127 practice nurses with a response rate of 19% (n = 24). Data were analysed using descriptive statistics. Results Rates of metabolic monitoring were low in both services. Survey participants expressed positive views towards physical health monitoring and confidence in relating to mental health consumers. Rates of treatment of metabolic abnormalities were low, and communication between primary and secondary services was limited. Conclusion Despite existence of guidelines and protocols, metabolic monitoring rates in both primary and secondary health services are low. Incorporating metabolic monitoring systems into service delivery, supported by appropriate tools and resourcing, is essential to achieve better clinical outcomes for people experiencing mental illness.

Effectiveness of nurse-led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface: A quantitative systematic review

BACKGROUND

Globally, chronic disease is a leading cause of illness, disability and death and an important driver of health system utilization and spending. Continuity of care is a significant component of quality healthcare. However, an association between nurse-led services, interventions, patient outcomes and continuity of care at the primary and secondary interface as an outcome, has not been established for people with chronic disease.

OBJECTIVE

To identify the effectiveness of nurse-led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface.

DESIGN

Quantitative systematic review.

DATA SOURCES

Systematic searches of Medline, Cochrane, Embase, Emcare, JBI and Scopus databases were conducted of studies published between 1946 and May 2019 using the search terms "nurse", "continuity of care" and "chronic disease".

REVIEW METHODS

Quality of the included studies was assessed using the Cochrane risk of bias tool for randomized controlled trials and Joanna Briggs Institute quality appraisal checklists. A second reviewer screened 10% of full text articles and all articles in critical appraisal. Studies were excluded from the review if they were of poor methodological quality or the description of the effect of the nurse-led service was inadequately reported.

RESULTS

Fourteen studies were included in the review (n=4,090 participants). All studies incorporated recognized continuity of care interventions. The nurse-led services were associated with fewer hospitalizations, reduced by 2-8.9% and re-admissions reduced by 14.8-51% (n=886). Reporting of positive patient experiences and improvement in symptoms and lifestyle was also evident. An association of nurse-led services with improved continuity of care between primary and secondary health services as an outcome per se could not be concluded.

CONCLUSION

Nurse-led services for adults provide coordinated interventions that support continuity of care for people with chronic disease in both the primary and secondary healthcare settings that are associated with reduced hospitalizations or readmissions and patient satisfaction. However, the limited use of validated continuity of care outcome measurement tools precluded establishing correlations between interventions, patient outcomes and continuity of care as a specific outcome.

Engagement with community liver disease management across the UK: a cross-sectional survey

Background

Liver disease is an increasing cause of premature mortality in the UK. Its management in primary care is not well understood. It is unclear what role commissioning bodies are playing in liver disease in the UK.

Aim

To assess the level of engagement with community chronic liver disease management among clinical commissioning groups (CCGs) and health authorities across the UK.

Design & setting

A cross-sectional survey to all UK CCGs and health authorities.

Method

Survey questions were developed by the British Liver Trust, in collaboration with topic experts, and evaluated structures in place relating to liver disease management at commissioning and health board level.

Results

There were 159 responses representing 99% UK coverage of CCGs and health boards. Twenty per cent reported an individual responsible for liver disease within their organisation, with 40% and 29% reporting having pathways in place to respond to abnormal liver blood tests and liver disease more generally, respectively. All those reporting use of pathways reported using national guidelines to guide content. Twenty-five per cent made use of transient elastography (FibroScan) and 16% of direct serum fibrosis markers (for example, enhanced liver fibrosis [ELF] score), which are both part of current National Institute for Health and Care Excellence (NICE) guidelines. There was marked regional variation in all areas of engagement surveyed, with Wales having exceptionally high levels of engagement in all areas in contrast to the other nations.

Conclusion

The results of this survey should be used as a catalyst to highlight necessary regional improvements to the primary care management of chronic liver disease across the UK.

Improving rates of metabolic monitoring on an inpatient psychiatric ward

Objectives

Cardiovascular disease is the leading cause of premature death in patients with mental illness. Metabolic syndrome is a cluster of co-occurring cardiovascular risk factors, seen in high frequency in severe mental illness. Despite ease of diagnosis, monitoring is often poor across psychiatric populations. This report details a quality improvement initiative undertaken on an inpatient psychiatric ward to improve rates of metabolic monitoring.

Methods

Four key interventions were developed: (1) A nurse-led intervention, where nurses were upskilled in performing metabolic monitoring, (2) Education was provided to all staff, (3) Introduction of a suite of interventions to improve metabolic risk and (4) Ongoing consumer involvement. A pre–post intervention study design was used to measure effectiveness, with an audit of metabolic monitoring rates performed 12 months after the intervention began.

Results

Rates of weight and height monitoring both increased from 46.0% to 69.5% (p=0.0185) and body mass index (BMI) recordings increased from 33% to 63% (p=0.0031). Rates of waist circumference monitoring increased from 44.2% to 65.2% (p=0.0498). Blood pressure (BP) measurements increased from 88.5% to 100% (p=0.0188). Lipid monitoring rates improved from 23% to 69.5% (p=0.001). Rates of glucose monitoring increased from 74% to 82.5% (p=0.8256), although this was not statistically significant.

Conclusions

We found that metabolic monitoring improved following these simple interventions, with a statistically significant increase in measurement rates of weight, BP, height, lipids, BMI and waist circumference (p<0.05). Overall monitoring of glucose also improved, although not to significant levels. The intervention was acceptable to both patients and staff.

Unmet needs as indicator of improving chronic care delivery system in China

In 2009, China strengthened its public health service system. Since then, the country has made remarkable achievements in community-based chronic disease prevention and control; however, certain groups still have unmet needs. During 2019 to 2029, China will consolidate the top-level design of its medical health system. During this period, the coordination of department policies, improvement of service delivery mechanisms, building an integrated health service system, and other issues will be highlighted. This study will provide a basis for designing China's chronic disease prevention and control system during the next stage of development. We will consider the unmet needs of patients with chronic diseases as an indicator for remodeling the prediction system in combination with the elements and structural theories of complex health systems. In this article, we first introduce the definition and measurement methods of unmet needs. Second, we identify the existing unmet needs found among patients with chronic diseases with reference to the chronic disease prevention and control policies of China as well as current service items. Finally, we propose the design of community chronic disease service package for the next development stage based on unmet needs of patients with chronic diseases. We also provide suggestions for how to improve China's chronic care delivery system.

Enhancing self-resources in patients with chronic diseases: development and initial validation of the Disease and Care Management Score

Introduction:

Despite the importance of the assessment in the primary care of the self-resources among patients with chronic diseases, there is not available a measurement that allows this kind of comprehensive assessment. For this reason, the aim of this study was to develop a multi-dimensional score to determine the level of self-resources in chronic patients, describing its initial validation through face and content validity. The developed score was labelled as Disease and Care Management Score.

Methods:

We performed a methodological study, encompassing two main phases. The first phase was aimed to develop the Disease and Care Management score, choosing the most suitable measurement to assess each pre-identified determinant of wellbeing in chronic patients. The second phase was aimed to determine the Disease and Care Management score face and content validity through the views of 20 experts.

Results:

Disease and Care Management score shows evidence of face and content validity. All the obtained quantitative content validity indices (i.e. Content Validity Ratio, Content Validity Indices) were higher than 0,70, showing the pertinence and the adequacy of each pre-identified measure to compute Disease and Care Management score.

Conclusion:

Disease and Care Management score has the potential of addressing the health coaching interventions in primary care for chronic patients. Future research should show its predictive performance, as well as the cut-off to discriminate patients. (www.actabiomedica.it)

Actions of nurses toward obesity in primary health care units

OBJECTIVES

To understand the actions of nurses toward obesity in primary health care units.

METHODS

A phenomenological study was carried out with 12 nurses of a city in the state of Minas Gerais. The interviews were organized into categories and analyzed according to the social phenomenology of Alfred Schütz and literature associated with the theme.

RESULTS

The following categories emerged, expressing the actions of nurses toward obesity prevention and control: "Guidance on healthy lifestyle habits", "Barriers to the actions of nurses", and "Focusing specifically on obesity".

FINAL CONSIDERATIONS

Considering that guidance on healthy lifestyle habits was mostly carried out during individual and collective activities directed to the general population, regardless of their weight conditions, nurses must reorganize their professional practice in primary health care units by implementing specific actions for users with obesity or at risk of developing it.

Chronic disease management models in nursing homes: a scoping review

OBJECTIVES

Nursing home (NH) residents experience a high burden of chronic disease. Chronic disease management (CDM) can be a challenge, as the context of care provision and the way care is provided impact care delivery. This scoping review aimed to identify types of chronic diseases studied in intervention studies in NHs, influential contextual factors addressed by interventions and future CDM research considerations.

DESIGN

The scoping review followed guidelines by Arksey and O'Malley (2005) and Levac, Colquhoun and O'Brien (2010). Six reviewers screened citations for inclusion. Data extraction was performed by one reviewer and verified by a second reviewer.

DATA SOURCES

We searched four databases: CINAHL, EMBASE, PubMed and Scopus, in March 2018.

ELIGIBILITY CRITERIA

Studies were included if (1) aim of intervention was to improve CDM, (2) intervention incorporated the chronic care model (CCM), (3) included NH residents, (4) analysed the efficacy of the intervention and (5) sample included adults over age 65 years. Studies were limited to English or French language and to those published after 1996, when the CCM was first conceptualised.

DATA EXTRACTION AND SYNTHESIS

Extracted information included the type of chronic disease, the type and number of CCM model components used in the intervention, the method of delivery of the intervention, and outcomes.

RESULTS

On completion of the review of 11 917 citations, 13 studies were included. Most interventions targeted residents living with dementia. There was significant heterogeneity noted among designs, outcomes, and type and complexity of intervention components. There was little evaluation of the sustainability of interventions, including feasibility.

CONCLUSIONS

Research was heavily focused on management of dementia. The most commonly included CCM components were multidisciplinary care, evidence-based care, coordinated care and clinical information systems. Future research should include subjective and objective outcomes, which are meaningful for NH residents, for common chronic diseases.

Middle-aged Australians’ perceptions of support to reduce lifestyle risk factors: a qualitative study

Increasingly, middle-aged people are demonstrating lifestyle risk factors that increase their risk of developing chronic disease. Reducing lifestyle risk in middle age can significantly reduce future morbidity and mortality and improve quality of life. Understanding peoples’ perceptions of health support is important to inform health professionals and policymakers regarding strategies to support lifestyle risk reduction. This paper seeks to explore middle-aged Australians’ perceptions of support for lifestyle risk reduction. Thirty-four middle-aged Australians were interviewed using a semi-structured interview schedule. Interviews were audio-recorded, transcribed and analysed using thematic analysis. The overarching theme ‘support for healthy lifestyles’ comprised three subthemes. ‘Engagement with general practice’ highlighted gender differences in why people attend and what impacts their access to general practice. ‘Providing information’ emphasised participants’ experiences of lifestyle risk communication in general practice. Finally, ‘Sources of support’ revealed participants’ current health advice-seeking behaviours. Findings highlight a need for general practices to better engage middle-aged people in behaviour change and educate them about the role of general practice in prevention and health promotion. Consistent messaging across the community and strategies that focus on gender-specific concerns are likely to ensure that middle-aged people are able to make informed choices about seeking support for lifestyle risk reduction.

Asthma control and acute healthcare visits among young adults with asthma-A population-based study

AIMS

To study asthma control and acute healthcare visits among young adults with asthma.

BACKGROUND

Despite the access to effective treatment and nursing interventions, poor asthma control is still common among individuals with asthma. However, studies describing clinical characteristics among young adults with asthma are rare.

DESIGN

A population-based cohort study.

METHODS

In 2015, as a part of the OLIN paediatric cohort I (recruited in 1996 at age 7-8 years), N = 2,291 young adults (27-28 years) completed a postal questionnaire survey including questions on asthma and respiratory symptoms. Of these, N = 280 (12%) were identified as having current asthma and were further studied.

RESULTS

Of those with current asthma, women reported respiratory symptoms and smoking to a greater extent than men. Approximately one-fourth had uncontrolled asthma and acute healthcare visits due to asthma was reported by 15% of women and 8% of men. Uncontrolled asthma was associated with smoking, lower educational level, use of reliever treatment most days, and acute healthcare visits. Acute healthcare visits due to asthma were associated with periodic use of regular controller treatment also after adjustment for uncontrolled asthma.

CONCLUSION

The result indicate poor adherence to asthma treatment which may lead to decreased asthma control and acute healthcare visits.

IMPACT

Most young adults with asthma are diagnosed and treated in primary care, ideally in a team with a nurse. The main findings highlight the need for evidenced-based nursing interventions, contributing to a more efficient asthma management in primary care.

To initiate the conversation - Public health nurses' experiences of working with obesity in persons with mobility disability

Aim

Developing a theory explaining how public health nurses accomplish and adapt counselling in lifestyle habits to decrease obesity in people with mobility disability.

Design

Empirical research ‐ qualitative.

Method

Classic grounded theory with face‐to‐face interviews, 2017–2018, using inductive approach to understand public health nurses' intervening experiences with obesity patients.

Results

To initiate the conversation emerged as the main concern meaning having difficulties initiating conversations about obesity with patients. Public health nurses’ facilitators to communicate lifestyle changes emerged as the pattern generating the theory, which consists of the categories; person‐centeredness in the situation, experience and knowledge, strengthening conditions, access to other professionals and prioritization in everyday work.

Conclusions

Public health nurses hesitate to raise topics of obesity in patients with mobility disability. They advocate increased integration with lifestyle changes in everyday work including multi‐professional cooperation. The implication is testing the emerged theory at primary health care centres.

Impact

Obesity is more common in people with mobility disability than in those without. There is a need to understand how public health nurses adapt counselling in lifestyle habits. Public health nurses hesitate to talk about obesity with patients in fear of offending anyone. Public health nurses did not distinguish between patients with or without mobility disability. Several facilitators could be helpful initiating conversation with the patients. Public health nurses need more time and resources to facilitate conversation with patients with mobility disability to counsel lifestyle changes.

Stepping outside the consultation room. On nurse-patient relationships and nursing responsibilities during a type 2 diabetes walking project

AIMS

To examine the care practices of nurses during the organization of 20 weeks of walking sessions for people with type 2 diabetes and to reflect on implications for nurse-patient relationships and nursing responsibilities in the provision of physical activity (PA) care.

DESIGN

Qualitative, ethnographic study.

METHODS

Almost 70 hr of field work was completed by participant observations and informal conversations with nurses and participating patients of two different walking groups (April-October 2016). Analysis of field notes followed an inductive holistic-content approach, using both within-case and across-case analysis.

RESULTS

The analysis revealed four main themes related to the nurses' care practices: (a) organizational efforts; (b) combining group and individual care; (c) stepping in- and outside the patient mode; and (d) implications back inside the consultation room. Underlying these themes was a process of relational development, both with and among patients.

CONCLUSION

Stepping outside the consultation room seems to offer more space for patients' lifeworld narratives and contribute to more continuous and person-centred care. However, it also raises new questions about the provision of PA care and nursing responsibilities in this.

IMPACT

Current nursing repertoires for PA counselling in type 2 diabetes care are insufficient and might be extended by organizing walking sessions for patients. Related nursing care practices impacted relationships both with and among participating patients. These have consequences for boundaries of both nursing responsibilities and care provision.

General practice palliative care: patient and carer expectations, advance care plans and place of death-a systematic review

BACKGROUND

With an increasing ageing population in most countries, the role of general practitioners (GPs) and general practice nurses (GPNs) in providing optimal end of life (EoL) care is increasingly important.

OBJECTIVE

To explore: (1) patient and carer expectations of the role of GPs and GPNs at EoL; (2) GPs' and GPNs' contribution to advance care planning (ACP) and (3) if primary care involvement allows people to die in the place of preference.

METHOD

Systematic literature review.

DATA SOURCES

Papers from 2000 to 2017 were sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.

RESULTS

From 6209 journal articles, 51 papers were relevant. Patients and carers expect their GPs to be competent in all aspects of palliative care. They valued easy access to their GP, a multidisciplinary approach to care and well-coordinated and informed care. They also wanted their care team to communicate openly, honestly and empathically, particularly as the patient deteriorated. ACP and the involvement of GPs were important factors which contributed to patients being cared for and dying in their preferred place. There was no reference to GPNs in any paper identified.

CONCLUSIONS

Patients and carers prefer a holistic approach to care. This review shows that GPs have an important role in ACP and that their involvement facilitates dying in the place of preference. Proactive identification of people approaching EoL is likely to improve all aspects of care, including planning and communicating about EoL. More work outlining the role of GPNs in end of life care is required.