Development of the Nurses’ Care Coordination Competency Scale for mechanically ventilated patients in critical care settings in Japan: Part 2 Validation of the scale

ObjectivesTo confirm the validity and reliability of the nurses' care coordination competency draft scale for mechanically ventilated patients in Japan.Design/MethodIn this cross sectional observational study, a draft scale measuring care coordination was distributed to 2189 nurses from 73 intensive care units in Japan from February–March 2016. Based on the valid 887 responses, we examined construct validity including structural validity (exploratory and confirmatory factor analysis), convergent and discriminant validity and internal consistency reliability.Settings73 Intensive care units.ResultsExploratory factor analyses yielded four factors with 22 items: 1) promoting team cohesion, 2) understanding care coordination needs, 3) aggregating and disseminating information, 4) devising and clearly articulating the care vision. The four-factor model was confirmed using a confirmatory factor analysis (confirmatory fit index = 0.942, root mean square error of approximation = 0.062). Scale scores positively correlated with team leadership and clearly identified and discriminated nurses’ attributes. Cronbach’s alpha coefficient for each subscale was between 0.812 and 0.890, and 0.947 for the total scale.ConclusionsThe Nurses’ Care Coordination Competency Scale with four factors and 22 items had sufficient validity and reliability. The scale could make care coordination visible in nursing practice. Future research on the relationship between this scale and patient outcomes is needed.     

Determining the effectiveness of an Elder Abuse Nurse Examiner Curriculum: A pilot study

ObjectivesTo pilot and evaluate a novel Elder Abuse Nurse Examiner Curriculum and its associated training materials for their efficacy in improving Sexual Assault Nurse Examiner (SANE)s' knowledge of elder abuse and competence in delivering care to abused older adults.MethodsPilot training was held with 18 SANEs from across Ontario, Canada. A 52-item pre- and post-training questionnaire was administered that assessed participants' self-reported knowledge and perceived skills-based competence related to elder abuse care. A curriculum training evaluation survey was also delivered following the training. Qualitative non-participant observational data were collected throughout the training.ResultsThere were statistically significant improvements in self-reported knowledge and perceived skills-based competence from pre-training to post-training for all content domains of the curriculum: older adults and abuse (p < 0.0001), documentation, legislative, and legal issues (p < 0.0001); interview with the older adult, caregiver, and other relevant contacts (p < 0.0001); assessment (p = 0.0018); medical and forensic examination (p < 0.0001); case summary, discharge plan, and follow-up care (p < 0.0001). The post-training evaluation survey demonstrated satisfaction among participants across all components of the curriculum and its delivery, particularly with reference to the comprehensiveness of the curriculum, and the clarity and appropriateness of the training materials.ConclusionsThe Elder Abuse Nurse Examiner Curriculum and associated training materials were efficacious in improving SANEs' self-reported knowledge of and perceived competence in delivering elder abuse care. Future steps will further evaluate these materials as a component of a pilot of a larger comprehensive Elder Abuse Intervention at multiple sites across Ontario.     

Primary care team communication networks,team climate,quality of care,and medical costs for patients with diabetes: A cross-sectional study

BackgroundPrimary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care.ObjectiveTo determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes.MethodsA cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling.Participants155 health professionals at 6 U.S. primary care clinics participated from May through December 2013.ResultsPrimary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (rate ratio = 0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: −US$2416, −US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds ratio = 0.83, 95% CI: 0.66, 0.99), increased hospital days (RR = 1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β = US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes.ConclusionsPrimary care teams which relied on frequent daily face-to-face communication among more team members, and had a single RN communicating patient care information to the PCP, had greater shared team vision, better patient outcomes, and lower medical costs for their diabetes patient panels.     

Changes over time in caregiving demand and difficulty in spousal caregivers of coronary artery bypass graft surgery patients

Patients who undergo coronary artery bypass graft (CABG) surgery are often dependent on spouses or family members for care during their recovery. The purpose of this study was to examine changes over time in spousal caregivers of coronary artery bypass graft (CABG) patients in caregiving demand and caregiving difficulty and to identify the key demands and difficulties at each time point. Spouses (n = 34) of CABG patients comprised the sample. Caregiving demand and caregiving difficulty were measured using the Caregiving Burden Scale at three time points (baseline [early hospital discharge] and 3 and 6 months later) and analyzed using repeated measures analysis of variance. Mean scores of each item were used to identify the top four caregiving demands and difficulties at each time point. There was a significant decrease over time in caregiving demands (F [1.696] = 13.62, p < 0.001) and caregiving difficulties (F [1.613] = 4.52, p = 0.02). The most demanding and/or difficult caregiving activities at all time points were providing social support, managing behavior problems, taking on additional household tasks, and monitoring symptoms. Early in recovery, providing transportation was a top ranked demand and difficulty. Later in recovery (3 and 6 months), managing finances became a top ranked demand and difficulty. In conclusion, caregiving demands and difficulties declined significantly over six months for the caregivers in this study. These results indicate that caregiving demands and difficulties change over time and ongoing assessments of spouses and family members are needed to help them manage the caregiving situation.     

Fulfilling the psychological and information need of the family members of critically ill patients using interactive mobile technology: A randomised controlled trial

BackgroundIntensive care nurses may have an important role in empowering families by providing psychological support and fulfilling the family's pivotal need for information.AimTo determine whether ‘education of families by tab’ about the patient’s condition was more associated with improved anxiety, stress, and depression levels than the ‘education of families by routine’.Research designA randomized control trial of 74 main family caregivers (intervention: 39; control: 35).SettingAn adult intensive care unit.Main outcome measuresDepression Anxiety Stress Scale, and Communication and Physical Comfort Scale.ResultsAlthough information need satisfaction was not significantly different between intervention and control groups, the former reported significantly better depression score on Depression Anxiety Stress Scale comparing to the control group (p < 0.01; η² = 0.09) with a medium effect size. Reduction of anxiety in the intervention group were clinically significant.ConclusionThe results suggest that use of ‘education of family by tab’ is promising for intensive care nurses to provide psychological support for family members. More studies are needed to investigate this aspect of family care for better psychological support and information need satisfaction that contributes to the evidence-based practice of intensive care nursing.     

Nurses’ personal and ward accountability and missed nursing care: A cross-sectional study

BackgroundMissed nursing care is considered an act of omission with potentially detrimental consequences for patients, nurses, and organizations. Although the theoretical conceptualization of missed nursing care specifies nurses’ values, attitudes, and perceptions of their work environment as its core antecedents, empirical studies have mainly focused on nurses’ socio-demographic and professional attributes. Furthermore, assessment of missed nursing care has been mainly based on same-source methods.ObjectivesThis study aimed to test the joint effects of personal and ward accountability on missed nursing care, by using both focal (the nurse whose missed nursing care is examined) and incoming (the nurse responsible for the same patients at the subsequent shift) nurses’ assessments of missed nursing care.DesignA cross-sectional design, where nurses were nested in wards.ParticipantsA total of 172 focal and 123 incoming nurses from 32 nursing wards in eight hospitals.MethodsMissed nursing care was assessed with the 22-item MISSCARE survey using two sources: focal and incoming nurses. Personal and ward accountability were assessed by the focal nurse with two 19-item scales. Nurses' socio-demographics and ward and shift characteristics were also collected. Mixed linear models were used as the analysis strategy.ResultsFocal and incoming nurses reported occasional missed nursing care of the focal nurse (Mean = 1.87, SD = 0.71 and Mean = 2.09, SD = 0.84, respectively; r = 0.55, p < 0.01). Regarding the focal nurse's assessment of his/her own missed nursing care, findings showed that, above and beyond nurses’ overload and personal socio-demographic characteristics, higher personal accountability was significantly associated with decreased missed care (β = −0.29, p < 0.01), whereas ward accountability was not (β = −0.23, p > 0.05). The interaction effect was significant (β = −0.31, p < 0.05); the higher the ward accountability, the stronger the negative relationship between nurses' personal accountability and missed nursing care. Similar patterns were obtained for the incoming nurses' assessment of focal nurse's missed care.ConclusionsUse of focal and incoming nurses' missed nursing care assessments limited the common source bias and strengthened our findings. Personal and ward accountability are significant values, which are associated with lower missed nursing care, beyond scarce resources. Implementation of local and national education programs for nurses and managers, accompanied with empirical research, might increase personal and ward accountability, thereby decreasing missed nursing care. This might help to create a safety culture and reduce negative outcomes for patients, nurses, and organizations.     

The risk of microaspiration during oral care in mechanically ventilated patients: A randomised cross-over study comparing two different suction protocols

ObjectivesTo assess whether optimised oral care including subglottic suction could reduce microaspiration in comparison with a routine oral care.Research methodology/designAn open prospective study comparing  optimized »versus a  routine  oral care procedure in two randomised crossover consecutive periods of one day each. Optimised oral care consisted of suction via the subglottic suction port before and after a 10 seconds chlorhexidine oral care, compared with no use of the port during routine care.SettingSingle-centre inclusion of critically ill patients ventilated for ≥48 hours with a subglottic suction endotracheal tube, no curare, Ramsay score not <3, and semi-quantitative assessments of tracheal secretions ≥ ++.Main outcome measuresAmylase being a relevant surrogate for oropharyngeal content, microaspirations were defined by tracheal/oral amylase ratio.Results21 patients (11 and 10 with routine and optimised care in the first day respectively) with no baseline difference in risk of microaspiration. Neither difference in tracheal amylase amount or in tracheal/oral amylase ratio (1.5% (0.7%–16%) and 2.3% (0.6%–6%), p = 0.37) was observed indicating that microaspirations were not significantly decreased after optimized versus routine oral care.ConclusionSuctioning by the subglottic port of endotracheal tubes may not decrease the risk of microaspiration during oral care of ventilated patients.     

Development and preliminary validation of the Neonatal Infant Acute Pain Assessment Scale (NIAPAS)

BackgroundSeveral pain scales are available for neonates, but, unfortunately they are only rarely used in clinical practice. To help with the current situation of unrecognized and under-treated pain in neonatal intensive care units (NICUs), we developed an assessment tool in close collaboration with clinical staff.ObjectivesTo develop a multidimensional scale, NIAPAS (the Neonatal Infant Acute Pain Assessment Scale), that is sensitive to the needs of infants in neonatal intensive care units, and to test the validity, reliability, feasibility and clinical utility of the scale for this population.DesignInstrument development and psychometric analysis.MethodsPain assessments (n = 180) were made of 34 neonates born between 23 and 42 weeks gestational age who were undergoing 60 painful procedures (heel lance 77%, tracheal suctioning 23%) in the NICU. Using bedside video recordings, each neonate was observed through three phases of the procedure: 1 min before the procedure, during the procedure (lasting from 0.6 to 11.2 min, mean 2.6), and 1 min after the procedure. In addition, an expert panel (n = 5) and nurses (n = 26) participated in the validation of the scale.ResultsA pool of 8 pain indicators (5 behavioral and 3 physiological indicators), including the gestational age of neonates as a contextual factor, was identified based on the nurses’ expertise in neonatal intensive care. Scores on the NIAPAS changed significantly across the phases (p < 0.001), indicating a good construct validity of the scale. Correlations between the NIAPAS and NIPS (the Neonatal Infant Pain Score) were high (0.751–0.873). The study also demonstrated high coefficients for inter-rater (r = 0.991–0.997) and intra-rater reliability (r = 0.992–1.00), with an internal consistency of 0.723. The content validity was very good (Mean I-CVI 1.00), as evaluated by the expert group. The nurses agreed that the scale was easy to administer and that it helped decision-making in the pain management of infants.ConclusionsThe NIAPAS was shown to be a valid and reliable scale for assessing acute pain in preterm and full-term infants in the NICU. It allows nurses to evaluate infants’ acute pain especially during painful procedures and help to provide pain relief for the infants.     

Association between self-reported sleep disturbance and other symptoms in patients with advanced cancer

ContextSleep disturbance (SD) is a significant source of distress for patients with cancer. Studies of patients with advanced cancer receiving palliative care to identify symptoms associated with the severity of SD are limited.ObjectivesIn this study, we sought to identify the symptoms measured by the Edmonton Symptom Assessment Scale (ESAS) that are associated with SD, as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary aims of the study were to determine the association between occurrences of SD with occurrences of other symptoms and screening performance of the ESAS-Sleep item against the PSQI.MethodsWe reviewed the completed ESAS and PSQI assessments of 101 patients with advanced cancer who were receiving palliative care and had been admitted to prospective clinical trials previously initiated by us. Patients with a PSQI score of ≥5 were considered to have an SD. The frequency and severity of the ESAS symptoms items, their correlation with each other, the PSQI score, and the screening performance of the ESAS-Sleep item were calculated.ResultsThe median age of patients was 60 years. Most were white non-Hispanic (73%), had lung or breast cancer (41%), and were diagnosed with SD (85%). The PSQI score was correlated with the ESAS items of pain (r = 0.27, P = 0.006), dyspnea (r = 0.25, P < 0.001), well-being (r = 0.35, P < 0.0001), and sleep (r = 0.44, P < 0.0001). Compared with patients without SD, those with SD were more likely to report pain (P = 0.0132), depression (P = 0.019), anxiety (P = 0.01), and a poorer sense of well-being (P = 0.035). An ESAS-Sleep item cutoff score of ≥3 (of 10) resulted in a sensitivity of 74% and a specificity of 73%.ConclusionSD is associated with increased frequency of pain, depression, anxiety, and a worse sense of well-being. These four symptoms should be assessed in all patients with advanced cancer with a complaint of SD. The ideal cutoff point of the ESAS-Sleep item for screening for SD is a score of ≥3. More research is needed to better characterize this frequent and distressing syndrome.     

Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study

ContextHome care programs in Italy.ObjectivesThe aim of this study was to assess a protocol for palliative sedation (PS) performed at home.MethodsA total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam.ResultsA total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P = 0.012). The principal reasons to start PS were agitated delirium (n = 20) and dyspnea (n = 4). Mean duration of PS was 42.2 ± 30.4 hours, and the mean doses of midazolam were 23–58 mg/day. Both the home care team and the patients' relatives expressed optimal or good levels of satisfaction with the procedure in all but one case, respectively.ConclusionThis protocol for PS was feasible and effective in minimizing distress for a subgroup of patients who died at home. The characteristics of patients who may be effectively sedated at home should be better explored in future studies.     

RN assessments of excellent quality of care and patient safety are associated with significantly lower odds of 30-day inpatient mortality: A national cross-sectional study of acute-care hospitals

BackgroundQuality and safety in health care has been increasingly in focus during the past 10–15 years. Stakeholders actively discuss ways to measure safety and quality of care to improve the health care system as a whole. Defining and measuring quality and safety, however, is complicated. One underutilized resource worthy of further exploration is the use of registered nurses (RNs) as informants of overall quality of care and patient safety. However, research is still scarce or lacking regarding RN assessments of patient safety and quality of care and their relationship to objective patient outcomes.ObjectiveTo investigate relationships between RN assessed quality of care and patient safety and 30-day inpatient mortality post-surgery in acute-care hospitals.DesignThis is a national cross-sectional study.Data sourcesA survey (n = >10,000 RNs); hospital organizational data (n = 67); hospital discharge registry data (n > 200,000 surgical patients).Data collection and analysisRN data derives from a national sample of RNs working directly with inpatient care in surgical/medical wards in acute-care hospitals in Sweden in 2010. Patient data are from the same hospitals in 2009–2010. Adjusted multivariate logistic regression models were used to estimate relationships between RN assessments and 30-day inpatient mortality.ResultsPatients cared for in hospitals where a high proportion of RNs reported excellent quality of care (the highest third of hospitals) had 23% lower odds of 30-day inpatient mortality compared to patients cared for in hospitals in the lowest third (OR 0.77, CI 0.65–0.91). Similarly, patients in hospitals where a high proportion of RNs reported excellent patient safety (highest third) had is 26% lower odds of death (OR 0.74, CI 0.60–0.91).ConclusionsRN assessed excellent patient safety and quality of care are related to significant reductions in odds of 30-day inpatient mortality, suggesting that positive RN reports of quality and safety can be valid indicators of these key variables.     

Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital

Background/objectivesResearch indicates up to one-third of rapid response team calls relate to end-of-life symptoms. The CriSTAL criteria were developed as a screening tool to identify high risk of death within three months. The primary purpose of this pilot study was to investigate the timing of palliative care referrals in patients receiving rapid response team services, and patients’ CriSTAL criteria score on admission. The potential feasibility of using the CriSTAL tool to stimulate earlier Palliative Care Team (PCT) referral served as an underlying goal, and investigation of a relationship between specific CriSTAL criteria and the prediction of in-hospital death was a secondary objective.DesignA retrospective chart review of rapid response calls made in 2015 was used to identify patient risk of death on admission based on the CriSTAL criteria. The presence and timing of PCT referral as well as patient survival status to hospital discharge were documented for comparison.Setting/participantsA sample of 183 charts from 584 inpatients involved in over 600 RRT events recorded in 2015. The study was undertaken in a 676-bed teaching hospital in the Midwestern U.S.Methods/resultsNinety-one patients died during the hospital stay while 92 patients from the 493 individuals who survived were randomly selected for full analysis. Applying CriSTAL criteria to the 141 individuals aged 50 years or older indicated that frailty (OR = 1.43, 95%CI 1.08–1.89, p = 0.012), being a male (OR = 3.14; 95%CI 1.40–7.05, p = 0.006), and the presence of two or more comorbidities (OR = 3.71, 95%CI 1.67–8.24, p = 0.001) were the most significant predictors of in-hospital death after adjusting for age. A CriSTAL score of 6 was the optimal cut-off for high-risk of in-hospital death. Palliative care consultations within the high-risk population occurred for 45.2% of the deceased and 40.4% of the survivors. Consultation often occurred within two days of the RRT event and many patients (46.8%) died within one day of the consultation.ConclusionA positive relationship was found between the CriSTAL score, palliative care referral, and in-hospital mortality in patients who received RRT services. The study indicates a need for earlier PCT referral, showcases the potential to identify high risk of in-hospital death upon admission and supports the feasibility of using the CriSTAL criteria tool to encourage earlier PCT referrals.     

Factors associated with anxiety in critically ill patients: A prospective observational cohort study

BackgroundAnxiety is an unpleasant emotion that most intensive care patients experience. This emotion is an important issue in intensive care settings because of its prevalence, adverse effects and severity. Little is known about the factors associated with state and trait anxiety during critical illness.ObjectivesTo describe the patterns of state anxiety reported by intensive care patients, and identify factors associated with state and trait anxiety.DesignProspective observational cohort study.SettingsOne mixed intensive care unit in Brisbane, Australia.ParticipantsAdults (n = 141, ≥18 years) admitted to the intensive care unit for ≥24 h; able to communicate verbally or non-verbally; understand English; and, open their eyes spontaneously or in response to voice.MethodsOutcomes were state anxiety as measured by the Faces Anxiety Scale and trait anxiety as measured by the State-Trait Anxiety Inventory. Pre-intensive care factors tested for possible associations with both state and trait anxiety were: age, gender, marital status, employment status, level of education, smoking status, personality trait of optimism and evidence of mental health care/treatment. Intra-intensive care factors tested were: reason for admission to the intensive care unit, delirium, pain, airway status, hours of mechanical ventilation, severity of illness, days of stay in intensive care, exposure to corticosteroids, opioids, benzodiazepines, anxiolytics, antidepressants, beta-blockers, anaesthetic agents and analgesics; length of sedation and analgesia and total doses of sedatives and analgesics.ResultsOf 141 participants, 98 (70%) were male with an average age of 54 (standard deviation: ±15) years and stayed in intensive care for about 4 (Interquartile Range: 3–7) days. The majority (n = 115; 82%) of participants experienced state anxiety at least once during their stay in intensive care, with 57% reporting moderate to severe levels. Factors related to state anxiety in intensive care were pain and trait anxiety. Factors associated with trait anxiety were trait optimism, state anxiety, evidence of mental health care/treatment and age.ConclusionsThis study provides a better understanding of contributing factors for anxiety in the critically ill. Trait anxiety and state anxiety were significantly associated with each other, namely, patients who were anxious by nature experienced higher levels of state anxiety, which persisted throughout their stay in the intensive care unit. Recognising the importance of state and trait anxiety assessments using validated tools and determining ways to manage anxiety in the critically ill are critical aspects of the intensive care nurses role.     

The impact of training program on nurses' attitudes toward workplace violence in Jordan

BackgroundNurses' attitudes toward workplace violence are still inadequately explored, and possess an impact in preventing, and managing the violent incidents and the quality of nursing care. Creating a demand for an effective intervention program to improve nurses' knowledge of and attitudes toward workplace violence.ObjectiveTo study the impact of the training program on nurses' attitudes toward workplace violence in a military hospital in Jordan.MethodsOne group before–after design was employed. A stratified random sample of 100 nurses working in three shifts was recruited. Data were collected earlier and after the preparation program using the Attitudes Toward Patient Physical Assault Questionnaire. “The Framework Guidelines for addressing workplace violence in the health sector”, was adopted in this work. The preparation sessions were for one day each week over five weeks. The post-test assessment was over five weeks using the same questionnaire.ResultsA total of 97 nurses completed the survey. The outcomes demonstrated the significant impact of the training program on nurses' attitudes towards workplace violence (t = 6. 62, df = 96, p = 0.000). The prevalence of verbal abuse by patients and visitors was 63.9% and for physical abuse, 7.2% were from patients and 3.1% of visitors. Most violent incidents occurred during day duty and during delivering nursing care (40.2% and 32%, respectively). Major source of emotional support for abused nurses was from the nursing team (88.7%), while the legal support was from nursing management (48.5%).ConclusionThe study highlights a general concern among nursing staff about workplace violence. Confirming that violence prevention education for staff is a necessary step forward to deescalate the problem. A significant effect of the training program was evident in this study.     

Effectiveness of a community based nurse-pharmacist managed pain clinic: A mixed-methods study

BackgroundChronic pain is predominantly managed in primary care, although often ineffectively. There is growing evidence to support the potential role of nurses and pharmacists in the effective management of chronic pain.ObjectivesTo evaluate the effectiveness of a pain clinic jointly managed by a nurse and pharmacist.DesignA mixed-methods design consisting of qualitative interviews embedded within a quasi-experimental study.SettingsA community-based nurse-pharmacist led pain clinic in the north of England.ParticipantsAdult chronic pain (non-malignant) patients referred to the pain clinic.MethodsPain intensity was the primary outcome. Questionnaires (the Brief Pain Inventory, the Hospital Anxiety and Depression Scale, the SF-36 and the Chronic Pain Grade questionnaire) were administered at the baseline, on discharge and at 3-month post-discharge (Brief Pain Inventory and Hospital Anxiety and Depression Scale only). Patient satisfaction was explored using face-to-face, semi-structured qualitative interviews.ResultsSeventy-nine patients with a mean age of 46.5 years (SD ± 14.4) took part in the quasi-experimental study. Thirty-six and nine patients completed the discharge and 3-month follow-up questionnaires respectively. Compared to baseline, statistically significant reductions were noted for two of the outcome measures: pain intensity (P = 0.02), and interference of pain with physical functioning (P = 0.02) on discharge from the service. Nineteen patients participated in qualitative interviews. The patients were, in general, satisfied with the quality of service. Four contributing factors to patient satisfaction were identified: ample consultation time, in-depth specialised knowledge, listening and understanding to patients’ needs, and a holistic approach.ConclusionsNurse and pharmacist managed community-based pain clinics can effectively deliver quality pain management services as they offer an interdisciplinary holistic approach to pain management. Such services have the potential not only to reduce the burden on secondary care but also decrease long waiting times for referral to secondary care. Further research is required to support the development of evidence based referral guidelines to such services.     

How do nurse practitioners work in primary health care settings? A scoping review

ObjectivesThis scoping review explores the work of nurse practitioners in primary health care settings in developed countries and critiques their contribution to improved health outcomes.DesignA scoping review design was employed and included development of a research question, identification of potentially relevant studies, selection of relevant studies, charting data, collating, summarising and reporting findings. An additional step was added to evaluate the methodological rigor of each study.DataData sources included literature identified by a search of electronic databases conducted in September 2015 (CINAHL, Informit, Web of Science, Scopus and Medline) and repeated in July 2016. Additional studies were located through hand searching and authors’ knowledge of other relevant studies.Results74 articles from eight countries were identified, with the majority emanating from the United States of America. Nurse practitioners working in communities provided care mostly in primary care centres (n = 42), but also in community centres (n = 6), outpatient departments (n = 6), homes (n = 5), schools (n = 3), child abuse clinics (n = 1), via communication technologies (n = 6), and through combined face-to-face and communication technologies (n = 5). The scope of nurse practitioner work varied on a continuum from being targeted towards a specific disease process or managing individual health and wellbeing needs in a holistic manner. Enhanced skills included co-ordination, collaboration, education, counselling, connecting clients with services and advocacy. Measures used to evaluate outcomes varied widely from physiological data (n = 25), hospital admissions (n = 10), use of health services (n = 15), self-reported health (n = 13), behavioural change (n = 14), patient satisfaction (n = 17), cost savings (n = 3) and mortality/morbidity (n = 5).ConclusionsThe majority of nurse practitioners working in community settings did so within a selective model of primary health care with some examples of nurse practitioners contributing to comprehensive models of primary health care. Nurse practitioners predominantly worked with populations defined by an illness with structured protocols for curative and rehabilitative care. Nurse practitioner work that also incorporated promotive activities targeted improving social determinants of health for people rendered vulnerable due to ethnicity, Aboriginal identity, socioeconomic disadvantage, remote location, gender and aging. Interventions were at individual and community levels with outcomes including increased access to care, cost savings and salutogenic characteristics of empowerment for social change.     

Screening for diabetic kidney disease in primary care for the underinsured: A quality improvement initiative

PurposeScreening rates for DKD in primary care are low, even though diabetes accounts for 44% of all new kidney disease cases. The purpose of this project was to determine if a primary care team for the underinsured improved screening and diagnosis of diabetic kidney disease (DKD) after initiating a quality improvement (QI) process.MethodsA chart audit with feedback, provider education of clinical practice guidelines, and strategies from TeamSTEPPS™ were implemented with the inter-professional primary care team.ResultsPre/post-intervention chart audit analysis showed the frequency of ordering microalbumin increased from 50.3% (n = 148) to 75% (n = 148), and diagnosing DKD rose from 3.3% (n = 10) to 10.7% (n = 21) over three months (P = .000).ConclusionImplementing a QI process in underinsured primary care centers improved the compliance of proper screening and diagnosing DKD AND introduced inter-professional practice competencies and teamwork strategies not previously recognized at the centers.