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Aspects of Nursing Education: The Types Of Skills And Knowledge Required To Meet The Changing Needs Of The Labour Force Involved In Nursing - Literature Review

• Services Provided By Specialist Nurses/Extended And Expanded Roles
• Effectiveness of Nurse Practitioners
• The Current Literature - Role of the Nurse Practitioner
  • The Acute Care Nurse Practitioner
  • The Nurse Practitioner in General Practice
  • The Emergency Nurse Practitioner
  • The Nurse Practitioner Role Generally
  • Other Nurse Practitioner Roles

Services Provided By Specialist Nurses/Extended And Expanded Roles

While the role of nurse practitioner was developed and became firmly established in both the USA and Canada approximately thirty years ago, the role has been introduced in the United Kingdom, Australia and New Zealand in the last five to ten years. The literature retrieved in the search can be grouped into the following categories: efficiency of the nurse practitioner; satisfaction with the nurse practitioner role; descriptions or discussions about the role; and the settings in which the nurse practitioner works.

Before going on to outline the nurse practitioner literature it is important to acknowledge that the title "nurse practitioner", its protection in legislation and the educational preparation of nurse practitioners vary from country to country and between States in Australia. As these differences influence the interpretation of the articles, brief background information regarding the same is contained in Appendix C

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Effectiveness of Nurse Practitioners

Four recent good quality studies (NHMRC level II evidence) have been reported in the literature.

One trial compared the cost effectiveness of general practitioners and nurse practitioners in primary care with the main outcome measures including the length of consultation, examinations, prescriptions, referrals, patient satisfaction, health status and return clinic visits over two weeks. The trial was undertaken in 20 general practices in England and Wales with patients requesting a same day appointment being randomly allocated to either the general practitioner (n=665) or nurse practitioner (n=651). The diagnoses of patients seen included upper respiratory tract infection, viral illness, minor injuries and eye and ear conditions. Significant results were that nurse practitioner consultations were longer than those of the general practitioner and that patients were more satisfied with nurse practitioner consultations. Overall the clinical care and health service cost of the two groups were similar (Venning, Durie, Roland, Roberts, & Leese, 2000 UK).

A second trial conducted in primary care clinics in New York studied outcomes in patients treated by nurse practitioners (n=806) and physicians (n=510). (Mundinger, Kane, Lenz, Totten, Tsai, Cleary, Friedwald, Siu, & Shelanski, M. 2000 USA) The results showed that where "... nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable." (p 59) In these first two trials the nurse practitioner undertook a role comparable to the physician.

Another randomised controlled trial in Washington compared a senior center based chronic illness self-management and disability prevention program led by a geriatric nurse practitioner with a control group who were shown the facilities of the senior center but had no contact with the geriatric nurse practitioner. (Leveille, Wagner, Davis, Grothaus, Wallace & LoGerfo, 1998 USA) The geriatric nurse practitioner role was one in which the nurse practitioner monitored the progress of participants in their disability prevention and chronic illness self-management. Specific aspects of the role included education about risk factors, nutrition and medications; encouragement of participants to select and continue with physical activities/exercises; counselling and support; follow-up visits and phone calls. Results indicated that the intervention group showed less decline in function, increased levels of physical activity and spent significantly less time as in-patients during the study year.

An Australian study (Chang Daly, Hawkins, McGirr, Fielding, Hemmings, O'Donoghue, & Dennis 1999 AUS) investigated whether there was a difference in care provided by medical officers and nurse practitioners in a specific area of primary health, that of wound management and treatment of blunt limb trauma. The nurse practitioners were involved in a pilot study prior to legislative change. The study comprised a four month supervised competency trial and a three and a half-month unsupervised comparative study. During the study the nurse practitioners followed clearly defined protocols. While the sample size of the comparative study is small (n=169) the results indicated that there were no significant differences between the nurse practitioners and medical officers in relation to client satisfaction. Very positive outcomes of treatment were consistent across both groups. One benefit was decreased waiting time for treatment. The role of the nurse practitioner in this case was limited but the authors indicate that the study supports training nurses in specified competencies to enable them to practice in rural settings.

Six articles were retrieved which met the criteria for level III evidence. Of these, two are controlled trials (level III-1), one is a cohort study (level III-2) and three are comparative studies (level III-3).

One controlled trial compares nurse practitioner and general practitioner treatment of same day consultations in primary care across 10 general practices in south Wales and south west England (Kinnersley, Anderson, Parry, Clement, Archard, Turton, Stainthorpe, Fraser, Butler, & Rogers 2000 UK). The nurse practitioners in this trial had completed the nurse practitioner diploma course at either the Royal College of Nursing (a precursor to the bachelor program) or the department of nursing, midwifery and health care, University of Wales. This trial is similar to one already described in the level II evidence above (Venning et al 2000 USA). Kinnersley's study showed that generally patients who consulted nurse practitioners were significantly more satisfied with their care. The numbers of prescriptions, investigations, referrals and reattendances were similar between the nurse practitioner and general practitioner groups however patients who were managed by nurse practitioners reported receiving significantly more information about their illness.

In a controlled trial in Ontario, Canada, (Mitchell-DiCenso, Guyatt, Marrin, Goeree, Willan, Southwell, Hewson, Paes, Rosenabum, Hunsberger, & Baumann, (1996 CAN) the management of critically ill neonates by clinical nurse specialist/nurse practitioner team in the day and a paediatric-resident team at night was compared with a paediatric-resident team around the clock. The results for the outcomes measured (number of neonatal complications; length of stay; quality of care; parent satisfaction; long term outcomes and costs) indicated that the two teams were similar. The authors state that the results support the use of clinical nurse specialist/nurse practitioner teams as an alternative to paediatric-residents. However the results must be interpreted cautiously, firstly because the neonates cared for by the clinical nurse specialist/nurse practitioner team were cared for by residents at night, and secondly as both teams were supervised by neonatologists. These confounders make the results difficult to interpret.

A cohort study of managed primary care of nursing home residents in Southern California demonstrated that the integration of the efforts of physicians, nurse practitioners and nursing home staff can lead to low rates of hospital use by nursing home residents. (Joseph and Boult, 1998 USA) The role of the nurse practitioner in the team was the provision of preventive and chronic care and other responsibilities in agreement with the physician.

A study to review the impact on geriatric nurse practitioner/physician teams for enrollees residing in 45 long-term care facilities in Massachusetts showed that the use of these teams, when compared with a physician alone, reduced emergency department and acute care utilisation costs. (Burl, Bonner, Rao, & Khan, 1998 USA) The nurse practitioner role in this case incorporated taking an admission history and conducting a physical examination, the development of a comprehensive plan of care addressing medical, functional and psychosocial issues in collaboration with the physician and nursing staff. The nurse practitioner also visited the resident regularly and coordinated other health care. Physicians involved in the study saw the nurse practitioner as a specialist on geriatric issues and the complex legislative guidelines influencing care.

Dahle, Smith, Ingersoll, & Wilson (1998 USA) describe a comparative study in Tennessee of the outcomes of patients suffering heart failure prior to and following the introduction of the role of nurse practitioner specialising in the management of this disease. The NP worked closely with the medical specialist and followed clearly defined protocols and treatment pathways. The outcomes compared were limited to length of stay and 30-day readmission rates. Total costs were found to be significantly lower following the implementation of the NP role, particularly for laboratory costs, ECG and respiratory therapy. However it is not clear from the 'before and after' study design whether this cost difference is due to the NP role or the use of clinical management pathways and protocols which were introduced concurrently.

A second comparative study in a similar group of patients was conducted by Dahl and Penque (2000 USA) in Minnesota. Here the outcomes of a historical control group were compared with the outcomes of a group of patients attending the in-patient heart failure program. This program was managed by an adult nurse practitioner and conducted by two second year students, one enrolled in a clinical nurse specialist program and the other in an adult nurse practitioner program. Length of stay, in-hospital mortality rates and readmission rates were significantly reduced for program participants.

The preceding articles, which include research at NHMRC levels of evidence II to III, indicate that nurse practitioners can provide

• equivalent care to physicians in primary care,
• specific care according to protocols in specialty areas,
• improve outcomes for seniors in self-management and disability prevention and in patients with heart failure, and
• improved care in collaborative teams with physicians, for residents in nursing homes or long-term care facilities.

In addition to these articles a number of evaluations not using research methodology related to the NHMRC levels of evidence have been conducted. These do however support the results provided by higher quality research.

The EROS (extended roles of staff) project team (Bond, Beck, Derrick, Sargeant, Cunningham, Healy, Rawes, Holdsworth, & Lawson (1999 UK) conducted a prospective study in Northumberland, England of the coordinated training and work of four trainee nurse practitioners in general practice over two years. The objectives were to compare trainee nurse practitioner and general practitioner decisions in consultations, describe the characteristics of patients attending independent trainee nurse practitioner training consultations and assess acceptability of the service to patients. The performances of all trainees were similar. It was not possible to judge the value of attending the Nurse Practitioner Bachelor of Science course since three out of four trainees were doing this while the other was not. Over the two years there was increased efficiency with the transfer rate to general practitioners and the return rate to surgery both lower than that observed elsewhere. Nurse practitioner efficiency was hindered by their lack of ability to give sick notes, prescriptions and referrals without these being countersigned by the general practitioner. Overall the general practitioner mentors judged the diagnostic and treatment decisions of the trainees as good. The trainees were liked by patients and were classified as a valuable substitute for general practitioners.

An evaluation of the appropriateness of triage decisions in a busy ophthalmic casualty department and assessment of the diagnostic and management skills of eye-dedicated nurse practitioners was carried out by Banerjee, Beatty, Tyagi, & Kirkby (1998 UK) in Birmingham over a two week period. The nurse practitioner saw fifty patients in the least urgent triage category. A supervising doctor saw all these patients subsequently without knowledge of the nurse practitioner's diagnosis or proposed management plan. The doctor concurred with diagnosis in all cases and proposed management in 96% of cases. The discrepancies were minor and would not have resulted in adverse outcomes. Nurse practitioners in this casualty department undertake a hospital structured training program of six months and are then assessed by the registrars. If they are successful they are able to work as nurse practitioners.

Duthie, Drew, Farouk, Hodson, Wedgwood, & Monson (1998 UK) have reported on the development of a training program for nurse practitioner flexible sigmoidoscopy in the United Kingdom. The training program required 35 observations and 30 hours of practice on colon models over a three week period during the observation time, 35 withdrawals and 35 supervised full procedures. The nurse practitioner's skill is outlined for the first 215 patients independently examined. Ninety-three percent of the examinations were successful as classified by the depth of insertion or accurate diagnosis following validation. The others were abandoned due to poor bowel preparation or pain. Pathology was identified in 51% of patients. There was disparity between the sigmoidoscopy results and barium enema results in 20 patients however in 17 patients the sigmoidoscopy results were superior and in the remaining three the barium enema identified moderate diverticular disease not recognised by the nurse endoscopist.

Another study (pilot) in the United Kingdom (Wan, Taylor, Gul, Taffinder, Gould, & Darzi, 1999 AUS) evaluated the feasibility of using rigid video-sigmoidoscopes in a community setting with realtime teleconsultation with a colorectal specialist. No information is included about the education of the nurse involved. All patients (32) seen in the clinic over a three month period agreed to be in the study. Two cases had excessive faecal residue but all other cases had good clarity of views. The study although with limited numbers of patients, showed successful implementation of the role with both patient and user satisfaction.

Williams, Assassa, Smith, Jagger, Perry, Shaw, Dallosso, McGrother, Clarke, Brittain, Castleden, and Mayne, (2000 UK) reported on an observational study of the effectiveness of and patient satisfaction with a service run by five specially trained continence nurse practitioners delivering predefined evidence-based treatment interventions. The training of the nurses is not described in this article. The nurse saw all patients over an eight week period with 194 patients completing treatment. The service was shown to be effective in reducing urinary symptoms and led to high levels of patient satisfaction. This service is currently being evaluated in a randomised controlled trail.

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The Current Literature - Role of the Nurse Practitioner

A large number of authors outline the role of the nurse practitioner. While the authors do not use research that fits within the NHMRC levels of evidence the articles can still be separated into two groups. The first group of articles is where the author has used a systematic process to collect and analyse information about the role. These include surveys, program evaluations and pilot studies. The second group is where the author provides a description of the evolution of the role in an organisation or a discussion about the role from the author's viewpoint. Articles where the author has used a systematic collection and analysis of data about the role are described individually. These are grouped according to the context of practice. Any other articles specifically adding to the body of knowledge about the skills and knowledge required by the nurse practitioner will be addressed following these.

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The Acute Care Nurse Practitioner

Kleinpell (1997, 1998 USA) and Kleinpell-Nowell (1999 USA) has reported on the predominant role components of the acute care nurse practitioner following surveys of the nurses undertaking the US national certification examination for this role which began in 1995. The survey of more than 740 advanced practice nurses (78% response rate from 940 surveys) showed that sixty-one percent of respondents were practising as acute care nurse practitioners with the majority working in intensive care and acute care tertiary sites. The major role components included discussing care with the family members, initiating discharge planning practices and monitoring laboratory and other diagnostic tests '...to enhance patient care management.' (Kleinpell-Nowell, 1999 p. 12). Time spent on direct client care was reported to range from 15% to 100% (mean 87%). Forty-three percent of respondents reported that 100% of their time was spent in direct client care. Other responsibilities included teaching, research, departmental projects, quality assurance, administrative duties and program development.

Kleinpell-Nowell (2001 USA) has since published the results of the second year of a five year longitudinal study exploring the role development of the acute care nurse practitioner which builds on her previous work. In this study the first six cohorts to take the national certification examination are sent an annual survey addressing role components, job characteristics, satisfaction with the acute care nurse practitioner position, plans for employment and demographic data. Each year additional questions are included to explore a different aspect of the role. Responses from 545 acute care nurse practitioners two years after national certification showed expansion of the role outside the traditional teaching hospital setting. Role components highlighted the comprehensive care of acute care nurse practitioner practice in terms of coordination of care, interactions with family members, consultation, and discharge planning. An identified area of concern was that some acute care nurse practitioners were working in staff nurse role to gain clinical experience. Kleinpell-Nowell comments that minimal clinical practice requirements prior to entry to nurse practitioner programs vary from no specified clinical experience to five or more years and that since the acute care nurse practitioner involves mastery of complex concepts that prior clinical experience is important.

Stetler, Effken, Frigon, Tiernan, & Zwingman-Bagley (1998 USA) evaluated the role of the acute care nurse practitioner in Connecticut. Forty-five role behaviors were evaluated by 106 health key stakeholders, the 15 acute care nurse practitioners, and 58 patient/family participants. The role behaviors were grouped into

• medically related role expectations such as prescribing medications, procedures, ordering and interpreting diagnostic tests, stabilization of patients in crisis;
• nursing related role expectations such as history, assisting staff patients and families in navigating the health system;
• case management role expectations such as coordination of patient care with multiple health providers, management of patients with a focus on cost and quality and
• shared medical-nursing role expectations such as participation in interdisciplinary quality of care improvement, contribution to professional development of peers colleagues and students and incorporation of patient and family education needs into the plan of care.

Results showed that the performance of the acute care nurse practitioners who had been in the role for more than six months was rated positively by both clinicians and managers. Providers and patients and their families viewed the acute care nurse practitioner as an acceptable provider of care. Noted in the patient and family responses were comments on the emotional and other support provided which indicated that the nursing component of the role was integral in the blended acute care nurse practitioner role.

Knaus, Felten, Burton, Fobes, & Davis (1997 USA) documented the introduction of nurse practitioner role in an acute setting in the University of Missouri Hospital and Clinics, Columbia. The nurse practitioners, in their first year of practice, collaborated to design a study to investigate their work activities, the time engaged in activities and the numbers of clients seen within designated time periods. Two nurse practitioners collected data for four months with the other nurse practitioner collecting data for five months. The results showed that overall

• 39% of time was spent in direct care (largest amount clinic visits and follow-up activities);
• 31% in indirect care (largest amount in-patient rounds with physicians);
• 13% in administrative activities (protocol and procedure development, product evaluation, committee meetings, computer time);
• 12% in educational activities (education of medical and nursing students, residents and professional organisations; materials development; and self-education) and
• 5% in research activities.

In addition physicians indicated that nurse practitioners were good at developing a plan of care, determining the need for laboratory studies and providing outpatient teaching. Patients were satisfied with the nurse practitioners bedside manner; teaching and indicated the nurse practitioners were extremely efficient at procedures and technical aspects of care (Knaus et al 1997 USA).

While the role of the acute care nurse practitioner seems similar in the studies described above it should be noted that Fox, Schira, & Wadlund (2000 USA) describe a role where the acute care nurse practitioner is also certified as the first assistant in surgery. In this role the nurse practitioner provides surgical assistance (suturing, dissection, wound closure) in-patient care, minor procedures, consultations and office practice.

Two other studies compare the role of the nurse practitioner with the clinical nurse specialist. The first (Mick & Ackerman, 2000 USA) explored the differences in the role of the acute care nurse practitioner and the clinical nurse specialist. Eighteen subjects from an academic medical centre (n=6) and an Internet advanced practice listserv (n=12) completed a questionnaire. Subjects were asked to rank their expertise in the domains of direct comprehensive care, support of systems, education, research, and publication and professional leadership. Each domain listed tasks, for example, support of systems included the tasks: actively contributing to medical centre and school of nursing recruitment and retention activities; participating in strategic planning; serving as a mentor; and serving as a spokesperson for nursing and the medical centre when interacting with other professionals, patients, families and the public. The results showed that although some individuals believe the two roles, nurse practitioner and clinical nurse specialist, have merged that they appear to be distinct. Areas of growth identified for the acute care nurse practitioner included research and publication and professional leadership and to a lesser degree education. It was noted that these should be incorporated into curricula.

A further study comparing the clinical nurse specialist (n=310) to the nurse practitioner (n=300), not necessarily in an acute care nurse practitioner, was conducted by Lincoln (2000 USA) and replicates the work done by Williams and Valdiviesco in 1992. Results showed that clinical nurse specialists spent significantly less time than nurse practitioners in direct practice. Clinical nurse specialists spent significantly more time in education, consultation, administration and research. Both spent the least time in administrative and research roles. The major differences in the roles between the two studies are that nurse practitioners in the latest study spent more time in providing direct care and less time in education and administration than in 1992. The clinical nurse specialists spent more time consulting (18% to 23%) and less time educating (29% to 21%) than in 1992.

The Nurse Practitioner in General Practice

One component of a two-year pilot study in the north west of England (Reveley, 1998 UK) was the analysis of the role of the triage nurse practitioner in a general medical practice. Doctors at the clinic supervised the nurse practitioner while she was concurrently undertaking the Bachelor of Science (Hons.) at the Royal College of Nursing. The aim of this component of the study, eighteen months after its commencement, was to examine the role of the nurse practitioner compared to the 'second on call' doctor and elicit patient perceptions of their consultations with the nurse practitioner or general practitioner. Ten three and a half hour surgeries of both the nurse practitioner and 'second on call' general practitioner were examined. The results found that the general practitioner saw more patients than the nurse practitioner, and that patients consulting the nurse practitioner were younger and more acutely ill. The triage role involved seeing same day patients with undiagnosed undifferentiated problems who regarded their problem as urgent while general practitioners saw more patients with ongoing problems. The nurse practitioner was under"... continual pressure to make decisions and exercise a high degree of skill in diagnosis and management as she has no previous care plan to follow through."(p. 589) The nurse practitioner role was acceptable to patients.

The Emergency Nurse Practitioner

A postal survey of senior nurses in all (n=293, response rate=94%) major accident and emergency departments in the United Kingdom (Tye, Ross & Kerry, 1998 UK) defined the emergency nurse practitioner as a designated qualified nurse who was '...authorised to independently assess, treat, and discharge predefined categories of patients'. Tye et al's survey collected information about emergency nurse practitioner activity which was independent of a medical practitioner. The following activities were identified: 82 departments authorised nurse practitioners to request X-rays; 35 departments allowed them to interpret the X-rays; 67 departments allowed "over the counter" drug supplying under local protocol and 52 departments allowed prescription drug supplying from an agreed list. Tye et al reports that "While the majority of the sample had received some sort of training, across the United Kingdom as a whole great variations in length, content, and academic level of courses are evident. ... Given ... (this) ... it is perhaps not surprising that the study also identified considerable variation in ENP scope of practice."

The Breast care nurse

The "Clinical Practice Guidelines for the Management of Early Breast Cancer Second Stage Consultation (2000 AUS) Draft" identifies the role of the breast care nurse. It recommends that one of the strategies to improve recall of information is the provision of a breast care nurse or counsellor (level II evidence). It also recommends the involvement of a breast care nurse in the treatment team as it reduces morbidity (level II evidence). The "Clinical Practice Guidelines for the Management of Advanced Breast Cancer (2001)" indicate that psychosocial interventions can improve physical, functional and psychological adjustment and should be considered for introduction into patient care (levels I-IV evidence). Nurses, mentioned in the guidelines, are one of the providers of such interventions. Specialist breast nurses are also identified in the "Psychosocial Clinical Practice Guidelines: providing information, support and counselling for women with breast cancer (1999)". The role is seen as advantageous by providing procedural information along with other health professionals (level II); enhancing early recognition of social support needs and decreasing psychological distress (level II); and improving and providing continuity of care throughout the treatment process (level II).

The Nurse Practitioner Role Generally

A postal survey in the United Kingdom (Hicks & Hennessy, 1999 UK) aimed to identify the role of the nurse practitioner in both the acute care and community setting. The survey was sent to all nurses working in an acute unit as clinical specialists (n=50, responses=49) and all practice nurses working with a general practitioner (n=1940, responses=420). None of the nurses had any from of nurse practitioner training nor did anyone possess the title of nurse practitioner. Clear areas of overlap and significant differences were identified in role functions between acute and community sector nurse practitioner role features. Areas of overlap included examining and diagnosing clinical problems, making appropriate referrals, designing research/audit reports and critically evaluating published literature. The differences illustrated the orientations of clinical nursing practice in the two sectors, for example, primary care nurses perceived that preventive health measures were more critical in their context than in the acute care sector. Primary care nurses also believed the nurse practitioner would be more involved with business and management activities. Acute care nurses placed greater significance on the provision of the total care package suggesting that planning for every stage of the patient's care is a priority for the acute sector nurse practitioner.

Walsh (1999 UK) surveyed 93 registered nurses taking level 2 or 3 continuing education modules at the University College of St Martin during summer term 1998 and 108 graduates of or undergraduates who had completed at least four modules of the Royal College of Nursing bachelor of science nurse practitioner course. There was a 71% return rate. The tool, the Caring Dimensions Inventory, has been tested for reliability and validity. There was a strong positive correlation between the two groups suggesting that nurses and nurse practitioners agree on the relative importance of many of the items. Nurses rated the following items of more importance than the nurse practitioners

• reporting a patient's condition to a senior nurse
• being with a patient during a clinical procedure
• assisting a patient with activities of daily living
• keeping relatives informed about a patient and
• being technically competent with a procedure
• Nurse practitioners rated the following items of more importance than the nurses:
• exploring a patient's lifestyle and
• psychosocial aspects

Walsh concludes that there is little difference between nurses and nurse practitioner perceptions of the relative importance of the aspects of care examined. The fact that nurse practitioners place more importance on psychosocial care and nurses on technical aspects contradicts the view nurse practitioners are mini-doctors.

Other Nurse Practitioner Roles

Other nurse practitioner roles are described in the literature including a clinical nurse specialist/neonatal nurse practitioner and a psychiatric nurse practitioner.

Gibbins, Green, Scott & MacDonell (2000 USA) describes the combined role of clinical nurse specialist/neonatal nurse practitioner in a breastfeeding clinic who acts as a consultant to Lactation Consultants in a large breastfeeding clinic. The clinical nurse specialist/neonatal nurse practitioner's primary role includes elements of advanced practice (critical thinking, assessment and analysis), leadership, education, consultation (re jaundice, infants with persistent weight loss, suspected breast infection, etc) and research.

Johnson (1998 USA) describes a role for the psychiatric nurse practitioner similar to that of other primary care nurse practitioners, with a context-specific focus, including using the psychosocial interventions of various psychodynamic and biological therapies, advocacy and psychopharmacology. Typically these NPs perform '...functions that overlap with psychiatrists, such as diagnosing mental disorders and treating them with various psychodynamic, analytic, or behavioral therapies' (Johnson, 1998 p. 22).

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