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.     

Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled trial

OBJECTIVE: To determine the effectiveness of specialist nurse-led clinics for hypertension and hyperlipidemia provided for diabetic patients receiving hospital-based care. RESEARCH DESIGN AND METHODS: This study was a randomized controlled implementation trial at Hope Hospital, Salford, U.K. The subjects consisted of 1,407 subjects presenting for annual review with raised blood pressure(>or=140/80 mmHg), raised total cholesterol (>or=5.0 mmol/l), or both. Individuals with diabetes were randomized to usual care or usual care with subsequent invitation to attend specialist nurse-led clinics. Nurses provided clinics for participants, with attendance every 4-6 weeks, until targets were achieved. Lifestyle advice and titration of drug therapies were provided according to the locally agreed upon guidelines. Patients with both conditions were eligible for enrollment in either or both clinics. At subsequent annual review, blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register. Data relating to deaths were obtained from the national strategic tracing service. The primary outcome was the odds ratio of achieving targets in hypertension and hyperlipidemia, attributable to the specialist nurse-led intervention. RESULTS: Overall, specialist nurse-led clinics were associated with a significant improvement in patients achieving the target after 1 year (odds ratio [OR] 1.37 [95% CI 1.11-1.69], P = 0.003). This primary analysis revealed a borderline difference in effect between the two types of clinics (test for interaction between groups: P = 0.06). Secondary analysis, consistent with the prior beliefs of the health care professionals involved, suggested that targets were achieved more frequently in patients enrolled in the specialist nurse-led clinic for hyperlipidemia (OR 1.69 [1.25-2.29], P = 0.0007) than for hypertension (OR 1.14 [0.86-1.51], P = 0.37). Intervention (enrolled to either or both clinics) was associated with a reduction in all-cause mortality (OR 0.55 [0.32-0.92], P = 0.02). CONCLUSIONS: This study provides good evidence to support the use of specialist nurse-led clinics as an effective adjunct to hospital-based care of patients with diabetes. If the standards of care recommended in the National Service Framework for Diabetes are to be achieved, then such proven methods for delivering care must be adopted.     

The safety and effectiveness of a nurse-led anticoagulant service

AIM: The aim of this study was to compare the safety and effectiveness of anticoagulant nurses and a consultant haematologist in managing anticoagulant patients in a hospital outpatient setting. BACKGROUND: Nurses are increasingly developing roles traditionally undertaken by medical staff. As a result nurse-led practice has expanded in many areas including anticoagulant services. Previous studies have attempted to demonstrate the effectiveness of using other professionals to manage anticoagulant clinics over short periods of time. This research evaluates the safety and effectiveness of a consultant-led and a nurse-led service over two sequential 18-month periods. RESEARCH METHODS: A nonexperimental design was adopted. Data were collected retrospectively, from a random sample of 197 patients, who had been managed by both the consultant-led and nurse-led service. Two main outcome measures were selected: anticoagulant control between professional groups and interval between outpatient clinic appointments. RESULTS: No statistically significant difference in anticoagulant control was found between professional groups (P=0.137). There was evidence that patients attended anticoagulant clinics on significantly fewer occasions with nurse-led management (P < 0.0005). CONCLUSION: At the department within which this research was conducted, anticoagulant nurses were found to be at least as safe and effective as the consultant haematologist in managing outpatient anticoagulant patients over the study period. These findings are of importance in both shaping the future provision of anticoagulant care and also contributing to the wider area in evaluating the impact of nurse-led practice within health care.     

Patients are satisfied with advanced practice physiotherapists in a role traditionally performed by orthopaedic surgeons

Purpose: To measure and compare patient satisfaction with follow-up care in advanced practice physiotherapist (APP) and orthopaedic surgeon clinics for patients following total hip or knee replacement.Method: Consecutive patients attending either an APP-led or a surgeon-led review clinic were surveyed using a modified nine-item satisfaction questionnaire based on the Visit-Specific Satisfaction Instrument (VSQ-9). Chi-square analyses were used to examine differences in patient characteristics and type of visit. Independent t-tests were used to examine potential differences in patient satisfaction.Results: Of the 123 participants, more than half were aged 65 years or older. Chi-squared analyses revealed no significant difference in participant characteristics (gender, age, and overall health status) between the two different types of clinics. There was a significant difference (χ(2) (4)=12.49, p=0.014) in the distribution of the timing of follow-up appointments. There was no significant difference between the groups in mean overall patient satisfaction scores on the modified VSQ-9 (p=0.34) nor in the mean of the sum of the seven items related to the service provider (p=0.85). Satisfaction scores for most of the service-provider items were above 90/100.Conclusion: Patients are highly satisfied with the care provided by APPs in follow-up clinics after joint replacement. Evaluation of the patient perspective is essential to any new role involving a shift in traditional practice boundaries.     

Consumers' and professionals' perceptions of a breast cancer review clinic

AIM: This paper is a report of a study to explore the healthcare needs of women attending consultant-led breast cancer review clinics from their own perspectives, how these healthcare needs were being met, and healthcare professionals' perceptions of ways in which the service could be delivered more efficiently and effectively. BACKGROUND: The value of routine medical follow-up both in terms of detection of recurrence and patient satisfaction has been questioned. However traditional, where routine follow-up continues, there are rising numbers of women with breast cancer attending review clinics. METHODS: A qualitative approach was adopted, using non-participant observation during seven outpatient oncology/surgical breast review sessions. Interviews were carried out in 2005 with a convenience sample of 21 women clinic attenders, two outpatient nurses, three breast care nurses, four oncologists, three surgeons and an outpatient sister. FINDINGS: Although women saw themselves as having returned to a precancer state, they still had fears of recurrence and a need for reassurance. This need was generally met through the review clinic but many psychosocial needs were unaddressed. However, nurses seemed to be under-used as a potential source of support. Medical and nursing staff perceived that women needed to be reviewed but acknowledged that appropriately prepared nurses could deliver a more holistic and efficient service. CONCLUSION: The number of women with breast cancer requiring ongoing review is likely to increase, but the current review service is not meeting all their needs. A nurse-led follow-up service could be an attractive alternative to routine medical follow-up.     

Evaluating a nurse-led DXA scanning service

AIM: To examine the feasibility of using a peripheral dual energy X-ray absorptiometry (DXA) scanning service in a nurse-led clinic and whether or not it would influence treatment and clinician satisfaction with the service. METHOD: A nurse-led clinic, using peripheral DXA scans to identify patients at risk of osteoporosis, was established in the rheumatology department of the hospital. Patients were referred from several sources. A questionnaire was sent to referring health professionals with each scan result. Returned questionnaires were statistically analysed. Of the sample size of 2000, 1024 questionnaires were returned, giving a response rate of 51 per cent. RESULTS: The results confirmed the hypothesis that a nurse-led peripheral DXA scanning service is feasible and beneficial to referring clinicians. Eighty nine per cent (n=912) of respondents stated that the scan results influenced treatment of patients. CONCLUSION: Further investigation of the extent that the DXA scanning service may have reduced unnecessary treatment is required.     

Patient Satisfaction in a One‐Stop Haematuria clinic and Urology Outpatients: A Comparison of Clinics

One‐stop clinics have shown to improve the patient experience in early diagnosis of potentially life threatening conditions, although this service is less evident in Urology, where morbidity and mortality resulting from bladder cancers are increasing. This study will discuss whether or not one‐stop haematuria clinics improve patient satisfaction. A survey analysis comparing patient satisfaction for a one‐stop haematuria clinic and a traditional outpatient service was developed, based around the ‘Determinants and Components’ theory. A convenience sample of 102 haematuria patients attending either the one‐stop clinic (Route A) or an outpatient clinic within the Urology service (Route B), at an assigned National Health Service hospital, were invited to complete a ‘patient satisfaction’ questionnaire. Data were compared between clinic routes according to the patient satisfaction themes of: Time and Availability, Quality of Care, Environment, Accessibility and Convenience and Global Satisfaction. Response rate was 51%; with overall positive patient satisfaction levels for both clinics. Route A patients were most satisfied with Quality of Care; however, reported problems relating to prior information provision and appointment co‐ordination. For Route B, Availability and Time was a primary source of both satisfaction and dissatisfaction, receiving contradictory qualitative and quantitative responses respectively. Both groups rated Environment and Accessibility and Convenience highly overall, yet these were not a primary determinant of satisfaction. The majority of haematuria patients (82%), expressed a preference to attend a one‐stop clinic over several outpatient appointments. Practical recommendations for related service improvements are offered.     

The Patient Satisfaction Scale--an empirical investigation into the Finnish adaptation

RATIONALE AND AIMS: The aim of this paper is to empirically investigate the performance characteristics of the Finnish adaptation PSS-Fin of the Patient Satisfaction Scale (PSS) intended to measure patient satisfaction with nursing care. The PSS-Fin includes three sub-scales: technical-scientific, informational and interaction/support care-needs. METHODS: The PSS-Fin was used in a cross-sectional survey measuring the satisfaction of Finnish surgical patients (n=454) with the nursing care they received. The feasibility, internal consistency, stability, equivalence and construct validity of the measure were investigated. Evaluation was based on statistical methods. RESULTS: The PSS is brief and easy to use, and it produced low missing data. Cronbach's alpha coefficient ranged from 0.79 to 0.89 for the sub-scales. The items correlated strongly with the sub-scales and the sub-scales with the total PSS as well. Test-retest reliability of 0.7 showed reasonable stability over time. Three factor analytic procedures supported for the three-factor solution with a technical-scientific, informational and interaction/support factors, explaining approximately 77% of the variance. The PSS had some equivalence with another satisfaction instrument, but also exhibited the ability to discriminate between each other. In multiple regression analysis the informational care-needs sub-scale was the most significant factor explaining patient satisfaction. CONCLUSION: The PSS-Fin demonstrated good psychometric properties and conceptual rigour and is thus reliable tool for examining patient satisfaction with nursing care.     

A patient satisfaction survey of a nurse-led colorectal clinic

A new service was set up to achieve government targets to see patients with signs or symptoms of a possible colorectal cancer within two weeks of referral from their GP. The new clinics were nurse-led. A patient satisfaction survey was used to assess patients' opinions about the clinic. The results showed patients had a positive view of the clinic.     

Feasibility and acceptability of providing nurse counsellor genetics clinics in primary care

AIM: This paper reports a pilot study to test the feasibility of providing genetic nurse counsellor clinics in primary care in the United Kingdom, to develop a questionnaire to evaluate patients' satisfaction with their genetics appointments, and to establish patient and provider costs. BACKGROUND: Genetic counsellors are healthcare professionals with experience in medical genetics and counselling and often have a professional background in nursing, science, genetics, psychology, or public health and work as members of multidisciplinary teams. Professional genetic counsellor accreditation is possible in the United Kingdom, United States of America, Australia and Canada. Increasing referrals to specialist genetics services have precipitated a review of models of service delivery in the United Kingdom. METHODS: A random half of 74 general practices in three primary care trusts were selected for the study, and the patients registered with these practices and referred to the clinical genetics service, were offered an appointment in primary care with a genetic nurse counsellor. A clinic follow-up postal questionnaire was developed. RESULTS: Between July 2002 and May 2003, 64 appointments were offered to patients referred and registered with the selected general practices, 45 (79%) patients attended their appointment and 34 (77%) returned their follow-up questionnaire. Total mean satisfaction score was high and patients were most satisfied with the information and affective domains of the appointment. Those referred with a family history of cancer were more satisfied than those referred with a non-cancer diagnosis. Forty-eight per cent of patients seen by the genetic nurse counsellor did not need to attend a further appointment with a doctor in secondary care. Patients were satisfied with the travel time and distance to clinic and patient clinic costs were low. CONCLUSION: Patients do attend genetic nurse counsellor clinics in primary care, and are satisfied with the new location. A large cluster randomized controlled trial is now being conducted to obtain a controlled comparison of clinic attendance rates and patients' satisfaction with clinics in primary vs. secondary care settings.     

Piloting a nurse-led gynaecology preoperative-assessment clinic

This article outlines a pilot project to develop and evaluate a nurse-led gynaecology preoperative-assessment clinic at an acute hospital trust. The main aim of the clinic was to offer an effective preoperative-assessment service that provided high quality individualised and sensitive patient care. Further aims were that the clinic could be a template for other preoperative-assessment clinics, an educational resource for staff, a tool for clinical nursing career progression and a service to help ease junior doctors' workloads.     

Patient satisfaction with retail health clinic care

Purpose: To analyze patient satisfaction with care provided at two retail clinics by family nurse practitioners (FNPs) and physician assistants (PAs). To analyze patient characteristics and preferences of those patients seeking care at two retail clinics.
Data Sources: Anonymous, voluntary, self-report surveys completed by patient, or parents of minor patients, in one of two medical retail clinics located in grocery stores in Arizona between May 2006 and July 2007.
Conclusions: We found that clients with varied incomes and different ethnicities valued the same attributes of retail health clinic care as those found in initial studies: convenient location, no appointment necessary, short wait time, and low cost.
Implications for Practice: The high degree of patient satisfaction found for retail health clinic care indicates that this type of entrepreneurial primary health care will continue to increase in numbers. Retail health clinics are a viable source of employment for FNPs.     

Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes

OBJECTIVE: To compare the effectiveness of a nurse-led hypertension clinic with conventional community care in general practice in the management of uncontrolled hypertension in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: We studied 120 men and women outpatient attendees (61% non-Caucasian) with type 2 diabetes and a seated blood pressure (BP) >or=140/80 mmHg. All patients were being treated for hypertension, and 71% had increased urinary albumin excretion (UAE). Patients were allocated to either a nurse-led hypertension clinic or conventional primary care. The primary outcome measure was a change in systolic BP. Secondary outcome measures were total cholesterol, HDL cholesterol, total triglycerides, HbA(1c), UAE, serum creatinine, and changes in absolute stroke and coronary heart disease (CHD) risk scores. RESULTS: The mean (95% CI) difference in the decrement of systolic BP was 12.6 mmHg (5.9-19.3) (P = 0.000) in favor of the nurse-led group, whose patients were three times more likely to a reach target systolic BP <140 mmHg compared with conventional care (P = 0.003). A significant fall in 10-year CHD (P = 0.004) and stroke risk (P = 0.000) scores occurred only in the nurse-led group. There were no significant differences in the reduction of diastolic BP or any of the other secondary outcome measures at 6 months. CONCLUSIONS: Compared with conventional care, a nurse-led hypertension clinic is a more effective intervention for patients with type 2 diabetes and uncontrolled hypertension. A target systolic BP <140 mmHg is more readily achieved and may be associated with significant reductions in 10-year cardiovascular disease risk scores.     

Measuring the experiences of health care for patients with musculoskeletal disorders (MSD): development of the Picker MSD questionnaire

Analysis of data from a survey of patients with musculoskeletal problems (mainly back and neck pain) to develop a core measure of patients' experiences of health care. A secondary purpose was to determine whether a single summary index figure could be generated from the instrument. The data reported here comes from a postal survey of patients attending a spine clinic in Stockholm, Sweden. After attending the clinic patients were mailed a questionnaire. Up to two reminders were sent to nonresponders. Questionnaires were sent to 342 patients. Totally 173 (51%) questionnaires were returned, of which 38.1% respondents were male and 61.2% female. The mean age of patients was 54 years (SD 13.84), ranging from 16 to 88. Sixteen items on the questionnaire were found to constitute a reliable index of patient experience and which seem to be tapping the most important aspects of patient experience. The index score was found to have high construct validity. The instrument provides a core set of issues that should be covered when assessing the quality of care patients attending clinics for musculoskeletal disorders.     

Development of a nurse-led ileo-anal pouch clinic

The ileo-anal pouch procedure is now seen as the operation of choice for individuals suffering with ulcerative colitis or familial adenomatous polyposis (Fazio, 1999); however, patient follow-up after this surgery remains variable. This article highlights the effectiveness of running a nurse-led follow-up service. A patient satisfaction survey has shown that having a familiar face at each follow-up visit is hugely beneficial, providing continuity and reassurance for patients and their relatives. This nurse-led clinic provides adequate time for patients to discuss a variety of issues including management of sore perianal skin and pouch dysfunction. The growth and development in clinical skills, knowledge and nursing autonomy has seen the emergence of many nurse-led clinics, where nurses are utilizing their advanced skills. Within the nurse-led ileo-anal pouch clinic in Oxford, physical and/or internal examination, and investigations, such as rigid or flexible pouchoscopy, are performed. Such procedures were positively evaluated by patients.     

上海地区开展糖尿病护理门诊现状调查与分析

目的 调查上海地区糖尿病护理门诊开展情况并进行分析。方法 2016年2月-2016年12月,将二级以上医院正在开展糖尿病护理门诊的医院列为研究对象,由出诊护士完成调查问卷,内容涉及门诊基本信息、就诊患者信息、出诊护士信息、护士自身评价。结果 （1）门诊基本信息：28家医院的护理门诊设立时间6个月—9年,平均（4.82±3.77）年;其中18家医院由护士独立出诊（占64%）并收费,其他为医护联合门诊并免费;年门诊量三级医院12-480人次（年平均158.12±125.08人次）,二级医院24-1200人次（年平均262±462.86人次）;患者教育/咨询时间10-120分钟/人（平均35.71±23.32分钟）等。（2）就诊患者信息：就诊病人中医生转介占64%,就诊病种不局限于糖尿病,内容广泛,护理门诊所提供服务包括个体咨询、健康教育、行为指导和直接护理。（3）出诊护士信息：出诊护士均为大专以上学历,高级职称占61%,由护士长兼护理门诊工作有占71%,所有护士均通过糖尿病专科护理相关培训并获得合格证书。（4）护士自身评价：所有护士对门诊工作满意,认为实现了自身价值并对今后发展充满信心。结论 上海地区糖尿病专科护理门诊正在稳步发展,不仅为患者提供了集咨询、教育、护理、管理为一体的高品质综合服务,也满足其从生理到心理等多方面的健康需要,对临床治疗和疾病改善发挥积极作用。为了完善服务机制和深化服务品质,护理门诊的服务形式、流程、评价、随访和管控机制有待规范和完善。     

Patient satisfaction in a nurse-led rheumatology clinic

Patient satisfaction with a nurse-led rheumatology clinic was tested using the Leeds Satisfaction Questionnaire (LSQ), which was specially developed and shown to be both reliable (Cronbach's alpha, 0.96) and stable (test-re-test r = 0·83). A total of 70 patients with rheumatoid arthrists, aged 22–75 years were randomly allocated to either a nurse's or a rheumatologist's clinic and seen on six occasions over a year. They completed the LSQ on entry and there were no significant differences between them. By week 48 the medical cohort showed significantly increased satisfaction with access and continuity ( P < 0.05) but no change in overall satisfaction. The patients in the nurse-led clinic recorded significant increases in overall satisfaction and in all subscales ( P < 0.0001). Between-group comparison at week 48 showed the nurse's patients to be significantly more satisfied than those of the rheumatologist.     

The patient satisfaction with nursing care quality: the psychometric study of the Serbian version of PSNCQ questionnaire

Scand J Caring Sci; 2012; 26; 598–606 The patient satisfaction with nursing care quality: the psychometric study of the Serbian version of PSNCQ questionnaire Introduction: Patient satisfaction with nursing is the most important predictor of patients’ overall satisfaction with their hospital care. According to the Law of Health Care of Republic of Serbia monitoring of patients’ satisfaction with hospital service is mandatory; however, the questionnaire applied to that purpose includes only several questions directly addressing the nursing care issue. Aim: The aim of the present study was to evaluate psychometric properties of the Serbian version Patient Satisfaction Nursing Care Quality Questionnaire (PSNCQQ) and explore patients’ satisfaction of nursing care they received and assess the relationship between patient satisfaction and patient characteristics. Methods: This cross‐sectional study included a sample population of 240 patients who were discharged from surgical clinics of the Clinical Center of Vojvodina in Novi Sad. The PSNCQQ was translated into Serbian according to standard procedures for forward and backward translation. Factor analysis was used to determine the construct validity, and predictive validity of the questionnaire was previously assessed. Cronbach’s α coefficient and item analysis was conducted to evaluate reliability of the scale. Results: The Serbian version Patient Satisfaction Nursing Care Quality Questionnaire (PSNCQQ) showed a one‐factor structure, Cronbach’s α reliability coefficient was excellent 0.94 and was similar across hospital categories. The correlation coefficient between 19 items and the total scale was high, and ranged from 0.56 to 0.76. Patients’ age, educational level and previous hospitalization period were important factors that affected their satisfaction with nursing care. Conclusion: The study provides a new tool for measuring patient satisfaction with nursing care in Serbia that may present a useful instrument for nursing care managers in improving the nursing care process.     

Improving the accuracy of medication history taking in a diabetic eye clinic

AIM: To assess whether the use of a pre-visit medication questionnaire combined with clinical interview improves the accuracy of medication history taking when compared with direct questioning only, for new patients attending a diabetic eye clinic. METHOD: A service evaluation was undertaken using a retrospective case-control design. Fifty consecutive new patients visiting the clinic before a new pre-visit medication questionnaire was introduced were used as controls (group 1). New patients attending the clinic after the introduction of the questionnaire, who had been sent the questionnaire and completed it (group 2), were then matched to patients in group 1 over a 6-month period. The reported medication histories for both groups were then checked with the patients' GP. RESULTS: Forty-two matched pairs were identified. There was no significant difference (P=0.71) between the number of medications prescribed in group 1 (mean=6.2; standard deviation [SD]=3.8) and group 2 (mean=6.5; SD=2.9). However, there was a highly significant difference in the number of errors in the stated medication lists between groups 1 and 2: this favoured group 2, who completed a pre-clinic questionnaire before attending the clinic. CONCLUSION: The use of a pre-clinic questionnaire combined with clinical interview provides a significantly more accurate assessment of a patient's current medication list than interview alone.