Nurse-led clinic explained

A nurse-led clinic is any outpatient clinic that is run or managed by registered nurses, usually nurse practitioners or Clinical Nurse Specialists in the UK. Nurse-led clinics have assumed distinct roles over the years, and examples exist within hospital outpatient departments,[1] public health clinics[2] and independent practice environments.[3]

Definition

A broad definition of a nurse-led clinic defines these clinics based on what nursing activities are performed at the site.[4] Nurses within a nurse-led clinic assume their own patient case-loads, provide an educative role to patients to promote health, provide psychological support, monitor the patient's condition and perform nursing interventions.[4] Advanced practice registered nurses, usually nurse practitioners, may have expanded roles within these clinics, depending on the scope of practice defined by their state, provincial or territorial government.

Overview

The recent growth of nurse-led clinics is considered an emerging area of nursing practice; they were originally discussed in nursing journals in the 1980s, and developed over the 1990s into practice areas that have generated financial, legal and professional challenges over the years.[4] There has been recent growth of nurse-led clinics both within hospitals and in the community.[4] However, that growth has been unequal across different legislative regions. As an example, Canada's only known nurse-led clinics exist in Ontario.[5] Unlike many clinics which exist in the United States, Ontario's clinics have been met with some criticism from the Ontario Medical Association and some family physicians who view nurse-led clinics to be unproven innovations in primary care.[5]

In Kenya, advanced nursing practice developed in the 2005 in response to increased health needs and cost, and in keeping with health policy. A later impetus came from the “New deal for junior doctors” which was a government response to the European Community directive to reduce junior doctors' hours of work.[6]

Nurse-led clinics typically focus on chronic disease management: conditions where regular follow-up and expertise is required, but also where a patient may not necessarily need to see a physician at every visit.[4] Most nurse-led clinics use nursing theory and knowledge to educate patients and form care plans to manage their conditions.[4]

Nursing consultations

In their consultations, nurses undertake a range of activities.[7] This may include a specific task such as giving patient education,[8] assessment and management of cardiovascular risks,[9] managing blood pressure,[10] exacerbations of COPD and overall disease management.[11]

Review of evidence

Nurse-led clinics have a brief history of evaluation in scientific literature. Not only is there a large amount of heterogeneity between nurse-led clinics, but there are also different educational backgrounds for nurses who wish to enter these roles.

In a partially blind randomized controlled trial, adult patients with Type II Diabetes were found to have better control of hypertension and hyperlipidemia in a nurse-led clinic when compared to conventional follow-up care.[12] A related study also found that nurse-led clinics were more effective than conventional care in controlling hypertension for adult patients with Type II Diabetes and uncontrolled hypertension.[13] Generally, it was found that most patients experienced improved outcomes following nurse-led clinic consultation, with the best improvement rates found for wound care and continence clinics.[14]

Randomised controlled trials in rheumatology have demonstrated that nurse-led clinics are effective in controlling disease activity in people with rheumatoid arthritis.[15] [16] [17] [18] [19] In addition, three studies have demonstrated cost effectiveness on this model of care in Denmark,[20] the Netherlands[21] and the UK.[22]

Many nurse-led clinics have also been associated with enhanced patient satisfaction with care. A nurse-led clinic for intractable constipation in paediatric populations was compared to a paediatric gastroenterology clinic, illustrating that parent satisfaction was significantly higher for those who attended the nurse-led clinic.[23] This has also been shown in rheumatology nurse-led clinics.[24]

In areas where nursing practice may require additional support to maintain patient safety, some nurse-led clinics have implemented decision support tools, computerized systems and evidence-based algorithms to support their practice. Nurse-led clinics which utilize computerized decision support tools to manage oral anticoagulation dosages were found be to as effective as hospital-based clinics for INR control and stability.[25]

In the UK, nurse-led care has been established in many chronic conditions such as diabetes, COPD and musculoskeletal disorders. Treatment guidelines in rheumatoid arthritis for example, specify the role of the nurse in managing the disease and coordinating care.[26]

The evidence for the effectiveness of nurse-led intervention is growing and increasingly supported by randomised controlled trials and systematic reviews.[27] [28] [29] [30] [31] [32]

See also

Bibliography

  1. Department of Health Nursing Division. A Strategy for Nursing: a report of the steering committee. London: HMSO; 1989.
  2. NHS Management Executive. Junior Doctors: The New Deal. London: HMSO; 1991.
  3. Department of Health. A Compendium of Solutions to Implementing the Working Time Directive for Doctors in Training from August 2004. London: Department of Health; 2004.

Notes and References

  1. Rudra, N. (2009, May). Heat on nurse-led clinic to succeed, in Canberra Times http://www.canberratimes.com.au/news/local/news/general/heat-on-nurseled-clinic-to-succeed/1521621.aspx
  2. http://www.sussex.nj.us/Cit-e-Access/webpage.cfm?TID=7&TPID=935 Sussex County, New Jersey (2002). Public Health Nursing Page
  3. Ontario Ministry of Health and Long-Term Care (2009, June). Introduction to nurse practitioner-led clinics. http://www.health.gov.on.ca/transformation/np_clinics/guides/np_clinic_intro.pdf
  4. Hatchett, R. (2003). Nurse-Led Clinics: Practice Issues. New York, NY: Routledge.
  5. Hodges, D. (2009, July). Ontario docs concerned by nurse-led clinics. Retrieved from--~~~~www.everbetter.ca, originally published in The Medical Post. http://www.everbetter.ca/money/focus-on-nurse-led-clinics-concerns-ontario-doctors-5938
  6. Pickersgill. Trevor. 2001-12-01. The European working time directive for doctors in training. BMJ: British Medical Journal. 323. 7324. 1266. 0959-8138. 1121739. 11731377. 10.1136/bmj.323.7324.1266.
  7. van Eijk-Hustings. Yvonne. van Tubergen. Astrid. Boström. Carina. Braychenko. Elena. Buss. Beate. Felix. José. Firth. Jill. Hammond. Alison. Harston. Benny. January 2012. EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Annals of the Rheumatic Diseases. 71. 1. 13–19. 10.1136/annrheumdis-2011-200185. 1468-2060. 22039168. free.
  8. Ndosi. M.. Johnson. D.. Young. T.. Hardware. B.. Hill. J.. Hale. C.. Maxwell. J.. Roussou. E.. Adebajo. A.. June 2016. Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial. Annals of the Rheumatic Diseases. 75. 6. 1126–1132. 10.1136/annrheumdis-2014-207171. 1468-2060. 4893097. 26162769.
  9. Primdahl. Jette. Ferreira. Ricardo J. O.. Garcia-Diaz. Silvia. Ndosi. Mwidimi. Palmer. Deborah. van Eijk-Hustings. Yvonne. September 2016. Nurses' Role in Cardiovascular Risk Assessment and Management in People with Inflammatory Arthritis: A European Perspective. Musculoskeletal Care. 14. 3. 133–151. 10.1002/msc.1121. 1557-0681. 26549188.
  10. Clark. Christopher E.. Smith. Lindsay F. P.. Taylor. Rod S.. Campbell. John L.. 2010-08-23. Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis. BMJ. en. 341. c3995. 10.1136/bmj.c3995. 0959-8138. 20732968. 2926309.
  11. Mora. Kathlyen. Dorrejo. Xiomara M.. Carreon. Kimberly Mae. Butt. Sadia. 2017-08-28. Nurse practitioner-led transitional care interventions: An integrative review. Journal of the American Association of Nurse Practitioners. 10.1002/2327-6924.12509. 2327-6924. 28845555. 29. 12. 773–790.
  12. 10.2337/diacare.26.8.2250 . New . J.P. . Mason . J.M. . Freemantle . N. . 2003 . Teasdale . S . Wong . LM . Bruce . NJ . Burns . JA . Gibson . JM . Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled trial . Diabetes Care . 26 . 8. 2250–2255 . 12882844 . free .
  13. 10.2337/diacare.26.8.2256 . Denver . E.A. . Barnard . M. . Woolfson . R.G. . Earle . K.A. . 2003 . Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes . Diabetes Care . 26 . 8. 2256–2260 . 12882845 . free .
  14. Wong . F.K. . Chung . L.C. . 2006 . Establishing a definition for a nurse-led clinic: structure, process, and outcome . Journal of Advanced Nursing . 53 . 3. 358–369 . 16441541 . 10.1111/j.1365-2648.2006.03730.x. 10397/28301 . free .
  15. Primdahl. Jette. Sørensen. Jan. Horn. Hans Christian. Petersen. Randi. Hørslev-Petersen. Kim. February 2014. Shared care or nursing consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis outpatients with low disease activity--patient outcomes from a 2-year, randomised controlled trial. Annals of the Rheumatic Diseases. 73. 2. 357–364. 10.1136/annrheumdis-2012-202695. 1468-2060. 23385306.
  16. Koksvik. Hege Svean. Hagen. Kåre Birger. Rødevand. Erik. Mowinckel. Petter. Kvien. Tore K.. Zangi. Heidi A.. June 2013. Patient satisfaction with nursing consultations in a rheumatology outpatient clinic: a 21-month randomised controlled trial in patients with inflammatory arthritides. Annals of the Rheumatic Diseases. 72. 6. 836–843. 10.1136/annrheumdis-2012-202296. 1468-2060. 23393144. 24873268 .
  17. Larsson. Ingrid. Fridlund. Bengt. Arvidsson. Barbro. Teleman. Annika. Bergman. Stefan. January 2014. Randomized controlled trial of a nurse-led rheumatology clinic for monitoring biological therapy. Journal of Advanced Nursing. 70. 1. 164–175. 10.1111/jan.12183. 1365-2648. 4285750. 23772698.
  18. Ndosi. Mwidimi. Lewis. Martyn. Hale. Claire. Quinn. Helen. Ryan. Sarah. Emery. Paul. Bird. Howard. Hill. Jackie. 2014-11-01. The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial. Annals of the Rheumatic Diseases. en. 73. 11. 1975–1982. 10.1136/annrheumdis-2013-203403. 0003-4967. 23982436. 4215359.
  19. Tijhuis. Gerhardus J.. Zwinderman. Aeilko H.. Hazes. Johanna M. W.. Breedveld. Ferdinand C.. Vlieland. P. M. Theodora Vliet. January 2003. Two-year follow-up of a randomized controlled trial of a clinical nurse specialist intervention, inpatient, and day patient team care in rheumatoid arthritis. Journal of Advanced Nursing. 41. 1. 34–43. 0309-2402. 12519286. 10.1046/j.1365-2648.2003.02503.x. 1765/60935. free.
  20. Sørensen. J.. Primdahl. J.. Horn. H. C.. Hørslev-Petersen. K.. 2015. Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial. Scandinavian Journal of Rheumatology. 44. 1. 13–21. 10.3109/03009742.2014.928945. 1502-7732. 25380077.
  21. van den Hout. W. B.. Tijhuis. G. J.. Hazes. J. M. W.. Breedveld. F. C.. Vliet Vlieland. T. P. M.. April 2003. Cost effectiveness and cost utility analysis of multidisciplinary care in patients with rheumatoid arthritis: a randomised comparison of clinical nurse specialist care, inpatient team care, and day patient team care. Annals of the Rheumatic Diseases. 62. 4. 308–315. 10.1136/ard.62.4.308. 0003-4967. 1754484. 12634227.
  22. Ndosi. Mwidimi. Lewis. Martyn. Hale. Claire. Quinn. Helen. Ryan. Sarah. Emery. Paul. Bird. Howard. Hill. Jackie. November 2014. The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial. Annals of the Rheumatic Diseases. 73. 11. 1975–1982. 10.1136/annrheumdis-2013-203403. 1468-2060. 4215359. 23982436.
  23. Sullivan . P.B. . Burnett . C.A. . Juszczak . E. . 2006 . Parent satisfaction in a nurse led clinic compared with a paediatric gastroenterology clinic for the management of intractable, functional constipation . Archives of Disease in Childhood . 91 . 6. 499–501 . 16531455 . 2082804 . 10.1136/adc.2005.087486.
  24. Koksvik . H. S. . Hagen . K. B. . Rødevand . E. . Mowinckel . P. . Kvien . T. K. . Zangi . H. A. . 2013 . Patient satisfaction with nursing consultations in a rheumatology outpatient clinic: a 21-month randomised controlled trial in patients with inflammatory arthritides . Annals of the Rheumatic Diseases . 55 . 6. 836–843 . 10.1136/annrheumdis-2012-202296 . 23393144. 24873268 .
  25. Fitzmaurice . D.A. . Hobbs . F.D. . Murray . E.T. . Holder . 2000 . RL . Allan . TF . Rose . PE . Oral anticoagulation management in primary care with the use of computerized decision support and near-patient testing: a randomized, controlled trial . Archives of Internal Medicine . 160. 15. 2343–2348 . 10927732 . 10.1001/archinte.160.15.2343. free .
  26. NICE. Rheumatoid arthritis: The management of rheumatoid arthritis in adults. Secondary Rheumatoid arthritis: The management of rheumatoid arthritis in adults [Online] August 2013 2009. http://www.nice.org.uk/nicemedia/pdf/CG79NICEGuideline.pdf
  27. Primdahl. Jette. Ferreira. Ricardo J. O.. Garcia-Diaz. Silvia. Ndosi. Mwidimi. Palmer. Deborah. van Eijk-Hustings. Yvonne. 2016. Nurses' Role in Cardiovascular Risk Assessment and Management in People with Inflammatory Arthritis: A European Perspective. Musculoskeletal Care. en. 14. 3. 133–151. 10.1002/msc.1121. 1557-0681. 26549188.
  28. Thurah. Annette de. Esbensen. Bente Appel. Roelsgaard. Ida Kristiane. Frandsen. Tove Faber. Primdahl. Jette. 2017-08-01. Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis. RMD Open. en. 3. 2. e000481. 10.1136/rmdopen-2017-000481. 28879053. 5574437. 2056-5933.
  29. Garner. Stephanie. Lopatina. Elena. Rankin. James A.. Marshall. Deborah A.. June 2017. Nurse-led Care for Patients with Rheumatoid Arthritis: A Systematic Review of the Effect on Quality of Care. The Journal of Rheumatology. 44. 6. 757–765. 10.3899/jrheum.160535. 0315-162X. 28202747.
  30. Horrocks. Sue. Anderson. Elizabeth. Salisbury. Chris. 2002-04-06. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. 100791. BMJ: British Medical Journal. 324. 7341. 819–823. 0959-8138. 11934775. 10.1136/bmj.324.7341.819.
  31. Clark. Christopher E.. Smith. Lindsay F. P.. Taylor. Rod S.. Campbell. John L.. 2010-08-23. Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis. BMJ (Clinical Research Ed.). 341. c3995. 10.1136/bmj.c3995. 1756-1833. 2926309. 20732968.
  32. Ndosi. Mwidimi. Vinall. Karen. Hale. Claire. Bird. Howard. Hill. Jackie. May 2011. The effectiveness of nurse-led care in people with rheumatoid arthritis: a systematic review. International Journal of Nursing Studies. 48. 5. 642–654. 10.1016/j.ijnurstu.2011.02.007. 1873-491X. 21392764.

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