Sue Randall

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

BACKGROUND The 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. OBJECTIVES This 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. METHODS A 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. RESULTS The 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. CONCLUSIONS Nurse-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.

Exercise barriers and the relationship to self-efficacy for exercise over 12 months of a lifestyle-change program for people with heart disease and/or diabetes

Background: Barriers to exercise are common in people with coronary heart disease (CHD) and/or diabetes mellitus (DM), and may influence self-efficacy for exercise. Purpose: The purpose of this study was to describe the exercise barriers experienced by people who have CHD and/or DM participating in the Healthy Eating and Exercise Lifestyle Program and to determine whether these barriers influence self-efficacy. Methods: Participants (n = 134) identified their barriers to exercise and completed the self-efficacy for exercise survey at baseline, at 4 months (following structured and supervised exercise) and at 12 months (following home-based exercise with three follow-up calls). Results: The sample mean age was 63.6 years (SD 8.5) and 58% were male. Barriers to exercise were reported by 88% at baseline, 76% at 4 months, and 47% at 12 months. The most common barriers were lack of motivation (40.3%), lack of time overall (30.6%), and lack of time due to family commitments (17.2%). Only motivation changed significantly over time from baseline (40%) to 4 months (23%, p = 0.040). Lower self-efficacy for exercise was associated with lack of motivation at 12 months only, more depressive symptoms at baseline and 4 months, and a CHD diagnosis and higher body mass index at 12 months. In contrast, male gender and having higher self-efficacy at baseline were associated with higher self-efficacy for exercise at 4 and 12 months. Conclusion: Patients identified many exercise barriers despite participating in a lifestyle-change program. Lack of motivation negatively influenced self-efficacy for exercise at 12 months. Other factors needing attention include baseline self-efficacy, depressive symptoms, being female, being more overweight, and having CHD.

Case management of individuals with long-term conditions by community matrons: report of qualitative findings of a mixed method evaluation

AIM To consider findings from a study that evaluated case management of individuals with long-term conditions (LTCs) by a community matron (CM) service. The paper highlights issues related to the implementation of a new role and the impact this had on the experience of care across hospital and community settings for patients and their carers. BACKGROUND The introduction of the role of CM was intended to increase effective management of patients with complex comorbid LTCs through the introduction of case management, thereby reducing unplanned hospital admissions. METHODS The overall methodological approach was one of mixed methods. This paper reports the qualitative findings from CMs (n = 15); patients (n = 13); family carers (n = 8); and secondary care staff who interface with the CM service (n = 7). Data were collected between October 2009 and May 2010. FINDINGS A thematic analysis resulted in the identification of four themes: (1) visibility; (2) interpersonal relationships; (3) leadership; and (4) systems/professional boundaries. Patients enjoyed being seen as a whole and family carers appreciated the coordination aspect of the role. Difficulties arose from the limited understanding of the CM role and from a lack of a shared vision across healthcare professionals concerning the role and its goals.

A systematic review examining the effectiveness of blending technology with team-based learning

BACKGROUND Technological advancements are rapidly changing nursing education in higher education settings. Nursing academics are enthusiastically blending technology with active learning approaches such as Team Based Learning (TBL). While the educational outcomes of TBL are well documented, the value of blending technology with TBL (blended-TBL) remains unclear. This paper presents a systematic review examining the effectiveness of blended-TBL in higher education health disciplines. OBJECTIVES This paper aimed to identify how technology has been incorporated into TBL in higher education health disciplines. It also sought to evaluate the educational outcomes of blended-TBL in terms of student learning and preference. METHOD A review of TBL research in Medline, CINAHL, ERIC and Embase databases was undertaken including the search terms, team based learning, nursing, health science, medical, pharmaceutical, allied health education and allied health education. Papers were appraised using the Critical Appraisal Skills Program (CASP). RESULTS The final review included 9 papers involving 2094 student participants. A variety of technologies were blended with TBL including interactive eLearning and social media. CONCLUSION There is limited evidence that blended-TBL improved student learning outcomes or student preference. Enthusiasm to blend technology with TBL may not be as well founded as initially thought. However, few studies explicitly examined the value of incorporating technology into TBL. There is a clear need for research that can discern the impact of technology into TBL on student preference and learning outcomes, with a particular focus on barriers to student participation with online learning components.

Self-Efficacy, Depression, and Self-Care Activities in Adult Jordanians with Type 2 Diabetes: The Role of Illness Perception

Diabetes mellitus is reaching epidemic levels worldwide. In a developing country like Jordan, type 2 diabetes mellitus (T2DM) has reached a prevalence rate of 17.1%. This cross-sectional study examined the relationship between self-care activities and: illness perception, depression, social support, religiosity and spiritual coping, and self-efficacy among patients with T2DM. A random sample of 220 patients with T2DM, who attended Jordan University Hospital in Jordan were enrolled. The data were collected through a structured interview and the medical files. The instruments consisted of a sociodemographic and clinical standardised questionnaires: Brief Illness Perception Questionnaire, Patients’ Health Questionnaire-9; ENRICH Social Support Instrument; Religious and Spiritual Coping Subscale; Diabetes Management Self-Efficacy Scale; and Summary of Diabetes Self-Care Activities. Bivariate analysis investigated the relationship between variables. Structure Equation Modelling (SEM) was performed to test the proposed conceptual model. The study found that approximately 70% of the respondents suffered some form of depressive symptoms. The SEM showed a direct relationship between self-efficacy and self-care activities (β = 0.40; p < 0.001). Depression was indirectly related to self-care activities through self-efficacy (β = –0.20; p = 0.003); nevertheless, it was directly related to perception of: treatment control, consequences, and emotional representations. Overall, the sequence between illness perception and self-efficacy was mediated by depression. Strategies to promote self-efficacy and illness perception are vital in customising a diabetes health plan to meet Arabic cultural expectations.

‘I can't walk away’: understanding the complexities in embedding a new nurse role

BACKGROUND The community matron (CM) role was introduced in England to provide a single point of access to patients living with comorbid long-term conditions who had, or were at risk of, frequent emergency hospitalisation. AIM This study explored the factors that affected embedding of the CM role. The qualitative study was undertaken in community health services in two cities and a rural area in central England. METHOD Participants comprised health professionals (n=30) including CMs, community service managers, and service commissioners; patients (n=10); and their family carers (n=5). RESULTS Findings reveal that participants were largely positive about the role. However, difficulties with role setup had led to numerous changes in service delivery, which affected how the role has embedded. CONCLUSION Many aspects of the CM role are invisible to other health professionals. Invisibility of community nursing, rather than autonomy of the CM role, seems to be a key factor in the challenges of embedding the role.

The evaluation of a home-based paediatric nursing service: concept and design development using the Kirkpatrick model

Background A new paediatric hospital-in-the-home nursing service required evaluation. Aims To determine whether the education and training provided for nursing staff employed in the service was effective. Methods This paper presents the way in which a training evaluation model supported the design and evaluation of a training programme for registered nurses working in an out-of-hospital, home-based nursing service for paediatric patients. Results The Kirkpatrick model provides a framework for evaluating the effectiveness of workforce training for any industry including healthcare (Kirkpatrick, 2009). Conclusions That the Kirkpatrick model is an appropriate framework to evaluate a nursing training programme, but it is imperative to evaluate all levels of the model to be able to ascertain the success of the training and the impact on clinical practice.

Development of Quality Indicators for Cardiac Rehabilitation in Australia: A Modified Delphi Method and Pilot Test

BACKGROUND International guidelines recommend cardiac rehabilitation (CR) for secondary prevention of cardiovascular disease, however, it is underutilised and the quality of content and delivery varies widely. Quality indicators (QIs) for CR are used internationally to measure clinical practice performance, but are lacking in the Australian context. This study reports the development of QIs for minimum dataset (MDS) for CR and the results of a pilot test for feasibility and applicability in clinical practice in Australia. METHODS A modified Delphi method was used to develop initial QIs which involved a consensus approach through a series of face-to-face and teleconference meetings of an expert multidisciplinary panel (n=8), supplemented by an environmental scan of the literature and a multi-site pilot test. RESULTS Eight QIs were proposed and sent to CR clinicians (n=250) electronically to rate importance, current data collection status, and feasibility of future collection. The top six of these QIs were selected with an additional two key performance indicators from the New South Wales (NSW) Ministry of Health and two QIs from international registers for a draft MDS. The pilot test in 16 sites (938 patient cases) demonstrated median performance of 93% (IQR 47.1-100%). All 10 QIs were retained and one further QI related to diabetes was added for a final draft MDS. CONCLUSIONS The MDS of 11 QIs for CR provides an important foundation for collection of data to promote the quality of CR nationally and the opportunity to participate in international benchmarking.

Perspectives of cardiac rehabilitation staff on strategies used to assess, monitor and review – a descriptive qualitative study

Background: The mechanisms contributing to the success of cardiac rehabilitation (CR) are poorly understood and may include assessment, monitoring and review activities enabled by continuity of care and this is investigated in this study. Objectives: To identify active assessment components of CR. Methods: A qualitative study using focus groups and individual interviews. CR staff (n = 39) were recruited via professional association email and network contacts and organised into major themes. Results: CR staff assessment strategies and timely actions undertaken provided a sophisticated post‐discharge safety net for patients. Continuity of care enabled detection of adverse health indicators, of which medication issues were prominent. Interventions were timely and personalised and therefore likely to impact outcomes, but seldom documented or reported and thus invisible to audit. Conclusion: CR staff assessment and intervention activities provide an unrecognised safety net of activities enabled by continuity of care, potentially contributing to the effectiveness of CR.