Effectiveness of registered nurses on system outcomes in primary care: a systematic review

Nurses' experiences with virtual care during the COVID-19 pandemic: a qualitative study in primary care

BACKGROUND

During the COVID-19 pandemic, virtual care was used to deliver primary care services. Nurses contributed to primary care teams' capacity to deliver care virtually. This study explored nurses' roles in virtual care delivery in primary care and the barriers and facilitators that influenced their contributions.

METHODS

We employed a qualitative descriptive approach and conducted semi-structured interviews with nurses representing each regulatory designation (i.e., Nurse Practitioners, Registered Nurses, Licensed/Registered Practical Nurses) working in primary care in four Canadian provinces (i.e., British Columbia, Ontario, Nova Scotia, and Newfoundland and Labrador). We performed thematic analysis on data related to the delivery of virtual care.

RESULTS

We interviewed seventy-six nurses and identified three key themes and various sub-themes related to virtual nursing practice during the COVID-19 pandemic: (1) variable adoption of virtual care among nurses, (2) facilitators and barriers to virtual nursing practice, and (3) impacts of virtual delivery on care provision by nurses. Nurses' involvement in virtual care varied across designations and nurses recalled various facilitators and impediments that influenced their virtual care experience, such as guidance documents, funding models, and the availability of equipment. Virtual care influenced nurses' workflow, their ability to deliver patient-centred care, and their ability to bridge the care gap.

CONCLUSIONS

Primary care teams are increasingly relying upon nurses to support virtual care delivery, emphasizing the need to understand nursing roles in virtual care. Primary care funding models should be leveraged to support nurses in virtual care delivery; and standardized learning opportunities and guidance documents focused on virtual care should be available to support primary care nurses and strengthen their contributions in future primary care teams that involve virtual nursing care.

[Enhancing Chronic Pain Management: Exploring the Essential Contribution of Primary Care Nurses]

Introduction

L’expertise infirmière en soins primaires est cruciale pour répondre aux besoins des patients vivant avec une maladie chronique. Au Canada, une personne sur cinq vit avec de la de douleur chronique (DC), créant ainsi un fardeau socioéconomique majeur. Cependant, le rôle du personnel infirmier en soins primaires en DC reste sous-développé.

Objectifs

Cette revue narrative analyse l’adéquation du récent Plan d’action québécois en DC avec les modèles de soins reconnus pour la gestion des maladies chroniques et examine le rôle potentiel du personnel infirmier dans la mise en œuvre de ce plan.

Méthode

La synthèse de la littérature a été menée à partir de diverses bases de données (CINAHL, PubMed) et sources documentaires en français et en anglais. Les résultats ont été interprétés à travers le prisme du Chronic Care Model , un cadre reconnu pour améliorer les soins.

Résultats

Bien que le Plan d’action québécois en DC soit aligné sur les objectifs visés, sa mise en œuvre devra surmonter divers défis. Les constats indiquent des opportunités efficaces dans la gestion de la DC, comme le montrent des études sur la pratique infirmière en soins primaires. Elles révèlent que le personnel infirmier exerce déjà des activités de gestion des maladies chroniques applicables à la DC.

Conclusion

Il est important de reconnaître l’apport de l’expertise infirmière en soins primaires pour réévaluer les modèles d’organisation des soins, promouvoir un partage de responsabilités fondé sur les données probantes, et soutenir la recherche future ainsi que l’innovation clinique dans la gestion de la DC.

Nurses' work in relation to patient health outcomes: an observational study comparing models of primary care

BACKGROUND

Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into seven models of primary care: Traditional, Corporate, Health Care Home, Māori, Pacific, Trusts / Non-governmental organisations (Trust/NGOs) and District Health Board / Primary Care Organisations (DHB/PHO). We describe nurse work in relation to these models of care, populations with high health need and patient health outcomes.

METHODS

We conducted a cross-sectional study (at 30 September 2018) of data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥ 65 years), glucose control testing in adults with diabetes, immunisations (at 6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics.

RESULTS

Nurse clinical time, and combined nurse, nurse practitioner and general practitioner clinical time, were substantially higher in Trust/NGO, Māori, and Pacific practices than in other models. Increased patient clinical complexity was associated with more clinical input and higher scores on all outcome measures. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, depression screening, glucose control testing) were in Māori, Trust/NGO and Pacific practices. There was an eightfold difference, across models of care, in percentage of depression screening undertaken by nurses and a fivefold difference in cervical screening and glucose control testing. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree.

CONCLUSIONS

Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release general practitioner clinical time for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner clinical time is required, especially in practices with high volumes of complex patients.

Understanding the factors associated with nurse employment in clinics: Experiences in Taiwan

BACKGROUND

The shortage and distribution of nurses affect healthcare access in aging societies. Limited research has explored the nursing workforce in clinics, which is vital for healthcare delivery. This study aimed to investigate the shortage and distribution of nurses in clinics in Taiwan, considering geographical, institutional, and specialty variations.

METHODS

We conducted a cross-sectional analysis of the national nursing workforce in Western medicine clinics in Taiwan using open government data. The nursing practice rate (NPR) was calculated. The ratio of clinics employing nurses (RCN) was determined by calculating the percentage of clinics with nurses in each category. A logistic regression model was fitted to examine the factors associated with nurse employment, including urbanization level and different specialty clinics. Adjusted odds ratios (OR) and 95% CIs were calculated.

RESULTS

The study revealed an overall NPR as low as 59.1%, and a decreasing trend with age. Among the 11 706 clinics in the study, nearly a quarter did not employ nurses, with an overall RCN of 72.3%. Urbanization level and clinic specialty were associated with nurse employment ( p < 0.05). After adjusting for urbanization level, the fitted regression model identified the top three specialties as plastic surgery (OR = 11.37, RCN = 96.8%), internal medicine (OR = 1.94, RCN = 84.1%), and orthopedics (OR = 1.89, RCN = 83.6%), while the bottom three were otolaryngology (OR = 0.59, RCN = 61.5%), psychiatry (OR = 0.49, RCN = 57.1%), and rehabilitation medicine (OR = 0.30, RCN = 45.2%). Nurses were more likely to be employed in areas at urbanization level 1 (OR = 1.17), 3 (OR = 1.37), and 6 (OR = 1.48), which represent highly urbanized areas within the urban, suburban, and rural categories, respectively, than in urbanization level 4.

CONCLUSION

Clinics in Taiwan showed nursing shortages and maldistribution, with 72.3% RCN and variations based on urbanization and specialty. These factors may be considered in nursing research conducted in other countries to inform future workforce planning.

Integrated self-management support provided by primary care nurses to persons with chronic diseases and common mental disorders: a qualitative study

BACKGROUND

More and more people suffer from concomitant chronic physical diseases and common mental disorders, calling for integrated self-management support in primary care. However, self-management support of chronic physical diseases and common mental disorders is not clearly operationalized by guidelines and is still conducted in silos by primary care nurses, especially in favour of chronic diseases. This study aims to better understand primary care nurses' experience of integrated self-management support for people with physical chronic diseases and common mental disorders.

METHODS

An interpretive descriptive qualitative approach was conducted with 23 primary care nurses from family medicine groups in Quebec (Canada). They were selected through purposive and snowball sampling methods to participate in an individual interview. Data were analysed using an iterative inductive and deductive analysis (Rainbow Model of Integrated Care and the Practical Reviews in Self-Management Support (PRISMS) taxonomy).

RESULTS

Nurses' experience of integrated self-management support for people with CD and CMD was structured around: (1) elements of the approach; (2) clinical integration through prevention and health promotion; and (3) operationalization of integrated self-management support. Several elements deemed essential to integrated self-management support were identified. Nurses offered integrated self-management support through prevention of risk factors and promotion of a healthy lifestyle for physical chronic diseases and common mental disorders. Nurses' self-management support activities included education, action plans, monitoring, and many practical, psychological, and social support strategies. A model of integrated self-management support for primary care nursing is proposed to better understand its clinical integration.

CONCLUSION

This study presents clinical integration of self-management support and activities for people with physical chronic diseases and common mental disorders in primary care settings. Understanding integrated self-management support will help implement future interventions.

Factors associated with work engagement among specialist nurses in china: a cross-sectional study

BACKGROUND

The positive impacts of work engagement among specialist nurses on retention, organizational commitment, and quality of care are well-documented. However, there is a lack of research on the specific differences in work engagement among specialist nurses. Therefore, the purpose of this study is to assess the level of work engagement among specialist nurses in China and identify its influencing factors.

METHODS

A descriptive cross-sectional study was conducted in China from April to July, 2023, with 724 nurses selected from 22 hospitals through convenience sampling involved. The survey was conducted by using self-administered general information questionnaires and work engagement scales. Questionnaire Star was employed as the online data collection tool. The collected data was analyzed by using descriptive statistics and stepwise regression analysis to draw meaningful conclusions from the study.

RESULTS

Among specialist nurses in Xiamen, China, who had a response rate of 97.10%, an average work engagement score is 140.35 (SD=18.17), with the highest score for the work attitude at 4.65 (SD=0.52) and the lowest score for the work recognition at 4.09 (SD=0.85). It was shown through regression analysis that factors such as career satisfaction, involvement in challenging case discussions, marital status, gender, presence of promotion advantage and title accounted for 14.5% of the total variance in the model and were significant explanatory variables that could predict work engagement.

CONCLUSION

It is shown that specialist nurses in Xiamen, China have a high level of work engagement. It is imperative for nursing managers to prioritize the work engagement of specialist nurses, provide the specialist nurses with ample development opportunities and room for growth, and effectively promote the overall development of specialist nurses by improving work engagement in various aspects.

Building a Practice Ready and Resilient Nursing Workforce

Nurse leaders depend upon resiliency skills to support their practice. It is important to provide opportunities for nursing students to learn, practice, and observe these skills, which are needed to navigate challenging work environments. This article describes the impact of a resiliency curricular component in a grant-funded BSN elective course, Concepts of Primary Care. Program evaluation was performed using a pre/posttest format and 2 surveys, the Brief Resilience Scale (BRS) and the Brief Resilience Coping Scale (BRCS). Three open-ended questions were administered upon completion of the elective course. A concurrent nested design was utilized with a thematic analysis undertaken to analyze qualitative data. Analysis of quantitative data was performed using descriptive statistics. Undergraduate BSN students showed an overall increase in resiliency (BRS: P = .112; BCRS: P = .064), and responses to open-ended questions supported the ability to apply and analyze most of the resiliency skills presented during the didactic portion of the elective course. This course promoted the development and refinement of undergraduate BSN student resilience skills. Integration of resilience content in the primary care course also supported student professional development. The addition of resiliency concepts and skills into undergraduate nursing curricula is recommended to enhance the ability of novice nurses to address work-related challenges and promote career satisfaction for the future.

Impact of the National Nursing Development Plan on nursing human resources in China: An interrupted time series analysis for 1978-2021

BACKGROUND

Shortages of nurses and unequal distribution of nursing staff have been huge challenges for global health services.

OBJECTIVES

The aim of our study was to evaluate the impact of the National Nursing Development Plan on nursing human resources in China.

METHODS

An interrupted time series design was used in this study. The data for this study were extracted from the National Health Statistics Yearbook from 1978 to 2021. The Ministry of Health issued the National Nursing Development Plan (2005-2010) in July 2005. Subsequently, the strategic plan was issued every 5 years: the National Nursing Development Plan (2011-2015), the National Nursing Development Plan (2016-2020), and the National Nursing Development Plan (2021-2025). This study used five indicators including 1) the number of registered nurses (RNs) in China, 2) the number of RNs per 1000 population in China, 3) the proportion of RNs in health technical personnel in China, 4) the doctor-nurse ratio and 5) the number of nurses working in primary medical institutions to evaluate the changing trend of nursing human resources in China from 1978 to 2021.

RESULTS

Interrupted time series analysis showed that after the implementation of the National Nursing Development Plan (2005-2010), the building of nurses in China was gradually strengthening, and the number of RNs in China increased by 0.198 million per year (95%CI 0.174-0.223; P < 0.001); the number of RNs per 1000 population (Coefficient = 0.139; 95%CI 0.123-0.154; P < 0.001); the proportion of RNs in the total number of health professionals in China has increased from 29.6 % to 44.6 % (Coefficient = 0.010; 95%CI 0.009-0.010; P < 0.001); in China, the doctor-nurse ratio increased by 0.024 (95%CI 0.019-0.029; P < 0.001). In 2021, the number of RNs working in primary medical institutions increased by approximately 0.86 million compared with that in 2005, and the proportion of RNs in the country increased by 1.4 %. The development of nurses is especially tilted to the primary level to meet the health and nursing needs of the primary level.

CONCLUSIONS

The implementation of the National Nursing Development Plan has greatly expanded the scale of nursing human resources in China and significantly optimized the efficiency of allocation. The implementation of the National Nursing Development Plan (2011-2015) and the National Nursing Development Plan (2016-2020) well continued the strategic plan from 2005 to 2010, further expanded the nursing workforce and further optimized the allocation efficiency.

TWEETABLE ABSTRACT

The implementation of the National Nursing Development Plan has greatly expanded the scale of nursing human resources in China and significantly optimized the efficiency of allocation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO REGISTRATION

CRD42021220004.

An examination of primary health care nursing service evaluation using the Donabedian model: A systematic review

Nurses are key to the delivery of global primary health care services. However, there appears to be a lack of evaluation of primary health care nursing delivery models in the published literature. This evaluation is vital to the improvement of patient experiences, national and global health outcomes, and the justification of future investment in primary health care nursing services. The purpose of this review was to explore and analyze the literature that reports on the evaluation of primary health care nursing services, to ascertain the nature and utility of these evaluation methods, and identify opportunities for future research in this area. A systematic review of the published literature was conducted following PRISMA guidelines, using the databases CINAHL, Joanna Briggs Institute, MEDLINE, and Proquest. Thirty-two articles published between 2010 and 2022 were selected. Results were organized using the Donabedian model. A paucity of research into the evaluation of nurse-led primary health care services was noted. Where evident, evaluation of primary health care nursing services tended to reflect the medical model. Medical outcomes measures dominated evaluation criteria including diagnosis rates, prescription costs, and disease outcomes. Primary health care principles such as service accessibility, cultural appropriateness, and availability were rarely used. The perspectives and experiences of nurses were not sought in service evaluation, including most of the nurse-led services. Development of an evidence-base of nursing primary health care services that are informed by the nursing experience and apply a framework of universal primary health care principles across the structure, process, and outcomes aspects of the service is recommended.

The impact of funding models on the integration of registered nurses in primary health care teams: protocol for a multi-phase mixed-methods study in Canada

BACKGROUND

Family practice registered nurses co-managing patient care as healthcare professionals in interdisciplinary primary care teams have been shown to improve access, continuity of care, patient satisfaction, and clinical outcomes for patients with chronic diseases while being cost-effective. Currently, however, it is unclear how different funding models support or hinder the integration of family practice nurses into existing primary health care systems and interdisciplinary practices. This has resulted in the underutilisation of family practice nurses in contributing to high-quality patient care.

METHODS

This mixed-methods project is comprised of three studies: (1) a funding model analysis; (2) case studies; and (3) an online survey with family practice nurses. The funding model analysis will employ policy scans to identify, describe, and compare the various funding models used in Canada to integrate family practice nurses in primary care. Case studies involving qualitative interviews with clinic teams (family practice nurses, physicians, and administrators) and family practice nurse activity logs will explore the variation of nursing professional practice, training, skill set, and team functioning in British Columbia, Nova Scotia, Ontario, and Quebec. Interview transcripts will be analysed thematically and comparisons will be made across funding models. Activity log responses will be analysed to represent nurses' time spent on independent, dependent, interdependent, or non-nursing work in each funding model. Finally, a cross-sectional online survey of family practice nurses in Canada will examine the relationships between funding models, nursing professional practice, training, skill set, team functioning, and patient care co-management in primary care. We will employ bivariate tests and multivariable regression to examine these relationships in the survey results.

DISCUSSION

This project aims to address a gap in the literature on funding models for family practice nurses. In particular, findings will support provincial and territorial governments in structuring funding models that optimise the roles of family practice nurses while establishing evidence about the benefits of interdisciplinary team-based care. Overall, the findings may contribute to the integration and optimisation of family practice nursing within primary health care, to the benefit of patients, primary healthcare providers, and health care systems nationally.

Nursing contributions to virtual models of care in primary care: a scoping review protocol

INTRODUCTION

Since the onset of the COVID-19 pandemic, virtual care has gained increased attention, particularly in primary care for the ongoing delivery of routine services. Nurses have had an increased presence in virtual care and have contributed meaningfully to the delivery of team-based care in primary care; however, their exact contributions in virtual models of primary care remain unclear. The Nursing Role Effectiveness Model, applied in a virtual care and primary care context, outlines the association between structural variables, nursing roles and patient outcomes. The aim of this scoping review is to identify and synthesise the international literature surrounding nurse contributions to virtual models of primary care.

METHODS AND ANALYSIS

The Joanna Briggs Institute scoping review methodology will guide this review. We performed preliminary searches in April 2022 and will use CINAHL, MEDLINE, Embase and APA PsycInfo for the collection of sources for this review. We will also consider grey literature, such as dissertations/theses and organisational reports, for inclusion. Studies will include nurses across all designations (ie, nurse practitioners, registered nurses, practical nurses). To ensure studies capture roles, nurses should be actively involved in healthcare delivery. Sources require a virtual care and primary care context; studies involving the use of digital technology without patient-provider interaction will be excluded. Following a pilot test, trained reviewers will independently screen titles/abstracts for inclusion and extract relevant data. Data will be organised using the Nursing Role Effectiveness Model, outlining the virtual care and primary care context (structure component) and the nursing role concept (process component).

ETHICS AND DISSEMINATION

This review will involve the collection and analysis of secondary sources that have been published and/or are publicly available. Therefore, ethics approval is not required. Scoping review findings will be published in a peer-reviewed journal and presented at relevant conferences, targeting international primary care stakeholders.

Effectiveness of registered nurses on patient outcomes in primary care: a systematic review

BACKGROUND

Globally, registered nurses (RNs) are increasingly working in primary care interdisciplinary teams. Although existing literature provides some information about the contributions of RNs towards outcomes of care, further evidence on RN workforce contributions, specifically towards patient-level outcomes, is needed. This study synthesized evidence regarding the effectiveness of RNs on patient outcomes in primary care.

METHODS

A systematic review was conducted in accordance with Joanna Briggs Institute methodology. A comprehensive search of databases (CINAHL, MEDLINE Complete, PsycINFO, Embase) was performed using applicable subject headings and keywords. Additional literature was identified through grey literature searches (ProQuest Dissertations and Theses, MedNar, Google Scholar, websites, reference lists of included articles). Quantitative studies measuring the effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN) that reported related outcomes were included. Articles were screened independently by two researchers and assessed for bias using the Integrated Quality Criteria for Review of Multiple Study Designs tool. A narrative synthesis was undertaken due to the heterogeneity in study designs, RN-led interventions, and outcome measures across included studies.

RESULTS

Forty-six patient outcomes were identified across 23 studies. Outcomes were categorized in accordance with the PaRIS Conceptual Framework (patient-reported experience measures, patient-reported outcome measures, health behaviours) and an additional category added by the research team (biomarkers). Primary care RN-led interventions resulted in improvements within each outcome category, specifically with respect to weight loss, pelvic floor muscle strength and endurance, blood pressure and glycemic control, exercise self-efficacy, social activity, improved diet and physical activity levels, and reduced tobacco use. Patients reported high levels of satisfaction with RN-led care.

CONCLUSIONS

This review provides evidence regarding the effectiveness of RNs on patient outcomes in primary care, specifically with respect to satisfaction, enablement, quality of life, self-efficacy, and improvements in health behaviours. Ongoing evaluation that accounts for primary care RNs' unique scope of practice and emphasizes the patient experience is necessary to optimize the delivery of patient-centered primary care.

PROTOCOL REGISTRATION ID

PROSPERO: International Prospective Register of Systematic Reviews. 2018. ID=CRD42 018090767 .