Effects of introducing a specialized nurse in the care of community-dwelling women suffering from urinary incontinence: a randomized controlled trial

Effects of task-shifting from primary care physicians to nurses: an overview of systematic reviews

BACKGROUND

Task-shifting from primary care physicians (PCPs) to nurses is a means of overcoming PCP shortages and meeting the needs of patients receiving primary care. The aim of this overview of systematic reviews is to assess the effects of delegation or substitution of PCPs' activities by nurses on patient relevant, clinical, professional and health services-related outcomes.

METHODS

We conducted a systematic literature search for secondary literature in Medline, Embase, Pubmed, the Cochrane Library, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). We included systematic reviews and meta-analyses that analysed randomised controlled trials (RCTs) and controlled, prospective trials in English and German. Abstracts and full-text articles were screened independently by two reviewers. Full-text articles were assessed using the Overview Quality Assessment Questionnaire. After data extraction a narrative synthesis was performed. We defined patient-relevant outcomes as our primary outcomes.

RESULTS

We included six systematic reviews. The interventions included first contact, history taking and assessment, patient education, review of drug treatment, referrals to GPs and other health professionals, ordering further investigations and ongoing care. Two meta-analyses showed a relative risk reduction of mortality in favour of nurse-led care, whereby the reduction in one analysis was significant. The effect was highest in the group of more highly qualified nurse practitioners (RR 0.19), as opposed to nurse practitioners (RR 0.76) and registered nurses (RR 0.92). Two meta-analyses showed a relative risk reduction in hospital admissions and patient satisfaction. Whereas care conducted by physicians and registered nurses led to the same outcomes, care conducted by nurse practitioners led to better outcomes (RR 0.74). An analysis according to nursing group showed that patients were more satisfied with treatment by registered nurses (SMD 1.37) than with treatment conducted by nurse practitioners and more qualified nurse practitioners (SMD 0.17). In terms of patient-relevant outcomes, no differences were observed between physician-led care and nurse-led care in terms of physical function, quality of life and pain.

CONCLUSION

Nurse-led care is probably as safe or safer than physician-led care in terms of mortality and hospital admissions. However, the impact of nursing staff training has not been sufficiently examined.

Nurses as substitutes for doctors in primary care

BACKGROUND

Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005.

OBJECTIVES

Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'.

SELECTION CRITERIA

Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis.

MAIN RESULTS

For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low.

AUTHORS' CONCLUSIONS

This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.

Development and Validation of the Role Profile of the Nurse Continence Specialist: A Project of the International Continence Society

Although nurses have specialized in the management of incontinence, bladder, bowel, and pelvic floor dysfunction for more than 30 years, there is a lack of awareness and underutilization of their role. This article describes a 6-year project to define, characterize, and validate a role profile of the Nurse Continence Specialist. Data collection used a 2-phase, mixed-methods design. Phase 1 of the project resulted in a draft Nurse Continence Specialist role profile and Phase 2 led to validation of the draft profile. The result was a broad consensus about what constitutes the specific skill set for Nurse Continence Specialist specialization within nursing.

Cost-effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care: Study protocol of the COCON study

Background

Guidelines on urinary incontinence recommend that absorbent products are only used as a coping strategy pending definitive treatment, as an adjunct to ongoing therapy, or for long-term management after all treatment options have been explored. However, these criteria are rarely met and a significant share of long-term product users could still benefit from therapeutic interventions recommended in guidelines for urinary incontinence. Better implementation of these guidelines can potentially result in both health benefits for women and long-term cost savings for society. The aim of the COCON study is to evaluate the (cost-)effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care in comparison with usual care for urinary incontinent women aged 55 years and over who use absorbent products.

Methods

This randomised clinical trial compares usual care with a nurse-led intervention to optimise implementation of guideline-concordant continence care. Women (anticipated N = 160) are recruited in 12 community pharmacies in three Dutch regions, and are eligible for trial entry when they are 55 years and over, community-dwelling and long-term users of absorbent products (≥4 months) reimbursed by health insurance. Measurements are administered at baseline, 3, 6 and 12 months. Primary outcome is severity of urinary incontinence (ICIQ-UI SF); other outcomes include health related quality of life (EQ-5D-5 L), use of absorbent products (in accordance with the recommended criteria in guidelines) (yes/no), and societal costs. Mixed model analysis will be performed to compare (the course) of outcomes between groups. The economic evaluation will be performed from a societal perspective. The implementation process is investigated using the Tailored Implementation for Chronic Diseases (TICD) framework.

Discussion

Results will add to current knowledge of the (cost-)effectiveness of nurse-led primary healthcare to improve guideline-concordant care for older women with urinary incontinence. In addition, the results will provide more insight into care needs and health service utilization of this group of women, as well as into use of absorbent products in accordance with the recommended criteria in guidelines. Finally, results will increase our understanding of the intervention’s uptake and could provide useful insights for future dissemination and sustenance.

Trial registration

Dutch Trial Register NTR4396, registered 13-January-2014

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-017-0204-8) contains supplementary material, which is available to authorized users.

Cost-Effectiveness of Including a Nurse Specialist in the Treatment of Urinary Incontinence in Primary Care in the Netherlands

Objective

Incontinence is an important health problem. Effectively treating incontinence could lead to important health gains in patients and caregivers. Management of incontinence is currently suboptimal, especially in elderly patients. To optimise the provision of incontinence care a global optimum continence service specification (OCSS) was developed. The current study evaluates the costs and effects of implementing this OCSS for community-dwelling patients older than 65 years with four or more chronic diseases in the Netherlands.

Method

A decision analytic model was developed comparing the current care pathway for urinary incontinence in the Netherlands with the pathway as described in the OCSS. The new care strategy was operationalised as the appointment of a continence nurse specialist (NS) located with the general practitioner (GP). This was assumed to increase case detection and to include initial assessment and treatment by the NS. The analysis used a societal perspective, including medical costs, containment products (out-of-pocket and paid by insurer), home care, informal care, and implementation costs.

Results

With the new care strategy a QALY gain of 0.005 per patient is achieved while saving €402 per patient over a 3 year period from a societal perspective. In interpreting these findings it is important to realise that many patients are undetected, even in the new care situation (36%), or receive care for containment only. In both of these groups no health gains were achieved.

Conclusion

Implementing the OCSS in the Netherlands by locating a NS in the GP practice is likely to reduce incontinence, improve quality of life, and reduce costs. Furthermore, the study also highlighted that various areas of the continence care process lack data, which would be valuable to collect through the introduction of the NS in a study setting.

Treatment by a nurse practitioner in primary care improves the severity and impact of urinary incontinence in women. An observational study

Background

Urinary Incontinence (UI) is a common problem in women. The management of UI in primary care is time consuming and suboptimal. Shift of incontinence-care from General Practitioners (GP’s) to a nurse practitioner maybe improves the quality of care. The purpose of this observational (pre/post) study is to determine the effectiveness of introducing a nurse practitioner in UI care and to explore women’s reasons for not completing treatment.

Methods

Sixteen trained nurse practitioners treated female patients with UI. All patients were examined and referred by the GP to the nurse practitioner working in the same practice. At baseline the severity of the UI (Sandvik-score), the impact on the quality of life (IIQ) and the impressed severity (PGIS) was measured and repeated after three months Differences were tested by the paired t and the NcNemar test.

Reasons for not completing treatment were documented by the nurse practitioner and differences between the group that completed treatment and the drop-out group were tested.

Results

We included 103 women, mean age 55 years (SD 12.6). The Sandvik severity categories improved significantly (P < 0.001), as did the impact on daily life (2.54 points, P = 0.012). Among the IIQ score the impact on daily activities increased 0.73 points (P = 0.032), on social functioning 0.60 points (P = 0.030) and on emotional well-being 0.63 points (P = 0.031). The PGIS-score improved in 41.3 % of the patients.

The most important reasons for not completing the treatment were lack of improvement of the UI and difficulties in performing the exercises. Women who withdraw from guidance by the nurse practitioner perceived more impact on daily life (P = 0.036), in particular on the scores for social functioning (P = 0.015) and emotional well-being (P = 0.015).

Conclusion

Treatment by a trained nurse practitioner seems positively affects the severity of the UI and the impact on the quality of life. Women who did not complete treatment suffer from more impact on quality of life, experience not enough improvement and mention difficulties in performing exercises.

Quality of care provided by mid-level health workers: systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of care provided by mid-level health workers.

METHODS

Experimental and observational studies comparing mid-level health workers and higher level health workers were identified by a systematic review of the scientific literature. The quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria and data were analysed using Review Manager.

FINDINGS

Fifty-three studies, mostly from high-income countries and conducted at tertiary care facilities, were identified. In general, there was no difference between the effectiveness of care provided by mid-level health workers in the areas of maternal and child health and communicable and noncommunicable diseases and that provided by higher level health workers. However, the rates of episiotomy and analgesia use were significantly lower in women giving birth who received care from midwives alone than in those who received care from doctors working in teams with midwives, and women were significantly more satisfied with care from midwives. Overall, the quality of the evidence was low or very low. The search also identified six observational studies, all from Africa, that compared care from clinical officers, surgical technicians or non-physician clinicians with care from doctors. Outcomes were generally similar.

CONCLUSION

No difference between the effectiveness of care provided by mid-level health workers and that provided by higher level health workers was found. However, the quality of the evidence was low. There is a need for studies with a high methodological quality, particularly in Africa - the region with the greatest shortage of health workers.

Substitution of physicians by nurses in primary care: a systematic review and meta-analysis

BACKGROUND

In many countries, substitution of physicians by nurses has become common due to the shortage of physicians and the need for high-quality, affordable care, especially for chronic and multi-morbid patients. We examined the evidence on the clinical effectiveness and care costs of physician-nurse substitution in primary care.

METHODS

We systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected and critically appraised published randomised controlled trials (RCTs) that compared nurse-led care with care by primary care physicians on patient satisfaction, Quality of Life (QoL), hospital admission, mortality and costs of healthcare. We assessed the individual study risk of bias, calculated the study-specific and pooled relative risks (RR) or standardised mean differences (SMD); and performed fixed-effects meta-analyses.

RESULTS

24 RCTs (38,974 participants) and 2 economic studies met the inclusion criteria. Pooled analyses showed higher overall scores of patient satisfaction with nurse-led care (SMD 0.18, 95% CI 0.13 to 0.23), in RCTs of single contact or urgent care, short (less than 6 months) follow-up episodes and in small trials (N ≤ 200). Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64 to 0.91), mortality (RR 0.89, 95% CI 0.84 to 0.96), in RCTs of on-going or non-urgent care, longer (at least 12 months) follow-up episodes and in larger (N > 200) RCTs. Higher quality RCTs (with better allocation concealment and less attrition) showed higher rates of hospital admissions and mortality with nurse-led care albeit less or not significant. The results seemed more consistent across nurse practitioners than with registered or licensed nurses. The effects of nurse-led care on QoL and costs were difficult to interpret due to heterogeneous outcome reporting, valuation of resources and the small number of studies.

CONCLUSIONS

The available evidence continues to be limited by the quality of the research considered. Nurse-led care seems to have a positive effect on patient satisfaction, hospital admission and mortality. This important finding should be confirmed and the determinants of this effect should be assessed in further, larger and more methodically rigorous research.

Effects of physician-nurse substitution on clinical parameters: a systematic review and meta-analysis

Background

Physicians’ shortage in many countries and demands of high-quality and affordable care make physician-nurse substitution an appealing workforce strategy. The objective of this study is to conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the impact of physician-nurse substitution in primary care on clinical parameters.

Methods

We systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected peer-reviewed RCTs comparing physician-led care with nurse-led care on changes in clinical parameters. Study selection and data extraction were performed in duplicate by independent reviewers. We assessed the individual study risk of bias; calculated the study-specific and pooled relative risks (RR) or weighted mean differences (WMD); and performed fixed-effects meta-analyses.

Results

11 RCTs (N = 30,247) were included; most were from Europe, generally small with higher risk of bias. In all studies, nurses provided care for complex conditions including HIV, hypertension, heart failure, cerebrovascular diseases, diabetes, asthma, Parkinson’s disease and incontinence. Meta-analyses showed greater reductions in systolic blood pressure (SBP) in favour of nurse-led care (WMD −4.27 mmHg, 95% CI −6.31 to −2.23) but no statistically significant differences between groups in the reduction of diastolic blood pressure (DBP) (WMD −1.48 mmHg, 95%CI −3.05 to −0.09), total cholesterol (TC) (WMD -0.08 mmol/l, 95%CI -0.22 to 0.07) or glycosylated haemoglobin (WMD 0.12%HbAc1, 95%CI -0.13 to 0.37). Of other 32 clinical parameters identified, less than a fifth favoured nurse-led care while 25 showed no significant differences between groups.

Limitations

disease-specific interventions from a small selection of healthcare systems, insufficient quantity and quality of studies, many different parameters.

Conclusions

trained nurses appeared to be better than physicians at lowering SBP but similar at lowering DBP, TC or HbA1c. There is insufficient evidence that nurse-led care leads to better outcomes of other clinical parameters than physician-led care.

Effectiveness of involving a nurse specialist for patients with urinary incontinence in primary care: results of a pragmatic multicentre randomised controlled trial

BACKGROUND

Urinary incontinence (UI) primary care management is substandard, offering care rather than cure despite the existence of guidelines that help to improve cure. Involving nurse specialists on incontinence in general practice could be a way to improve care for UI patients.

AIMS

We studied whether involving nurse specialists on UI in general practice reduced severity and impact of UI.

METHODS

Between 2005 and 2008 a pragmatic multicentre randomised controlled trial was performed comparing a 1-year intervention by trained nurse specialists with care-as-usual after initial diagnosis and assessment by general practitioners in adult patients with stress, urgency or mixed UI in four Dutch regions (Maastricht, Nijmegen, Helmond, The Hague). Simple randomisation was computer-generated with allocation concealment. Analysis was performed by intention-to-treat principles. Main outcome measure was the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) severity sum score.

RESULTS

A total of 186 patients followed the intervention and 198 received care-as-usual. Patients in both study groups improved significantly in UI severity and impact on health-related quality of life. After correction for effect modifiers [type of UI, body mass index (BMI)], we found significant differences between groups in favour of the intervention group at 3 months (p = 0.04); no differences were found in the 1-year linear trend (p = 0.15). Patients in the intervention group without baseline anxiety/depression improved significantly better compared with care-as-usual after 1 year (p = 0.03).

CONCLUSION

Involving nurse specialists in care for UI patients supplementary to general practitioners can improve severity and impact of UI, after correction for effect modifiers. This is also the case in specific situations such as anxiety/depression.

Pelvic floor dysfunction: a scoping study exploring current service provision in the UK, interprofessional collaboration and future management priorities

OBJECTIVE

Pelvic floor dysfunction (PFD) has a significant socioeconomic and healthcare cost. This study aimed to investigate current service provision for PFD in the UK, highlighting any gaps and areas for improvement to inform future service improvement.

METHODS

A three-phase design comprised a scoping literature review, consultation survey with frontline practitioners from four key professional groups and an overarching synthesis. An interpretative analytical framework was informed by the concepts of interdisciplinary and interprofessional collaboration.

RESULTS

Empirical evidence on PFD service provision is limited. No overarching strategic approach to PFD as a single clinical entity in the UK was identified. Two hundred and forty-three medical, nursing and physiotherapy practitioners from different clinical subspecialties participated in the survey. Access and availability to services, models of delivery and individual practice vary widely within and across the disciplines. Time restrictions, mixed professional attitudes, lack of standardisation and low investment priority were identified as major barriers to optimal service provision. Five overlapping areas for improvement are highlighted: access and availability, team working and collaboration, funding and investment, education, training and research, public and professional awareness.

CONCLUSIONS

Current services are characterised by a fragmented approach with asynchronous delivery, limited investment and poor interprofessional integration. An improved service delivery model has the potential to improve outcomes through better interdisciplinary collaboration and efficient use of resources.