A systematic review of the effectiveness of advanced practice nurses in long‐term care

Aim

To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living in long‐term care residential settings.

Background

Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted.

Design

Quantitative systematic review.

Data sources

Twelve electronic databases were searched (1966–2010); leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group.

Review methods

Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria.

Results

Four prospective studies conducted in the USA and reported in 15 papers were included. Long‐term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services.

Conclusion

Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long‐term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.     

A qualitative study on the roles and responsibilities of nurse consultants in Hong Kong

This study aims to explore the roles and responsibilities of seven newly appointed nurse consultants (NCs) in various clinical specialties in Hong Kong as a pioneer project. Qualitative approaches using direct observation and semi‐structured interviews were adopted with two full‐day observations on the seven NCs plus 56 semi‐structured interviews of NCs, nurses, doctors and patients. Five major NCs’ roles and responsibilities had been identified, namely providing expert practice, initiating service development, leading education, guiding continuous quality improvement (CQI) and conducting research and providing evidence‐based practice. The seven NCs within this study have by and large achieved building professional excellence, respect and trust within their own spheres. It is strongly recommended that the NC post be formally established in the new Nurses Career Structure to enable expert clinical nurses to develop a clinical career to contribute to service and patient care to its maximum.     

Working with the team: strategies employed by hospital cancer nurse specialists to implement their role

Aim. This paper describes the strategies used by cancer nurse specialists in the UK to implement their role within the multiprofessional team. Background. The prevalence of cancer increasingly preoccupies the developed world causing concern about the effective use of healthcare resources. The demand to contain healthcare costs and meet the complex needs of patients has led to the development of new and different types of nurse specialist roles. In the UK, these initiatives have been supplemented by reorganizing cancer services to ensure care is delivered by collaborative multiprofessional teams: nurse specialists are considered core team members. While role ambiguity and conflict are acknowledged as barriers to the successful introduction of new roles, little is known about the strategies used by individuals to facilitate role implementation. Design. A grounded theory design using purposive and theoretical sampling. Methods. Twenty‐nine cancer nurse specialists from five hospitals participated in observation and semistructured interviews. The data were analysed concurrently using the constant comparative method. Results. Acceptance, especially by doctors, was the main problem facing cancer nurse specialists. In addition, they experienced insufficient organizational support for their role. Difficulties with acceptance impaired nurses’ ability to provide supportive care to cancer patients. Nurse specialists responded by employing several strategies including building relationships and establishing role boundaries. Conclusions. Some strategies used by nurse specialists are more successful than others in facilitating role implementation. While recommendations exist to assist the introduction of new roles in practice, their implementation by healthcare organizations may be limited. Future approaches should focus on helping nurses develop awareness of the problems they face, why they arise and effective mechanisms for their resolution. Relevance to clinical practice. The findings highlight the mismatch between cancer policy aspirations and reality and the actions taken by nurse specialists to overcome the problems they encounter.     

SARS (severe acute respiratory syndrome): reflective practice of a nurse manager

Aims and objectives. This paper describes the reflective practice of a nurse manager in Hong Kong in supporting frontline nurses to overcome the crisis of SARS. Background. SARS infection was a crisis for everyone in endemic areas because of its threat to physical and emotional health. Hong Kong was the second leading endemic area in the world. Inadequate supplies of protective devices and the death of a nurse infected with SARS triggered nurses’ negative emotions. Methods. A model of structured reflection was adopted to examine one's practice. A problem‐solving model for crisis intervention was integrated into the reflective stage of structured reflection. Results. Promotion of nurses’ safety and emotional stability were the major goals in handling the crisis. Strategies were employed including self‐awareness, empowerment and team building, information sharing, provision of personal protective equipment and emotional support for frontline nurses. Conclusions. SARS infection threatens the physical and emotional health of nurses. From a positive perspective, such a crisis created an opportunity to learn and grow in terms of ethical, personal and aesthetic arenas. Relevance to clinical practice. SARS epidemic raised worldwide attention and challenged the Hong Kong's health care system. Reflective practice is useful to guide and examine nurses’ professional action during the crisis, and to put the experience into a learning perspective.     

A literature review of principles, policies and practice in extended nursing roles relating to UK intensive care settings

Aims. To provide an overview of the literature relating to the principles, policy and practice of extended nursing roles in UK intensive care settings to date; to review and critically assess evidence of impact, outcomes and effect on practice and provide suggestions for future research. Background. It is known that career development opportunities, new technologies, patient needs, as well as the reduction in junior doctors’ hours, are driving the development of new roles for nurses. Policy initiatives aim to expand nursing roles to support professional substitution. In adult, neonatal and paediatric intensive care, specialist trained nurses and designated advanced nursing practitioners are increasingly taking on extended practice of clinical tasks previously undertaken by medical staff. As yet there are no statutory regulations on the perceived scope and definition of the role of extended and advanced roles. Design. Systematic review. Methods. Search of electronic databases and selection of policy and peer‐reviewed reports and reviews of extended nursing roles or advanced nursing practitioners in UK intensive care settings. Results. Chronological review shows policy development proceeding in a relatively ad hoc way. There is limited information available about how extensively or effectively extended nursing roles are being implemented in intensive care settings in the UK, particularly in adult and paediatric intensive care. To test local initiative findings for reliability and generalisability, a more robust evidence base is required. Conclusions. More data are needed on definition and outcomes of extended nursing roles in intensive care and care process measures should be developed to better inform implementation of nurse role development in the UK. Relevance to clinical practice. The review of policy and research evidence in this paper may better inform clinicians working in adult, neonatal or paediatric intensive care, as they continue to be challenged by expansion and development of their role. It may also help to form a basis and evaluation for future research into extended and advanced nursing roles in intensive care settings.     

Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis

AIMS: This paper reports a study whose aim was to identify and synthesize qualitative research studies reporting barriers or facilitators to role development and/or effective practice in specialist and advanced nursing roles in acute hospital settings. BACKGROUND: The number of clinical nurse specialist, nurse practitioner, advanced nurse practitioner and consultant nurse roles has grown substantially in recent years. Research has shown that nurses working in innovative roles encounter a range of barriers and facilitators to effective practice. METHODS: Systematic literature searches were undertaken, and relevant studies identified using specific inclusion and exclusion criteria. The selected studies were appraised, and their findings synthesized using Ritchie and Spencer's 'Framework' approach. RESULTS: Fourteen relevant studies were identified, mostly from the UK. They described a range of barriers and facilitators affecting specialist and advanced nursing practice. These related to the practitioner's personal characteristics and previous experience, professional and educational issues, managerial and organizational issues, relationships with other health care professionals, and resources. The factors most widely identified as important were relationships with other key personnel, and role definitions and expectations. CONCLUSIONS: Relationships with other staff groups and role ambiguity are the most important factors which hinder or facilitate the implementation of specialist and advanced nursing roles. These factors seem interlinked, and the associated problems do not appear to resolve spontaneously when staff become familiar with the new roles. In order to reduce role ambiguity and the consequent likelihood of negative responses we recommend that, when specialist and advanced nursing roles are introduced, clear role definitions and objectives are developed and communicated to relevant staff groups; these definitions and objectives should be updated as necessary.     

Consensus and diversity: an action research study designed to analyse the roles of a group of mental health consultant nurses

Aim. The purpose of this action research study was to enable a group of mental health consultant nurses in the UK to map the scope and dimensions of their roles. This initial benchmarking exercise is a precursor to the development of plans for role improvement and evaluation. Background. There is a growing body of literature that addresses advanced nursing practice roles. There is, however, no international agreement on what constitutes an advanced practice role. A few countries have addressed the statutory requirements governing such roles. Consultant nurses’ roles in the UK are relatively new innovations that aim to enhance care. However, only a few investigations have evaluated the dimensions and impact of these roles. Methods. The study was framed by use of action research as a form of self‐reflective enquiry. Initial data were generated through use of four focus group discussions, which were held with a group of consultant nurses employed predominately at a mental health National Health Service Trust. Five structured confirmatory questionnaires developed from the focus group data were also administered. Findings. Analysis of the focus group data gave five themes, 71 categories and 271 items that were used to inform development of the questionnaires. Responses to the questionnaire showed that 61% (n = 166) of the items had non‐consensus responses. It was found there was most consensus relating to leadership theme with 63% (n = 19) items having consensus responses. Least agreement was found in the education theme where there was <15% (n = 5) agreement to individual items. Conclusions. The study demonstrated complexity and variety in how the consultant nurses’ roles in the UK are being developed. Relevance to clinical practice. The potential for consultant nurse roles to enhance patient care is tremendous. This study provides initial indicators, which the practitioners involved, can use to plot future developments and changes to their roles.     

Nursing work in Jordan: an example of nursing work in the Middle East

Aim. The study aimed to investigate Jordanian nurses’ perceptions of their role in clinical practice. Background. The lack of regulation of nursing practice by the profession across the Middle East until now has led to each institution setting its own policies regarding the role of the nurse and the practice of nursing. No study to date has examined the role of the nurse working in the acute hospital environment nor explored the practice of nursing in this region. Design and methods. A cross‐sectional questionnaire survey was conducted using a quota sample. A total of 348 medical‐surgical staff nurses and practical nurses from the three healthcare sectors in Jordan participated in the study with a response rate of 77%. The results were analysed by constructing multiple response tables, chi‐square test, anova and log‐linear analysis. Results. Staff nurses in Jordan were expected to carry out the majority of nursing care activities. The role of the practical nurse was limited to the physical and professional domains of nursing care. Activities requiring higher levels of emotional or intellectual labour and interdisciplinary communication were attributed only to the staff nurse. The majority of the respondents reported nursing had not been their first choice of career. Male nurses had a higher intention to leave the nursing profession. The predominant method of care delivery used by nurses was task‐oriented. Conclusion. There was a general consensus regarding what constituted the nurse's work in the clinical area across the three healthcare sectors in Jordan. Role delineation between the two levels of nurses was also clear. There is a need to move from task‐oriented to patient‐centred care to promote quality patient care. Relevance to clinical practice. This study explores the role of the nurse working in the acute hospital environment in Jordan.     

Examining the language–place–healthcare intersection in the context of Canadian homecare nursing

Currently, much of the western world is experiencing a shift in the places where care is provided, namely from institutional settings like hospitals to diverse community settings such as the home. However, little is known about how language and the physical and social aspects of place interact to influence how health‐care is delivered and experienced in the home environment. Drawing on ethnographic participant observations of homecare nursing visits and semi‐structured interviews with Canadian family caregivers, care recipients and nurses, the intersection of language, place and health‐care was explored in this secondary analysis. Our findings reveal four themes: homecare nurses view themselves as ‘guests’; home environments facilitate the development of nurse–client relationships; nurses adapt healthcare language to each home environment; and storytelling and illness narratives largely prevail during medical interactions in the home. These findings demonstrate the spatiality of language and how the home environment informs decisions regarding language use. Furthermore, these findings exemplify how language and place mutually influence the experiences and delivery of home health‐care. We conclude by discussing the importance of considering the language–place–healthcare intersection in order to gain a better understanding of medical exchanges in places and the associated implications for optimizing best nursing practice.     

A multi-method evaluation of interprofessional education for healthcare professionals caring for women during and after pregnancy

This multi-method evaluation assessed the perceived impact of interprofessional workshops targeting enhanced collaboration between healthcare professionals who care for women during and after pregnancy. Current policy recommends partnership working to improve care for women and babies, however, there is little interprofessional education in this area. Five one-day workshops were delivered to 18 healthcare professionals (47.4% of the 38 healthcare professionals registered). The workshop was evaluated through questionnaires before and after the workshop measuring attitudes and willingness towards collaboration; observations of the workshops by a researcher and follow-up interviews 2 months’ post-workshop to explore changes in practice. Workshops were attended by midwives, health visitors (trained nurses specialising in community care for children 0–5 years), dietitians, nurses, a general practitioner and a breastfeeding specialist. Attitudes and willingness to participate in interprofessional collaborative practice improved after the workshop. Observations made at the workshop included engaged participants who reported numerous barriers towards collaboration. Follow-up contact with 12 participants identified several examples of collaboration in practice resulting from workshop attendance. These findings suggest that the workshops influenced attendees to change their practice towards more collaborative working. Future work needs to confirm these results with more participants.     

Contextual Barriers to the Successful Implementation of Family-Centered Practice in Mental Health Care: A Hong Kong Study

This article presents findings from an exploratory study to identify nurses' perspectives on factors that hinder the implementation of family-centered practice in mental health settings in Hong Kong. Thirty-four nurses participated in the study by completing the pre- and post-questionnaires. Ten nurses were invited to participate in focus group and case interviews. The analysis identified knowledge–practice gap, role of psychiatric nurses, professional identity of psychiatric nurses, and management support as negatively affecting the nurses in implementing a family-centered approach to mental health care. Suggestions about facilitating the implementation of the family-centered approach into clinical practice are offered.     

Illuminating the clinical nurse specialist role of advanced practice nursing: a qualitative study

As the advanced practice nursing initiative in Canada gains momentum, effort is being directed towards clarifying and defining advanced practice roles. A qualitative study was undertaken to increase understanding of the clinical nurse specialist role of advanced practice. Sixteen nurses who worked in advanced practice roles, organizing and providing healthcare for children with complex health needs and their families across the continuum of care, participated in in-depth conversations about the nature of their practice, the knowledge that informs it and the factors that influence it. Findings suggest that clinical nurse specialists have a unique role in the organization and delivery of healthcare for specialized populations with complex health needs in their dual focus on the system level of healthcare and on population health needs. Initiatives directed to children and families within the study participants' specialties included program development, consultation and educational outreach and the development of clinical guidelines and policies. Although the nurses described their practice as focusing both on individual children and families and on the population of children and families within their specialty, it is at the population level that they see their greatest potential for contributing to the delivery of high-quality, cost-effective healthcare.     

Pre-operative patient teaching in an acute care ward in Hong Kong: a case study

Many nurses have acknowledged that adequate pre-operative teaching can alleviate patients' anxiety, increase patient participation in their own care, and minimize post-operative complications. However, the organization and degree to which pre-operative patient teachingfeatured in nurses' practice varies in different acute care settings. A case study design was used to explore the practice of pre-operative teaching in a surgical ward of an acute general hospital in Hong Kong. Seventeen registered nurses working on the ward were interviewed and observed in order to explore how they conduct a pre-operative teaching program and the difficulties encountered by them in carrying out pre-operative teaching on this acute care setting. Thefindings of this study indicate that pre-operative teaching workshops are organized and conducted by nursesfrom the operating theatre, in the day surgery center. Ward nurses were not actively involved in this pre-operative teaching. The results of this study present some similarities to a study with the similar design in Australia. There are also issues unique to the Hong Kong context. This case study was to review Hong Kong nurses' current practices of pre-operative teaching and to understand the cultural, conceptual and managementfactors influencing the practice in pre-operative teaching.     

Evolving towards professionalism in emergency nursing in Hong Kong

This paper aims to share with the readers about the experience of emergency nursing development and related roles in Hong Kong. The roles of emergency nurses are evolving and triggered by three major historical milestones. The three milestones consist of: (1) Transition of nursing education from hospital training to nursing degree program at universities in 1990; (2) The re-evolution after the establishment of Hospital Authority in 1993; (3) Hong Kong's return to China in 1997. These milestones have contributed immensely to the development of quality nursing education, nursing professionalism with emphasis on specialty knowledge and skill training in Accident and Emergency departments (AED) in Hong Kong. Since 1991, the emergency nursing role has been expanded and extended. Wound management remains one of the major extending roles for emergency nurses, who confine themselves to manage simple wounds. Nurse initiated tetanus immunization, intravenous access; investigations such as electrocardiogram, blood glucose, and urinalysis are well implemented in all AEDs under the governance of guidelines and protocols. Initial triage analgesic for the minor musculoskeletal injury and fever are also part of the triage care in some AEDs in Hong Kong now. To meet the demand and challenge, innovative role development such as lecturer practitioners and emergency nurse practitioners have been piloted and implemented recently. Besides the normal duty, emergency nurses also participate in the work outside the hospitals such as involvement in emergency medical teams to assist in various rescue missions or volunteer for Flight Nursing (Government Flying Services). However, the nursing shortage is another common problem faced by the Hong Kong health care body. With the help of advanced technology, better pre-graduate and specialty-training programs, Hong Kong health care strives to achieve the highest standards of quality care. Emergency nursing role development in Hong Kong is evolving and starts to chart its way to meet the demand.     

The first evaluation of the advanced practice nurse role in Finland - the perspective of nurse leaders

fagerström l. & glasberg a.-l. (2011) Journal of Nursing Management 19, 925–932 The first evaluation of the advanced practice nurse role in Finland – the perspective of nurse leaders Aims The aim of this study is to explore and describe nurse leaders’ (NLs) experiences of the role of advanced practice nurses (APNs). Background The first group of advanced practice nurses (17) in Finland graduated in 2006 and were thereafter employed by seven different organizations in more or less clearly defined advanced practice nurses roles. Methods Seven nurse leaders at the relevant organizations were interviewed a year after the introduction of the advanced practice nurses role. Content analysis was used to analyze the data. Results All of the nurse leaders emphasized the importance of the advanced practice nurses role in their organization. The advanced practice nurses’ scope of practice comprised a more autonomous and independent role than registered nurses. Advanced practice nurses are an important resource in the care of patients with chronic diseases and acute health problems. An important aspect regarding support for the advanced practice nurses role is the provision of information to all health-care personnel and patients about the role and clearly defined areas of responsibility. Conclusions Advanced practice nurses are an important resource in the development of evidence-based nursing and improve the availability of health-care services for patients. Implications for nursing management Nurse leaders are responsible for creating sustainable structures and the prerequisites needed for advanced practice nursing through the formation of supportive organizational systems.     

Implementation of evidence‐based nursing practice for diabetic patients: An Iranian experience

Evidence‐based nursing is recognized as an indicator of quality in nursing practice, a basis for accountability and the gold standard of professional nursing care. The aim of this study was to explore nurses’ experiences and perceptions about evidence‐based nursing practice in giving care to patients with diabetic foot ulcers. A qualitative research design was adopted, and content analysis was used to analyse data. Semistructured interviews were held with 19 bachelor‐degree nurses working in a teaching hospital in an urban area of Iran. During data analysis, two main themes developed: ‘structural backgrounds of the organization’ and ‘empowerment’. Accordingly, it was concluded that successful implementation of evidence‐based nursing requires the reconfiguration of the administrative structure in the hospital. In addition, it requires the support of nurse leaders to facilitate the implementation of evidence‐based nursing in the practice.