The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review

Advanced Practice Nurses and Their Roles in Swiss Cancer Care: A Cross-Sectional Study

OBJECTIVES

To examine the advanced practice nurse workforce in Swiss cancer care and how their roles are being implemented (eg, role structures, processes) to achieve optimal outcomes for patients and their families, care organizations, and the broader health care system.

METHODS

A cross-sectional study was conducted. The sample included master-prepared advanced practice nurses in cancer care, who completed an online questionnaire from December 2021 to January 2022. Thirty-nine items assessed structures (eg, role characteristics, utilization), processes (eg, role activities, interventions), and perceived outcomes (eg, for patients, the health care system) of advanced practice nurses in Swiss cancer care. Data from closed questions were analyzed using descriptive statistics. Data from open-ended questions were organized and summarized into categories related to domains of advanced practice nursing and its reported frequency by the advanced practice nurses.

RESULTS

The participating advanced practice nurses (n = 53), worked in half of the 26 Swiss cantons. Interventions were identified within nine categories, of which most were targeted to patients and their families (n = 7), followed by health care professionals (n = 2). Perceived positive outcomes were patient symptom management, length of hospital stay, and health care costs. Participants felt less confident in cancer care (eg, autonomous practice) and reported 15 professional development needs (eg, medical interventions, teaching).

CONCLUSIONS

This study provides a comprehensive examination of 53 advanced practice nurses, detailing the characteristics of their roles and utilization across various jurisdictions and health care settings. The results highlight the diverse dimensions of advanced practice nursing and its potential to enhance cancer services and outcomes in Switzerland. Opportunities for role development support and expansion are identified.

IMPLICATIONS FOR NURSING PRACTICE

More systematic health human resource planning is needed to expand the deployment of advanced practice nurses across jurisdictions, practice settings, and more diverse patient populations. Role development needs show the desire for specialized educational preparation in cancer care.

Lung transplant recipients' experiences of and attitudes towards self-management: a qualitative systematic review

OBJECTIVE

The objective of this review was to identify lung transplant recipients' experiences of and attitudes towards self-management.

INTRODUCTION

Lung transplantation is an established treatment to improve the survival of patients with end-stage lung diseases and has been performed on over 40,000 patients worldwide. The current focus of care for lung transplant recipients is on their long-term management. Patients need to adapt and adhere to complex self-management tasks to prevent complications and to enable them to keep the transplanted graft as long as possible. However, to date, no qualitative systematic review exists that identifies lung transplant recipients' experiences of and attitudes towards self-management.

INCLUSION CRITERIA

This review included adults over 18 years of age who had received a lung transplant and were able to perform their self-management tasks independently. All studies that investigated lung transplant recipients' experiences of and attitudes towards self-management in any setting were included in this review. All types of studies that focused on qualitative data, including, but not limited to, phenomenology, grounded theory, ethnography, action research, and feminist research were considered for inclusion. Mixed methods studies were included only when qualitative data could be extracted separately, and if they reported results relating to the phenomena of interest. Studies published in English or German were considered for inclusion in this review.

METHODS

The search strategy aimed to find published studies from 6 databases from the database inception to March 2022. Methodological quality of studies was independently assessed by 2 independent reviewers using the JBI checklist for qualitative research. A standardized data extraction tool from JBI was used by 2 reviewers for data collection. Meta-aggregation was undertaken to synthesize the data, and the final synthesis of the findings was reached through discussion. Results were graded according to ConQual.

RESULTS

Ten studies with a sample size from 8 to 73 participants from North America and Central/Northern Europe were included in the review. The critical appraisal scores of the included studies varied from 3 to 9 out of 10. A total of 137 findings were extracted and aggregated to form 19 categories and the following 4 aggregated syntheses: i) Changes in routines, beliefs, and sense of responsibility are essential for better adaptation and self-management after lung transplantation; ii) Life after transplantation is characterized by both positive and negative feelings and experiences; iii) Better adjustment and self-management after a lung transplant require dealing with one's own feelings and beliefs; iv) After transplantation, engaging with relatives, friends, medical team and donors is essential to improve experiences and adapt to being a transplant recipient. Based on the ConQual scores, 2 synthesized findings were graded as moderate and 2 as low.

CONCLUSIONS

Nuanced emotional, social, relational, and psychological adjustment is required of lung transplant recipients to be able to successfully self-manage. Loved ones and health professionals contribute significantly to this process, but psychosocial or peer support may further facilitate this transition.

SUPPLEMENTAL DIGITAL CONTENT

A German-language version of the abstract of this review is available as Supplemental Digital Content [http://links.lww.com/SRX/A46].

Advancing Palliative Care through Advanced Nursing Practice: A Rapid Review

Objectives

This study addresses the growing demand for palliative care (PC) by exploring the role of advanced nursing practice (ANP) within the multidisciplinary team. The purpose is to outline the background of ANP in PC, its interest, training needs, and some recommendations for its establishment in the Moroccan healthcare system.

Materials and Methods

A rapid review of relevant studies was carried out through databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards, edition (2020). The inclusion criteria focussed on studies published within the nursing domain between 2012 and 2022, with a preference for the English language.

Results

Study selection allowed to obtain eight relevant studies. The studies agreed that ANP improves the quality of care provided. It has a major role to play in the multidisciplinary team by mobilising all the knowledge required to offer a complete range of care for patients with needs. Nevertheless, its implementation is fraught with challenges.

Conclusion

ANP will be able to address the complexity of patient and family needs and serve as cost-effective medical care coordinators for patients and families with both chronic and life-limiting illnesses, to reduce suffering and improve the quality of living and dying across the lifespan. Advanced practice nurses execute assigned authorisations by mobilising the knowledge acquired through university training. The establishment of this cadre in the healthcare system is subject to many challenges that Morocco must anticipate.

Contemporary European practice in transcatheter aortic valve implantation: results from the 2022 European TAVI Pathway Registry

Background

A steep rise in the use of transcatheter aortic valve implantation (TAVI) for the management of symptomatic severe aortic stenosis occurred. Minimalist TAVI procedures and streamlined patient pathways within experienced Heart Valve Centres are designed to overcome the challenges of ever-increasing procedural volume.

Aims

The 2022 European TAVI Pathway Survey aims to describe contemporary TAVI practice across Europe.

Materials and methods

Between October and December 2022, TAVI operators from 32 European countries were invited to complete an online questionnaire regarding their current practice.

Results

Responses were available from 147 TAVI centres in 26 countries. In 2021, the participating centres performed a total number of 27,223 TAVI procedures, with a mean of 185 TAVI cases per centre (median 138; IQR 77-194). Treatment strategies are usually (87%) discussed at a dedicated Heart Team meeting. Transfemoral TAVI is performed with local anaesthesia only (33%), with associated conscious sedation (60%), or under general anaesthesia (7%). Primary vascular access is percutaneous transfemoral (99%) with secondary radial access (52%). After uncomplicated TAVI, patients are transferred to a high-, medium-, or low-care unit in 28%, 52%, and 20% of cases, respectively. Time to discharge is day 1 (12%), day 2 (31%), day 3 (29%), or day 4 or more (28%).

Conclusion

Reported adoption of minimalist TAVI techniques is common among European TAVI centres, but rates of next-day discharge remain low. This survey highlights the significant progress made in refining TAVI treatment and pathways in recent years and identifies possible areas for further improvement.

Exploring Clinical Nurse Specialist Impact in Primary Health Care: Exemplars From a Student's Clinical Practice

PURPOSE/OBJECTIVES

Primary healthcare (PHC) is a clinical frontier full of opportunities for clinical nurse specialists (CNSs) to improve population outcomes, facilitate smooth care transitions, and overcome challenges through a unique lens. Clinical nurse specialist practice in primary care is exceedingly rare, and there is a paucity of literature on the topic. This article provides exemplary projects implemented by a CNS student in a primary care clinic.

DESCRIPTION OF THE PROJECT/PROGRAM

Primary healthcare has been described as the "front door" of the health system. It has increasingly relied on nursing to deliver health services, yet PHC and nursing practice in this setting remain poorly defined. Clinical nurse specialists are well-positioned to define these concepts, standardize processes used to deliver services, and impact patient outcomes in PHC. The CNS student successfully supported a primary care clinic in these activities.

OUTCOME

Reviewing the impact of the CNS student's experience offers a better understanding of CNS practice in PHC.

CONCLUSION

Gaps exist in the literature regarding best practices and care delivery in PHC. Clinical nurse specialists are educationally prepared to address these gaps and improve patient outcomes at the health system's "front door." Utilizing a CNS's unique skill set achieves cost-effective and efficient healthcare delivery in a new way that bolsters the strategy of utilizing nurse practitioners to meet the challenge of provider shortages.

Emotional intelligence: Its place in infection prevention and control

Background

The Infection Prevention Societies Competency Framework is a detailed tool that recognises the multi factorial work of Infection Prevention and Control Teams. This work often takes place in complex, chaotic and busy environments where non-compliance with policies, procedures and guidelines is endemic. As reductions in Healthcare Associated Infection became a health service priority the tone of Infection Prevention and Control (IPC) became increasingly uncompromising and punitive. This can create conflict between IPC professionals and clinicians who may take a different view as to the reasons for sub optimum practice. If unresolved, this can create a tension that has a negative impact on working relationships and ultimately patient outcomes.

Concepts and Context

Emotional Intelligence, that ability to recognise, understand and manage our own emotions and recognise, understand and influence the emotions of others, is not something, hitherto, that has been headlined as an attribute for individuals working in IPC. Individuals with higher level of Emotional Intelligence show a greater capacity for learning, deal with pressure more effectively, communicate in interesting and assertive ways and recognise the strengths and weaknesses of others. Overall, the trend is that they are more productive and satisfied in the workplace.

Conclusion

Emotional Intelligence should be a much sought after trait in IPC as this will better equip a post holder to deliver challenging IPC programmes. When appointing to an IPC team, the candidates Emotional Intelligence should be considered and then developed through a process of education and reflection.

Nutrition nurse-led outpatient 'hot' clinics are efficient and cost-effective: a retrospective single-centre evaluation

BACKGROUND

Nutrition nurses work in multidisciplinary and nurse-led outpatient clinics. The daily nutrition nurse-led 'hot' clinic in this study sees patients for enteral or home parenteral nutritional support. Appointments may be for routine procedures or emergency reviews.

AIMS

This study aimed to identify activities and procedures performed in the nutrition nurse-led clinic, identifying admission avoidance activity.

METHODS

Nurse-held records for the period from April 2018 to March 2020 were reviewed retrospectively. Data were collated in an Excel spreadsheet for analysis and results are presented using descriptive statistics.

RESULTS

Records covered a total of 590 patients, 294 men and 296 women with a median age of 59 years, and 606 procedures. Key activities were troubleshooting enteral feeding tubes (29%), insertion of fine-bore nasogastric feeding tubes (18%) and management of home parenteral nutrition issues (11%). The presenting problem or issue was resolved in 90% of patients, with no need for hospital admission or additional medical review.

CONCLUSION

The nutrition nurse-led clinic provides an efficient and cost-effective service, preventing hospital admission and emergency department attendance in most cases.

Transforming nursing care for children with serious long-term conditions: A mixed methods exploration of the impact of Roald Dahl Specialist Nurses in the United Kingdom

PURPOSE

A new model of paediatric nursing, funded initially by a charitable organisation working in partnership with UK healthcare providers, was implemented to support children living with serious long-term conditions. This study explored, from the perspective of multiple stakeholders, the impact of services provided by 21 'Roald Dahl Specialist Nurses' (RDSN) within 14 NHS Trust hospitals.

DESIGN AND METHODS

A Mixed Methods Exploratory design commenced with interviews with RDSNs (n = 21) and their managers (n = 15), alongside a medical clinician questionnaire (n = 17). Initial themes (constructivist grounded theory) were validated through four RDSN focus groups, and informed development of an online survey of parents (n = 159) and children (n = 32). Findings related to impact were integrated using a six-step triangulation protocol.

RESULTS

Zones of significant impact included: Improving quality and experience of care; Improved efficiencies and cost-effectiveness; Provision of holistic family-centred care; and Impactful leadership and innovation. The RDSNs forged networks across inter-agency boundaries to safeguard the child and enhance the family experience of care. RDSNs delivered improvements across a range of metrics, and were valued for their emotional support, care navigation and advocacy.

CONCLUSIONS

Children living with serious long-term conditions have complex needs. Regardless of the specialty, location, organisation or service focus, this new model of care crosses organisational and inter-agency boundaries to ensure that the healthcare delivered has maximum impact. It has a profoundly positive impact on families.

PRACTICE IMPLICATIONS

This integrated and family-centred model of care is strongly recommended for children with complex needs crossing organisational divides.

Dynamics and processes influencing role integration of advanced practice nurses and nurse navigators in oncology teams

PURPOSE

Exploring the persisting presence of underlying processes, dynamics, experienced barriers and facilitators of Advanced Practice Nurses (APN) in oncology and Oncology Nurse Navigators (ONN) during their role integration in an interprofessional team over a research period of seven years.

METHODS

A qualitative study based on the principles of Grounded Theory, in which individual semi-structured interviews and focus groups were conducted with 51 ONN and APN from 11 university and local hospitals in Belgium between 2011-2018. Data were analyzed to develop a framework that consists of different themes.

RESULTS

ONN and APN experienced a lonely journey during role integration. They were searching for partners, medical knowledge and acknowledgement from the interprofessional team. ONN and APN had a watchful attitude and tried to make themselves visible to ensure they were involved in the team and to preserve their role and responsibilities. An unclear role description to the interprofessional team, and a lack of coaching and guidance were influencing factors in the experience of ONN and APN.

CONCLUSION

ONN and APN in oncology feel difficulties to integrate their role in existing interprofessional teams. A lack of role clarity, the interprofessional team environment and a desire for coaching and guidance are influencing factors to implement APN roles. Coaching and mentorship of novice ONN/APN and their interprofessional team and healthcare managers are needed to address these issues. These findings could form the basis for a mentorship program for ONN/APN and their interprofessional team to enhance role integration.

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.

Experiences of nurses working in nurse-led clinics in Traditional Chinese Medicine hospitals: A focused ethnographic study

BACKGROUND

Traditional Chinese Medicine (TCM) nurse-led clinics (NLC) is an innovative working model in China, representing the specialization and extension of nurses' role. However, as a pioneer in TCM nursing, this new model of working is facing both opportunities and challenges because it is known little about the operational status of NLCs.

AIMS

To explore the experiences of nurses who work in NLC in TCM hospitals.

MATERIALS & METHODS

A focused ethnographic study was conducted in three TCM hospitals affiliated with Guangzhou University of Chinese Medicine. We interviewed eleven nurses in those hospitals and observed seven of them working with patients. We used snowball sampling for data collection including interview, non-participant observation and documents from medical records. All the data were processed as following steps: (a) coding for descriptive labels; (b) sorting for patterns; (c) identifying outliers or negative cases; (d) generalizing with construction and theories and (e) noting reflective remarks.

RESULTS

Nurse-led clinics help nurses develop their skills and knowledge that are highly recognized by public since they meet the growing needs of patients and also relieve the workload of physicians in the hospitals. However, lack of specialization is still a major challenge in NLCs due to insufficiency of full-time staff with specialized education, nurse-led practice without standardized guidelines, restrictions on prescription right of nurses, and also inadequate support from hospitals.

DISCUSSIONS

As a revolutionary innovation of working model for nurses in TCM hospitals, NLCs could improve quality of care and lead to a comprehensive promotion of nursing career. However, there are several challenges on providing high quality care for patients whilst improving educational development of nurses. This study suggests that nurses, hospital administration and the government should cooperate with each other to develop standard nursing programs for NLCs.

CONCLUSIONS

It is imperative to identify nursing roles, collect available resources, and develop supportive policies and training programs to enhance the quality of NLCs.

Efficacy of models of palliative care delivered beyond the traditional physician-led, subspecialty consultation service model: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to determine the effectiveness of non-physician provider-led palliative care (PC) interventions in the management of adults with advanced illnesses on patient-reported outcomes and advance care planning (ACP).

METHODS

We included randomised trials and cluster trials published in MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Register of Controlled Trials and ClinicalTrials.gov searched until July 2021 that examined individuals ≥18 years with a diagnosis of advanced, life-limiting illness and received a PC intervention led by a non-physician (nurse, advance practitioner or social worker). Our primary outcome was quality of life (QOL), which was extracted as unadjusted or adjusted estimates and measures of variability. Secondary outcomes included anxiety, depression and ACP.

RESULTS

Among the 21 studies (2370 subjects), 13 included patients with cancer, 3 with heart failure, 4 with chronic respiratory disease and 1 with chronic kidney disease. The interventions were diverse and varied with respect to team composition and services offered. For QOL, the standardised mean differences suggested null effects of PC interventions compared with usual care at 1-2 months (0.04; 95% CI=-0.14 to 0.23, n=10 randomised controlled trials (RCTs)) and 6-7 months (0.10; 95% CI=-0.15 to 0.34, n=6 RCTs). The results for anxiety and depression were not significant also. For the ACP, there was a strong benefit for the PC intervention (absolute increase of 0.32% (95% CI=0.06 to 0.57).

CONCLUSIONS

In this meta-analysis, PC interventions delivered by non-physician were not associated with improvement in QOL, anxiety or depression but demonstrated an impact on the ACP discussion and documentation.

Role dimensions of practice nurses and interest in introducing advanced nurse practitioners in general practice in Ireland

Background

Internationally many countries have implemented strategies to enhance primary care, to strengthen their health systems to cope with an aging population, the rise of chronic conditions, and increased costs. Primary care has the potential to address these challenges, however, general practitioners are increasingly struggling to meet patient demand resulting from a growing and aging population. Expanding the role of general practice nurses to advanced nurse practitioner (ANP) level has worked internationally and could equally be a solution to the Irish context. However, their current role must first be established as well as their level of interest in becoming an ANP.

Aim

To explore the role of general practice nurses and their interest in becoming an ANP.

Design

A survey design.

Method

A purposeful sample of general practice nurses (n = 40) was undertaken between April and June 2019. Data were analyzed using the Statistical Package for Social Science (SPSS V 25.0; IBM).

Results

General practice nurses appear to have an agenda in relation to activities associated with wound care, immunizations, respiratory and cardiovascular issues. Just over half of the respondents were not interested in becoming an ANP. Their perceived challenges associated with the implementation of the role include a lack of support from general practitioners, a lack of resources, insurance issues, and a lack of understanding of the role. Challenges were associated with undertaking further training and their experience of having more work transferred to general practice without concomitant reallocation of resources.

Conclusion

General practice nurses have extensive clinical experience to deliver major improvements in primary care. Educational opportunities need to be provided for upskilling existing general practice nurses to advanced practice level. Greater understanding of the role and the potential contribution of the role in general practice is required among medical colleagues and the public.

Advanced practice role delineation within Finland: A comparative descriptive study

AIM

To identify and differentiate the practice patterns of generalist, specialist and advanced practice nursing roles in specialist and central hospital contexts.

BACKGROUND

In Finland, as in other Nordic countries, advanced practice nursing roles emerged around 2000. There are over 60,000 registered nurses/midwives in Finland and the clinical career pathway from a registered nurse to advanced practice nurse has been described yet not fully implemented in healthcare organizations. However, the number and activities of nonadvanced and advanced practitioner roles are not well known.

DESIGN

A descriptive comparative study.

METHODS

An online self-report survey was conducted between August and October 2020 using an advanced practice role delineation tool. A census sample of registered nurses, registered midwives, specialist nurses and advanced practice nurses in five university hospitals and one central hospital was recruited. Descriptive statistics were used to summarize the characteristics of participants and group differences were compared using analysis of variance (ANOVA). The STROBE checklist was used as the reporting guideline.

RESULTS

A total of 1497 responses were obtained (response rate = 10%). Overall, nurses used comprehensive care and education activities most frequently. The least used activities were research and publication and professional leadership. Univariate analysis of variance test between role effects, when education and grouped age were taken into account, showed statistically significant difference in all of the observed five activities (p < .001).

CONCLUSION

Identifying activities in different levels of nursing is a crucial first step in delineating nursing roles thus improving the governance of the human resource management.

IMPACT

The study results add to the international literature, delineating nursing roles in the spectrum of generalist to advanced practice nursing. As these roles become more formalized, we may incorporate novel ways of promoting the career development and optimal use and assessment of nursing roles and practice in various career levels.

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.

Evaluating the specialist palliative care clinical nurse specialist role in an acute hospital setting: a mixed methods sequential explanatory study

Background

Special palliative care is provided in a range of settings including a patient’s home (their primary place of dwelling), a hospice in-patient unit, or an acute hospital. The aim of the study was to evaluate the role of the specialist in palliative care clinical nurse specialist (SPC CNS) role in an acute hospital setting.

Methods

This study was conducted using a mixed methods sequential explanatory approach in two phases; phase 1 involved completion of a study questionnaire (n = 121) and phase 2 involved part-taking in a focus group (n = 6) or individual interview (n = 4).

Results

Phase 1 results indicated that respondents held positive attitudes towards the Specialist Palliative Care Clinical Nurses Specialist (SPC CNS) in relation to clinical care, education and patient advocacy. Phase 2 qualitative findings identified the importance of the role in terms of symptom management, education and support.

Conclusions

This study provides an evaluation of a SPC CNS role since it was established in an acute hospital setting. The evidence indicates that there is a varied understanding of the role of the SPC CNS. The role was seen as an important one particularly in terms of referrals to and support provided by the SPC CNS, as well as recognition of the importance of the role is providing ongoing education to staff.

[An exploratory study of hospital stakeholders' perceptions on the introduction of advanced practice nurses]

Introduction : One solution proposed by the authorities to address public health issues is to deploy a new category of professionals with a greater range of skills : advanced practice nurses (APNs). The literature identifies the complexity of the deployment projects of these professionals. The PEPPA model approved by the International Council of Nurses is the reference model for the introduction of APNs. The objectives of this study were to explore various stakeholders' perceptions on the introduction of APNs into health institutions, in order to propose recommendations to support the institutions.Method : A multicenter qualitative study was conducted in France's Provence-Alpes-Côte d'Azur region with physicians, managers, nurses, patients, and advanced practice students.Results : APNs are beneficial for patients and the health system, but their introduction into health institutions brings with it risks, primarily linked to their integration. APN introduction projects need to be well planned and should prioritize their integration.Discussion : Results consistent with the PEPPA model identified seven recommendations to facilitate the successful introduction of APNs into hospitals.Conclusion : This work needs to be continued with studies related to the out-of-hospital setting and the evaluation of the successfulness of APNs' introduction.

The association between advanced practice nursing roles and outcomes in adults following cardiac surgery: A systematic review of randomized controlled trials

BACKGROUND

Empirical findings have shown significant and non-significant effects of advanced practice nursing roles within postoperative cardiac settings. The inconsistencies of the current literature preclude the identification of a significant effect of advanced practice nursing roles on patient and organizational outcomes.

OBJECTIVE

1) identify patient and organizational outcomes of advanced practice nursing roles in postoperative cardiac surgery and 2) synthesize the evidence of current roles of advanced practice nurses in postoperative cardiac surgery to provide the best quality of care for patients.

METHOD

A systematic review of randomized controlled trials was conducted in six electronic databases, including Medline, CINHAL, Embase, Cochrane Database, Joanna Briggs Database and Web of Science, and the grey literature. Randomized controlled trials published after 1999 were included if they examined advanced practice nursing roles and recruited patients who underwent cardiac surgery. The study selection was performed by two independent reviewers, and consensus was achieved with a third reviewer. Data extraction was conducted by one reviewer and revised by a second reviewer. The methodological quality of the included studies was assessed with the Evidence Project risk of bias tool by two independent reviewers and revised by a third reviewer. A narrative synthesis of the available evidence was completed. No meta-analysis technique was attempted because of the high heterogeneity of the included studies.

RESULTS

Among 4,448 retrieved papers, ten randomized controlled trials and three secondary analyses were included in this review. The methodological quality of the included studies was moderate. All studies included a comparison group and the majority of the studies collected data using a blinded researcher. However, all studies were based on small sample sizes and failed to randomly recruit participants. Five studies implemented nurse practitioner roles and five studies implemented clinical nurse specialist roles. The advanced practice nursing care included health condition management, lifestyle promotion and coping strategies with patients. A total of 22 outcomes were identified, including 13 patient outcomes (e.g., depressive symptoms) and nine organizational outcomes (e.g., rehospitalization after discharge). Each outcome was examined in one to five studies. All of the included outcomes were associated with inconsistent findings.

CONCLUSION

The findings from existing literature remain inconsistent. The high risk of bias and the small sample sizes could potentially explain the non-significant findings. Avenues for future research should focus on the development of methodologically high-quality studies with larger sample sizes to enhance our understanding of the effectiveness of advanced practice nursing roles.

Training of advanced practice nurses in oncology for the best care: a systematic review

OBJECTIVE

To search for evidence on the training of advanced practice nurses, through clinical practice and nursing care with cancer patients.

METHOD

Systematic review, searching the databases: MEDLINE-PubMed, LILACS, Web of Science, Scopus, CINAHL and Cochrane CENTRAL. A manual search of the reference list and Google Scholar was also carried out. To assess the methodological quality of the studies, the following tools were used: Cochrane Collaboration Risk of Bias Tool (RoB 1) for randomized controlled trials and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) for quasi-experimental studies.

RESULTS

A total of 12 experimental studies were identified. The main intervention identified in the studies was educational guidance. The studies showed improvement in pain control or other symptoms related to disease and/or treatment, satisfaction and improvement in the quality of life of cancer patients.

CONCLUSION

It is observed that there are studies that demonstrate the value of advanced practice nursing in oncology, through differentiated clinical training and advanced professional performance. Registration number of the systematic review: CRD42018098906.

Impact of type of health care provider on long term asthma control

OBJECTIVE

Asthma prevalence is high and adherence to asthma guidelines is still less than adequate. The main objective of this study was to determine if there were significant differences in outcome measures if asthma care was provided per guidelines either by physicians (pediatric pulmonologists) or specialty trained advance practice nurses (APNs).

METHODS

This was a three-year, prospective cohort study of children referred by their primary care providers to a tertiary care center for better asthma control. Patients were provided asthma care per NAEPP guidelines including asthma education. Results were compared over time and between patients followed by physicians or APNs. Alpha level of significance was ≤0.05.

RESULTS

The sample included 471 children, ages 2-17 years (mean = 6.4 ± 2.4 years). Physicians and APN's provided asthma care. Of the 471 children enrolled in the study, 176 (37%) were followed for the full three-year study period. At the initial visit, physician group reported more short courses of oral steroids and more unscheduled visits to PCP for acute asthma care in the past 6 months compared to those followed by APNs (<0.05 for all). Among the total cohort and both subgroups, there were significant improvements in mean Asthma Control Test (ACT), acute care need and mean days/month with asthma symptoms over a three-year period (p < 0.05). There was significantly more improvement in use of oral steroids and urgent care visits in physician group (p < 0.05).

CONCLUSION

When asthma guidelines are followed, improvements in asthma control are achieved in children in both the MD and APN groups.

Nursing now and always: evidence for the implementation of the Nursing Now campaign

OBJECTIVE

to identify the guiding axes of the documents that grounded the Nursing Now campaign and relate the recommendations of these documents to the campaign goals.

METHOD

documentary research, based on the analysis of the documents that promoted the Nursing Now campaign. The data were collected between March and April 2020, using a form structured into: background, scope, challenges and potentials of health/nursing professionals and recommendations for the future.

RESULTS

the challenges and the need for investments in the health and nursing workforce to achieve the Sustainable Development Goals were evidenced. The report of the High Level Commission on health Employment and Economic Growth presents important recommendations, also introduced in the Triple Impact Report and in the Strategic Directions for Nursing and Midwifery, converging to the goals of the Nursing Now campaign, stimulating a profile of nurses with technical, political and leadership skills, engaged in health policy-making, and the effectiveness of their practice is clear to the entire society.

CONCLUSION

knowledge about the dynamics of the factors that converged to the development of the Nursing Now campaign may be a condition for achieving its goals. This reality reveals evidence that global health will not be ensured without strengthening Nursing first.

Improving the care and health of populations through optimal use of clinical nurse specialists

Patients with complex and chronic illnesses and those who have significant needs related to care coordination and transitions of care are dependent on access to healthcare providers who are skilled at meeting the distinct needs of these populations and are current in the latest evidence-based practices and guidelines. Clinical nurse specialists (CNSs) are uniquely qualified to care for patients with complex illnesses as well as having the skills to optimize care for entire populations with complex needs. The absence of consistent legislative advanced practice registered nurse recognition of CNSs prevents health care systems from optimal use of this advanced practice registered nurse role to improve and provide safe and quality care for these patients. Additional barriers in optimal utilization of CNSs include lack of consistency: in title protection and licensing from state to state; ensuring patient access through identification and tracking of CNS numbers across the United States in order to determine workforce and educational program requirements; and ensuring appropriate reimbursement for care provided by CNSs. Therefore, it is the position of the American Academy of Nursing that addressing public and private sector regulatory, legislative, and policy concerns related to CNSs is essential to achieving optimal population health outcomes across the nation.

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.

An integrative review of leadership competencies and attributes in advanced nursing practice

Aim

To establish what leadership competencies are expected of master level‐educated nurses like the Advanced Practice Nurses and the Clinical Nurse Leaders as described in the international literature.

Background

Developments in health care ask for well‐trained nurse leaders. Advanced Practice Nurses and Clinical Nurse Leaders are ideally positioned to lead healthcare reform in nursing. Nurses should be adequately equipped for this role based on internationally defined leadership competencies. Therefore, identifying leadership competencies and related attributes internationally is needed.

Design

Integrative review.

Methods

Embase, Medline and CINAHL databases were searched (January 2005–December 2018). Also, websites of international professional nursing organizations were searched for frameworks on leadership competencies. Study and framework selection, identification of competencies, quality appraisal of included studies and analysis of data were independently conducted by two researchers.

Results

Fifteen studies and seven competency frameworks were included. Synthesis of 150 identified competencies led to a set of 30 core competencies in the clinical, professional, health systems. and health policy leadership domains. Most competencies fitted in one single domain the health policy domain contained the least competencies.

Conclusions

This synthesis of 30 core competencies within four leadership domains can be used for further development of evidence‐based curricula on leadership. Next steps include further refining of competencies, addressing gaps, and the linking of knowledge, skills, and attributes.

Impact

These findings contribute to leadership development for Advanced Practice Nurses and Clinical Nurse Leaders while aiming at improved health service delivery and guiding of health policies and reforms.

Use of health economic evaluation in the implementation and improvement science fields-a systematic literature review

Background

Economic evaluation can inform whether strategies designed to improve the quality of health care delivery and the uptake of evidence-based practices represent a cost-effective use of limited resources. We report a systematic review and critical appraisal of the application of health economic methods in improvement/implementation research.

Method

A systematic literature search identified 1668 papers across the Agris, Embase, Global Health, HMIC, PsycINFO, Social Policy and Practice, MEDLINE and EconLit databases between 2004 and 2016. Abstracts were screened in Rayyan database, and key data extracted into Microsoft Excel. Evidence was critically appraised using the Quality of Health Economic Studies (QHES) framework.

Results

Thirty studies were included—all health economic studies that included implementation or improvement as a part of the evaluation. Studies were conducted mostly in Europe (62%) or North America (23%) and were largely hospital-based (70%). The field was split between improvement (N = 16) and implementation (N = 14) studies. The most common intervention evaluated (43%) was staffing reconfiguration, specifically changing from physician-led to nurse-led care delivery. Most studies (N = 19) were ex-post economic evaluations carried out empirically—of those, 17 were cost effectiveness analyses. We found four cost utility analyses that used economic modelling rather than empirical methods. Two cost-consequence analyses were also found. Specific implementation costs considered included costs associated with staff training in new care delivery pathways, the impacts of new processes on patient and carer costs and the costs of developing new care processes/pathways. Over half (55%) of the included studies were rated ‘good’ on QHES. Study quality was boosted through inclusion of appropriate comparators and reporting of incremental analysis (where relevant); and diminished through use of post-hoc subgroup analysis, limited reporting of the handling of uncertainty and justification for choice of discount rates.

Conclusions

The quantity of published economic evaluations applied to the field of improvement and implementation research remains modest; however, quality is overall good. Implementation and improvement scientists should work closely with health economists to consider costs associated with improvement interventions and their associated implementation strategies. We offer a set of concrete recommendations to facilitate this endeavour.

Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm

BACKGROUND

Rapid changes in health care are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity.

LOCAL PROBLEM

The Directors of the APP-Best Practice Center conducted assessments of each clinical area at MUSC Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (nurse practitioners/physician assistants) but also in the utilization of APPs to practice to the fullest extent of their license, education, and experience.

METHODS

By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built while following updated practice laws, compliance/legal standards, and hospital bylaws/regulations.

INTERVENTIONS

A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation.

RESULTS

This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity.

CONCLUSIONS

With the APP work force growing, the implementation of electronic medical record systems, and today's health care financial constraints, it is imperative that health care systems standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.

Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm

BACKGROUND

Rapid changes in healthcare are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity.

LOCAL PROBLEM

The directors of the APP-Best Practice Center conducted assessments of each clinical area at the Medical University of South Carolina (MUSC) Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (NPs and physician assistants) but also in the use of APPs to practice to the fullest extent of their license, education, and experience.

METHODS

By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built that follows updated practice laws, compliance/legal standards, and hospital bylaws and regulations.

INTERVENTIONS

A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation.

RESULTS

This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity.

CONCLUSIONS

With the APP workforce growing, the implementation of electronic medical record systems, and today's healthcare financial constraints, healthcare systems must standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.

Describing the leadership capabilities of advanced practice nurses using a qualitative descriptive study

AIM

The aim of this study is to explore advanced practice nurses' perceptions of their leadership capabilities.

DESIGN

A qualitative descriptive methodology informed by a well-established leadership framework was used to explore advanced practice nurses' perceptions of their leadership.

METHODS

Purposive sampling of advanced practice nurses working in tertiary acute care facilities in Eastern Canada was employed. Data sources included face-to-face interviews and document analysis. Fourteen advanced practice nurses participated in two audio-taped semi-structured interviews from March 2013-January 2014. Data were transcribed and analysed using NVIVO 10 software and content analysis.

RESULTS

Two main themes were identified: "Patient-focused leadership" and "organization and system-focused leadership". These two themes are further described through leadership domains and capabilities that clearly articulate advanced practice nursing leadership and its contribution to improving the care environment for patients and families, nurses and other healthcare providers, organizations and the healthcare system.

Nurse-led versus doctor-led care for bronchiectasis

BACKGROUND

Specialist nursing roles to manage stable disease populations are being used to meet the needs of both patients and health services. With increasing cost pressures on health departments, alternative models such as nurse-led care are gaining momentum as a substitute for traditional doctor-led care. This review evaluates the safety, effectiveness, and health outcomes of nurses practising in autonomous roles while using advanced practice skills, within the context of bronchiectasis management in subacute, ambulatory, and/or community care.

OBJECTIVES

To compare the effectiveness of nurse-led care versus doctor-led care in the management of stable bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register and bibliographies of selected papers in addition to grey literature such as electronic clinical trials registries. Searches were current as of March 2018.

SELECTION CRITERIA

Randomised controlled trials were eligible for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted and entered data from included studies. Primary outcomes were numbers of exacerbations requiring treatment with antibiotics, hospital admissions, and emergency department attendances.

MAIN RESULTS

We included one United Kingdom (UK) study in the review. In this randomised controlled trial, a total of 80 participants, with a mean age of 58 years, were treated for 12 months by a specialist nurse or doctor, then were crossed over to the other clinician for the next 12 months. Two participants died during the study period. Six participants failed to cross over to nurse-led care because of unstable bronchiectasis. Overall, the level of study completion was high.Data show no difference in the numbers of exacerbations requiring treatment with antibiotics (rate ratio 1.09, 95% confidence interval (CI) 0.91 to 1.30, 80 participants, moderate-certainty evidence). Investigators reported more hospital admissions in the nurse-led care group (rate ratio 1.52, 95% CI 1.04 to 2.23, 80 participants, moderate-certainty evidence) and did not report emergency department attendance.For secondary outcomes, participants in the nurse-led care group used more healthcare resources during the first year of the trial. Increased admissions and greater use of resources made treatment costs for nurse-led groups' higher. Total costs for both years of the study were £8,464 and £5,228 for nurse-led care compared with doctor-led care. However, by the second year, treatment costs were almost equitable between the two groups, which may reflect the nurses' learning of how to better treat people with bronchiectasis. No statistically significant changes were observed in quality of life, exercise capacity, mortality, or lung function. Wide confidence intervals led to uncertainty regarding these results. Adverse events were not an outcome for this review.

AUTHORS' CONCLUSIONS

This update of the review shows that only one trial met review criteria. Review authors were unable to demonstrate effectiveness of nurse-led care compared with doctor-led care on the basis of findings of a single study. The included study reported no significant differences, but limited evidence means that differences in clinical outcomes between nurse-led care and usual care within the setting of a specialist clinic remain unclear. Further research is required to determine whether nurse-led care is cost-effective, if guidelines and protocols for bronchiectasis management are followed does this increases costs and how effective nurse-led management of bronchiectasis is in other clinical settings such as inpatient and outreach.

Lung transplant recipients' experiences of and attitudes towards self-management: a qualitative systematic review protocol

REVIEW QUESTION

The question for this review is: what are lung transplant recipients' experiences of and attitudes towards self-management?

The costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs: A systematic review of international evidence

BACKGROUND

Patients with palliative care needs do not access specialist palliative care services according to their needs. Clinical Nurse Specialists working across a variety of fields are playing an increasingly important role in the care of such patients, but there is limited knowledge of the extent to which their interventions are cost-effective.

OBJECTIVES

To present results from a systematic review of the international evidence on the costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs, defined as seriously ill patients and those with advanced disease or frailty who are unlikely to be cured, recover or stabilize.

DESIGN

Systematic review following PRISMA methodology.

DATA SOURCES

Medline, Embase, CINAHL and Cochrane Library up to 2015. Studies focusing on the outcomes of Clinical Nurse Specialist interventions for patients with palliative care needs, and including at least one economic outcome, were considered. The quality of studies was assessed using tools from the Joanna Briggs Institute.

RESULTS

A total of 79 papers were included: 37 randomized controlled trials, 22 quasi-experimental studies, 7 service evaluations and other studies, and 13 economic analyses. The studies included a wide variety of interventions including clinical, support and education, as well as care coordination activities. The quality of the studies varied greatly.

CONCLUSION

Clinical Nurse Specialist interventions may be effective in reducing specific resource use such as hospitalizations/re-hospitalizations/admissions, length of stay and health care costs. There is mixed evidence regarding their cost-effectiveness. Future studies should ensure that Clinical Nurse Specialists' roles and activities are clearly described and evaluated.

An overview of the outcomes and impact of specialist and advanced nursing and midwifery practice, on quality of care, cost and access to services: A narrative review

OBJECTIVES

This paper presents the results of a systematic rapid review and narrative synthesis of the literature of the outcomes and impact of specialist and advanced nursing and midwifery practice regarding quality of care, cost and access to services.

DESIGN

A rapid review was undertaken of the relevant national and international literature, regulatory and policy documents relating to the establishment and definition of nurses' and midwives' specialist and advanced practice roles.

DATA SOURCES

A search of the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), PubMed (MEDLINE) was undertaken from 2012 to 2015. The study also included primary data collection on the perceived impact of specialist and advanced practice nursing and midwifery roles and enablers and barriers to these roles using semi-structured interviews. These are not included in this paper.

REVIEW METHOD

To facilitate a systematic approach to searching the literature, the PICO framework, was adapted.

RESULTS

The database search yielded 437 articles relevant to the analysis of specialist and advanced practice in relation to quality care, cost and access to services with additional articles added in a manual review of reference lists. In the final review a total of 86 articles were included as they fulfilled the eligibility criteria.

CONCLUSION

The evidence presented in the 86 articles indicates that nursing and midwifery practitioners continue to be under-utilised despite the evidence that greater reliance on advanced nurse practitioners could improve accessibility of primary care services while also saving on cost. Results point to continued difficulties associated with accurate measurement of the impact of these roles on patient outcomes. This review demonstrates that there is a need for robust measurement of the impact of these roles on patient outcomes.

Association between advanced practice nursing and 30-day mortality in mechanically ventilated critically ill patients: A retrospective cohort study

PURPOSE

Little is known about the association between advanced practice nursing and mortality. The aim of this study was to evaluate whether the presence of advanced practice nurses (APN), that is, certified nurse (CN) and certified nurse specialist (CNS) in intensive care, is associated with 30-day mortality for mechanically ventilated critically ill patients.

MATERIALS AND METHODS

Using a Japanese national in-patient database, we identified 45,620 patients who were admitted to an intensive care unit (ICU) and received mechanical ventilation within 2 days of hospital admission between 1 April 2014 and 31 March 2015. We assessed the association between the number of CN/CNSs per 10 adult ICU beds and 30-day mortality.

RESULTS

We examined 8955 patients in 134 hospitals without CN/CNSs and 36,665 in 284 hospitals with CN/CNSs. Overall, the number of CN/CNSs per 10 adult ICU beds ranged from 0 to 7.5. In the multivariable analysis, the number of CN/CNSs per 10 adult ICU beds was significantly associated with a reduction in 30-day mortality (adjusted odds ratio 0.97; 95% confidence interval, 0.94-1.00; P=0.023).

CONCLUSIONS

Our findings show that APNs may play an important role in improving patient outcome in the adult ICU.

Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review

BACKGROUND

Advanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness.

OBJECTIVE

To examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles.

METHODS

Our methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel.

RESULTS

The narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles.

CONCLUSION

Current guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.

Gastroenterologist and nurse management of symptoms after pelvic radiotherapy for cancer: an economic evaluation of a clinical randomized controlled trial (the ORBIT study)

BACKGROUND

Over 20 distressing gastrointestinal symptoms affect many patients after pelvic radiotherapy, but in the United Kingdom few are referred for assessment. Algorithmic-based treatment delivered by either a consultant gastroenterologist or a clinical nurse specialist has been shown in a randomized trial to be statistically and clinically more effective than provision of a self-help booklet. In this study, we assessed cost-effectiveness.

METHODS

Outcomes were measured at baseline (pre-randomization) and 6 months. Change in quality-adjusted life years (QALYs) was the primary outcome for the economic evaluation; a secondary analysis used change in the bowel subset score of the modified Inflammatory Bowel Disease Questionnaire (IBDQ-B). Intervention costs, British pounds 2013, covered visits with the gastroenterologist or nurse, investigations, medications and treatments. Incremental outcomes and incremental costs were estimated simultaneously using multivariate linear regression. Uncertainty was handled non-parametrically using bootstrap with replacement.

RESULTS

The mean (SD) cost of treatment was £895 (499) for the nurse and £1101 (567) for the consultant. The nurse was dominated by usual care, which was cheaper and achieved better outcomes. The mean cost per QALY gained from the consultant, compared to usual care, was £250,455; comparing the consultant to the nurse, it was £25,875. Algorithmic care produced better outcomes compared to the booklet only, as reflected in the IBDQ-B results, at a cost of ~£1,000.

CONCLUSION

Algorithmic treatment of radiation bowel injury by a consultant or a nurse results in significant symptom relief for patients but was not found to be cost-effective according to the National Institute for Health and Care Excellence (NICE) criteria.

Advanced Practice Nursing: A Strategy for Achieving Universal Health Coverage and Universal Access to Health

Objective:

to examine advanced practice nursing (APN) roles internationally to inform role development in Latin America and the Caribbean to support universal health coverage and universal access to health.

Method:

we examined literature related to APN roles, their global deployment, and APN effectiveness in relation to universal health coverage and access to health.

Results:

given evidence of their effectiveness in many countries, APN roles are ideally suited as part of a primary health care workforce strategy in Latin America to enhance universal health coverage and access to health. Brazil, Chile, Colombia, and Mexico are well positioned to build this workforce. Role implementation barriers include lack of role clarity, legislation/regulation, education, funding, and physician resistance. Strong nursing leadership to align APN roles with policy priorities, and to work in partnership with primary care providers and policy makers is needed for successful role implementation.

Conclusions:

given the diversity of contexts across nations, it is important to systematically assess country and population health needs to introduce the most appropriate complement and mix of APN roles and inform implementation. Successful APN role introduction in Latin America and the Caribbean could provide a roadmap for similar roles in other low/middle income countries.

Improved quality-of-life of caregivers of children with asthma through guideline-based management

OBJECTIVE

The quality of life (QOL) of caregivers of children with asthma may be related to children's responses to asthma management.

AIM

To evaluate change in QOL over time of caregivers of children with asthma through guideline-based management.

DESIGN

This was a 3-year prospective cohort study of children with asthma referred to our pediatric asthma center. Families completed Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), the Asthma Control Test™ (ACT), and reported the number of days/month of albuterol use and wheezing at each clinic visit.

RESULTS

We enrolled 143 children, ages 7-17 years (mean = 10.6 ± 2.9), 56.6% male, 70.6% Caucasian. Patients were managed by the same MD (n = 65,45.5%) or APN (n = 78,54.5%) over time. The mean total PACQLQ significantly increased over the 3-year period (F = 67.418, p < .001). Total scores at the first visit were 4.8 ± 1.6, which improved to 6.1 ± 1 at the 3-month follow-up visit. This improvement was sustained at the 1, 2, and 3-year clinic visits. PACQLQ emotional function (F = 60.798, p < .001) and activity limitation (F = 41.517, p < .001) domains significantly improved as well. PACQLQ scores were significantly associated with improved ACT scores (r = .37 to .47, p < .05), fewer days/month of albuterol use (r = -.25 to -.36., p < .05), and wheezing (r = -.28 to -.33, p < .05). There were no significant differences in PACQLQ, or asthma clinical outcome measures between MD and APN providers.

CONCLUSION

Use of National Asthma Education and Prevention Program (NAEPP) guidelines significantly improved QOL of caregivers of children with asthma and in asthma-related symptoms. Improvements over time were independent of type of providers.

Cost-effectiveness of a nurse practitioner-family physician model of care in a nursing home: controlled before and after study

AIMS

To examine the cost-effectiveness of a nurse practitioner-family physician model of care compared with family physician-only care in a Canadian nursing home.

BACKGROUND

As demand for long-term care increases, alternative care models including nurse practitioners are being explored.

DESIGN

Cost-effectiveness analysis using a controlled before-after design.

METHODS

The study included an 18-month 'before' period (2005-2006) and a 21-month 'after' time period (2007-2009). Data were abstracted from charts from 2008-2010. We calculated incremental cost-effectiveness ratios comparing the intervention (nurse practitioner-family physician model; n = 45) to internal (n = 65), external (n = 70) and combined internal/external family physician-only control groups, measured as the change in healthcare costs divided by the change in emergency department transfers/person-month. We assessed joint uncertainty around costs and effects using non-parametric bootstrapping and cost-effectiveness acceptability curves.

RESULTS

Point estimates of the incremental cost-effectiveness ratio demonstrated the nurse practitioner-family physician model dominated the internal and combined control groups (i.e. was associated with smaller increases in costs and emergency department transfers/person-month). Compared with the external control, the intervention resulted in a smaller increase in costs and larger increase in emergency department transfers. Using a willingness-to-pay threshold of $1000 CAD/emergency department transfer, the probability the intervention was cost-effective compared with the internal, external and combined control groups was 26%, 21% and 25%.

CONCLUSION

Due to uncertainty around the distribution of costs and effects, we were unable to make a definitive conclusion regarding the cost-effectiveness of the nurse practitioner-family physician model; however, these results suggest benefits that could be confirmed in a larger study.

An exploration of clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners, in Ireland

BACKGROUND

Clinical specialist (CS) and advanced practitioner (AP) roles have increased in nursing and midwifery internationally. This study explored clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners in Ireland.

METHODS

Using a case study design, interview, observational and documentary data from postholding sites (CSs or APs employed) were compared with data from non-postholding sites (no CSs or APs employed). Interviews and observations were conducted with postholders (n = 23), and compared with data from healthcare professionals (nurses or midwives, doctors) (n = 23) in matched services. Interviews were held with Directors of Nursing and Midwifery (n = 23), healthcare professionals (n = 41), service users (n = 41) with experience of receiving care or working with postholders, and non-postholders in matched services. The data were analysed using Nvivo (Version 8).

RESULTS

The findings suggest that postholders' practice appeared to differ from non-postholders' in relation to case management and service provision. Postholders were seen as having an impact on readmission rates, waiting lists/times, collaborative decision-making, continuity of care and workload management. Postholders' autonomy to manage caseloads was perceived to lead to smoother transition of patients/clients through the healthcare system. Service-users' self-reports appeared to appreciate the individualised holistic care provided by postholders. Postholders' role in facilitating person-centred care and promoting interprofessional team working, are essential elements in quality care provision and in global healthcare workforce planning.

CONCLUSIONS

To meet changing healthcare demands, promote person-centred care, and improve service delivery, more specialist and advanced practice posts in nursing and midwifery should be developed and supported within healthcare.