Many countries are seeking to improve health care delivery by reviewing the roles of health
professionals, including nurses. Developing new and more advanced roles for nurses could improve
access to care in the face of a limited or diminishing supply of doctors. It might also contain costs by
delegating tasks away from more expensive doctors. This paper reviews the development of advanced
practice nurses in 12 countries (Australia, Belgium, Canada, Cyprus, Czech Republic, Finland, France,
Ireland, Japan, Poland, United Kingdom and United States), with a particular focus on their roles in
primary care. It also reviews the evaluations of impacts on patient care and cost.
The development of new nursing roles varies greatly. The United States and Canada established
"nurse practitioners" in the mid-1960s. The United Kingdom and Finland also have a long experience in
using different forms of collaboration between doctors and nurses. Although development in Australia and
Ireland is more recent, these two countries have been very active in establishing higher education
programmes and posts for advanced practice nurses in recent years. In other countries, the formal
recognition of advanced practice nurses is still in its infancy, although unofficial advanced practices may
already exist in reality.
Evaluations show that using advanced practice nurses can improve access to services and reduce
waiting times. Advanced practice nurses are able to deliver the same quality of care as doctors for a range
of patients, including those with minor illnesses and those requiring routine follow-up. Most evaluations
find a high patient satisfaction rate, mainly because nurses tend to spend more time with patients, and
provide information and counselling. Some evaluations have tried to estimate the impact of advanced
practice nursing on cost. When new roles involve substitution of tasks, the impact is either cost reducing
or cost neutral. The savings on nurses’ salaries – as opposed to doctors – can be offset by longer
consultation times, higher patient referrals, and sometimes the ordering of more tests. When new roles
involve supplementary tasks, some studies report that the impact is cost increasing.

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Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries

Evolution of the concept of self-care and implications for nurses: A literature review

Background: Information and communication technologies (ICTs) are becoming an impetus for quality health care delivery by nurses. The use of ICTs by nurses can impact their practice, modifying the ways in which they plan, provide, document, and review clinical care. Objective: An overview of systematic reviews was conducted to develop a broad picture of the dimensions and indicators of nursing care that have the potential to be influenced by the use of ICTs. Methods: Quantitative, mixed-method, and qualitative reviews that aimed to evaluate the influence of four eHealth domains (eg, management, computerized decision support systems [CDSSs], communication, and information systems) on nursing care were included. We used the nursing care performance framework (NCPF) as an extraction grid and analytical tool. This model illustrates how the interplay between nursing resources and the nursing services can produce changes in patient conditions. The primary outcomes included nurses’ practice environment, nursing processes, professional satisfaction, and nursing-sensitive outcomes. The secondary outcomes included satisfaction or dissatisfaction with ICTs according to nurses’ and patients’ perspectives. Reviews published in English, French, or Spanish from January 1, 1995 to January 15, 2015, were considered. Results: A total of 5515 titles or abstracts were assessed for eligibility and full-text papers of 72 articles were retrieved for detailed evaluation. It was found that 22 reviews published between 2002 and 2015 met the eligibility criteria. Many nursing care themes (ie, indicators) were influenced by the use of ICTs, including time management; time spent on patient care; documentation time; information quality and access; quality of documentation; knowledge updating and utilization; nurse autonomy; intra and interprofessional collaboration; nurses’ competencies and skills; nurse-patient relationship; assessment, care planning, and evaluation; teaching of patients and families; communication and care coordination; perspectives of the quality of care provided; nurses and patients satisfaction or dissatisfaction with ICTs; patient comfort and quality of life related to care; empowerment; and functional status. Conclusions: The findings led to the identification of 19 indicators related to nursing care that are impacted by the use of ICTs. To the best of our knowledge, this was the first attempt to apply NCPF in the ICTs’ context. This broad representation could be kept in mind when it will be the time to plan and to implement emerging ICTs in health care settings. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews: CRD42014014762; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014014762 (Archived by WebCite at http://www.webcitation.org/6pIhMLBZh) [J Med Internet Res 2017;19(4):e122]

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Impact of Information and Communication Technologies on Nursing Care: Results of an Overview of Systematic Reviews.

Mental health nurses work with acutely unwell patients, and the busy setting is characterised by unpredictable events. This paper is a report of a review conducted to identify, analyse and synthesize research in adult acute inpatient mental health units, which focused on nurse-patient interaction. Several electronic databases were searched using relevant keywords to identify studies published from 1999-present. Qualitative studies published in English were included if they specifically investigated nurse-patient interaction in acute inpatient care in adult settings. Eighteen studies were included (23 papers). Findings were grouped into the following six categories: 1) sophisticated communication; 2) subtle discriminations; 3) managing security parameters; 4) ordinary communication; 5) reliance on colleagues; and 6) personal characteristics. These studies of acute inpatient mental health units reveal that nurse communication involves interpersonal approaches and modalities that exemplify highly developed communication and personal skills designed specifically for this challenging setting. Further quality research should focus on the conditions that enable the development of therapeutic interactional skills and the relationship of these skills to the nuanced context in which they are practiced.

Nurse-Patient Interaction in Acute Adult Inpatient Mental Health Units: a Review and Synthesis of Qualitative Studies

sangster-gormley e., martin-misener r., downe-wamboldt b. & dicenso a. (2011) Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review. Journal of Advanced Nursing67(6), 1178–1190.

Abstract
Aim.  To review the literature about the Canadian experience with nurse practitioner role implementation and identify influencing factors.

Background.  Although nurse practitioners have been in existence for more than 40 years, their integration into healthcare systems has been challenging. While frameworks exist to guide implementation of these roles, clear identification of factors influencing role implementation may inform best practices. Given that Canada has witnessed considerable growth in nurse practitioner positions in the past decade, an exploration of its experience with role implementation is timely.

Data sources.  A review of Canadian literature from 1997 to 2010 was conducted. Electronic databases including CINAHL, Cochrane Database of Systematic Reviews, Health Source: Nursing Academic Edition, Medline, Social Science Index, PubMed, Web of Science and PsychINFO and government and professional organization websites were searched.

Methods.  An integrative review was performed guided by Whittemore and Knafl’s method.

Results.  Ten published studies and two provincial reports were included. Numerous facilitators and barriers to implementation were identified and analysed for themes. Three concepts influencing implementation emerged: involvement, acceptance and intention. Involvement is defined as stakeholders actively participating in the early stages of implementation. Acceptance is recognition and willingness to work with nurse practitioner. Intention relates to how the role is defined.

Conclusion.  This integrative review revealed three factors that influence nurse practitioner role implementation in Canada: involvement, acceptance and intention. Strategies to enhance these factors may inform best practice role implementation processes.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2648.2010.05571.x

Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review

purc-stephenson r.j. & thrasher c. (2010) Nurses’ experiences with telephone triage and advice: a meta-ethnography. Journal of Advanced Nursing66(3), 482–494.

Abstract
Aims.  This study is a meta-ethnography of nurses’ experiences with telephone triage and advice and factors that facilitate or impede their decision-making process.

Background.  Telephone triage and advice services are a rapidly expanding development in health care. Unlike traditional forms of nursing practice, telenurses offer triage recommendations and advice to the general public without visual cues.

Data sources.  Published qualitative research on telephone triage and advice were sought from interdisciplinary research databases (1980–2008) and bibliographical reviews of retrieved studies.

Review methods.  Our systematic search identified 16 relevant studies. Two researchers independently reviewed, critically appraised, and extracted key themes and concepts from each study. We followed techniques of meta-ethnography to synthesize the findings, using both reciprocal and refutational translation to compare similar or contradictory findings, and a line-of-arguments synthesis.

Results.  We identified five major themes that highlight common issues and concerns experienced by telenurses: gaining and maintaining skills, autonomy, new work environment, holistic assessment, and stress and pressure. A line-of-arguments synthesis produced a three-stage model that describes the decision-making process used by telenurses and highlights how assessments largely depend on the ability to ‘build a picture’ of the patient and the presenting health issue.

Conclusion.  Telenurses experience a range of common concerns and issues which either impede or facilitate the decision-making process. Although ‘building a picture’ of the patient is key to making assessments over the telephone, final triage decisions are influenced by balancing the conflicting demands of being both carer and gatekeeper to limited healthcare services.

Nurses’ experiences with telephone triage and advice: a meta-ethnography

Purpose: To measure patient satisfaction with care delivered by nurse practitioners (NPs) in emergency departments (EDs) in Canada using a psychometrically valid survey.

Data sources: All patients who received care from an NP in six participating EDs in Ontario province over a 1-week period were asked to complete a self-administered patient satisfaction survey designed specifically to assess satisfaction with NP care in EDs.

Conclusions: One hundred and thirteen patients completed the survey. Principal components analysis of the survey revealed three factors or subscales: Attentiveness, Comprehensive care, and Role clarity. Scores on the three subscales indicated that patients were satisfied with Attentiveness (M = 3.72, SD = 0.38) and Comprehensive care (M = 3.52, SD = 0.49) and had a moderate understanding of Role clarity (M = 2.99, SD = 0.66). Participants with higher income levels reported higher levels of satisfaction with the attentiveness they received, whereas patients with previous experience with an NP reported higher levels of satisfaction with the comprehensive care they received. There was no appreciable increase in patient satisfaction with the NP based on age, gender, education, or health status.

Implications for practice: These findings indicate that attentiveness, comprehensive care, and role clarity are reflected by the NP in emergency healthcare settings as indicated by the patient‘s responses to the survey. This study supports that meeting expectations is a critical component of patient satisfaction.

Patient satisfaction with nurse practitioner care in emergency departments in Canada

Patient compliance with telephone triage recommendations: a meta-analytic review.

Objective: The objective of this study was to identify the facilitators and barriers associated with integrating nurse practitioners (NPs) into Canadian emergency departments (EDs) from the perspectives of NPs and ED staff. Methods: We conducted 24 semi-structured interviews with key multidisciplinary stakeholders in 6 Ontario EDs to gain a broad range of perspectives on implementation issues. Data were analyzed using a grounded-theory approach. Results: Qualitative analysis of the interview data revealed 3 major issues associated with NP implementation: organizational context, role clarity and NP recruitment. Organizational context refers to the environment an NP enters and involves issues related to the ED culture, physician reimbursement system and patient volume. Role clarity refers to understanding the NP’s function in the ED. Recruitment issues are associated with attracting and retaining NPs to work in EDs. Examples of each issue using respondent’s own words are provided. Conclusion: Our study identified 3 issues that illustrate the complex issues involved when implementing NPs in EDs. The findings may inform policy makers and health care professionals in the future development of the role of NPs in Canadian EDs.

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Integrating nurse practitioners into Canadian emergency departments: a qualitative study of barriers and recommendations.

Purpose
To critically analyze the role of the primary care nurse practitioner (NP) as advocate in promoting health through self care

Data Sources
Selected philosophical and theoretical texts and articles, scientific literature, professional standards, and ethical arguments

Conclusions
Philosophical reasoning and nursing theory must be used to validate and direct human practice If self-care and well-being are desirable as an end and are defined as a movement toward self-determination, then the philosophical goal of the NP must be the protection and promotion of self care and autonomy through client advocacy Implications for Practice The role of the NP must be defined by its philosophy of care rather than by its function The influence of philosophical reasoning, nursing, and critical social theory impact the ability of the NP to promote self-care through advocacy Understanding the lived experience is an essential component of advocacy

Christine Thrasher

Papers

Nurses’ experiences with telephone triage and advice: a meta-ethnography

Patient satisfaction with nurse practitioner care in emergency departments in Canada

Patient compliance with telephone triage recommendations: a meta-analytic review.

Integrating nurse practitioners into Canadian emergency departments: a qualitative study of barriers and recommendations.

The Primary Care Nurse Practitioner: Advocate for Self Care