Experiences and attitudes of nurse specialists in primary care regarding their role in care for patients with urinary incontinence

Scand J Caring Sci; 2011; 25; 303–310
Experiences and attitudes of nurse specialists in primary care regarding their role in care for patients with urinary incontinence Aim: To explore experiences and attitudes of nurse specialists in primary care regarding their role in care for patients with urinary incontinence (UI), thereby identifying facilitators and barriers for wider implementation. Background: Currently, primary care for patients with UI lacks sufficient adherence to existing guidelines on UI and is far from optimal. Studies in various countries show that involving nurse specialists may offer a solution to the inadequate care for UI. As qualitative studies on experiences of nurses with this type of intervention are lacking, we performed this study with a qualitative approach and data collection method within the course of a randomized controlled trial (RCT). Method: A focus group study was conducted in 2007 with six nurse specialists who were trained in caring for patients with UI in our pragmatic RCT. The focus group interview was audio‐taped and transcribed verbatim. The data were analysed using qualitative content analysis to identify themes. To understand obstacles and incentives for change, we relied on an existing ‘implementation model’. Findings: Nurse specialists feel competent to provide advice and information, to offer possible solutions and to give attention and guidance to the process of care of people with UI. They feel appreciated by patients and feel they offer an added value to the usual care of general practitioners (GPs). Nurses sometimes notice that GPs lack interest in UI. Personal contact with the GPs, availability of enough time, adequate equipment and financial resources are important preconditions for effective nurse specialist care. Nurse specialists value continuous education and feedback in daily care for patients with UI. Conclusion: Trained nurse specialists appeared to feel competent and satisfied to support GPs in care for patients with UI. They feel highly appreciated by both patients and GPs.     

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.     

Substitution model with central role for nurse specialist is justified in the care for stable type 2 diabetic outpatients

AIM OF THE STUDY: Assessment of effects on quality of care, in terms of patient outcomes, when tasks in the care for outpatients with stable type 2 diabetes are transferred from internist to nurse specialist and from outpatient clinic to general practice. BACKGROUND: For the management of chronic diseases with a high prevalence and requiring current monitoring, it is suggested that substitution of care may be an appropriate solution to safeguard high quality care. DESIGN AND METHODS: A 12-month nonequivalent control group design was used. General practitioners (GPs) referring diabetes patients to the University Hospital Maastricht were asked to choose for the traditional model or the nurse specialist model. Informed consent was obtained from patients with stable diabetes type 2 attending these practices. All patients received care according to the model chosen by their GP. Identified outcomes were: clinical status, health status, self-care behaviour, knowledge of diabetes, patient satisfaction, and consultation with care-providers. RESULTS: In the control group (n=47) no patients were treated with oral hypoglycaemic agents (OHA) only. The control group was compared with an intervention subgroup (n=52) also without patients receiving OHA only. Clinical data were available for all patients. Patients without complete data from questionnaires had better mean concentration of HbA1c than patients with complete data (P=0.004). The traditional care model and the nurse specialist model achieved equal outcomes, while glycaemic control of patients in the nurse specialist model improved (from 8.6% to 8.3%) but deteriorated in the traditional model (from 8.6% to 8.8%; P-value between groups=0.001). CONCLUSIONS: The model with nurse specialists taking on roles and tasks beyond those traditionally regarded as their remit as well as new ones, is effective for the care of stable diabetic outpatients.     

An audit of patient satisfaction with uro-oncology nurse specialists – a questionnaire study

Specialist nurses have an established role in the management of urological cancer in helping patients to understand their disease and treatment options and in offering counselling and emotional support. There is evidence to suggest that patients who see the nurse specialist express more satisfaction and have less anxiety than those who see junior doctors. Other studies have found that the specialist nurses’ clinical expertise compared favourably with that of other clinicians. This audit aimed to assess the patient satisfaction with uro‐oncology nurse specialists and their nurse‐led clinics. One hundred, 15‐point patient satisfaction questionnaires were sent to new and existing patients with urological cancer who had been randomly identified by the uro‐oncology nurse specialist. The questions were concerned with the provision of information to patients and with the satisfaction of the nurse specialist service. The results showed that patients found contact with the uro‐oncology nurse specialist supportive, informative and beneficial to their treatment. The authors felt that raising the profile of the uro‐oncology nurse specialist would be beneficial to patient treatment and care.     

A study to evaluate nurse-led on-treatment review for patients undergoing radiotherapy for head and neck cancer

Aims and objectives. To evaluate a nurse‐led clinic for patients undergoing radiotherapy to the head and neck. Background. The side effects of radiotherapy to the head and neck are superimposed on already significant physical and psychological morbidity. Medical review clinics tend to focus on treatment complications and there is evidence that specialist nurses can provide more holistic care for patients. However, doubts have been raised about the appropriateness of nurse‐led review in this highly symptomatic and complex group. Design. This evaluation compared medical on‐treatment review (Phase 1) with a nurse‐led clinic (Phase 2) for patients having radiotherapy to the head and neck, using an historical control group. Methods. Twenty patients were reviewed by their consultant and 23 by a nurse specialist, using a clinic protocol. A mixed‐method approach to data collection was taken. Patients completed weekly quality of life questionnaires and were asked about their experiences of support and care. General practitioners completed a questionnaire about the communication received from the clinic. Checklists assessed the content of clinic consultations. Results. Patients valued the relationship developed with the nurse specialist, had longer, more frequent consultations and were more often referred to the multidisciplinary team. The nurse specialist managed 83% of consultations without referral to the consultant. Few significant differences in quality of life were found between the groups. There were indications that oral and nutritional problems were managed more effectively in the nurse‐led clinic, although emotional functioning was higher in the medical group. GPs were positive about the timing and content of information received. Conclusions. On‐treatment review for patients with head and neck cancer can be effectively managed by a nurse specialist. Relevance to Practice. Radiotherapy nurse specialists make an important contribution to the supportive care of patients with head and neck cancer. More investment is required to maximize their contribution.     

Treatment of patients with airflow obstruction by general practitioners and chest physicians

The study comprised 223 patients with airflow obstruction and/or bronchial hyperreactivity from 29 general practices in the catchment area of Nijmegen University. Fifty-six patients were treated by 19 chest physicians, the remaining 167 by their general practitioners (GPs), without specialist care. The specialists treated more allergic patients than the GP (p less than 0.05). No other relevant differences in sex, age, smoking behaviour, and severity of the disease (symptoms, lung function, and bronchial hyperreactivity) could be observed between these two groups of patients. Chest physicians prescribed almost three times as many drugs as GPs. No immediate response to the prescribed bronchodilators was found in 16% of the patients treated by the GPs, nor in 20% of the patients treated by the specialists. We could identify only a weak relationship between the severity of the disease (symptoms and pulmonary function combined) and the prescribed pharmacotherapy: with growing degrees of severity the GP seems to prescribe more bronchodilators, the specialist more inhaled corticosteroids. Prescribed pharmacotherapy should be based on the combination of symptoms, pulmonary function, bronchial hyperreactivity, and reversibility on the prescribed bronchodilators.     

Working relationships between practice nurses and general practitioners in Australia: a critical analysis

This research set out to explore shared care between practice nurses and general practitioners in South Australia. Nine practice nurses (PNs), two nurse practitioners and 10 general practitioners (GPs) were interviewed in urban and rural practices in order to build up a picture of how GPs and PNs worked together. The interviews showed that shared care was not a reality, although practice nurses were very busy, enjoyed their work and were no longer performing as receptionists doing a little nursing on the side, but as highly skilled nurses. Questions that emerged included whether or not practice nurses are specialists or generalists; their relationship to nurse practitioners; the extent to which the doctor–nurse game explains the relationship between practice nurses and general practitioners; and the potential for expanding the practice nurse role.     

Nurse specialist led follow-up in lung cancer: The experience of developing and delivering a new model of care

Data from an earlier paper reporting on a study comparing conventional medical follow-up with nurse specialist follow-up of patients with lung cancer demonstrated that follow-up by nurse specialists is safe, effective and can lead to greater levels of patient satisfaction. The process and experience of developing a nurse specialist role in lung cancer follow-up care has not yet been described. The aims of this paper are to describe the preparation and development of a model of nurse led follow-up care, identify key nursing interventions provided within nurse led follow-up care and provide insights into the experiences of nurse specialists providing follow-up care. Data were collected from nurse specialists' patient case-records and from meetings held with the study team. Semi-structured interviews were conducted with the nurse specialists providing follow-up care and the study coordinators. The nature of the nursing role in lung cancer follow-up care is described. In addition, four themes relating to the process of developing a nurse led follow-up role are identified. These are: 'training', 'becoming credible', 'emotional burden' and 'making a difference'. Managing follow-up care for patients with lung cancer can be rewarding for nurse specialists. However, it can also be emotionally demanding. Training and support for such roles is vital and requires further in-depth research.     

General practitioners' perceptions and attitudes to infertility management in primary care: focus group study

Background Infertility management in primary care is variable. National Institute of Clinical Excellence have recommended hysterosalpingography (HSG) as a first‐line investigation for tubal assessment. Aim To explore general practitioners’ (GPs) perceptions of, and attitudes to, the initial management of the infertile couple and their views on open access to HSG. Method Design: Qualitative study using three focus groups. Setting: Seven general practices in Newcastle upon Tyne and Northumberland. Subjects: We purposively selected the three focus groups to provide a range of GPs’ views. In total 13 practitioners participated: 11 GPs, one GP registrar and one nurse practitioner. Results The key themes to emerge were: (1) perceived professional responsibilities, (2) uncertainty and lack of knowledge, (3) consistency of approach to the initial management of infertility, and (4) access to infertility services. Some GPs felt that they should do all they possibly could, while others felt it was the responsibility of the infertility specialist. Uncertainty and lack of knowledge was linked to the relative infrequency of primary care infertility consultations and the difficulty ‘keeping up to date’ with rapidly advancing reproductive technologies in tertiary care. Some GPs subscribed to the notion of one suitably trained clinician delivering the service on behalf of a group of GPs. Some were unsure where HSG fitted into the overall management plan, but they were comfortable with following recommended guidelines. Conclusions GPs recognize an advocacy role and many take on a significant degree of clinical responsibility welcoming the introduction of a new technology in primary care. Nevertheless, GPs feel that they lack proficiency and have little opportunity to rehearse the necessary skills. These findings contribute to an understanding of the management of infertility, an infrequently presenting problem in primary care.     

Building bridges in palliative care: evaluating a GP Facilitator programme

The objective of this study was to evaluate the impact of the Macmillan GP Facilitator Programme in Palliative Care on the knowledge, attitudes and confidence in symptom control of general practitioners (GPs), communication with patients and out-of-hours practice. GP Facilitators work on average for two sessions a week with practices in their locality. The design included a before and after study, with geographical controls matched on type of area (inner city, urban and rural) and broadly on Jarman scores using postal questionnaires sent to GPs. Scores measured change in GP awareness, attitudes and practice over two years of the intervention, derived from Likert scale responses to the postal questionnaires. Although overall few significant results were found, we did identify an increase in the use of palliative care guidelines in Facilitator districts, together with an increase in awareness of day care. The programme was associated with increased positive attitudes towards specialist palliative care services and results suggested increased satisfaction with out-of-hours services for patients. No change was found for confidence in symptom control and communication over diagnosis with cancer patients was less than in control districts. The design also incorporated a qualitative component, and from this we found the Facilitator programme to be popular with local GPs who valued the support of a colleague who knew the demands and constraints of general practice. In conclusion, we have demonstrated an impact of the GP Facilitator programme on GP awareness of, use and increased positive attitudes towards specialist palliative care services. By improving communication between primary and specialist palliative care, the programme should contribute substantially to improved care of the dying at home.     

General practitioners' perceptions of a community-based nurse-led assessment clinic for patients with benign prostatic hyperplasia

The prevalence of benign prostatic hyperplasia (BPH) increases with age; therefore, this condition is likely to rise as people live longer. This poses challenges in how best health services can be organized to diagnose, treat or manage this disease effectively. A community‐based nurse‐led clinic was set up to assess and advice people with BPH who were referred by general practitioners (GPs). The aim of this study was to explore the perceptions of GPs of the value and benefits of the nurse‐led BPH clinic. Two focus groups were carried out with a random sample of 10 GPs (five in each group). The findings showed that the assessment carried out at the clinic by the specialist nurse helped them to avoid the ‘trial and error’ approach that GPs sometimes used in treating this condition. Although they did not find that the clinic reduced their (GPs) workload, it offered a valuable, enhanced service to help them make accurate diagnosis and prescribe appropriately, thereby contributing to the quality of life of patients. This study showed that nurses’ and doctors’ work can complement each other to the benefit of patients. It adds to the growing evidence that appropriate skill mix can contribute to effective practice.     

Antibiotic prescribing in primary care: The need for interprofessional collaboration

Abstract

Patients with self-limiting respiratory tract infections (RTIs) are frequently seen in general practice. Although antibiotics are ineffective for these conditions, they are often prescribed by general practitioners (GPs), and perceived patient expectations for an antibiotic plays an important role in the decision to prescribe one. Superfluous use of antibiotics contributes to antimicrobial resistance. High numbers of nurse prescribers work alongside GPs and these prescribers see education and self-management advice as central to the care of these patients. Multi-faceted interventions, designed to reduce antibiotic prescribing, only exist for GPs. Such interventions should foster interprofessional collaboration and, as such, consider the needs and experiences of the different prescribers, and the views of patients. This paper outlines a research study in which a questionnaire will be distributed to patients who consult with a nurse prescriber to see whether their expectations influence their satisfaction with the consultation outcome. Findings will guide the development of an interprofessional intervention designed to promote collaborative practice and appropriate and responsible antibiotic prescribing in primary care.     

Management of urinary incontinence following radical prostatectomy

INTRODUCTION: The impact of a urology oncology nurse specialist in the practice environment to assist with both pre and postoperative education needs of men undergoing genitourinary surgery for cancer was evaluated. OBJECTIVE: This study aimed to improve the preoperative process and teaching for men planning surgery for genitourinary cancers, including the delivery of pathology results. A secondary aim was to decrease the incidence of postoperative incontinence. METHODS: Male patients undergoing a radical prostatectomy were recruited. Patients who underwent surgery were evaluated both before and after the urology oncology nurse specialist role was established. Followup was via phone call interview and International Prostate Symptom Score questionnaire. RESULTS: Men who received the personalized education from the urology oncology nurse specialist had a higher return of continence postoperatively, as well as higher satisfaction scores with the outcome of their surgery, including higher quality of life scores. CONCLUSION: The urology oncology nurse specialist role had a significant impact on the postoperative incontinence rate and provided a missing patient education piece that improved the overall patient satisfaction rate with oncology-related care.     

How and why do GPs use specialist palliative care services?

This study presents findings on the interaction of generalists and specialists within palliative care. General practitioners (GPs) are central to community palliative care as most of the last year of a patient's life is spent at home under the care of the primary health care team. GPs see few palliative care patients each year, however, and access to specialist palliative care services for support, advice and referral can be important particularly to support patients who wish to die at home. The aim of this study was to explore GP use of and attitudes towards specialist palliative care services through semi-structured interviews in inner city, urban and rural areas. It was part of a longitudinal evaluation of an educational intervention, and the quantitative components are reported elsewhere. Sixty-three GPs were interviewed, having been sampled randomly from inner city, urban and rural health authority district lists. While most interviewees reported using specialist palliative care services as a resource, other models of use included working together as an extended team, seldom using such services and handing over care or responsibility entirely. Availability of services clearly shaped use, but previous experience and expectations of easy access were also important. Patterns of use were not necessarily fixed, but dependent also on the differing needs of and wishes of patients and carers. Specialist palliative care services need to be aware of such variations in ways of working and to consider the implications for the capacity and flexibility of both primary care and specialist service provision.     

Nurse practitioners substituting for general practitioners: randomized controlled trial

Title.  Nurse practitioners substituting for general practitioners: randomized controlled trial.
Aim.  This paper is a report of a study conducted to evaluate process and outcomes of care provided to patients with common complaints by general practitioners or specially trained nurse practitioners as first point of contact.
Background.  Studies in the United States of America and Great Britain show that substituting nurse practitioners for general practitioners results in higher patient satisfaction and higher quality of care. As the American and British healthcare system and settings differ from that in the Netherlands, a Dutch trial was conducted.
Methods.  A total of 1501 patients in 15 general practices were randomized to consultation by a general practitioner or a nurse practitioner. Data were collected over a 6-month period in 2006 by means of questionnaires, extracting medical records from practice computer systems and recording the length of consultations.
Findings.  In both groups, the patients highly appreciated the quality of care. No statistically significant differences were found in health status, medical resource consumption and compliance of practical guidelines in primary care in the Netherlands. Patients in the NP intervention group were more often invited to re-attend, had more follow-up consultations and their consultations took statistically significantly longer.
Conclusion.  Nurse practitioners and general practitioners provide comparable care. Our findings support an increased involvement of specially trained nurse practitioners in the Dutch primary care and contribute to knowledge of the effectiveness of care provision by nurse practitioners from a national and international perspective.     

Protecting the kidneys of patients with diabetes

Diabetes is the most common cause of end-stage renal disease; however, there is evidence that diabetes-related renal disease can be prevented with interventions currently available. The purposes of this article are to describe current screening and intervention guidelines for renal complications in patients with diabetes and to provide clinical nurse specialists with tools to facilitate the education and expert guidance needed by patients with diabetes to preserve their kidney function. This article includes (1) a review of the pathology of diabetic nephropathy, (2) a summary of screening guidelines, (3) current treatment recommendations to prevent or delay nephropathy, and (3) nursing strategies and tools framed within the education, expert coaching, and guidance roles of the clinical nurse specialist practice model.     

Allergological examination in general practice and in the specialist field of allergology. A comparative study of the concordance between a group of general practitioners and the allergological specialised health care services to which they refer

OBJECTIVE: To study the concordance between specially trained general practitioners (GPs) and specialist doctors working as consultants to GPs, with regard to diagnosis of allergic illnesses, evaluation of indications for hyposensitisation, and referrals from GPs to specialists. DESIGN: Thirty-four GPs and five specialists practising privately and eight allergologic outpatient clinics participated. The patients included had symptoms indicating allergologic examination. An identical diagnostic procedure was used by the GPs and by the specialists/outpatient clinics. SETTING: General practices, specialist practices, outpatient clinics. SUBJECTS: One-hundred and forty-eight patients. MAIN OUTCOME MEASURES: With regard to skin-prick test there was concordance between the GPs and the specialists in 82.5% of 1322 paired comparisons, in 74.0% with regard to anamnesis + skin-prick test, and in 66.5% with regard to the statement allergy. There was concordance with regard to indication for hyposensitisation in 88.3%, and for referral in 54.1%. There was symmetry concerning prick test and anamnesis + prick test, and asymmetry concerning the statement allergy, and indication for hyposensitisation and for referral. CONCLUSIONS: Specially trained GPs diagnosed specific allergy in concordance with specialists. There was asymmetry between GPs and specialists concerning the statement allergy, indication for hyposensitisation and for referral.     

Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review

BackgroundAdvanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness.ObjectiveTo examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles.MethodsOur methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel.ResultsThe narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles.ConclusionCurrent guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.     

A literature review of advanced clinical nursing practice in the United States of America

Advanced nursing practice in the United States of America has evolved over the past decades in two related but distinct directions:- the nurse practitioner (NP) and the clinical nurse specialist (CNS). This two-role evolution was in response to social demands for increased access to affordable, quality primary health care, and at the same time to the specialised nursing care requirements of increasingly complex patients. Thus, nurse practitioners became synonymous with primary and clinical nurse specialists with specialised, acute care. There is evidence that there is an advanced practice role for both the CNS and the NP and that much of the knowledge, skills and competencies are shared depending on the clinical situation. There have been successes and failures in the development of the two roles. The clinical nurse specialists have a more respectable image among the powerful nursing education elite, but nurse practitioners are widely recognised by consumers and other health care professionals and are valued by cost-conscious managers as a viable, cheaper alternative to physicians. The literature suggests it may well be time to take the best attributes of the two roles and merge them under the term 'advanced nurse practitioner'.