Rhetoric or reality? What nurse practitioners do to provide self-management support in outpatient clinics: an ethnographic study

Impact, scope of practice and competencies of Advanced Practice Nurses within APN-led models of care for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings: a scoping review protocol

INTRODUCTION

The increase of young and middle-aged adult patients with multimorbid and/or complex chronic conditions has created new challenges for healthcare systems and services. Advanced Practice Nurses (APNs) play an essential role in treating these patients because of their expertise and advanced nursing skills. Little is known about competencies, scope of practice and impact of APNs within APN-led care models for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings. The objective of this scoping review is to describe the impact, scope of practice and competencies of APNs within APN-led care models for young and middle-aged adult patients in hospital settings.

METHODS AND ANALYSIS

This scoping review will be conducted using the methodological framework proffered by Arksey and O'Malley, incorporating the methodological enhancement of Levac et al. It will comply with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for Scoping Reviews' guidelines of Tricco et al. Systematic research will be conducted in the databases MEDLINE (PubMed), CINAHL (EBSCO), EMBASE (Ovid), CENTRAL and PsycINFO (Ovid) using all recognised keywords, index terms and search strings. Grey literature will be scanned. Bibliography of all selected studies will be hand searched. Studies will be selected based on defined inclusion and exclusion criteria, screened by title and abstracts. Data from full-text articles meeting the inclusion criteria will be extracted independently by two authors. Disagreements in evaluation will be discussed and resolved by consensus. Results will be reported in the form of descriptive tables. Narrative summery is used to present the results of the review in the context of the study's objectives and questions.

ETHICS AND DISSEMINATION

This scoping review does not require ethics approval. The review will be handed in as part of a doctoral thesis and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER OSF

4PM38.

Nurse Practitioners' Self-Efficacy and Behavior in Supporting Self-Management of Patients With a Progressive, Life-Threatening Illness and Their Relatives: A Nationwide, Cross-Sectional Online Survey

This study aimed at investigating nurse practitioners' self-efficacy and behavior in supporting self-management of patients with a progressive, life-threatening illness and their relatives. We adapted an existing validated instrument for this purpose, amongst other things by adding a seventh subscale "attention for relatives," and administered it in a nationwide, cross-sectional online survey among Dutch nurse practitioners. We analyzed associations between self-reported self-efficacy and behavior using Pearson correlations and paired sample t tests. Associations between self-efficacy and behavior with nurse practitioners' characteristics were examined using linear regression models. Most nurse practitioners (n = 327; 26% complete responses) were women (93%). Subscale and total scores for nurse practitioners' self-efficacy were moderately positively correlated with those for their behavior in self-management support. Subscale and total scores were statistically significantly higher for their self-efficacy than for their behavior. Increased work experience with patients with a progressive, life-threatening illness was associated with higher scores on self-efficacy and behavior in self-management support. We conclude that nurse practitioners are confident in their ability to support self-management; yet, they do not always use these competencies in practice.

Patient perceived needs and experiences of person-centered care in patients with inflammatory arthritis

BACKGROUND

Health care is shifting toward a person-centered care (PCC) approach. For implementation of PCC, there may be a special role for nurse practitioners (NPs).

PURPOSE

The aim of this study was to explore the patient-perceived levels of and needs for of PCC in inflammatory arthritis patients who visited the NP at the outpatient clinic of an academic hospital in the Netherlands.

METHODS

A cross-sectional study was performed. Disease characteristics were inventoried from the patient records. Patients filled out the PCCoc/rheum instrument, an instrument to measure patient perceived PCC, and a questionnaire based on the 14 life areas of the Self-Management Web, extended with areas including pain, fatigue, and night's rest. Participants were asked which life areas caused problems, and whether these problems were discussed. Mean values were calculated for normally distributed data and medians for nonnormally distributed data.

RESULTS

Most of the patients had well-controlled disease (86.1%). The mean score of the PCCoc/rheum was 55.3 (SD 8.1). Patients experienced most problems in life areas fatigue (37.3%) and pain (35.3%), these were also the life areas that were most often addressed at consultation. The life areas that gave problems and that were least addressed during consultation were intimate relationships & sexuality (66.7%) and household chores (58.8%).

CONCLUSIONS

Despite an overall high level of patient perceived PCC delivered by NPs, patient with low disease activity frequently reported problems in life areas not addressed at consultation.

IMPLICATIONS FOR PRACTICE

Implementation of the Self-Management Web and changing the focus of NP consultations may help to improve accommodating individual patient needs.

How do nurses support chronically ill clients' participation and self-management in primary care? A cross-country qualitative study

BACKGROUND

In the context of the advancement of person-centered care models, the promotion of the participation of patients with chronic illness and complex care needs in the management of their care (self-management) is increasingly seen as a responsibility of primary care nurses. It is emphasized that nurses should consider the psychosocial dimensions of chronic illness and the client's lifeworld. Little is known about how nurses shape this task in practice.

METHODS

The aim of this analysis is to examine how primary care nurses understand and shape the participation of patients with chronic illness and complex care needs regarding the promotion of self-management. Guided interviews were conducted with nurses practicing in primary care and key informants in Germany, Spain, and Brazil with a subsequent cross-case evaluation. Interpretive and practice patterns were identified based on Grounded Theory.

RESULTS

Two interpretive and practice patterns were identified: (1) Giving clients orientation in dealing with chronic diseases and (2) supporting the integration of illness in clients' everyday lives. Nurses in the first pattern consider it their most important task to provide guidance toward health-promoting behavior and disease-related decision-making by giving patients comprehensive information. Interview partners emphasize client autonomy, but rarely consider the limitations chronic disease imposes on patients' everyday lives. Alternatively, nurses in the second pattern regard clients as cooperation partners. They seek to familiarize themselves with their clients' social environments and habits to give recommendations for dealing with the disease that are as close to the client's lifeworld as possible. Nurses' recommendations seek to enable patients and their families to lead a largely 'normal life' despite chronic illness. While interview partners in Brazil or Spain point predominantly to clients' socio-economic disadvantages as a challenge to promoting client participation in primary health care, interview partners in Germany maintain that clients' high disease burden represents the chief barrier to self-management.

CONCLUSIONS

Nurses in practice should be sensitive to client's lifeworlds, as well as to challenges that arise as they attempt to strengthen clients' participation in care and self-management. Regular communication between clients, nurses, and further professionals should constitute a fundamental feature of person-centered primary care models.

Evaluation of a Nurse-Led Patient Navigation Intervention: Follow-Up of Patients After Autologous and Allogeneic Stem Cell Transplantation

BACKGROUND

Complex survivorship cancer care requires nurse-led interventions. Therefore, a nurse-led patient navigation intervention was developed in which trained cancer nurses gave advice and referred to other professionals during the process of recovery and rehabilitation of hematopoietic stem cell transplantation (HSCT) patients.

OBJECTIVE

The aim of this study was to understand the nature and effect of this nurse-led information and referral intervention.

METHODS

Of the 199 included patients in the intervention group, 75 completed the quality of life, quality of care, self-efficacy, and self-management behavior questionnaires at baseline and at 6 and 12 months after HSCT. A historical control group of 62 patients completed the same questionnaires 12 months after HSCT. In addition, patients' experiences with the intervention were evaluated in 2 focus groups.

RESULTS

Patients emphasized the holistic approach of the cancer nurses and the opportunity to discuss psychosocial domains of life. Within the intervention group, a statistically significant effect on quality of life was demonstrated over time. The differences in quality of life, self-efficacy, and self-management were not significant between the intervention group and control group.

CONCLUSION

The holistic focus of this nurse-led intervention proved to be acceptable to the HSCT patients and promising in supporting the (complex) challenges that these patients face during their process of recovery and rehabilitation.

IMPLICATIONS FOR PRACTICE

Nurse-led patient navigation interventions with a holistic approach when included in the daily practice of complex survivorship cancer care can support HSCT patients' information and referral needs during their rehabilitation.

Quadangulation: A New Methodology Combining Ethnographic Research and Quality Improvement Projects in Health Science Research

The purpose of this paper is to describe quadangulation as a methodology for conducting and analyzing combined ethnographic studies and quality improvement (QI) projects into one comprehensive investigation to improve the quality of health care. A comprehensive base of cultural influences in all health-care delivery settings, obtained from the design, implementation, and interpretation of a rigorous ethnographic investigation, and a QI project is new proposed methodology, called quadangulation. This new methodology has the potential to influence transformational cultural change, quality whole-person patient-centered care, and improved population health, through in-depth qualitative and quantitative analysis of cultural influences and clinical problems.

Interactions between women with rheumatoid arthritis and nurses during outpatient consultations: A qualitative study

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory disease, and patients with RA receive services in various settings-for example, in nurse-led follow-up consultations. The present study aimed to investigate how the management of RA in everyday life is expressed in interactions between nurses and women with RA during nursing consultations.

METHODS

The study was conducted in accordance with constructivist grounded theory, with data based on participant observations and subsequent interviews with 10 women with RA.

RESULTS

A core category was developed, "Collaboration through mutual acknowledgement", which documented how the women and nurses confirmed their shared understanding of the content and the structure of the consultation. Three subcategories were identified: (i) "On safe ground", which illustrated that biomedical factors, such as blood test results and pharmacological treatment, structured the basis of the dialogue; (ii) "Venturing forward", which documented how both parties were aware of each other's reactions when the dialogue dealt with women's perspectives of illness in their everyday lives; and (iii) "Gentle steering", which showed that the nurses gently steered the dialogue if the women strayed from the planned content.

CONCLUSIONS

Both parties agreed that a disease perspective consistent with biomedical factors formed the basis for further dialogue. Subsequently, the women's perspectives on illness were included, and the women felt acknowledged. Therefore, the recommendation is that the consultations start by all parties agreeing on a shared agenda to facilitate the inclusion of the women's perspectives on illness.

An exploration of learning needs: identifying knowledge deficits among hospitalized adults with heart failure

The current study examined the learning needs of hospitalized patients with chronic heart failure (CHF) by identifying their current CHF self-care behaviors and knowledge levels, while identifying relationships between clinical variables, and their learning needs. A descriptive, cross-sectional design was utilized to examine a convenience sample of 42 hospitalized patients with CHF. Self-care behaviors and knowledge levels were measured using the Self Care of Heart Failure Index V. 6.2, and the Japanese Heart Failure Knowledge Scale. Descriptive statistics were used to describe the learning needs and sociodemographic data and Pearson product moment correlation examined relationships between the learning needs and clinical variables. The mean scores of self-care were 38.6% (maintenance), 41.6% (management) and 17.8% (confidence). The participant's mean knowledge level score was 74.9%. Multiple CHF hospital readmissions had a significant negative correlation with CHF knowledge scores (r = -0.358, p < 0.05), suggesting the lower the knowledge score, the higher the prevalence of CHF readmissions. There were significant positive correlations between self-care maintenance (r = 0.525, p < 0.05), management (r = 0.435, p < 0.05), confidence (r = 0.366, p < 0.05), knowledge level (r = 0.752, p < 0.05) and not living alone. Thus, indicating that living with family support is correlated with better self-care and greater knowledge. The presence of multiple comorbidities revealed significant positive correlations (p < 0.05) with self-care scores (maintenance [r = 0.391], management [r = 0.438], and confidence r = 0.504), indicating a higher number of comorbidities, yielded lower self-care behaviors. Findings revealed poor self-care behaviors in all three areas (maintenance, management, confidence). These findings suggested that patients had difficulty implementing knowledge into self-care. By identifying knowledge deficits and contributing factors to suboptimal self-care, the chronic care model can be used as a guideline for ideal CHF education and management. Improving self-care behaviors can be obtained by initiating an active engagement between health care teams and the patient.

Support Needs of People With Head and Neck Cancer Regarding the Disease and Its Treatment

OBJECTIVES

To provide insight into people's experiences in dealing with the consequences of head and neck cancer (HNC) in daily life and their needs for self-management support.

SAMPLE & SETTING

13 people with HNC who were successfully treated in the Department of Radiation Oncology at the Erasmus MC Cancer Institute in Rotterdam, the Netherlands.

METHODS & VARIABLES

Two focus groups and six individual interviews; data were analyzed with directed content analysis.

RESULTS

Most patients wished to receive professional support for dealing with post-treatment consequences. Apart from physical complaints, patients had difficulties in dealing with the emotional aspects of HNC and its treatment and struggled with building self-confidence to move on with their lives. Patients mentioned the importance of relatives being there for them but complained that their needs were not always met. Support from fellow patients was valued for their empathetic capacity.

IMPLICATIONS FOR NURSING

Nurses must provide self-management support that meets people's integral needs inherent in living with the consequences of HNC, particularly in the initial post-treatment period. Practical interventions could be useful.

Evaluating the feasibility of a nurse-led self-management support intervention for kidney transplant recipients: a pilot study

Background

To support effective self-management after kidney transplantation, a holistic nurse-led self-management support intervention was developed using the Intervention Mapping approach. The primary aim was to evaluate the feasibility, acceptability and fidelity of the intervention for kidney transplant recipients and professionals. The secondary aim was to explore preliminary effects on outcomes.

Methods

A pilot study was conducted in 2015–2017 to evaluate the intervention. Nurse Practitioners (NP) guided recipients in assessing 14 life areas using the Self-Management Web. Participants were supported in developing self-regulation skills which can be applied to self-management of the illness. Strategies included goal setting, action planning, and promotion of motivation and self-efficacy. Adult recipients from an outpatient clinic of a Dutch University Hospital who underwent their transplant at least 1 month ago, were invited to participate. NPs, nephrologists and recipients were interviewed to assess feasibility, fidelity and implementation experience. Consultations were videoed and analysed to assess fidelity. To assess the preliminary effects, the intervention group completed baseline (T0) and follow-up (T1) questionnaires on self-management behavior, self-efficacy, quality of life and quality of care. A historical control group of kidney transplant recipients completed the same questionnaires at T1.

Results

Twenty-seven recipients agreed to participate in the intervention group, of which 24 completed the intervention and 16 completed baseline and follow-up surveys. The control group consisted of 33 recipients. Professionals and recipients appraised the open, holistic focus of the intervention as a welcome addition to standard care and felt that this helped to build a relationship of trust. Recipients also felt they became more competent in problem-solving skills. The within-group analysis showed no significant increase in patients’ self-management skills. The between-groups analysis showed significantly higher medication adherence among the intervention group (P = 0.03; G = 0.81). The within-groups analysis showed a significantly higher perceived quality of care (P = 0.02) in the intervention group.

Conclusion

This holistic nurse-led self-management support intervention was found to be feasible and acceptable by professionals and recipients alike. This pilot had a small sample therefore further research is needed into the potential effects on self-management behavior and well-being of transplant recipients. ISRCTN Trial Registry: ISRCTN15057632 (registered retrospectively on 20-07-2018).

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1300-7) contains supplementary material, which is available to authorized users.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

A cross-sectional descriptive survey.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

A Nurse-Led Self-Management Support Intervention (ZENN) for Kidney Transplant Recipients Using Intervention Mapping: Protocol for a Mixed-Methods Feasibility Study

Background

Optimal self-management in kidney transplant recipients is essential for patient and graft survival, reducing comorbidity and health care costs while improving the quality of life. However, there are few effective interventions aimed at providing self-management support after kidney transplantation.

Objective

This study aims to systematically develop a nurse-led, self-management (support) intervention for kidney transplant recipients.

Methods

The Intervention Mapping protocol was used to develop an intervention that incorporates kidney transplant recipients’ and nurses’ needs, and theories as well as evidence-based methods. The needs of recipients and nurses were assessed by reviewing the literature, conducting focus groups, individual interviews, and observations (step 1). Based on the needs assessment, Self-Regulation Theory, and the “5A’s” model, change objectives were formulated (step 2). Evidence-based methods to achieve these objectives were selected and subsequently translated into practical implementation strategies (step 3). Then, program materials and protocols were developed accordingly (step 4). The implementation to test the feasibility and acceptability was scheduled for 2015-2017 (step 5). The last step of Intervention Mapping, evaluation of the intervention, falls outside the scope of this paper (step 6).

Results

The intervention was developed to optimize self-management (support) after kidney transplantation and targeted both kidney transplant recipients and nurse practitioners who delivered the intervention. The intervention was clustered into four 15-minute sessions that were combined with regular appointments at the outpatient clinic. Nurses received a training syllabus and were trained in communication techniques based on the principles of Solution-Focused Brief Therapy and Motivational Interviewing; this entailed guiding the patients to generate their own goals and solutions and focus on strengths and successes. Kidney transplant recipients were encouraged to assess self-management challenges using the Self-Management Web and subsequently develop specific goals, action plans, and pursuit skills to solve these challenges.

Conclusions

The Intervention Mapping protocol provided a rigorous framework to systematically develop a self-management intervention in which nurses and kidney transplant recipients’ needs, evidence-based methods, and theories were integrated.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11856

Enhancing metabolic monitoring for children and adolescents using second-generation antipsychotics

The prevalence of children and adolescents using second-generation antipsychotics (SGAs) has increased significantly in recent years. In this population, SGAs are used to treat mood and behavioural disorders although considered 'off-label' or not approved for these indications. Metabolic monitoring is the systematic physical health assessment of antipsychotic users utilized to detect cardiovascular and endocrine side effects and prevent adverse events such as weight gain, hyperglycaemia, hyperlipidemia, and arrhythmias. This practice ensures safe and efficacious SGA use among children and adolescents. Despite widely available, evidence-based metabolic monitoring guidelines, rates of monitoring continue to be suboptimal; this exposes children to the unnecessary risk of developing poor cardiovascular health and long-term disease. In this discursive paper, existing approaches to metabolic monitoring as well as challenges to implementing monitoring guidelines in practice are explored. The strengths and weaknesses of providing metabolic monitoring across outpatient psychiatry, primary care, and collaborative community settings are discussed. We suggest that there is no one-size-fits-all solution to improving metabolic monitoring care for children and adolescents using SGA in all settings. However, we advocate for a pragmatic global approach to enhance safety of children and adolescents taking SGAs through collaboration among healthcare disciplines with a focus on integrating nurses as champions of metabolic monitoring.

Patellar dislocation: Not the bees knees

BACKGROUND

Patellar dislocations are common, particularly in the adolescent polulation. Registered Advanced Nurse Practitioners are healthcare professionals who can appropriately manage these injuries to minimise the risk of chronicity.

METHODS

This is a case study which uses a clinical examplar from the authors practice focusing on the assessment, diagnosis and managment of patellar dislocations. Particular reference is made of the significance of the MPFL.

RESULTS

This paper highlights the importance of recognition of appropriate management of patellar dislocations in the ED setting. Discussion points include the role of the MDT and the role of exercise prescription in the injury management.

CONCLUSION

The diagnosis of patellar dislocation is heavily dependant on eliciting a comprehensive history and conducting an appropriate clinical exam. Patient outcomes may be optimised by adopting an MDT approach.