Development and Evaluation of an Atopic Dermatitis Care Plan for Providers

Background/Significance of problem: Atopic Dermatitis (AD) is a common, chronic, inflammatory dermatosis and skin disease that follows a relapsing pattern and requires a dynamic stepwise approach to management. Providers feel comfortable treating chronic disease states with a guided tool or care plan in many chronic diseases. Care plans used in many chronic diseases such as asthma, diabetes, and COPD have demonstrated effectiveness in disease and healthcare provider management. There is an unmet need for a universal AD care plan for providers. Clinical question/project purpose: A universal AD care plan was developed to improve AD disease management and patient outcomes. Post-implementation of providers & perceptions was assessed for how the AD universal care plan affected their ability to provide patient education. Search of literature/best evidence: Review of literature includes: CINAHL, ProQuest Health, PubMed, Fusion, and UpToDate databases from 2008-2018.Search terms included: Atopic Dermatitis, Eczema, care plans, care plan use in chronic disease. Clinical appraisal of literature/best evidence: Analysis of the evidence supported the need for AD education, which then supported the need for a universal AD care plan for providers. Integration into practice: "Your Eczema Care Plan" was used by thirty-five healthcare providers to improve patient outcomes in a similar manner as other evidence-based care plans.Evaluation of evidenced-based practice: Post-implementation of providers & perceptions were evaluated on how the AD care plan tool affected their ability to provide patient education. Results suggest patient education, disease management, and QOL are all improved when utilizing "Your Eczema Action Plan." J Drugs Dermatol. 2020;19(10): 950-955. doi:10.36849/JDD.2020.5090.

The Effect of Supervision Waivers on Practice: A Survey of Massachusetts Nurse Practitioners During the COVID-19 Pandemic

BACKGROUND

While optimal utilization of the nurse practitioner (NP) workforce is an increasingly popular proposal to alleviate the growing primary care shortage, federal, state, and organizational scope of practice policies inhibit NPs from practicing to the full extent of their license and training. In March of 2020, NP state-specific supervisory requirements were temporarily waived to meet the demands of the coronavirus disease 2019 (COVID-19) pandemic in Massachusetts.

OBJECTIVE

The objective of this study was to examine the impact of temporarily waived state practice restrictions on NP perception of care delivery during the initial surge of the COVID-19 pandemic in Massachusetts.

RESEARCH DESIGN

Mixed methods descriptive analysis of a web-based survey of Massachusetts NPs (N=391), conducted in May and June 2020.

RESULTS

The vast majority (75%) of NPs believed the temporary removal of practice restriction did not perceptibly improve clinical work. Psychiatric mental health NPs were significantly more likely than other NP specialties to believe the waiver improved clinical work (odds ratio=6.68, P=0.001). NPs that experienced an increase in working hours during the pandemic surge were also more likely to report a positive effect of the waiver (odds ratio=2.56, P=0.000).

CONCLUSIONS

Temporary removal of state-level practice barriers alone is not sufficient to achieve immediate full scope of practice for NPs. The successful implementation of modernized scope of practice laws may require a collective effort to revise organizational and payer policies accordingly.

Nurse Practitioner Management of a Blinatumomab Infusion Program: Impact on Patient Safety and Quality of Care

The prognosis of children with acute lymphoblastic leukemia can be improved with the use of monoclonal antibodies such as blinatumomab. Many studies discuss the management and treatment of symptoms; however, none of them describe practical complications related to the continuous infusion of blinatumomab, especially during home-based therapy. The purpose of this study is to describe the experience gained over 4 years in the management of pediatric patients undergoing therapy with blinatumomab in an Italian tertiary hospital. The establishment of a nursing program dedicated to improving infusion pump management, patient support, quality of care, and patient safety will be discussed.

Sustaining Primary Health Care Programs and Services: A Scoping Review Informing the Nurse Practitioner Role in Canada

Sustainability is a key concept in the politics and local policy of health care delivery, particularly during discussions on the principles of primary health care (PHC) and health care reform. In Canada, previous reforms in PHC were implemented with the goal of achieving long-term sustainable change in health systems across the country. However, insufficient resources and a changing environment have impeded the sustainability of many PHC programs and services. An example is the nurse practitioner (NP) role, which was introduced in Canada in 1967 but failed to be sustained. In the mid-1990s, in response to a call for PHC reform, the role was reimplemented with the support of government legislation, regulation, and remuneration mechanisms. However, despite evidentiary success of NP role effectiveness and efficiency in Canada's health system, many barriers toward full implementation of the role continue to exist and sustainability remains at risk. This scoping review was undertaken to inform a research project exploring the closure of an NP clinic in a western Canadian province. The review searched relevant peer-reviewed and gray literature from Canada, United Kingdom, and Australia, to better understand and describe the factors influencing sustainability of the NP role and other PHC programs and services.

Clinical trial testing in-home multidisciplinary care management for older adults with cognitive vulnerability: Rationale and study design

Care management approaches are being widely tested in the Medicare-eligible population to manage chronic conditions, but few have focused on cognitive vulnerability as the pathway to optimizing independence in the community-dwelling older population. Cognitive vulnerability refers to living with dementia, depression, and/or a history of delirium. Many studies have shown that cognitive vulnerability is associated with poor health-related outcomes in community-dwelling older adults, raising the health policy importance of finding evidence-based approaches to improve outcomes for this target population. Moreover, very little is known about effects of care management approaches in the rapidly growing Medicare Advantage population. In response to these knowledge gaps, we are testing the efficacy of an in-home, nurse practitioner-led care management team for adults age ≥ 65 with cognitive vulnerability in a Medicare Advantage population. Older adults and family caregivers randomized either to this multidisciplinary care management team, or to a telephonic care management program routinely offered by our Medicare Advantage partner. The intervention period is 12 months and the primary outcome is any emergency department visit or hospitalization over the 12-month period. In this paper, we report on the rationale for testing a multidisciplinary care management intervention for this target population, and explain how a university-based research team collaborated with a Medicare Advantage insurer to conceptualize and implement the clinical trial. We also provide details on study design, and on components of the in-home and telephonic care management interventions. We conclude with a synopsis of recruitment progress along with selected baseline characteristics of the study cohort.

The evolving roles of Operating Department Practitioners in contemporary healthcare: A service evaluation

A mixed method study was undertaken to capture quantitative and qualitative data in relation to the contemporary roles and skills of Operating Department Practitioners. The data provide evidence that Operating Department Practitioners take opportunities to widen their knowledge skills and practice, with over 37% of the sample completing a mentorship qualification and 14% having completed or studying towards a postgraduate or Master’s Degree. The study provides evidence of the development in the roles of the Operating Department Practitioner and suggests that Operating Department Practitioners offer an eclectic mix of skills which are delivered in a variety of clinical settings. It is recognised that Operating Department Practitioners have the potential to further improve patient safety and service delivery in roles other than those historically associated with the profession.

Does task delegation to non-physician health professionals improve quality of diabetes care? Results of a scoping review

Objective

As a result of unhealthy lifestyles, reduced numbers of healthcare providers are having to deal with an increasing number of diabetes patients. In light of this shortage of physicians and nursing staff, new concepts of care are needed. The aim of this scoping review is to review the literature and examine the effects of task delegation to non-physician health professionals, with a further emphasis on inter-professional care.

Research design and methods

Systematic searches were performed using the PubMed, Embase and Google Scholar databases to retrieve papers published between January 1994 and December 2017. Randomised/non-randomised controlled trials and studies with a before/after design that described the delegation of tasks from physicians to non-physicians in diabetes care were included in the search. This review is a subgroup analysis that further assesses all the studies conducted using a team-based approach.

Results

A total of 45 studies with 12,092 patients met the inclusion criteria. Most of the interventions were performed in an outpatient setting with type-2 diabetes mellitus patients. The non-physician healthcare professionals involved in the team were nurses, pharmacists, community health workers and dietitians. Most studies showed significant improvements in glycaemic control and high patient satisfaction, while there were no indications that the task delegation affected quality of life scores.

Conclusions

The findings of the review suggest that task delegation can provide equivalent glycaemic control and potentially lead to an improvement in the quality of care. However, this review revealed a lack of clinical endpoints, as well as an inconsistency between the biochemical outcome parameters and the patient-centred outcome parameters. Given the vast differences between the individual healthcare systems used around the world, further high-quality research with an emphasis on long-term outcome effects and the expertise of non-physicians is needed.

Protocolled practice nurse-led care for children with asthma in primary care: protocol for a cluster randomised trial

INTRODUCTION

In children with asthma, daily symptoms and exacerbations have a significant impact on the quality of life of both children and parents. More effective use of asthma medication and, consequently, better asthma control is advocated, since both overtreatment and undertreatment are reported in primary care. Trials in adults suggest that asthma control is better when patients receive a regular medical review. Therefore, protocolled care by the general practitioner may also lead to better asthma control in children. However, such protocolled care by the general practitioner may be time consuming and less feasible. Therefore, this study aims to determine whether protocolled practice nurse-led asthma care for children in primary care provides more effective asthma control than usual care.

METHODS AND ANALYSIS

The study will be a cluster-randomised open-label trial with an 18-month follow-up. Practice nurses will be the units of randomisation and children with asthma the units of analysis. It is planned to include 180 children aged 6-12 years. Primary outcome will be average asthma control during the 18-month follow-up measured by the Childhood Asthma Control Test (C-ACT). Secondary outcomes include C-ACT scores at t=3, t=6, t=12 and t=18 months; the frequency and severity of exacerbations; cost-effectiveness; quality of life; satisfaction with delivered care; forced expiratory volume in 1 s and forced expiratory flow at 75% and the association of high symptoms scores at baseline and baseline characteristics. Besides, we will conduct identical measurements in a non-randomised sample of children.

ETHICS AND DISSEMINATION

This will be the first trial to evaluate the effectiveness of protocolled practice nurse-led care for children with asthma in primary care. The results may lead to improvements in asthma care for children and can be directly implemented in revisions of asthma guidelines.The study protocol was approved by the Medical Research Ethics Committee of the Erasmus Medical Centre in Rotterdam.

TRIAL REGISTRATION

NTR6847.

Association of Electronic Health Record Design and Use Factors With Clinician Stress and Burnout

IMPORTANCE

Many believe a major cause of the epidemic of clinician burnout is poorly designed electronic health records (EHRs).

OBJECTIVES

To determine which EHR design and use factors are associated with clinician stress and burnout and to identify other sources that contribute to this problem.

DESIGN, SETTING, AND PARTICIPANTS

This survey study of 282 ambulatory primary care and subspecialty clinicians from 3 institutions measured stress and burnout, opinions on EHR design and use factors, and helpful coping strategies. Linear and logistic regressions were used to estimate associations of work conditions with stress on a continuous scale and burnout as a binary outcome from an ordered categorical scale. The survey was conducted between August 2016 and July 2017, with data analyzed from January 2019 to May 2019.

MAIN OUTCOMES AND MEASURES

Clinician stress and burnout as measured with validated questions, the EHR design and use factors identified by clinicians as most associated with stress and burnout, and measures of clinician working conditions.

RESULTS

Of 640 clinicians, 282 (44.1%) responded. Of these, 241 (85.5%) were physicians, 160 (56.7%) were women, and 193 (68.4%) worked in primary care. The most prevalent concerns about EHR design and use were excessive data entry requirements (245 [86.9%]), long cut-and-pasted notes (212 [75.2%]), inaccessibility of information from multiple institutions (206 [73.1%]), notes geared toward billing (206 [73.1%]), interference with work-life balance (178 [63.1%]), and problems with posture (144 [51.1%]) and pain (134 [47.5%]) attributed to the use of EHRs. Overall, EHR design and use factors accounted for 12.5% of variance in measures of stress and 6.8% of variance in measures of burnout. Work conditions, including EHR use and design factors, accounted for 58.1% of variance in stress; key work conditions were office atmospheres (β̂ = 1.26; P < .001), control of workload (for optimal control: β̂ = -7.86; P < .001), and physical symptoms attributed to EHR use (β̂ = 1.29; P < .001). Work conditions accounted for 36.2% of variance in burnout, where challenges included chaos (adjusted odds ratio, 1.39; 95% CI, 1.10-1.75; P = .006) and physical symptoms perceived to be from EHR use (adjusted odds ratio, 2.01; 95% CI, 1.48-2.74; P < .001). Coping strategies were associated with only 2.4% of the variability in stress and 1.7% of the variability in burnout.

CONCLUSIONS AND RELEVANCE

Although EHR design and use factors are associated with clinician stress and burnout, other challenges, such as chaotic clinic atmospheres and workload control, explain considerably more of the variance in these adverse clinician outcomes.

The presence of a Surgical Care Practitioner in the perioperative team is of benefit both to the patient and the consultant-led extended surgical team

Non-medically qualified professionals have progressively advanced and developed in line with the country's constantly evolving health care system. Recently, increasing hospital activity, underfunding in health care and a falling number of doctors have left the NHS perpetually underdoctored, underfunded and overstretched. As the current health care climate demands these 'non-doctors' to demonstrate competent knowledge and skill in providing safe and effective care, this paper discusses limitations, the scope of practice as well as the benefits the Surgical Care Practitioner provides to the modern extended surgical team, and most importantly - the patients under their care.

What does the nurse practitioner mean to you? A patient-oriented qualitative study in oncological/palliative care

AIMS AND OBJECTIVES

To explore what meaning patients associate with their experiences with a nurse practitioner (NP) in oncological or palliative care.

BACKGROUND

Care provided by NPs results in high patient satisfaction, mostly related to the assurance of continuity of care, and to receiving information and advice on coping with the disease. Research shows that health care provided by NPs equals the quality of care provided by physicians. Patients may be even more satisfied with care provided by NPs. Because patients' views have only been examined quantitatively, underlying experiences and meanings remain unclear.

DESIGN

A qualitative study from a phenomenological perspective.

METHODS

In 2017, seventeen outpatients aged 45-79 years, receiving oncological or palliative care, were interviewed in depth. Data were analysed by Colaizzi's seven-step method and by the Metaphor Identification Procedure.

RESULTS

Six fundamental themes emerged: the NP as a human (1) and as a professional (2), the NP providing care (3) and cure (4), NPs organising patient care (5) and the impact on patient's well-being (6). MIP analysis revealed six metaphors: NP means trust; is a travel aid; is a combat unit; is a chain; is a signpost; and is a technician.

CONCLUSIONS

NPs mean a lot to patients. NPs are valued as reliable, helpful and empathic. Patients feel empowered, at peace and in control as a result of the support, guidance and attention to them as a person as well as to aspects of the disease. Providing expert, integrated care makes patients feel safe and embraced in the NP's expertise.

RELEVANCE TO CLINICAL PRACTICE

This qualitative insight into patients' experiences will contribute to the body of knowledge on patients' perceptions of the treatment and support provided by NPs. It adds to the further development of the NPs' profession and education.

Nurse practitioner's perceptions of the impact of the nurse practitioner-led clinic model on the quality of care of complex patients

AimTo evaluate the organizational processes that influence the quality of care for patients with multimorbidity at nurse practitioner-led clinics (NPLCs). BACKGROUND: People are living longer, most with one or more chronic diseases (mulitmorbidity) and primary healthcare for these patients has become increasingly complex. One response was the establishment of new models of primary healthcare. NPLCs are an example of a model developed in Ontario, Canada, which feature nurse practitioners as the primary care providers practicing within an interprofessional team. Evaluation of the extent to which the processes within NPLC model addressed the needs of patients with multimorbidity is warranted. METHODS: Eight nurse practitioners were interviewed to determine their perception of the quality of care provided to patients with multimorbidity at NPLCs. Interpretive description guided the analysis and themes were identified.FindingsThree themes arose from the analysis, each of which has an impact on the quality of care. The level of patient vulnerability at the NPLCs was high resulting in the need to address social and financial issues before the care of chronic conditions. Dynamics within the interprofessional team impacted the quality of patient care, including NP recruitment and retention, leaves of absence and turnover in staff at the NPLCs had an effect on interprofessional team functioning and patient care. Finally, coordination of care at the NPLCs, such as length of appointments, determined the extent to which attention was given to individual clinical issues was a factor. Strategies to address social determinants of health and for recruitment and retention of NPs is essential for improved quality of care. Comprehensive orientation to the interprofessional team as well as flexibility in care processes may also have positive effects on the quality of care of patients with complex clinical issues.

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.

An alternative ICU staffing model: implementation of the non-physician provider

INTRODUCTION

Literature in Europe regarding implementation of nurse practitioners or physician assistants in the intensive care unit (ICU) is lacking, while some available studies indicate that this concept can improve the quality of care and overcome physician shortages on ICUs. The aim of this study is to provide insight on how a Dutch ICU implemented non-physician providers (NPP), besides residents, and what this staffing model adds to the care on the ICU.

METHODS

This paper defines the training course and job description of NPPs on a Dutch ICU. It describes the number and quality of invasive interventions performed by NPPs, residents, and intensivists during the years 2015 and 2016. Salary scales of NPPs and residents are provided to describe potential cost-effectiveness.

RESULTS

The tasks of NPPs on the ICU are equal to those of the residents. Analysis of the invasive interventions performed by NPPs showed an incidence of central venous catheter insertion for NPPs of 20 per fulltime equivalent (FTE) and for residents 4.3 per FTE in one year. For arterial catheters the NPP inserted 61.7 per FTE and the residents inserted 11.8 per FTE. The complication rate of both groups was in line with recent literature. Regarding their salary: after five years in service an NPP earns more than a starting resident.

CONCLUSION

This is the first European study which describes the role of NPPs on the ICU and shows that practical interventions normally performed by physicians can be performed with equal safety and quality by NPPs.

Primary Care Nurse Practitioner Practice Characteristics: Barriers and Opportunities for Interprofessional Teamwork

Developing team-based care models and expanding nurse practitioner (NP) workforce in primary care are recommended by policy makers to meet demand. Little is known how to promote interprofessional teamwork. Using a mixed-methods design, we analyzed qualitative interview and quantitative survey data from primary care NPs to explore practice characteristics important for teamwork. The Interprofessional Teamwork for Health and Social Care Framework guided the study. We identified NP-physician and NP-administration relationships; organizational support and governance; time and space for teamwork; and regulations and economic impact as important. Practice and policy change addressing these factors is needed for effective interprofessional teamwork.

Primary care professionals providing non-urgent care in hospital emergency departments

BACKGROUND

In many countries emergency departments (EDs) are facing an increase in demand for services, long waits, and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. However, it is unknown how this impacts the quality of patient care and the utilisation of hospital resources, or if it is cost-effective. This is the first update of the original Cochrane Review published in 2012.

OBJECTIVES

To assess the effects of locating primary care professionals in hospital EDs to provide care for patients with non-urgent health problems, compared with care provided by regularly scheduled emergency physicians (EPs).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library; 2017, Issue 4), MEDLINE, Embase, CINAHL, PsycINFO, and King's Fund, from inception until 10 May 2017. We searched ClinicalTrials.gov and the WHO ICTRP for registered clinical trials, and screened reference lists of included papers and relevant systematic reviews.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs attending to patients with non-urgent conditions, as compared to the care provided by regularly scheduled EPs.  DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We identified four trials (one randomised trial and three non-randomised trials), one of which is newly identified in this update, involving a total of 11,463 patients, 16 general practitioners (GPs), 9 emergency nurse practitioners (NPs), and 69 EPs. These studies evaluated the effects of introducing GPs or emergency NPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The studies were conducted in Ireland, the UK, and Australia, and had an overall high or unclear risk of bias. The outcomes investigated were similar across studies, and there was considerable variation in the triage system used, the level of expertise and experience of the medical practitioners, and type of hospital (urban teaching, suburban community hospital). Main sources of funding were national or regional health authorities and a medical research funding body.There was high heterogeneity across studies, which precluded pooling data. It is uncertain whether the intervention reduces time from arrival to clinical assessment and treatment or total length of ED stay (1 study; 260 participants), admissions to hospital, diagnostic tests, treatments given, or consultations or referrals to hospital-based specialist (3 studies; 11,203 participants), as well as costs (2 studies; 9325 participants), as we assessed the evidence as being of very low-certainty for all outcomes.No data were reported on adverse events (such as ED returns and mortality).

AUTHORS' CONCLUSIONS

We assessed the evidence from the four included studies as of very low-certainty overall, as the results are inconsistent and safety has not been examined. The evidence is insufficient to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs and NPs versus EPs in the ED to mitigate problems of overcrowding, wait times, and patient flow.

Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: protocol for a realist evaluation case study

INTRODUCTION

In developed countries, substituting physicians with nurse practitioners, physician assistants and nurses (physician substitution) occurs in nursing homes as an answer to the challenges related to the ageing population and the shortage of staff, as well as to guarantee the quality of nursing home care. However, there is great diversity in how physician substitution in nursing homes is modelled and it is unknown how it can best contribute to the quality of healthcare. This study aims to gain insight into how physician substitution is modelled and whether it contributes to perceived quality of healthcare. Second, this study aims to provide insight into the elements of physician substitution that contribute to quality of healthcare.

METHODS AND ANALYSIS

This study will use a multiple-case study design that draws upon realist evaluation principles. The realist evaluation is based on four concepts for explaining and understanding interventions: context, mechanism, outcome and context-mechanism-outcome configuration. The following steps will be taken: (1) developing a theory, (2) conducting seven case studies, (3) analysing outcome patterns after each case and a cross-case analysis at the end and (4) revising the initial theory.

ETHICS AND DISSEMINATION

The research ethics committee of the region Arnhem Nijmegen in the Netherlands concluded that this study does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act (WMO) (registration number 2015/1914). Before the start of the study, the Board of Directors of the nursing home organisations will be informed verbally and by letter and will also be asked for informed consent. In addition, all participants will be informed verbally and by letter and will be asked for informed consent. Findings will be disseminated by publication in a peer-reviewed journal, international and national conferences, national professional associations and policy partners in national government.

Towards an optimal composition of general practitioners and nurse practitioners in out-of-hours primary care teams: a quasi-experimental study

OBJECTIVES

To gain insights into the ability of general practitioners (GPs) and nurse practitioners (NPs) to meet patient demands in out-of-hours primary care by comparing the outcomes of teams with different ratios of practitioners.

DESIGN

Quasi-experimental study.

SETTING

A GP cooperative (GPC) in the Netherlands.

INTERVENTION

Team 2 (1 NP, 3 GPs) and team 3 (2 NPs, 2 GPs) were compared with team 1 (4 GPs). Each team covered 35 weekend days.

PARTICIPANTS

All 9503 patients who were scheduled for a consultation at the GPC through a nurse triage system.

OUTCOME MEASURES

The primary outcome was the total number of consultations per provider for weekend cover between 10:00 and 18:00 hours. Secondary outcomes concerned the numbers of patients outside the NPs' scope of practice, patient safety, resource use, direct healthcare costs and GPs' performance.

RESULTS

The mean number of consultations per shift was lower in teams with NPs (team 1: 93.9, team 3: 87.1; p<0.001). The mean proportion of patients outside NPs' scope of practice per hour was 9.0% (SD 6.7), and the highest value in any hour was 40%. The proportion of patients who did not receive treatment within the targeted time period was higher in teams with NPs (team 2, 5.2%; team 3, 8.3%) compared with GPs only (team 1 3.5%) (p<0.01). Team 3 referred more patients to the emergency department (14.7%) compared with team 1 (12.0%; p=0.028). In teams with NPs, GPs more often treated urgent patients (team 1: 13.2%, team 2: 16.3%, team 3: 21.4%; p<0.01) and patients with digestive complaints (team 1: 11.1%, team 2: 11.8%, team 3: 16.7%; p<0.01).

CONCLUSIONS

Primary healthcare teams with a ratio of up to two GPs and two NPs provided sufficient capacity to provide care to all patients during weekend cover. Areas of concern are the number of consultations, delay in patient care and referrals to the emergency department.

TRIAL REGISTRATION

NCT02407847.

Trends in the diagnosis and management of hypertension: repeated primary care survey in South West England

BACKGROUND

Previous surveys identified a shift to nurse-led care in hypertension in 2010. In 2011 the National Institute for Health and Care Excellence (NICE) recommended ambulatory (ABPM) or home (HBPM) blood pressure (BP) monitoring for diagnosis of hypertension.

AIM

To survey the organisation of hypertension care in 2016 to identify changes, and to assess uptake of NICE diagnostic guidelines.

DESIGN AND SETTING

Questionnaires were distributed to all 305 general practices in South West England.

METHOD

Responses were compared with previous rounds (2007 and 2010). Data from the 2015 Quality and Outcomes Framework (QOF) were used to compare responders with non-responders, and to explore associations of care organisation with QOF achievement.

RESULTS

One-hundred-and-seventeen practices (38%) responded. Responders had larger list sizes and greater achievement of the QOF target BP ≤150/90 mmHg. Healthcare assistants (HCAs) now monitor BP in 70% of practices, compared with 37% in 2010 and 19% in 2007 (P<0.001). Nurse prescribers alter BP medication in 26% of practices (11% in 2010, none in 2007; P<0.001). Of the practices, 89% have access to ABPM, but only 71% report confidence in interpreting results. Also, 87% offer HBPM, with 93% of these confident in interpreting results.

CONCLUSION

In primary care BP monitoring has devolved from GPs and nurses to HCAs. One in 10 practices are not implementing NICE guidelines on ABPM and HBPM for diagnosis of hypertension. Most practices express confidence interpreting HBPM results but less so with ABPM. The need for education and quality assurance for allied health professionals is highlighted, and for training in ABPM interpretation for GPs.

Listening to paediatric primary care nurses: a qualitative study of the potential for interprofessional oral health practice in six federally qualified health centres in Massachusetts and Maryland

OBJECTIVES

To explore the opportunities for interprofessional collaboration (IPC) to improve paediatric oral health in federally qualified health centres (FQHCs), to identify challenges to IPC-led integration of oral health prevention into the well-child visit and to suggest strategies to overcome barriers.

SAMPLE

Nurse managers (NMs), nurse practitioners (NPs), paediatric clinical staff and administrators in six FQHCs in two states were interviewed using a semistructured format.

DESIGN

Grounded theory research. Topics included feasibility of integration, perceived barriers and strategies for incorporating oral health into paediatric primary care.

MEASUREMENTS

Qualitative data were coded and analysed using NVivo 10 to generate themes iteratively.

RESULTS

Nurses in diverse roles recognised the importance of oral health prevention but were unaware of professional guidelines for incorporating oral health into paediatric encounters. They valued collaborative care, specifically internal communication, joint initiatives and training and partnering with dental schools or community dental practices. Barriers to IPC included inadequate training, few opportunities for cross-communication and absence of charting templates in electronic health records.

CONCLUSIONS

NMs, NPs and paediatric nursing staff all value IPC to improve patients' oral health, yet are constrained by lack of oral health training and supportive charting and referral systems. With supports, they are willing to take on responsibility for introducing oral health preventive measures into the well-child visit, but will require IPC approaches to training and systems changes. IPC teams in the health centre setting can work together, if policy and administrative supports are in place, to provide oral health assessments, education, fluoride varnish application and dental referrals, decrease the prevalence of early childhood caries and increase access to a dental home for low-income children.

Improving breast cancer screening in a federally qualified health center with a team of nursing leaders

To improve breast cancer screening in a federally qualified health center, NPs developed a collaborative team of nurses to implement innovative strategies that improved mammography rates from 23% to 40% over a 12-month period. Through shared expertise, this team led the way in translating mammography guidelines into clinical practice.

Mentoring: Positively Influencing Job Satisfaction and Retention of New Hire Nurse Practitioners

The purpose of study was to determine whether mentoring based on Watson's Caring Model positively influences nurse practitioner (NP) job satisfaction. This nonexperimental mixed-methods study utilized an online survey, administered through Qualtrics containing demographic and mentoring variables. Job satisfaction results were obtained from the Misener Nurse Practitioner Job Satisfaction Scale (MNPJSS). Also, open-ended questions regarding mentoring were reported. There was a 54% response rate in which 37 of the 69 participants responded (n = 37), with statistical significance set at p < .05. All or 100% of participants reported that the mentor experience/relationship positively influenced job satisfaction. Scores from the MNPJSS ranged from 141 to 246, with a mean of 195.26 (SD = 28.29) corresponding to "minimally satisfied" or a mean of 4.44 on the 6-point scale. These results are similar to the MNPJSS score with a mean of 4.39. A mentoring experience can provide a positive environment, which can lead to increased job satisfaction. In turn, a higher level of satisfaction in the work environment can be associated with reduced turnover and improved retention and patient outcomes. Ultimately, a safer health care system will evolve and improve patient care and outcomes. Through Watson's Caring Model, a reciprocal relationship between the mentor and the mentee can provide a new NP hire a sense of community and direct availability. By experiencing a mentor relationship, job satisfaction can improve, which is a key factor in retaining NPs. As E-mentoring is a newer topic in nursing literature, further research is needed. Further studies could also review and develop one-on-one mentoring programs.

Diabetes Educators

A survey evaluating the professional characteristics and practice patterns of diabetes educators was distributed across the United States. The specific survey aims were to assess whether (1) there continues to be a growing trend among US health professionals who consider themselves diabetes educators to obtain certification as certified diabetes educators (CDEs), (2) duties/services associated with diabetes self-management training (DSMT) and medical/medication management differ between diabetes educators who are CDEs versus those who are non-CDEs, and (3) educator practice patterns differ across the major geographic regions of the United States. Of the 507 diabetes educators completing the survey, 83% identified themselves as CDEs. Diabetes educators responding to similar surveys done in 1992 and 1999, 51% and 63%, respectively, identified themselves as CDEs. In this survey, a similar percentage of CDEs and non-CDEs employed DSMT practices of relatively low complexity (eg, general diabetes education) whereas a significantly higher percentage (P< .001) of CDEs employed DSMT practices of relatively high complexity (eg, insulin pump training). Significantly (P < .001) more CDEs provided medical/medication management services compared to non-CDEs. Finally, the practice patterns among CDEs were minimally influenced by region of the country. These results suggest that (1) the trend toward increased certification among diabetes educators has continued, (2) certification is associated with a greater likelihood of delivering complex DSMT services and medical/medication management, and (3) this pattern is consistent across the nation as a whole.

A nurse-led model of chronic disease management in general practice: Patients' perspectives

BACKGROUND

Evidence suggests that current models of chronic disease management within general practice are not effective in meeting the needs of the community.

OBJECTIVE

The objective of this article is to examine patients' perceptions of a nurse-led collaborative model of care trialled in three general practices in Australia.

METHODS

This article reports on the second phase of a mixed-methods study in which semi-structured interviews with purposively selected patients were conducted to elicit information about their perceptions of nurse-led care.

RESULTS

Three themes emerged from the data - time, ambiance and dimensions of the nurse role.

DISCUSSION

The results suggest that general practice nurses had a positive impact on patients' ability to manage their chronic disease. This infers that there is scope for general practice nurses to expand their role in chronic disease management to assist patients to better self-manage their chronic diseases.

Marginalization and School Nursing

The concept of marginalization was first analyzed by nursing researchers Hall, Stevens, and Meleis. Although nursing literature frequently refers to this concept when addressing “at risk” groups such as the homeless, gays and lesbians, and those infected with HIV/AIDS, the concept can also be applied to nursing. Analysis of current school nursing literature and research suggests school nursing may be a marginalized specialty, encompassing many of the characteristics of marginalization including isolation, role confusion, and barriers to practice. School nurses can reduce or eliminate these characteristics by increasing their visibility and collaborative opportunities in the educational and nursing communities while also providing mentoring opportunities to new school nurses.

Advanced Practice Nursing and Conceptual Models of Nursing

This column focuses on advanced practice nursing. A definition and central competency of advanced practice are given and four roles assumed by advanced practice nurses are identified. Questions related primarily to the advanced practice role of nurse practitioner are raised. Two nurse scholars who teach and practice discuss their experiences as advanced practice nurses, with an emphasis on the importance of using a conceptual model of nursing as a guide for their practice.

Nurse Practitioner Autonomy and Relationships with Leadership Affect Teamwork in Primary Care Practices: a Cross-Sectional Survey

BACKGROUND

The Nurse Practitioner (NP) workforce represents a substantial supply of primary care providers able to contribute to meeting a growing demand for care. However, controversy exists regarding the expanding role of NPs in primary care in terms of challenging the teamwork between NPs and physicians. To date, no empirical evidence exists regarding how to promote teamwork in primary care between NPs and physicians.

OBJECTIVE

We investigated whether NP autonomy within primary care practices and the relationships they have with leadership affect teamwork between NPs and physicians.

DESIGN

Using a cross-sectional survey design, data was collected from 163 primary care practices in Massachusetts.

PARTICIPANTS

Three hundred and fourteen primary care NPs completed and returned the mail survey yielding a response rate of 40 %.

MAIN MEASURES

The Autonomy and Independent Practice (AIP) and NP-Administration Relations (NP-AR) scales were used to measure NP independent practice and the relationships with leadership, respectively. These measures were aggregated to the practice level. Teamwork between NPs and physicians was measured at the individual NP level using the Teamwork (TW) scale.

KEY RESULTS

The multilevel linear regression models investigated the influence of practice-level NP autonomy and the relationship between NPs and leadership on teamwork. With every unit increase on the practice-level mean score of AIP centered at the grand mean, the mean TW score increased by 0.271 units (p < 0.0001). With every unit increase of NP-AR centered at the grand mean, the mean TW score increased by 0.375 (p < 0.001). Over one-third (41.3 %) of the variance in teamwork could be explained by the final model.

CONCLUSION

The study findings demonstrate that NP autonomy and favorable relationships with leadership improve teamwork. Policy and organizational change should focus on promoting NP autonomy and improving the relationship between NPs and leadership to improve teamwork and consequently improve patient care and outcomes.

Is Heart Failure Nursing Practice at the Level of a Clinical Nurse Specialist or Advanced Nurse Practitioner? The Irish Experience

Since 2000 there has been a significant increase of Heart Failure Nursing positions in the Irish health service. The background to these positions has been based on the model established at St. Vincent's University Hospital, Dublin since 1998. Recognition of nursing practice in Ireland has also transformed with the introduction of Clinical Nurse Specialist and Advance Nurse Practitioner positions. To date Clinical Nurse Specialists coordinate and manage heart failure programmes, however it remains to be seen whether current practices are within the scope of practice of these nurses. Advanced Nurse Practitioner is a new position in Irish Nursing from examining guidelines and education this may be the way forward for Heart Failure Nursing in Ireland.

A framework for advanced clinical practice

The NHS needs a skilled, knowledgeable workforce of advanced clinical practitioners, who require multidisciplinary approach to their postgraduate development. To meet these demands we set up a regional programme to help clinical practitioners move into these new and demanding roles. As a result, health professionals who want to progress their career and advance their practice have an opportunity in the West Midlands to qualify as advanced clinical practitioners.

The Australian 'grey nomad' and aged care nurse practitioner models of practice: a case study analysis

INTRODUCTION

The Nurse Practitioner - Aged Care Models of Practice Initiative supported the roll-out of a range of nurse practitioner (NP) models of practice, across Australia. One of these models was a community-based clinic-located practice, situated in a remote tourist destination where there is no resident general practitioner. Services were delivered by a NP to the local population as well as the many seasonal tourists passing through the region. These seasonal tourists included a growing number of older people, many of whom had chronic health conditions such as hypertension, diabetes and cardiac disease.

METHODS

A case study approach was taken to test and develop connections between the theory of nursing models and the practice of the NP. This approach enabled the development of a detailed explanation of the community-based, clinic-located NP model, including the model's associated enablers and challenges. The case study approach also supported further theoretical development of nursing models more generally.

RESULTS

Enablers of the NP model were the sponsoring not-for-profit organisation, which provided pre-existing structures for clinical governance and general management, as well as funding; and the collaborative agreements negotiated at a systems level between the NP, other health professionals, and a variety of service providers. Challenges to the model included the organisation's limited capacity to back-fill the NP for leave and professional development entitlements obtaining recurrent funding to sustain the model. Also identified was the need for the organisation to more clearly explain the NP role to consumers of the services being delivered. Theoretically, analysis led to the inclusion of an additional component of the nursing model: influence of context. This component is important because it highlights the way in which nursing models of practice are affected by local conditions.

CONCLUSIONS

The community-based, clinic-located NP model of practice described in this article provides a rigorous exemplar for other organisations providing similar services in remote, rural or other suitable locations.

The Role of Army Nurse Practitioners Supporting Wars in Iraq and Afghanistan

Family nurse practitioners are an essential member of the military medical team. They were incorporated into the Army medical system almost as soon as there was an academic program to develop the role in primary care settings. The role for nurse practitioners during deployment has not been as clear. Even though they have been around for 50 years, the specific role nurse practitioners provide is still evolving. This article explores the incorporation of nurse practitioners into Army medicine with a focus on deployed medicine. Nurse practitioners have been shown to be very versatile providers with the requisite skill sets to meet the demands of the combat environment and are able to substitute for other medical assets that are critically short due to sustained conflict. Clarifying the value a nurse practitioner brings to medical care in the combat environment is essential to insure all assets are being employed to provide the best medical care to the US fighting force.

Maryland Medicine Integrating Nurse Practitioners Into a Hospital Medical Staff

Under the new law, nurse practitioners expect that medical staffs will offer privileges without a requirement for supervision. Medical staffs have a responsibility to ensure quality of care and verify every member's competence, even as she or he acquires clinical experience. We believe that a model using progressive tiers of supervision, culminating in a level that allows practice directly accountable to OPPE and peer review, will meet nurse practitioners' expectations and medical staff responsibilities. Medical staff organizations and nurse practitioners have much to offer one another and need to develop processes that allow them to work together for the optimum benefit of their patients. The author wishes to thank Helen Brown, CRNP, for her assistance in the preparation of this article.

Using the Virtual Reality World of Second Life to Promote Patient Engagement

Patients have typically been passive participants in their own healthcare. However, with a change in philosophy towards outcomes driven care, it has become necessary to make sure that patients mutually set their healthcare goals with their providers Both eHealth and mobile health applications have required patient participation in ways never before valued. The virtual reality world of Second Life offers one eHealth solution that requires computer literate patients to participate via avatars in synchronous healthcare visits and support groups, as well as explore online resources asynchronously. This paper describes the development of a Second Life environment that served as a platform for nurse practitioner driven care supplemented by a patient portal as well as the institutional electronic health record. In addition, the use of Second Life is described as an active exercise to expose students in a Consumer Health course to support groups and resources available to actively engage patients.

In the Palm of Your Hand - Normalizing the Use of Mobile Technology for Nurse Practitioner Education and Clinical Practice

The use of mobile devices by nurse practitioners (NPs) to meet an evolving technological landscape is expanding rapidly. A longitudinal study of the ways NP students "normalize" the use of mobile devices in clinical education was completed. This study used researcher-designed survey tools, including sociodemographic questions, and the numerical picture was augmented and interpreted in light of the textual data in the form of selected interviews. Data indicate that mobile technology is normalized in the social realm but still developing in the clinical realm. Progress is hindered by non-modelling by faculty, inconsistent healthcare policy and lack of understanding of the affordances available through this technology. Overall, mobile technology is utilized and normalized in practice; this in turn has influenced their ability to prepare students for practice. Data presented can assist educators and clinicians alike in developing a more fulsome understanding on how to appropriately incorporate mobile technology into education and practice.

Development of The Johns Hopkins University School of Nursing Adult/Geriatric Primary Care Nurse Practitioner Program in HIV Prevention, Treatment, and Care

In response to the call to create an AIDS Education and Training Center for Nurse Practitioner Education by the Health Resources and Services Administration, The Johns Hopkins University School of Nursing embarked on a transformative curriculum overhaul to integrate HIV prevention, treatment, and care into the Adult/Geriatric Nurse Practitioner Program. A six-step process outlined in the Curriculum Development for Medical Education was followed. A pilot cohort of Adult/Geriatric Nurse Practitioner students were enrolled, including 50% primary care setting and 50% HIV-focused primary care through a 12-month HIV continuity clinic experience. Through this pilot, substantive changes to the program were adopted. Programmatic outcomes were not compromised with the modification in clinical hours. The model of a 12-month HIV continuity clinical experience reduced the number of required preceptors. This model has important implications for the HIV workforce by demonstrating successful integration of HIV and primary care training for nurse practitioners.

Impact of APN Home Visits in Reducing Healthcare Costs and Improving Function in Homebound Heart Failure

By providing quality primary care in the home setting, nurse practitioners can treat homebound patients effectively and decrease the number of hospitalizations, 30-day readmissions, and emergency department visits. Forty patients with a diagnosis of Class III or IV heart failure who were homebound were chosen for this project. The project manager, an Adult-Gerontological nurse practitioner, made home visits to these patients on a monthly and as-needed basis throughout the 3-month project. The rate of hospital admissions, emergency department visits, and 30-day readmissions was reduced by 64%, 85%, and 95%, respectively. Patients were assessed using the Kansas City Cardiomyopathy Questionnaire (Green et al., 2000) at the initial visit and at 3 months. The scoring for physical functionality, symptom frequency, and quality of life were improved by 44%, 40%, and 54%, respectively.