Exploring the roles of advanced practice nurses in the care of patients following fragility hip fracture: A systematic review

AIM

This study aimed to explore the role and impact of advanced practice nurses (APNs) in care of patients following fragility hip fracture by systematically reviewing the available evidence.

REVIEW DESIGN

Systematic review.

DATA SOURCES

A search of the databases Ovid Medline, CINAHL, Embase, Emcare, Cochrane Library, and Google Scholar was conducted from January-February 2019.

METHOD

This systematic review adhered to The PRISMA Statement. Study selection was managed using the Covidence software platform and quality was assessed using JBI Critical appraisal tools. Studies included adults >18 years and described the role and impact of APNs in care of patients following fragility hip fracture on clinical and non-clinical outcomes.

RESULTS

There were 19 papers identified that met the inclusion/exclusion criteria. Quality was graded as moderate to low risk of bias. Six characteristics of APNs were identified: (1) coordination; (2) collaboration; (3) education; (4) assessment, investigation and treatment recommendations; (5) discharge planning, support and follow up; and (6) documentation. Overall mortality and LOS improved when characteristics of the APN role were present.

CONCLUSION

Key findings from this systematic review showed: (1) The APN title and role are not clearly defined, but characteristics of the APN role are evident; (2) characteristics of APNs promote the delivery of best practice hip fracture care and have a positive impact on mortality and LOS; and (3) innovative service delivery models involving APNs should be considered to address future projections of hip fracture rates and improve outcomes.

IMPACT

This systematic review provides evidence of the role characteristics of APNs in fragility hip fracture and the impact of the role on outcomes. Findings from this research could be used to develop service delivery models using APNs to care for patients following fragility hip fracture and to inform practice where APN roles may improve outcomes for other patient cohorts.

[New therapies in oncogeriatrics]

Cancer management is changing rapidly. Changes in practices are not all transferable to the elderly population, which is heterogeneous. The description of the intrinsic toxicity of anti-cancer treatments is insufficient in the elderly. Recent studies dedicated to the elderly incorporate composite evaluation criteria combining efficacy and toxicity with a broad definition including, among other things, loss of functional autonomy. These new data acquired, as well as new organisations integrating the new profession of advanced practice nurse in oncogeriatrics will enable us to better respond to the challenge of caring for elderly patients in the future.

Psychometric evaluation of a Patient Satisfaction Survey Questionnaire to assess advanced practice nurse ambulatory services in primary care

AIM

To determine the construct validity and test-retest reliability of the Patient Satisfaction Survey Questionnaire (PSSQ).

BACKGROUND

Advanced practice nurses (APNs) co-manage patients with non-communicable diseases (NCDs) with public primary care physicians in Singapore. The original Nurse Practitioner Satisfaction Survey (NPSS) instrument was adapted (renamed as PSSQ) to assess satisfaction with APN service.

METHOD

A total of 209 patients self-administered the PSSQ at first visit and repeated it in a retest through phone within the next 2 weeks in 2018. Cronbach's alpha and intra-class correlation (ICC) coefficients were performed to evaluate the internal consistency and test-retest reliability. Construct validity was determined by confirmatory factor analysis (CFA).

RESULTS

The overall Cronbach's alpha (>0.7) and ICC scores (0.697-0.729) indicated excellent test-retest reliability and good internal consistency, respectively. The CFA results of three-factor model showed poor fit. Additional exploratory factor analysis (EFA) and principal component analysis (PCA) with varimax rotation revealed that adding another factor (communication with physician) resulted in a better model (eigenvalue > 1). The ICC for the four-factor model ranged from 0.664 to 0.825, indicating fair to excellent reliability.

CONCLUSION

The PSSQ shows good internal consistency and test-retest reliability. The four-factor model is a better instrument to assess APN service in local populations.

IMPLICATIONS FOR NURSING MANAGEMENT

The validated PSSQ can be used as instrument to assess the quality of services provided by various categories of nurses, including registered nurses, nurse clinicians and APNs.

Exploration of advanced practice nurses' competencies necessary for achievement of universal health coverage in Jordan

BACKGROUND

Given the global shortage of the health workforce and the nature of diseases, strengthening and improving health care systems become a necessity. One of the solutions that is recommended by the literature is to utilize advanced practice nurses (APNs) to accelerate the progress toward the Sustainable Development Goals and universal health coverage (UHC).

PURPOSE

To delineate APN practice and competencies in relation to UHC and primary care in Jordan from the perspective of nurse administrators, clinical nurse specialist, academics, and policymakers.

PROCEDURE

A descriptive exploratory survey design was utilized to identify APN competencies that are important in achieving UHC. The survey developed by one of the authors (JH) at a PAHO Collaborating Center to delineate APN practice and APN competencies was adapted and utilized. A convenience sample of 94 nurse leaders was recruited from the education sector, nursing associations, councils, and hospitals.

RESULTS

The results showed that all four competencies (clinical care; interdisciplinary and patient-centered communication; systems of care; and using evidence for best practice) were rated as agree/strongly agree across all four domains. There was a consensus of participates on dimensions of all competency domains.

CONCLUSION

The current study confirms that the role of APNs is still in its infancy in Jordan. The current study provides nurse educators with baseline information that can be utilized as a framework for APN education programs. The faculty readiness to start new competency-based APN programs or revise the current graduate programs needs to be assessed.

Advanced practice registered nurses' work environment perceptions in hospitals: A cross-sectional survey

AIM

To examine work environment differences between hospital certified nurse practitioners (CNPs) and certified registered nurse anaesthetists (CRNAs).

BACKGROUND

Nurse work environments impact patient and nurse outcomes. How differing advanced practice nurse (APRN) roles influence work environments is unknown.

METHODS

Multi-level cross-sectional survey design. APRNs (n = 490) completed the APRN Organizational Climate Questionnaire and Psychological Ownership Questionnaire. Nurse executives (N = 24) reported on Scope of Practice and Institutional Voice. Descriptive, t test, chi-square and linear and mixed-effects regression statistical analyses were employed.

RESULTS

CNPs reported better organisational climate and job ownership than CRNAs. The largest effects involved relationships with physicians, control over practice and independent practice. Among CNPs, a significant positive relationship was observed between relations with physicians and work engagement. In CRNAs, a similar positive relationship between physician relations and work engagement was only observed for those working in higher scope of practice settings, not for those working in more restrictive settings.

CONCLUSIONS

Significant differences exist in the perceived work environments between CNPs and CRNAs that may be related to differences in job design and historical relations with physician colleagues.

IMPLICATIONS FOR NURSING MANAGEMENT

Efforts to improve APRN work environments in hospital settings should consider differing CRNA and CNP perspectives.

Improving emergency department transfer for patients arriving by ambulance: A retrospective observational study

Objective

Extended delays in the transfer of patients from ambulance to ED can compromise patient flow. The present study aimed to describe the relationship between the use of an Emergency Department Ambulance Off‐Load Nurse (EDAOLN) role, ED processes of care and cost effectiveness.

Methods

This was a retrospective observational study over three periods of before (T1), during (T2) and after (T3) the introduction of the EDAOLN role in 2012. Ambulance, ED and cost data were linked and used for analysis. Processes of care measures analysed included: time to be seen by a doctor from ED arrival (primary outcome), ambulance‐ED offload compliance, proportion of patients seen within recommended triage timeframe, ED length of stay (LoS), proportion of patients transferred, admitted or discharged from the ED within 4 h and cost effectiveness.

Results

A total of 6045 people made 7010 presentations to the ED by ambulance over the study period. Several measures improved significantly between T1 and T2 including offload compliance (T1: 58%; T2: 63%), time to be seen (T1: 31 min; T2: 28 min), ED LoS (T1: 335 min; T2: 306 min), ED LoS <4 h (T1: 31%; T2: 33%). Some measures carried over into T3, albeit to a lesser extent. Post‐hoc analyses showed that outcomes improved most for less urgent patients. The annualised net cost of the EDAOLN (if funded from additional resources) of $130 721 could result in an annualised reduction of approximately 3912 h in waiting time to be seen by a doctor.

Conclusion

With the EDAOLN role in place, slight outcome improvements in several key ambulance and ED efficiency criteria were noted. During times of ED crowding, the EDAOLN role may be one cost‐effective strategy to consider.

[Advanced practice nurse in oncology]

In many countries, health systems are facing major difficulties in maintaining the quality, continuity and safety of the care provision. That is why healthcare systems are being reformed across the world. These reforms are redefining the boundaries between medical and paramedical professions, and have resulted in the emergence of advanced practices, notably in nursing. The field of oncology is not immune from these issues. It must deal with the evolution of techniques and technologies, the increase in knowledge as well as an evolution in the needs of patients with cancer. In France, advanced practice nurses appear to have found their place in oncology as they can take an active part in the priorities fixed by the different national cancer plans, notably through the prevention role which is one of the objectives.

The Effectiveness of Advanced Practice Nurses with Respect to Complex Chronic Wounds in the Management of Venous Ulcers

This study aims to evaluate the effectiveness of advanced practice nurses with respect to complex chronic wounds (APN-CCWs) in the care of patients with venous ulcers. A multicentric, quasi-experimental pre-post study was conducted without a control group in the sanitary management areas where the APN-CCW program is being piloted. The intervention consisted of a mass training of clinical nurses from the participating districts on the proper management of injuries and the use of compression therapy. The data were collected through a specifically constructed questionnaire with questions regarding descriptive variables of injuries and their treatment. A total of 643 professionals responded (response rate of 89.1%), attending to a total population of 707,814 inhabitants. An increase in multilayer bandage use by 15.67%, an increase in elastic bandage use by 13.24%, and a significant decrease in the referral of patients to consultation with hospital specialists was achieved, from 21.08% to 12.34%. The number of patients referred to the APNs was 13.25%, which implied a resolution rate of 94.08% of their injuries. In conclusion, the coordination by the APN-CCWs in patients with venous ulcers was effective in improving the continuity of care, in the optimization of resources, and in their care role.

[Nurses' feedback on advanced nursing practice in mental health]

Nurses will soon be able to develop advanced practice in mental health through a state certified diploma. This new role will see caregivers acquire other competencies, such as prescribing, and marks a development of the profession through the growth of nursing sciences. The evolution of practices and the clinical approach in care would gain from collaboration between advanced practice nurses undergoing training and qualified clinical nurse specialists. Based on feedback from nurses in the field, perspectives for collaboration and organisation are assessed in terms of the health challenges facing our society.

[Oral treatments for cancer]

Oral chemotherapy is a therapy which is increasingly prescribed in outpatient care but which should not be trivialised. The patient must be given information and education to ensure compliance and awareness of the side effects to share with the care team as soon as they appear.

[Leadership and advanced practice nurses]

Clinical leadership is expected of advanced practice nurses with regard to their scope of competencies. The effective implementation of this competency within the teams requires management support. It is a first step towards the reinforcement of clinical leadership in France.

[Advanced practice, a springboard for nursing leadership]

The introduction of advanced nursing practice in France is a necessity but also constitutes a challenge. The French National Order of Nurses has been a key player in this project. This experience has shown that the profession needs to mobilise itself and acquire the codes and skills needed to tackle the difficulties and obstacles. It must develop its ability to negotiate with stakeholders and with its leadership to move the profession forwards.

[Legal responsibility of the advanced practice nurse]

While the profession of advanced practice nurse has finally been codified, this new regulation raises issues. Today, nursing is no longer subject to altruistic ideology. Advanced practice nurses have real expertise which has consequences on their responsibility. It is essential to be fully aware of the legal framework in which they practise.

[Not Available]

THE STRATEGIES FOR DEPLOYING THE ROLE OF ADVANCED PRACTICE NURSE IN HOSPITALS.: Advanced practice is developing in France and is a real opportunity for patients, health professionals and for the health system as a whole. Advanced practice nurses will bring real added value in this context. The director of nursing has a key role to play in terms of communication and supporting the teams with the deployment of these new professionals on the wards.

[Not Available]

The recognition of advanced nursing practice is being met with great optimisim among patients. The care relationship will be enhanced by the creation of different partnerships between health professionals, patients and carers, which will ensure a better quality of initial and follow-up care. The patient will now be able to rely on the advanced practice nurse to guide them along a more global healthcare pathway. As a result, the care and support relationship will feel more human.

[Assessing the contribution of the advanced practice nurse]

An assessment of the impact of advanced practice will be presented to the French parliament in 2021. Advanced practice nurses must make use of this opportunity. Indeed, this assessment is likely to come with major challenges in terms of the reorganisation of the healthcare provision following the implementation of this new function. The definition of adapted indicators is essential.

[Advanced practice nurse in the United Kingdom]

For twenty years, the author has worked as an advanced nurse practitioner in a large general practice in the north of England. In pioneering times for these new nursing roles, she completed her training at university and alongside her doctor colleagues. In this article she looks back at this highlight of her career and describes the deployment of this practice in the United Kingdom.

De l’infirmière à l’infirmière de pratique avancée, gérer au mieux la transition

MANAGING THE TRANSITION FROM NURSE TO ADVANCED PRACTICE NURSE

Qualified nurses who go on to undertake further training often find the transition difficult. This phenomenon has been studied more specifically in the field of advanced practice nursing. As France prepares to train and deploy state registered advanced practice nurses, it is essential to incorporate the learnings arising from research, in order to facilitate their training programme and their integration into their first role. Taking these elements into account will have a direct impact on the clinical results for which they will be accountable and their quality of working life.

[The integration of advanced practice nurses in emergency departments]

The saturation of emergency departments due to inappropriate attendance by patients is becoming increasingly commonplace. It often leads to the discontent of users, due to long waiting times, and stretches the hospital staff physically, mentally and psychologically. Innovative organisation models have been developed abroad. They draw on the skills of advanced practice nurses in emergency departments. The impact of these models has been assessed very positively in numerous studies. They improve the quality and safety of care as well as the satisfaction of users.

Nurse-led multidisciplinary initiatives to improve outcomes and reduce hospital admissions for older adults: The Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration project

OBJECTIVES

This article describes the Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration (CEDRiC) project.

METHODS

CEDRiC is designed to improve the health outcomes for older people with an acute illness. It attempts this via enhanced primary care in residential aged care facilities, focused and streamlined care in the emergency department and enhanced intersectoral communication and referral.

RESULTS

Implementing this approach has the potential to decrease inappropriate hospital admissions while improving care for older people in residential aged care and community settings.

CONCLUSION

This article discusses an innovative way of caring for older adults in an ageing population utilising the existing evidence. A formal evaluation is currently underway.

The Relationship Between Practice Environment and Psychological Ownership in Advanced Practice Nurses

Barriers in advanced practice nurses' work environment impede effective use in acute care settings, reduce job satisfaction, and increase intent to leave. Fostering psychological ownership for work through improved work design has increased satisfaction, motivation, and productivity, and lowered turnover in other fields, and may have similar effects for advanced practice nurses. This multilevel cross-sectional survey study examined the relationship between advanced practice nurse work environment and psychological ownership using data from a survey of advanced practice nurses and nurse executives in Florida hospitals. Barriers in scope of practice and exclusion from hospital governance were common. Advanced practice nurses reported good relations with physicians and moderate organizational climate but poor relations with administrators and limited control over work. Organizational climate had a strong positive relationship with psychological ownership. Fostering advanced practice nurse psychological ownership could improve job satisfaction and decrease turnover leading to increased effectiveness in acute care settings.

The Impact of Zika Virus Education on Selection of Birth Control Methods Among Cuban Refugees Resettling in Louisville, Kentucky in 2016

BACKGROUND

Cubans represented almost 40% of all refugees resettling in KY during 2015 and 2016. Their route to the United States included extended time in areas recognized as Zika endemic, making them vulnerable to Zika virus (ZV) exposure and infection. Early availability of birth control is one strategy stressed by the Centers for Disease Control and Prevention (CDC) to delay an unintended pregnancy after ZV exposure and prevent the catastrophic impact on a developing fetus.

OBJECTIVES

The objectives were to determine: (a) awareness of ZV among Cuban refugees, and (b) the impact of education regarding ZV on their initial birth control decisions.

METHODS

During May-November 2016, 167 Cuban men and women aged 19-50 were seen by advanced practice nurses (APNs) in the University of Louisville Global Health Center (UL GHC). During the visit, awareness regarding ZV, current planned birth control method(s), and education about ZV was imparted using information developed by the CDC and provided by clinic personnel competent in delivery of culturally, socially, and linguistically appropriate messaging. Anticipated methods of birth control were then reassessed.

RESULTS

Condom use was the most prevalent contraceptive method used before and after ZV education (29% and 58% respectively, p < .001). The influence of education regarding ZV and ZV infection on selection of birth control methods (condom use) was significant (p < .001).

CONCLUSIONS

Findings indicate education provided by APNs regarding ZV influence birth control selection among Cuban refugees.

[Collaboration in the prevention of frailty]

Hospitalisation is an opportunity for frailty in the elderly to be detected. The collaboration of the assessment and prevention geriatrician-nurse partnership, combined with the skills of the advanced practice nurse in gerontology, helps to instil a culture of frailty prevention in the teams and create adapted care pathways.

[Innovation, digital application and nursing leadership]

The private practice nurse has her own particular holistic vision for helping patients to remain living in their home. With entry to the profession now requiring university level studies, advanced practice is based on the clinical aspect, the reflexive approach and the leadership necessary to initiate innovative projects aimed at improving the quality of the care provided by removing the barriers between the different players for the benefit notably of elderly people.

The role of nurse practitioners in delivering rheumatology care and services: Results of a U.S. survey

BACKGROUND AND PURPOSE

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation, pain, joint stiffness, and progressive joint destruction. An increased demand for rheumatology healthcare professionals is anticipated in coming years; utilizing more nurse practitioners (NPs) in rheumatology may help meet this demand, and improve early detection and diagnosis of RA.

METHODS

The American Association of Nurse Practitioners surveyed, via e-mail, members who were working in primary care settings to understand their educational and professional needs to help manage their patients with RA. Respondents were surveyed about their NP certifications, patient panel, information received from rheumatologists on shared patients, RA tools or resources that would be helpful, confidence in diagnosing and managing patients with RA, interest in learning about particular topics regarding RA medications, and preferences for exchanging educational information with their professional colleagues.

CONCLUSIONS

The results from this survey indicate that the role of NPs in managing RA could be optimized by improved communication with treating rheumatologists, access to educational tools and resources, and further education and training in the management of RA.

IMPLICATIONS FOR PRACTICE

NPs in primary care can fill a resource gap and provide access to health care for patients with RA.

Use of spiritual coping strategies by gender, race/ethnicity, and religion at 1 and 3 months after infant's/child's intensive care unit death

BACKGROUND AND PURPOSE

In the United States, 57,000 children (newborn to 18 years) die annually. Bereaved parents may rely on religious or spiritual beliefs in their grief. The study's purpose was to examine differences in parents' use of spiritual and religious coping practices by gender, race/ethnicity, and religion at 1 and 3 months after infant/ICU death.

METHODS

The sample consisted of 165 bereaved parents, 78% minority. The Spiritual Coping Strategies Scale was used to measure religious and spiritual coping practices, separately. One-way ANOVAs indicated that Black non-Hispanic mothers used significantly more religious coping practices at 3 months than White non-Hispanic mothers. Protestant and Catholic parents used more religious coping practices than the "no" and "other" religion groups at 1 and 3 months. Within the 30 mother-father dyads (paired t-tests), mothers reported significantly greater use of religious coping practices at 1 and 3 months and spiritual coping practices at 3 months than fathers.

CONCLUSION

Religious coping practices were most commonly used by Black mothers and Protestant and Catholic parents. Within dyads, mothers used more spiritual and religious coping practices than fathers.

IMPLICATIONS FOR PRACTICE

These findings are beneficial for healthcare personnel in providing support to bereaved parents of diverse races/ethnicities and religions.

Implementing an evidence-based clinical decision support tool to improve the detection, evaluation, and referral patterns of adult chronic kidney disease patients in primary care

BACKGROUND AND PURPOSE

Chronic kidney disease (CKD) is undertreated and under-recognized in primary care. The majority of primary care providers (PCPs) are not aware or knowledgeable of current CKD guidelines. The purpose of this project was to develop a quality improvement intervention for PCPs through the delivery of evidence-based guidelines at the point of care.

METHODS

An evidence-based clinical algorithm was developed in the electronic medical record for providers to access within one organization comprising 11 primary care offices with 80 PCPs. Baseline knowledge surveys and baseline data were obtained in August 2016. A CKD educational intervention and tutorial on a clinical decision support (CDS) tool was presented to physicians, nurse practitioners, and physician assistants. Postimplementation data and knowledge surveys were collected in December 2016.

CONCLUSIONS

Most PCPs were willing to use a CKD CDS tool to help them with CKD patients. A CDS tool in addition to an educational intervention can improve PCP knowledge and identification of CKD and early referral to nephrology.

IMPLICATIONS FOR PRACTICE

CDS tools can promote evidence-based guided care for PCPs and CKD patients. By using these applications, patients can be properly identified, managed, treated, and appropriately referred to nephrology.

Delivery of Clinical Services: Mobilizing Advanced Practice Providers to Enhance Patient Care

Advanced practice providers (APPs) are increasingly being used in a variety of healthcare settings to provide care, treatment, and services to patients with cancer. They are also being deployed to acute oncologic settings to enhance patient care delivery and address the ever-evolving needs of patients in academic medicine. In response, the University of Texas MD Anderson Cancer Center developed a series of innovative clinical programs staffed by acute care APPs. These provide an opportunity to rapidly adapt to the acute care needs of patients with cancer while fostering the professional development of APPs within the full scope of their oncologic clinical practice.
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Increasing awareness with recognition of pulsatile tinnitus for nurse practitioners in the primary care setting: A case study

BACKGROUND AND PURPOSE

Pulsatile tinnitus is a whooshing sound heard synchronous with the heartbeat. It is an uncommon symptom affecting fewer than 10% of patients with tinnitus. It often goes unrecognized in the primary care setting. Failure to recognize this symptom can result in a missed or delayed diagnosis of a potentially life-threatening condition known as a dural arteriovenous fistula. The purpose of this case study is to provide a structured approach to the identification of pulsatile tinnitus and provide management recommendations.

METHOD

A case study and review of pertinent literature.

CONCLUSIONS

Pulsatile tinnitus usually has a vascular treatable cause. A comprehensive history and physical examination will alert the nurse practitioner (NP) when pulsatile tinnitus is present. Auscultation in specific areas of the head can detect audible or objective pulsatile tinnitus. Pulsatile tinnitus that is audible to the examiner is an urgent medical condition requiring immediate consultation and referral.

IMPLICATIONS FOR PRACTICE

Knowledge of pulsatile tinnitus and awareness of this often treatable condition directs the NP to perform a detailed assessment when patients present with tinnitus, directs appropriate referral for care and treatment, and can reduce the risk of delayed or missed diagnosis.

Evaluation of specialist referrals at a rural health care clinic

PURPOSE

Transition to a value-based care system involves reducing costs improving population health and enhancing the patient experience. Many rural hospitals must rely on specialist referrals because of a lack of an internal system of specialists on staff. This evaluation of the existing specialist referrals from primary care was conducted to better understand and improve the referral process and address costs, population health, and the patient experience.

DATA SOURCES

A 6-month retrospective chart review was conducted to evaluate quality and outcomes of specialty referrals submitted by 10 primary care providers. During a 6-month period in 2015, there was a total of 13,601 primary care patient visits and 3814 referrals, a referral rate of approximately 27%.

CONCLUSIONS

The most striking result of this review was that nearly 50% of referred patients were not making the prescribed specialist appointment. Rather than finding a large number of unnecessary referrals, we found overall referral rates higher than expected, and a large percentage of our patients were not completing their referrals.

IMPLICATIONS FOR PRACTICE

The data and patterns emerging from this investigation would guide the development of referral protocols for a newly formed accountable care organization and lead to further quality improvement projects: a LEAN effort, dissemination of results to clinical and executive staff, protocols for orthopedic and neurosurgical referrals, and recommendations for future process improvements.

Key considerations for moving to a nurse faculty role: A dean's perspective

Expert nurse practitioners (NPs) grounded in clinical practice are needed to prepare the future NPs. This article discusses key considerations for moving from the role of expert clinician to nurse educator. The considerations for making the move to the educator role including reflection on rewards associated with teaching, similarities between practice and education, faculty support, and role responsibilities are presented from a dean's perspective. The typical hiring process is discussed including what questions may be asked of the faculty candidate as well as what questions should be asked by the faculty candidate.

Effectiveness of a nurse-led preadmission intervention for parents of children with profound multiple disabilities undergoing hip-joint surgery: A quasi-experimental pilot study

PURPOSE

The aim of this study was to assess the effectiveness of a family-centered care (FCC) intervention provided by an advanced practice nurse (APN) for parents of children with profound disabilities undergoing surgery.

DESIGN AND METHODS

In a quasi-experimental design, we used the MPOC-20 to assess satisfaction with FCC and interviews to identify potential mechanisms for improving satisfaction.

RESULTS

There was a positive effect on the MPOC-20 domain "general information," albeit with a small effect size (Cohen's d = 0.35). The interviewed parents expected additional support.

PRACTICE IMPLICATIONS

Emphasis should be placed on providing comprehensive care coordination by an experienced APN. Shared care management is crucial in improving FCC.

Laboratory diagnosis of overt type 2 diabetes in the first trimester of pregnancy

OBJECTIVE

The objective of this study was to compare the use of hemoglobin A1C to oral glucose tolerance testing to diagnose overt type 2 diabetes in the first trimester of pregnancy. The study used a nonexperimental descriptive design to compare the use of the hemoglobin A1C test results to oral glucose tolerance test results.

METHODS

The study used a sample of 45 women at high risk for type 2 diabetes in the first trimester of pregnancy. Participants were consented to draw a hemoglobin A1C with their ordered oral glucose tolerance testing for comparison of the two tests' ability to diagnose overt type 2 diabetes.

RESULTS

Hemoglobin A1C tests were highly positively correlated with oral glucose tolerance testing for diagnosis of type 2 diabetes in women in the first trimester of pregnancy.

CONCLUSION

The research provides beginning evidence that the hemoglobin A1C should be considered as a first-tier diagnostic test for overt type 2 diabetes in the first trimester of pregnancy.

Childhood vaccine status and correlation with common nonvaccine-preventable illnesses

BACKGROUND AND PURPOSE

Current trends in parental decision making involve alteration from vaccine schedules in children, citing concerns for altered immune function. The purpose of this study was to determine if there is a difference in incidence of common childhood illnesses dependent on vaccination status.

METHODS

An investigator-designed survey was administered to parents of children aged 12 months to 7 years. Participants were separated into one of three groups: fully vaccinated, partially vaccinated, and unvaccinated. There were 111 total participants. Power analysis indicated a minimum of 30 participants per group to detect an 80% effect. Descriptive statistics were applied to variables with chi-square for group comparison.

CONCLUSIONS

The results indicated a statistically significant difference between all three groups in the categories of ear infections, influenza, and common colds. Fully immunized group had significantly more ear infections than partial or unimmunized. The unimmunized group had significantly more colds and flu.

IMPLICATIONS FOR PRACTICE

Nurse practitioner practice implications relate directly to further education of parents, support, and trust building. Many parents question the possible association between childhood vaccines and immune function and have a distrust of current research. This study showed that most common childhood illnesses are equitable across the population and not dependent on vaccine status.

Prime movers: Advanced practice professionals in the role of stroke coordinator

BACKGROUND AND PURPOSE

Following a stroke quality improvement clustered randomized trial and a national acute ischemic stroke (AIS) directive in the Veterans Health Administration in 2011, this comparative case study examined the role of advanced practice professionals (APPs) in quality improvement activities among stroke teams.

METHODS

Semistructured interviews were conducted at 11 Veterans Affairs medical centers annually over a 3-year period. A multidisciplinary team analyzed interviews from clinical providers through a mixed-methods, data matrix approach linking APPs (nurse practitioners and physician assistants) with Consolidated Framework for Implementation Research constructs and a group organization measure.

CONCLUSION

Five of 11 facilities independently chose to staff stroke coordinator positions with APPs. Analysis indicated that APPs emerged as boundary spanners across services and disciplines who played an important role in coordinating evidence-based, facility-level approaches to AIS care. The presence of APPs was related to engaging in group-based evaluation of performance data, implementing stroke protocols, monitoring care through data audit, convening interprofessional meetings involving planning activities, and providing direct care.

IMPLICATIONS FOR PRACTICE

The presence of APPs appears to be an influential feature of local context crucial in developing an advanced, facility-wide approach to stroke care because of their boundary spanning capabilities.

Management of skin adverse events associated with immune checkpoint inhibitors in patients with melanoma: A nursing perspective

PURPOSE

Immune checkpoint inhibitors are associated with a unique immune-related side effect profile that requires prompt recognition and management. Skin toxicities are the most common, and often earliest occurring, drug-related adverse events (AEs) of any grade observed upon treatment with these agents. The purpose of this review is to provide practical guidance on the identification and treatment of skin AEs associated with the immune checkpoint inhibitors (ipilimumab, nivolumab, and pembrolizumab) from a nursing perspective, and demonstrate hands-on application of the guidance using relevant patient case studies.

DATA SOURCES

Data for drug-related skin AEs were summarized from phase 3 nivolumab and nivolumab + ipilimumab trials and phase 2 and 3 pembrolizumab trials. Patient case studies were provided by the lead (M.T.) and senior (J.N.C.) authors.

CONCLUSIONS

The recommendations presented here, based on accumulated clinical trial and clinical practice experience are consistent with established treatment guidelines and reach beyond established guidelines and recommendations for the management of AEs associated with immune checkpoint inhibitors.

IMPLICATIONS FOR PRACTICE

The practical treatment guidance presented here may help familiarize medical teams with the recognition and management of skin AEs associated with these recently approved agents. The enclosed recommendations may contribute to optimized treatment through awareness of typical time to onset and clinical presentation, knowledge of management options, and appropriate application of treatment.

[Not Available]

Zusammenfassung. Chronisch kranke und multimorbide Menschen erfordern neue Versorgungsmodelle, in denen die Zusammenarbeit der Berufsgruppen neu definiert wird. Während sich interprofessionelle Modelle international bewähren, bestehen in der Schweiz erst wenige solche Versorgungsteams. Insbesondere ist wenig bekannt über die Ansicht von Hausärzten zu neuen Versorgungsmodellen mit Advanced Practice Nurses (APNs). Deshalb untersuchten wir, wie Hausärzte mögliche Zusammenarbeitsformen mit APNs in der Grundversorgung beschreiben. Wir führten Fokusgruppeninterviews mit Hausärzten durch. Vorgängig explorierte ein Expertengremium Themen der interprofessionellen Zusammenarbeit. Die Interviews wurden mittels qualitativer Inhaltsanalyse analysiert. Die Analyse ergab, dass den Ärzten die Beibehaltung der heutigen Versorgungsqualität wichtig ist. Sie stehen einer Zusammenarbeit mit APNs offen gegenüber, wissen aber wenig über deren Kompetenzen. Erschwerend wirkt sich zudem aus, dass die Finanzierung noch nicht geregelt ist.

Health literacy in the urgent care setting: What factors impact consumer comprehension of health information?

BACKGROUND

An increasing number of Americans are using urgent care (UC) clinics due to: improved health insurance coverage, the need to decrease cost, primary care offices with limited appointment availability, and a desire for convenient care. Patients are treated by providers they may not know for episodic illness or injuries while in pain or not feeling well. Treatment instructions and follow-up directions are provided quickly.

PURPOSE

To examine health literacy in the adult UC population and identify patient characteristics associated with health literacy risk.

METHODS

As part of a larger cross-sectional study, UC patients seen between October 2013 and January 2014 completed a demographic questionnaire and the Newest Vital Sign. Descriptive, nonparametric analyses, and a multinomial logistic regression were done to assess health literacy, associated and predictive factors.

RESULTS

A total of 57.5% of 285 participants had adequate health literacy. The likelihood of limited health literacy was associated with increased age (p < .001), less education (p < .001), and lower income (p = .006).

CONCLUSIONS/IMPLICATIONS

Limited health literacy is common in a suburban UC setting, increasing the risk that consumers may not understand vital health information. Clear provider communication and confirmation of comprehension of discharge instructions for self-management is essential to optimize outcomes for UC patients.

Fiber supplements and clinically proven health benefits: How to recognize and recommend an effective fiber therapy

BACKGROUND

Only 5% of adults consume the recommended level of dietary fiber. Fiber supplements appear to be a convenient and concentrated source of fiber, but most do not provide the health benefits associated with dietary fiber.

PURPOSE

This review will summarize the physical effects of isolated fibers in small and large intestines, which drive clinically meaningful health benefits.

DATA SOURCES

A comprehensive literature review was conducted (Scopus and PubMed) without limits to year of publication (latest date included: October 31, 2016).

CONCLUSIONS

The physical effects of fiber in the small intestine drive metabolic health effects (e.g., cholesterol lowering, improved glycemic control), and efficacy is a function of the viscosity of gel-forming fibers (e.g., psyllium, β-glucan). In the large intestine, fiber can provide a laxative effect if (a) it resists fermentation to remain intact throughout the large intestine, and (b) it increases percentage of water content to soften/bulk stool (e.g., wheat bran and psyllium).

IMPLICATIONS FOR PRACTICE

It is important for nurse practitioners to understand the underlying mechanisms that drive specific fiber-related health benefits, and which fiber supplements have rigorous clinical data to support a recommendation.

CLINICAL PEARL

For most fiber-related beneficial effects, "Fiber needs to gel to keep your patients well."

Psoriasis for the primary care practitioner

Primary care practitioners (PCPs) are playing an increasingly important role in the management and care of psoriasis. Thus, it is important for PCPs to be knowledgeable about the disease and to be able to differentiate between common myths and facts related to diagnosis and treatment. By building relationships with their patients and working collaboratively with dermatology health professionals and other specialists, PCPs can facilitate communication about the patient's treatment preferences and expectations for symptom relief, and they may be better able to work with the patient to optimize treatment adherence. This review aims to provide PCPs with a primer on psoriasis, its associated comorbidities, and its impact on patients' quality of life. Discussion topics include psoriasis epidemiology, triggering factors, clinical presentation, differential diagnosis, comorbidities, and approaches to treatment. This review also highlights the importance of staying abreast of advances in the understanding of psoriasis pathogenesis as well as emerging therapeutic treatment options, because these advances may change the treatment landscape and increase patients' expectations for skin clearance.

Assessment of a National Diabetes Education Program diabetes management booklet: The GRADE experience

BACKGROUND AND PURPOSE

The National Diabetes Education Program created the 4 Steps to Manage Your Diabetes for Life (4 Steps) booklet to help patients with diabetes learn the basics of self-management and care recommendations. The purpose of this study is to explore the impact of 4 Steps on participants' diabetes management knowledge and self-efficacy in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE).

METHODS

A sample of 348 adults with type 2 diabetes enrolled in GRADE was included in this analysis. Participants took a pretest, were sent home with 4 Steps, then took a posttest at their next visit. The Wilcoxon signed rank test was used to detect differences in knowledge and self-efficacy between scale scores pre- and posttest.

CONCLUSIONS

Analyses revealed increases in participants' diabetes management knowledge (p < .001) and self-efficacy (p < .001) from pre- to posttest. Participants who reported no formal previous diabetes education showed a statistically significant increase in knowledge scores compared to those with previous diabetes education (p < .05).

IMPLICATIONS FOR PRACTICE

Appropriate, relevant diabetes education materials may improve self-management knowledge and self-efficacy among adults with type 2 diabetes. Providers should feel confident using 4 Steps as a resource for clinical practice.

We are different: the voices of psychiatric advanced practice nurses on the performance of their roles

BACKGROUND

Many studies have affirmed that psychiatric advanced practice nurses (APNs) perform multifaceted roles. However, only a limited amount of research has been conducted on their perceptions of the performance of their roles.

AIM

To explore the lived experiences of psychiatric APNs concerning the performance of their roles.

DESIGN

Data were collected from individual semi-structured interviews and analysed using the interpretative phenomenological analysis method.

METHODS

The study was conducted in a hospital cluster in Hong Kong. Thirteen psychiatric APNs were purposively recruited.

RESULTS

Three themes were discerned, namely, 'We are different', 'Who am I?', and 'I am who I am'.

CONCLUSIONS

The findings can help psychiatric APNs and nurse administrators to better understand the needs of the role-bearers (APNs) and to develop strategies to support the development of advanced psychiatric nursing practices in Hong Kong and worldwide.

Effectiveness of advanced practice nurse-led telehealth on readmissions and health-related outcomes among patients with post-acute myocardial infarction: ALTRA Study Protocol

AIM

To develop and examine the effectiveness of an advanced practice nurse-led telehealth rehabilitative programme as a transitional nursing therapeutic on readmission rates and health-related outcomes among patients with acute myocardial infarction postdischarge.

BACKGROUND

Patients suffering from acute myocardial infarction are experiencing an increasing trend of frequent readmissions. This implicates both the effectiveness of healthcare services and patient's quality of life. Advanced Practice Nurse-led telehealth rehabilitative programme has yet to be explored as a strategy to minimize preventable readmissions and improve patient's self-efficacy so as to enhance quality of life after a heart attack.

DESIGN

Randomized controlled trial with repeated measures.

METHODOLOGY

A consecutive sampling of 172 patients with acute myocardial infarction will be recruited from a tertiary acute hospital in Singapore. Participants will be randomized into two groups. The experimental group (ALTRA) will receive Advanced Practice Nurse-led telehealth rehabilitative programme on discharge. The control group will receive only standard follow-up care. The outcome measures include readmissions, cardiac self-efficacy, cardiovascular risk factors, quality of life, anxiety and depression. The data will be collected at the baseline, 1 and 6 month postdischarge. A postprogramme evaluation will be conducted among the participants to assess its acceptability, strengths and weakness.

DISCUSSION

ALTRA aims to engage and support patients with acute myocardial infarction by increasing self-care management through education and telehealth contacts with Advanced Practices Nurses. This provides a smoother transition of illness to health and ultimately, reduces preventable costly readmissions.

TRIAL REGISTRATION

The study has been registered with clinicaltrials.gov. The trial registration number is NCT02483494.

The Role of the Advanced Practice Nurse in Geriatric Oncology Care

OBJECTIVES

To describe how the Advanced Practice Nurse (APN) is uniquely suited to meet the needs of older adults throughout the continuum of cancer, to explore the progress that APNs have made in gero-oncology care, and make suggestions for future directions.

DATA SOURCE

Google Scholar, PubMed, and CINAHL. Search terms included: "gero-oncology," "geriatric oncology," "Advanced Practice Nurse," "Nurse Practitioner," "older adult," "elderly," and "cancer."

CONCLUSION

Over the last decade, APNs have made advances in caring for older adults with cancer by playing a role in prevention, screening, and diagnosis; through evidence-based gero-oncology care during cancer treatment; and in designing tailored survivorship care models. APNs must combat ageism in treatment choice for older adults, standardize comprehensive geriatric assessments, and focus on providing person-centered care, specifically during care transitions.

IMPLICATIONS FOR NURSING PRACTICE

APNs are well-positioned to help understand the complex relationship between risk factors, geriatric syndromes, and frailty and translate research into practice. Palliative care must expand beyond specialty providers and shift toward APNs with a focus on early advanced care planning. Finally, APNs should continue to establish multidisciplinary survivorship models across care settings, with a focus on primary care.

Examining Nurse Consultant connectivity: An Australian mixed method study

The nurse consultant (NC) role in Australia is a senior classification of advanced practice nurse has been described as enhancing health care outcomes largely through extensive collaboration with consumers, nurses, and other health professionals. However, little is known about the actual nature, amount, and quality of NC interactions. This study examines the connectivity of the NC role across metropolitan and rural contexts, using a mixed method sequential design with an online survey and focus groups with NCs and other stakeholders. Results demonstrated that NCs most commonly have high density connectivity patterns with other nursing colleagues, medical staff, patients/clients, and administrative staff. Position grade (1, 2 or 3) influences density of connectivity, as does location, with those based in metropolitan roles engaging significantly less with other clinicians. Findings demonstrate that many NCs are highly collaborative and predominantly embedded into interprofessional practice models. This study provides valuable insight into the diverse and often complex NC role and the way in which NC expertise and influence is deployed and integrated across a large local health district.

Doctor of Nursing Practice: The Role of the Advanced Practice Nurse

OBJECTIVES

To explore the evolution and emerging roles of the Doctor of Nursing Practice (DNP) Advanced Practice Nurse (APN).

DATA SOURCES

Published peer reviewed literature, cancer-related professional resources, and Web-based resources.

CONCLUSION

The DNP education has prepared the APN for process improvement initiatives, providing quality care, and evidence-based practice translation, which are critical with the emerging trends in this complex health care environment.

IMPLICATIONS FOR NURSING PRACTICE

DNP-prepared APNs have the opportunity to impact oncology care across the cancer trajectory, in various settings, and in various innovative roles as entrepreneurs.

A pilot randomized control trial: testing a transitional care model for acute psychiatric conditions

OBJECTIVE

People with multiple and persistent mental and physical health problems have high rates of transition failures when transferring from a hospital level of care to home. The transitional care model (TCM) is evidence-based and demonstrated to improve posthospital outcomes for elderly with physical health conditions, but it has not been studied in the population with serious mental illness.

METHOD

Using a randomized controlled design, 40 inpatients from two general hospital psychiatric units were recruited and randomly assigned to an intervention group (n = 20) that received the TCM intervention that was delivered by a psychiatric nurse practitioner for 90 days posthospitalization, or a control group (n = 20) that received usual care. Outcomes were as follows: service utilization, health-related quality of life, and continuity of care.

RESULTS

The intervention group showed higher medical and psychiatric rehospitalization than the control group (p = .054). Emergency room use was lower for intervention group but not statistically significant. Continuity of care with primary care appointments were significantly higher for the intervention group (p = .023). The intervention group's general health improved but was not statistically significant compared with controls.

CONCLUSIONS

A transitional care intervention is recommended; however, the model needs to be modified from a single nurse to a multidisciplinary team with expertise from a psychiatric nurse practitioner, a social worker, and a peer support specialist. A team approach can best manage the complex physical/mental health conditions and complicated social needs of the population with serious mental illness.

[Centennial retrospective on the role expansion of the nursing profession in Taiwan]

Advanced practice nurses were introduced in Taiwan to address increasingly complex public healthcare needs, reimbursement reform in the National Health Care Insurance system, and healthcare organization changes and to ensure high-quality care for patients. This article discusses the role and the function of nurses; the expansion and extension of nursing responsibilities; the specific roles of the advanced practice nurse, the nurse practitioner, the case manager, and the care manager; the affect of advanced practice on nursing identity and effectiveness; and key current issues in advanced practice. Suggestions are provided to improve the professional development of nurses in the future.