Effects of Nurse-Led Pain Management Interventions for Patients with Total Knee/Hip Replacement

BackgroundA literature review was conducted to assess nurse-led nonpharmacologic pain management interventions intended for total knee/hip replacement patients.DesignThis was a systematic review and meta-analysis.Data SourcesThe PubMed, Embase, CINAHL, and Cochrane Library databases were searched to identify relevant studies.Review MethodsThe systematic review was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and all Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines. Two reviewers independently selected the studies and appraised their quality. Thereafter, the effects of all described nurse-led nonpharmacologic pain management interventions were estimated regarding pain, anxiety, and satisfaction through a meta-analysis.ResultsIn total, 219 relevant studies were found through a search. Finally, 23 studies were selected for review, with 17 included in the meta-analysis. Nurse-led nonpharmacologic pain management was effective for pain relief (effect size, −0.22; 95% confidence interval [CI], −0.42 to −0.02), and educational interventions were especially effective (effect size, −0.36; 95% CI, −0.69 to −0.03). Although interventions reduced anxiety and improved satisfaction, these results were not statistically significant based on the analysis.ConclusionOur findings support that nurse-led nonpharmacologic pain management interventions could help reduce pain in patients with total knee/hip replacement by supplementing pharmacologic pain management.Implications for NursingNurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement.     

Satisfaction with nurse-led telephone follow up for low to intermediate risk prostate cancer patients treated with radical radiotherapy. A comparative study

Purpose of the researchAs the number of men living with prostate cancer is increasing worldwide, the requirement for follow up care also grows. This study was undertaken to evaluate nurse-led, telephone follow up, for men with low to intermediate risk prostate cancer treated with radical radiotherapy when compared with medical follow up.Methods and sampleA non-randomized, two-cohort, comparative study. 169 men diagnosed with prostate cancer were recruited from outpatient clinics at a tertiary cancer centre in Australia. 83 men were recruited to cohort 1 (control) (51 low to intermediate risk; 32 high risk) and 86 to cohort 2 (intervention) (51 low to intermediate risk; 35 high risk). High risk patients, regardless of cohort, received medical follow up. Low to intermediate risk patients in cohort 2 were triaged to nurse-led review for their six month review appointment. Nurse-led follow up consisted of six monthly telephone consultations and PSA testing.MeasuresParticipants completed the Satisfaction with Consultation Scale, the Brief Distress Thermometer and the Expanded Prostate Cancer Index Composite.Key resultsThere was no statistically significant difference in patient satisfaction on any of the study measures between the nurse-led and standard medical follow up at six months following treatment completion. However, where there was a trend towards significance (p = 0.051), it favoured the nurse-led follow up regimen.ConclusionsNurse-led telephone consultation provides an acceptable model of follow-up for men diagnosed with low to intermediate risk prostate cancer. Multi-centre randomised controlled trials are needed to support the efficacy of nurse-led, telephone follow up services.     

Evaluation of a nurse-led education program to improve cross-cultural care for older people in aged care

BackgroundCultural diversity is significant in aged care facilities. Registered nurses play a leading role in the care setting. Nurse-led education interventions to improve the cultural competence of aged care workers are in high demand.AimThe aims of the study were to evaluate the effect of a nurse-led cross-cultural care program on cultural competence of Australian and overseas-born care workers.DesignA pre- and post-evaluation design and a sub-group analysis.Settings and participantsThis study was undertaken in four large-sized aged care facilities in Australia. Direct care workers were invited to participate in the study.MethodsThe intervention lasted 12 months. Data were collected at baseline, 6 months and 12 months using the Clinical Cultural Competency Questionnaire and site champion reports. One-way ANOVA was applied to determine the changes of outcomes over time for the whole group. A mixed effect linear regression model was applied in the sub-group analyses to compare the differences of outcomes between the Australian-born and overseas-born groups.ResultsOne hundred and thirteen staff participated in the study including Australian-born (n = 62) and overseas-born (n = 51). Registered nurses were trained as site champions to lead the program. The results showed a statistically significant increase in participants' scores in Knowledge (p = .000), Skills (p = .000), Comfort Level (p = .000), Importance of awareness (p = .01) and Self-Awareness (p = .000) in a 12-month follow-up. The increased scores in the Skills (p = .02) and Comfort Level (p = .001) were higher in the Australian-born group compared to the overseas-born group. The results also showed a statistically significant increase in participants' overall satisfaction scores with the program at 12 months (p = .009). The overseas-born group demonstrated a higher score in Desire to Learn More (p = .016) and Impact of the Program on Practice (p = .014) compared to the Australian-born group.ConclusionA nurse-led cross-cultural care program can improve aged care workers' cultural competence.     

Clinical outcomes of a nurse-led post-discharge education program for heart-transplant recipients: A retrospective cohort study

BackgroundAdvances in immunosuppressive therapeutics and medical technology have improved survival rates after heart transplantation. Although there is a rigorous schedule of outpatient visits and testing to detect early signs of rejection and other complications in the first year after transplantation, repeated unplanned readmissions of heart transplant recipients remains a challenge.ObjectiveThis study aimed to compare the effects of specialized nurse-led discharge education, including continuous post-transplant education and counselling, on heart transplant recipients' clinical outcomes, with the effects of existing discharge education.MethodsParticipants were 136 heart transplantation recipients at a university-affiliated hospital in South Korea from November 1, 1994, to November 30, 2018. Participants' electronic medical records were retrospectively analyzed. Participants were grouped according to usual care (n = 25), nurse-led program (n = 66), and nurse-led program with post-discharge education (n = 45). We assessed the number of outpatient visits with clinical problems and days to first unplanned rehospitalization within one year after transplantation.ResultsThe nurse-led program with post-discharge education was associated with significantly reduced outpatient visits with clinical problems, compared to usual care and the existing nurse-led program. We also found a significantly longer time until first unplanned rehospitalization in the nurse-led program with post-discharge education group, compared to the usual care group.ConclusionThis study identified the heart transplantation-specialized nurse-led discharge and subsequent post-discharge education as an effective strategy for positive clinical outcomes within one year after heart transplantation.     

Nurses leading volunteer support for older adults in hospital: A discussion paper

BackgroundThe ageing population has led to growing numbers of older adults in hospital. Given the increased care needs of older adult patients, hospitals are facing resource challenges to ensure patient safety and quality of care. Support from trained volunteers focussed on older adults needs, such as eating, drinking, ambulation and cognitive stimulation have been found to improve patient outcomes.AimThis discussion paper describes a novel nurse-led model of volunteer support providing individualised supportive care for hospitalised older adults.MethodsDiscussion paper.FindingsNurses’ clinical expertise, 24-hour care and leadership skills makes them ideally placed to guide support provided by volunteers to ensure patient safety and improve quality of care. This nurse-led approach to volunteer support is underpinned by an innovative volunteer support care plan. The care plan was devised based on existing literature, and in consultation with nurses, allied health professionals, consumer representatives and volunteer managers. In practice, the plan is completed for each patient by a nurse in consultation with the patient and family following admission assessments. Trained volunteers then provide support to the patient following the care plan.DiscussionThe benefits, barriers and enablers of a nurse-led volunteer support program are considered in the context of organisational and professional requirements.ConclusionA nurse-led model of volunteer support capitalises on the clinical expertise of nurses to optimise the contribution of volunteers, positively impacting on patient outcomes, satisfaction and quality of care, with potential additional benefits to staff, volunteers and hospitals.     

Outcomes of a randomised pilot trial of a nurse-led clinic for patients after percutaneous coronary intervention

BackgroundHospitalisation for percutaneous coronary intervention (PCI) in Australia is reducing. Patients who undergo PCI may be discharged home without a post-discharge health management plan, referral for secondary prevention, or understand their chronic condition. Subsequently, negative psychological symptoms such as anxiety and depression may be experienced in the post-discharge period.ObjectivesThis study assessed the effectiveness of a nurse-led clinic on patients' cardiac self-efficacy and negative psychological symptoms of anxiety and depression 1-week post-PCI discharge.MethodsOne-hundred and eighty-eight potential participants were screened, and 33 participants were block-randomised to study groups. The nurse-led clinic used a person-centred approach and delivered tailored education, health assessment, and post-discharge support. In Phase 1, the Cardiac Self-efficacy Scale and State-Trait Anxiety Inventory measured primary outcomes, while the Cardiac Depression Scale was used to measure secondary outcomes. Phase 2 evaluated participants' experiences and healthcare professionals' perceptions of the intervention through semi-structured interviews.ResultsIn Phase 1, intervention group participants did not show improvements in mental health indicators compared to standard care group participants, except for a moderate reduction in anxiety levels (d = 0.50). Phase 2 qualitative findings; however, highlighted the benefits of the nurse-led clinic.ConclusionsOverall, findings suggest that nurse-led clinics may be valuable to reduce anxiety and act as a supportive measure in the early post-discharge period until commencement of a secondary prevention program. Further research with a more powered sample is needed to determine the significance of the findings.     

Clinical and economic outcomes of nurse-led services in the ambulatory care setting: A systematic review

BackgroundWith the increasing burden of chronic and age-related diseases, and the rapidly increasing number of patients receiving ambulatory or outpatient-based care, nurse-led services have been suggested as one solution to manage increasing demand on the health system as they aim to reduce waiting times, resources, and costs while maintaining patient safety and enhancing satisfaction.ObjectivesThe aims of this review were to assess the clinical effectiveness, economic outcomes and key implementation characteristics of nurse-led services in the ambulatory care setting.DesignA systematic review was conducted using the standard Cochrane Collaboration methodology and was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Data sourcesWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE EBSCO, CINAHL EBSCO, and PsycINFO Ovid (from inception to April 2016).Review methodsData were extracted and appraisal undertaken. We included randomised controlled trials; quasi-randomised controlled trials; controlled and non-controlled before-and-after studies that compared the effects of nurse-led services in the ambulatory or community care setting with an alternative model of care or standard care.ResultsTwenty-five studies of 180,308 participants were included in this review. Of the 16 studies that measured and reported on health-related quality of life outcomes, the majority of studies (n = 13) reported equivocal outcomes; with three studies demonstrating superior outcomes and one demonstrating inferior outcomes in comparison with physician-led and standard care. Nurse-led care demonstrated either equivalent or better outcomes for a number of outcomes including symptom burden, self-management and behavioural outcomes, disease-specific indicators, satisfaction and perception of quality of life, and health service use. Benefits of nurse-led services remain inconclusive in terms of economic outcomes.ConclusionsNurse-led care is a safe and feasible model of care for consideration across a number of ambulatory care settings. With appropriate training and support provided, nurse-led care is able to produce at least equivocal outcomes or at times better outcomes in terms of health-related quality of life compared to physician-led care or standard care for managing chronic conditions. There is a lack of high quality economic evaluations for nurse-led services, which is essential for guiding the decision making of health policy makers. Key factors such as education and qualification of the nurse; self-management support; resources available for the nurse; prescribing capabilities; and evaluation using appropriate outcome should be carefully considered for future planning of nurse-led services.     

Nurse-led services in Queensland: A scoping study

Background

Nurse-led services are expanding in Australia, yet current information about the scope and nature of these services is lacking. The need for more coordinated service planning and systematic evaluation prompted a scoping study to inform future development.

Factors associated with supportive care needs of patients under treatment for breast cancer

PurposeThis study aimed at gaining insight into supportive care needs and cancer treatment-related symptoms, and to determine factors associated with supportive care needs.Breast cancer and its treatment cause emotional trauma and health complaints. These lead to supportive care needs in some patients, while others are more able to cope with these consequences themselves. To be able to address these needs, it is important to identify patients' needs at the time they arise.MethodsWomen (n = 175) with newly-diagnosed breast cancer, under treatment in two Swiss breast cancer clinics, participated in a cross-sectional survey. Standardized instruments were used: Supportive Care Needs Survey, Cancer- and Cancer Treatment-related Symptom Scale, Hospital Anxiety and Depression Scale, Distress Thermometer, and Interpersonal Relationship Inventory.ResultsThe patients' most needed help with psychological issues. Many had treatment-related symptoms like fatigue (87.7%), hot flashes (71.5%), and a changed body appearance (55.8%). The majority suffered from distress (56.2%), fewer from anxiety (24.1%) and depression (12.1%). Physical and social impairment, impaired body image, distress, anxiety and depression, a lack of social support and conflicts in their personal relationships were associated with supportive care needs.ConclusionsThe findings can help to identify more vulnerable patients with unmet needs and a higher demand for support. Assessment of patients enables health care professionals to provide support and counselling. In these assessments, the patients' relationship to close relatives should also be addressed.     

Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial

BackgroundThe hypertension prevalence rate is increasing but the control rate is unsatisfactory. Nurse-led healthcare may be an effective way to improve outcomes for hypertensive patients but more evidence is required especially at the community level.ObjectiveThis study aims to establish a nurse-led hypertension management model and to test its effectiveness at the community level.DesignA single-blind, randomized controlled trial was performed in an urban community healthcare center in China. Hypertensive patients with uncontrolled blood pressure (systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg) were randomly allocated into two groups: the study group (n = 67) and the control group (n = 67). The nurse-led hypertension management model included four components (delivery system design, decision support, clinical information system and self-management support). Patients in the control group received usual care. Patients in the study group received a 12-week period of hypertension management. The patient outcomes, which involved blood pressure, self-care behaviors, self-efficacy, quality of life and satisfaction, were assessed at three time points: the baseline, immediately after the intervention and 4 weeks after the intervention.ResultsAfter the intervention, the blood pressure of patients in the study group decreased significantly compared to those in the control group, and the mean reduction of systolic/diastolic blood pressure in the study and control groups was 14.37/7.43 mmHg and 5.10/2.69 mmHg, respectively (p < 0.01). In addition, patients in the study group had significantly greater improvement in self-care behaviors than those in the control group (p < 0.01). The study group had a higher level of satisfaction with hypertensive care than the control group (p < 0.01). No statistically significant difference in self-efficacy and quality of life was detected between the two groups after the intervention.ConclusionsThe nurse-led hypertension management model is feasible and effective in improving the outcomes of patients with uncontrolled blood pressure at the community level.     

Impact of community based nurse-led clinics on patient outcomes,patient satisfaction,patient access and cost effectiveness: A systematic review

BackgroundThe role and scope of nursing practice has evolved in response to the dynamic needs of individuals, communities, and healthcare services. Health services are now focused on maintaining people in their communities, and keeping them out of hospital where possible. Community based nurse-led clinics are ideally placed to work towards this goal. The initial impetus for these services was to increase patient access to care, to provide a cost-effective and high quality streamlined service.ObjectivesThis systematic review aimed to identify the impact of nurse-led clinics in relation to patient outcomes, patient satisfaction, impact on patient access to services, and cost effectiveness.MethodsA review of community based nurse-led clinic research in Medline, CINAHL and Embase was undertaken using MeSH terms: Nurse-managed centres, Practice, Patterns, Nurse, Ambulatory Care, keywords: nurse-led clinic, nurse led clinic, community and phrases primary health care and primary care. Papers were appraised using the Joanna Briggs Appraisal criteria.ResultsThe final review comprised 15 studies with 3965 participants. Most studies explored patient satisfaction which was largely positive towards nurse-led clinics. Patient outcomes reported were typically from self-report, although some papers addressed objective clinical measures; again positive. Access was reported as being increased. Cost-effectiveness was the least reported impact measure with mixed results.ConclusionsNurse-led clinics have largely shown positive impact on patient outcomes, patient satisfaction, access to care and mixed results on cost-effectiveness. Future research evaluating NLCs needs to adopt a standardised structure to provide rigorous evaluations that can rationalise further efforts to set up community based nurse-led clinical services.     

What are the unmet supportive care needs of people with cancer? A systematic review

Goals of work  The identification and management of unmet supportive care needs is an essential component of health care for people with cancer. Information about the prevalence of unmet need can inform service planning/redesign. Materials and methods  A systematic review of electronic databases was conducted to determine the prevalence of unmet supportive care needs at difference time points of the cancer experience. Results  Of 94 articles or reports identified, 57 quantified the prevalence of unmet need. Prevalence of unmet need, their trends and predictors were highly variable in all domains at all time points. The most frequently reported unmet needs were those in the activities of daily living domain (1–73%), followed by psychological (12–85%), information (6–93%), psychosocial (1–89%) and physical (7–89%). Needs within the spiritual (14–51%), communication (2–57%) and sexuality (33–63%) domains were least frequently investigated. Unmet needs appear to be highest and most varied during treatment, however a greater number of individuals were likely to express unmet need post-treatment compared to any other time. Tumour-specific unmet needs were difficult to distinguish. Variations in the classification of unmet need, differences in reporting methods and the diverse samples from which patients were drawn inhibit comparisons of studies. Conclusion  The diversity of methods used in studies hinders analysis of patterns and predictors of unmet need among people with cancer and precludes generalisation. Well-designed, context-specific, prospective studies, using validated instruments and standard methods of analysis and reporting, are needed to benefit future interventional research to identify how best to address the unmet supportive care needs of people with cancer.     

Nurse-led follow-up care for cancer patients: what is known and what is needed

Traditionally, cancer patient follow-up has focused on disease surveillance and detecting recurrence. However, an increasing number of patients who have survived cancer acknowledge the importance of cancer rehabilitation issues and the need for more patient-oriented models of care by reporting their unmet physical, emotional, and social needs. Nurse-led follow-up care for cancer patients fulfills this need and has been developing gradually for various cancer diagnoses and prognoses. A growing body of evidence suggests that these services provide high-quality care that is both safe and efficient. Furthermore, patients benefit from the continuity of care and easy access to support for their multitude of needs, provided by such organized care. In this paper, we review the literature published in the past 5 years regarding nurse-led follow-up care for cancer patients in order to provide input and opinion for future research, clinical practice development, and nursing leadership. We pay special attention to head and neck cancer patients, a group that has been largely understudied and hence underreported in the literature. These patients have specific needs with respect to information and education regarding their cancer and potential treatment side-effects as well as a particular need for long-term psychosocial support and practical advice.     

Coordination of palliative cancer care in the community: “unfinished business”

Goal  This study assessed the degree to which services in south–central Ontario, Canada, were coordinated to meet the supportive care needs of palliative cancer patients and their families. Participants and method  Programs within the region that were identified as providing supportive care to palliative cancer patients and their families were eligible to participate in the study. Program administrators participated in a semi-structured interview and direct-care providers completed a survey instrument. Main results  Administrators from 37 (97%) of 38 eligible programs and 109 direct-care providers representing 26 (70%) programs participated in the study. Most administrator and direct-care respondents felt that existing services in the community were responsive to palliative care patients’ individual needs. However, at a system level, most respondents in both groups felt that required services were not available and that resources were inadequate. The most frequently reported unmet supportive care need identified by both respondent groups was psychological/social support. Most administrator (69%) and direct-care (64%) respondents felt that palliative care services were not available when needed. The majority of administrator and direct-care respondents were satisfied with the exchange of patient information within and between programs, although direct-care staff identified a deficit in information transferred on palliative care patients’ social/psychological status. Conclusions  The study demonstrated the value of a theory-based approach to evaluate the coordination of palliative cancer care services. The findings revealed that service programs faced significant challenges in their efforts to provide coordinated care.     

Nurse-Led Follow-Up at Home vs. Conventional Medical Outpatient Clinic Follow-Up in Patients With Incurable Upper Gastrointestinal Cancer: A Randomized Study

ContextUpper gastrointestinal cancer is associated with a poor prognosis. The multidimensional problems of incurable patients require close monitoring and frequent support, which cannot sufficiently be provided during conventional one to two month follow-up visits to the outpatient clinic.ObjectivesTo compare nurse-led follow-up at home with conventional medical follow-up in the outpatient clinic for patients with incurable primary or recurrent esophageal, pancreatic, or hepatobiliary cancer.MethodsPatients were randomized to nurse-led follow-up at home or conventional medical follow-up in the outpatient clinic. Outcome parameters were quality of life (QoL), patient satisfaction, and health care consumption, measured by different questionnaires at one and a half and four months after randomization. As well, cost analyses were done for both follow-up strategies in the first four months.ResultsIn total, 138 patients were randomized, of which 66 (48%) were evaluable. At baseline, both groups were similar with respect to clinical and sociodemographic characteristics and health-related QoL. Patients in the nurse-led follow-up group were significantly more satisfied with the visits, whereas QoL and health care consumption within the first four months were comparable between the two groups. Nurse-led follow-up was less expensive than conventional medical follow-up. However, the total costs for the first four months of follow-up in this study were higher in the nurse-led follow-up group because of a higher frequency of visits.ConclusionThe results suggest that conventional medical follow-up is interchangeable with nurse-led follow-up. A cost utility study is necessary to determine the preferred frequency and duration of the home visits.     

The effect of supportive program on maternal self-confidence in caring of infants with gastrointestinal anomalies: A randomized clinical trial

PurposeThis study aimed to determine the effect of supportive program on maternal self-confidence in caring of infants with gastrointestinal anomalies.MethodsIn this randomized clinical trial, 50 mothers of infants with gastrointestinal anomalies randomly allocated into control and intervention groups. The mothers of intervention group, in addition to the routine care, received supportive program. Maternal self-confidence was measured before and after the intervention, using Karitane Parenting Confidence Scale.ResultsThere was a significant difference in the pre-test and post-test scores of the intervention group (P < 0.001). Also, post-test scores of self-confidence was significant in both intervention and control groups after adjusting pre-test score (P < 0.001).ConclusionThe present study confirms the impact of a supportive program on increasing mothers' confidence. According to this, the four-dimensional support program can be offered as a systematic program in the neonatal units for mothers of infants with gastrointestinal anomalies.     

Effects of a nurse-led transitional care program on clinical outcomes,health-related knowledge,physical and mental health status among Chinese patients with coronary artery disease: A randomized controlled trial

BackgroundCoronary artery disease is a major cause of morbidity and mortality among adults worldwide, including China. After a hospital stay, transitional care could help to ensure improved patient care and outcomes, and reduce Medicare costs. Nevertheless, the results of the existing transitional care are not always satisfactory and our knowledge of how to perform effective transitional care for patients with coronary artery disease is limited in mainland China.ObjectivesTo examine the effectiveness of a nurse-led transitional care program on clinical outcomes, health-related knowledge, and physical and mental health status among Chinese patients with coronary artery disease.DesignRandomized controlled trial.MethodsThe Omaha system and Pender’s health promoting model were employed in planning and implementing this nurse-led transitional care program. The sample was comprised of 199 Chinese patients with coronary artery disease. The experimental group (n = 100) received nurse-led transitional care intervention in addition to routine care. The nurse-led transitional care intervention included a structured assessment and health education, followed by 7 months of individual teaching and coaching (home visits, telephone follow-up and group activity). The control group (n = 99) received a comparable length routine care and follow-up contacts. Evaluations were conducted at baseline and completion of the interventions using the perceived knowledge scale for coronary heart disease, the medical outcomes study 36-item short-form health survey and clinical measures (blood pressure, blood glucose, lipids, body mass index). Data were collected between March and October 2014.ResultsCompared with the control group, participants in the experimental group showed significant better clinical outcomes (systolic blood pressure, t = 5.762, P = 0.000; diastolic blood pressure, t = 4.250, P = 0.000; fasting blood glucose, t = 2.249, P = 0.027; total cholesterol, t = 4.362, P = 0.000; triglyceride, t = 3.147, P = 0.002; low density lipoprotein cholesterol, t = 2.399, P = 0.018; and body mass index, t = 3.166, P = 0.002), higher knowledge scores for coronary artery disease (total knowledge score, t = −7.099, P = 0.000), better physical health status (t = −2.503, P = 0.014) and mental health status (t = −2.950, P = 0.004).ConclusionsThis study provides evidence for the value of a nurse-led transitional care program using both the Omaha system and Pender’s health promoting model as its theoretical framework. The structured interventions in this nurse-led transitional care program facilitate the use of this program in other settings.     

Effects of Multidisciplinary Team-Based Nurse-led Transitional Care on Clinical Outcomes and Quality of Life in Patients With Ankylosing Spondylitis

PurposeThe purpose of this study is to investigate the impact of transitional care by a nurse-led multidisciplinary team (MDT) on clinical outcomes and quality of life of patients with ankylosing spondylitis.MethodsA randomized control study design was used. Subjects were allocated randomly to an experimental group and a control group. The experimental group received intensive transitional care by a nurse-led MDT, whereas the control group received routine nursing care. Disease activity, spinal mobility, comprehensive function, health service utilization, and quality of life were assessed at the baseline and at six months with the Bath Ankylosing Spondylitis Metrology Index, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), a health service utilization questionnaire and version 2 of the Short Form-36 health survey.ResultsCompared with the baseline, the BASDAI, BASFI, emergency visits, hospitalizations, hospitalization days, and bodily pain, vitality, mental health, total score, and average score of version 2 of the Short Form-36 health survey were improved in the experimental group (p < .05), whereas only bodily pain, vitality, and role-emotional were improved in the control group (p < .05). At six months, the experimental group exhibited significantly more improvement on the BASDAI, BASFI, hospitalizations, all domains except Role-physical as well as total score and average score (p < .05) compared with the control group.ConclusionA MDT-based nurse-led transitional care improves clinical outcomes and quality of life of patients with ankylosing spondylitis. Future research should be carried out on modes of follow-up and family support.