Nurse Practitioner-Led Clinic Research Articles

Patient Complexity in Nurse Practitioner-Led Clinics in Ontario

Aim: To assess the level of complexity of patients in Nurse Practitioner-Led Clinics (NPLCs).
 Background: Complexity has emerged as a key issue in primary health care. There is no easily accessible dataset to evaluate the level of complexity and needs of their patients in this clinic model.
 Methods: NPs at four NPLCs assessed patients during the study period with the PCAM, which is a reliable and valid tool that is used to evaluate physical and biopsychosocial elements contributing to complexity. A total of 677 PCAM evaluations were completed which were analyzed to determine the level of complexity of patients in NPLCs.
 Findings: The results showed that patients with the highest complexity are those with high social/economic needs: low education; low income; low levels of employment.
 Conclusions: These results demonstrate the potential positive impact of an interdisciplinary team and may inform changes to the allocation of resources in the clinic settings.

Abstract 117: Low-to-moderate Risk Transient Ischemic Attack Patients Can Be Safely Discharged From The Emergency Department To A Nurse Practitioner-Led Clinic

Background: Unnecessary admissions fuel rising healthcare costs and take away resources from higher acuity patients without evidence of increased safety. Purpose: The purpose of this quality improvement project was to determine if the care diversion for transient ischemic attack (TIA), from inpatient to a nurse practitioner (NP)-led specialty clinic, resulted in no increase in stroke incidence at 90 days. Methods: The sample included all adults (18 years or older) presenting to the emergency department (ED) with TIA at low-to-moderate risk for stroke. Risks were defined by the ABCD 2 score and non-invasive vessel imaging. Patients who met the criteria were discharged and evaluated by a stroke NP at the TIA clinic within seven days. These patients were compared to those who were admitted to the hospital prior to clinic launch. Chart reviews were conducted to determine stroke incidence at 90 days post TIA. Descriptive statistics were used to evaluate clinical variables, and Fisher’s Exact test was used to assess difference in stroke rates. Patient satisfaction score was collected using the existing institutional survey. Results: Eighty-one participants were included, 40 in the clinic group and 41 in the admission group. The mean ages in the clinic group and the admission group were 72.8 and 75.2 years, respectively ( p =0.37). Females comprised 45% of patients in the clinic group, compared to 51.2% in the admission group ( p =0.58). The mean ABCD 2 scores were 4.08 and 3.95 in the clinic and admission groups, respectively ( p= 0.63). The median clinic follow-up time was six days. There was no stroke incidence in the clinic group and one incidence in the admission group ( p =1.0) within 90 days of index TIA. Patient satisfaction score of the NP was 92.6%. Conclusions: In conclusion, referral to an NP-led clinic in patients with low-to-moderate risk TIA was equally safe as hospital admission.

Low-to-Moderate Risk Transient Ischemic Attack Patients can be Safely Discharged from the Emergency Department to a Nurse Practitioner-Led Clinic.

Low-to-Moderate Risk Transient Ischemic Attack Patients can be Safely Discharged from the Emergency Department to a Nurse Practitioner-Led Clinic.

Improving pediatric experience of pain during vaccinations: a quality improvement project.

The purpose of this paper is to share lessons learned from a quality improvement (QI) project that studied pediatric pain assessment scores after implementing additional evidence-based pain mitigation strategies into practice. Most nurses will acknowledge they implement some practices to mitigate pain during injections. Addressing pain during vaccination is important to prevent needle fear, vaccine hesitancy and health care avoidance. The aim of this project was to reduce pain as evidenced by pain scores at the time of vaccination at the North Bay Nurse Practitioner-Led Clinic (NBNPLC). The design for this study was quasi-experimental utilizing descriptive statistics and QI tools. The NBNPLC utilized the model for improvement to test change ideas. A validated observation tool to assess pain during vaccination with the pediatric population (revised Face Legs Activity Cry and Consolability) was used to test changes. The team deliberately planned improvements according to best practice guidelines to optimize use of strategies to mitigate pain during injections. QI tools and leadership skills were utilized to improve the pediatric experience of pain during vaccinations. Parents and clinicians provided qualitative and quantitative feedback to the project. Nurses tested pain assessment tools and agreed to use a validated tool to assess pain during vaccinations. Parents agreed to use of topical anesthetic during vaccinations. Improved pain scores during vaccinations were demonstrated with the use of topical anesthetic. Parents agreed to use of standardized sucrose solution during vaccination. Reduced pain scores were observed with the use of standardized sucrose water. To sustain implementation of the guideline, a nursing documentation form was devised with nurses agreeing to ongoing use of the form. This is a QI project that examined the intricacies of moving clinical practice guidelines into clinical practice. The project validates guidelines for pain management during vaccinations. Leaders within clinics who want to improve pediatric pain during vaccinations will find this paper helpful as a guide. Pain management in the pediatric population will be touched on in the context of parental expectations of pain. QI tools, lessons learned and suggestions for nurses will be outlined. Leadership plays an influential role in translating practice guidelines into practice. This paper outlines how organizational supports were instrumental to give clinicians time to deliberately challenge practice to improve quality of care of children during vaccinations.

Nutrition care practices of primary care providers for weight management in multidisciplinary primary care settings in Ontario, Canada - a qualitative study

BackgroundDespite the recommended guidelines on addressing diet for the management and prevention of obesity in primary care, the literature highlights that their implementation has been suboptimal. In this paper, we provide an in-depth understanding of current nutrition-related weight management practices of primary care providers (PCPs) working in relatively new multidisciplinary health care settings in Ontario.MethodsThree types of multidisciplinary primary care settings were included (2 Family Health Teams, 3 Community Health Centres and 1 Nurse Practitioner-Led Clinic). Participants (n = 20) included in this study were nurse practitioners (n = 13) and family physicians (n = 7) supporting care for adult patients (18 years or older). In-depth interviews were transcribed, coded and the content was analyzed using an integrated approach.ResultsOur analysis showed that most PCPs used anthropometric measures such as weight for screening patients who would benefit from nutrition counselling with a dietitian. The topic of nutrition was generally brought up either during physical examinations, when patients were diagnosed with a chronic disease, or when blood markers were out of normal range. Participants also mentioned that physical examinations are no longer occurring annually, with most PCPs offering episodic care. All participants reported utilizing dietetic referrals, noting the enablers for providing the referral, which included access to an on-site dietitian. Nonetheless, dietetic referrals were mostly used when patients had an obesity-related co-morbidity. Participants mentioned that healthy eating advice was reinforced during follow-up visits with patients only when there was enough time to do so. Electronic Health Records (EHRs) were utilized to facilitate message reinforcement by PCPs, who perceived EHRs to be helpful for viewing what was discussed in the session with the dietitian.ConclusionsPCPs mostly used objective measures to screen for patients who would benefit from nutrition counselling rather than diet assessment, which undermines the importance of dietary intake and overemphasizes weight. With physical examinations occurring less frequently, there will be additional missed opportunities for addressing nutrition-related concerns. The presence of a dietitian on site allowed for PCPs to refer patients to nutrition counselling. Having sufficient time during medical visits and EHRs seemed to facilitate message reinforcement by PCPs in follow-up visits with patients.

Nutrition and obesity care in multidisciplinary primary care settings in Ontario, Canada: Short duration of visits and complex health problems perceived as barriers.

Nutrition care in the primary care setting is integral in obesity management, but there is a substantial gap between patients who would benefit from this service and those receiving it. This study provides an in-depth understanding of how relatively new multidisciplinary primary care settings may be affecting nutrition care practices of family physicians and nurse practitioners. This qualitative comparative case study sought to assess nutrition care practices in three different types of multidisciplinary clinics (2 Family Health Teams, 3 Community Health Centers, 1 Nurse Practitioner-Led Clinic) in Ontario, Canada. Individual semi-structured interviews were conducted with nurse practitioners (n = 13) and family physicians (n = 7) in fall 2017. Data analysis was conducted using NVivo Software. The integrated approach was used for elucidating codes and themes. Findings suggest that suboptimal duration of medical visits and increasing prevalence of complex patients were reported by most participants and were perceived as barriers for addressing nutrition and obesity. However, improved nutrition care was fostered through Electronic Medical Records, primary care providers' positive attitude towards nutrition and cost-free dietitian services at point of access. Site-specific challenges, such as duration of medical visits, incentive programs, access to dietitians on site, and continued professional development could enhance nutritional care for weight management in these multidisciplinary primary care settings.

Nurse practitioner's perceptions of the impact of the nurse practitioner-led clinic model on the quality of care of complex patients.

AimTo evaluate the organizational processes that influence the quality of care for patients with multimorbidity at nurse practitioner-led clinics (NPLCs). BACKGROUND: People are living longer, most with one or more chronic diseases (mulitmorbidity) and primary healthcare for these patients has become increasingly complex. One response was the establishment of new models of primary healthcare. NPLCs are an example of a model developed in Ontario, Canada, which feature nurse practitioners as the primary care providers practicing within an interprofessional team. Evaluation of the extent to which the processes within NPLC model addressed the needs of patients with multimorbidity is warranted. METHODS: Eight nurse practitioners were interviewed to determine their perception of the quality of care provided to patients with multimorbidity at NPLCs. Interpretive description guided the analysis and themes were identified.FindingsThree themes arose from the analysis, each of which has an impact on the quality of care. The level of patient vulnerability at the NPLCs was high resulting in the need to address social and financial issues before the care of chronic conditions. Dynamics within the interprofessional team impacted the quality of patient care, including NP recruitment and retention, leaves of absence and turnover in staff at the NPLCs had an effect on interprofessional team functioning and patient care. Finally, coordination of care at the NPLCs, such as length of appointments, determined the extent to which attention was given to individual clinical issues was a factor. Strategies to address social determinants of health and for recruitment and retention of NPs is essential for improved quality of care. Comprehensive orientation to the interprofessional team as well as flexibility in care processes may also have positive effects on the quality of care of patients with complex clinical issues.

Quality of Care for Patients With Diabetes and Mulitmorbidity Registered at Nurse Practitioner-Led Clinics.

Background Nurse Practitioner-Led Clinics are a new model of primary healthcare in Ontario. Nurse Practitioner-Led Clinics are distinctive in that nurse practitioners are the primary care providers working with an interprofessional team. There have been no evaluations of the quality of care within the Nurse Practitioner-Led Clinic model. Purpose Evaluation of the Nurse Practitioner-Led Clinic model, specifically for complex clinical presentations, will provide insights that may be used to inform improvements to the delivery of care in the Nurse Practitioner-Led Clinics. The aim of this study was to evaluate the extent to which diabetes care was complete and to determine the impact of organizational tools, including electronic medical record tracking, diabetes care template, and referral to community programs, on the completeness of care for patients with diabetes and multimorbidity at Nurse Practitioner-Led Clinics. Methods An audit of 30 charts was conducted at five different Nurse Practitioner-Led Clinics (n = 150) for patients with diabetes and at least one other chronic condition. Indicators included patient and organizational characteristics as well as diabetes care items taken from diabetes clinical guidelines. Results Overall, care for patients with diabetes and multimorbidity in Nurse Practitioner-Led Clinics was complete. However, there were no significant associations between patient or organizational characteristics and the extent to which diabetes care was complete.

Politics and Professions: Interdisciplinary Team Models and Their Implications for Health Equity in Ontario.

Ontario's efforts to reform primary care through interdisciplinary primary care teams are unprecedented in Canada. Since 2004, the provincial government has focused its reform efforts on three models: Family Health Teams (FHTs), Community Health Centres (CHCs), and Nurse Practitioner-led Clinics (NPLCs). These models vary by team structure, funding, and governance. I examine the strong preference for the FHT model by the government and medical profession, and the implications of this preference on health equity. The opportunity for teams to increase health equity in Ontario may be limited due to the preference for physician-centered FHTs over more egalitarian team models.

Impact of Advanced Access Scheduling on Patient Care Choices and Health Behaviours in a Nurse Practitioner-Led Clinic

The Nurse Practitioner-Led Clinic (NPLC) is a new model of primary healthcare. The wholistic approach of nurse practitioner (NP) led care in an NPLC that implements Advanced Access scheduling has the potential to enhance timely access to care and improve health outcomes. The purpose of this study was to determine the experience of patients in one NPLC as well as their healthcare behaviours related to Advanced Access scheduling. A previously developed survey with items related to appointment access, health behaviours and satisfaction was mailed once to patients at a NPLC in northern Ontario. 535 patients replied for a response rate of 29%. A majority (85.4%) were able to access same-day appointments. Access to same-day appointments was associated with less likelihood of attending a walk-in-clinic or emergency department in addition to self-reports of improvements in lifestyle and better control of medical condition(s). Advanced access scheduling contributes to optimal patient care in an NPLC setting. The NP role in lifestyle counselling and wholistic care in the NPLC model contributes to improved self-reported health. Access to an appointment at a point of ‘readiness’ may positively contribute to lifestyle changes and overall health of patients.

A Multiple-Case Study in Nurse Practitioner-Led Clinics: An Exploration of the Quality of Care for Patients with Multimorbidity.

The previous 16 years have seen a number of healthcare reforms meant to increase access to primary healthcare services in Ontario. This included the establishment of an innovative model, the nurse practitioner-led clinics (NPLCs). NPLCs held promise for nurse practitioners (NPs) to practice to their full potential and optimize patient care. A multiple-case study was undertaken to evaluate the quality of care for patients with diabetes and multimorbidity at NPLCs. Five NPLCs, all in underserved areas in the mid-northern region of the province, were part of the study. Data collection included a chart audit, NP interviews and review of organizational information. Multiple-case analysis was conducted and four interrelated themes emerged about the quality of care of patients with diabetes and multimorbidity at the NPLCs. It was confirmed that the NP is the primary care provider at NPLCs. Healthcare policy such as a lack of increase in NP salary for 10 years has contributed to poor NP recruitment and retention. Insufficient healthcare resources in the communities where NPLCs are located and high patient vulnerability have a negative influence on the quality of care. Strategies, including mentoring, offer possible solutions to improve the quality of care at NPLCs.

Stakeholder Participation in System Change: A New Conceptual Model.

A recent change in Canada's primary care system led to the introduction of Nurse Practitioner-Led clinics. The literature suggests that stakeholders can influence system change initiatives. However, very little is known about healthcare stakeholder motivations, particularly stakeholders who are seen as resistors to change. To examine stakeholder participation in the system change process that led to the introduction of the first Nurse Practitioner-Led clinic in Ontario. This single case study included two site visits, semistructured individual tape-recorded interviews, and the examination of relevant public documents. Qualitative content analysis was used to analyze the data. Sixteen individuals from different healthcare sectors and professions participated in the interviews and 20 documents were reviewed. Six key themes emerged from the data. Linking Evidence to Action The findings from the study present a new perspective on stakeholder participation that includes both those who supported the proposed change and those who advocated for a different change. The findings identify stakeholder activities used to shape, share, and protect their visions for system change. The conceptual model presented in this study adds to the understanding of challenges and complexities involved in healthcare system change. Understanding why and how stakeholders participate in change can help healthcare leaders in planning activities to enhance stakeholder involvement in healthcare system change.

An Exploration of Patient Satisfaction in a Nurse Practitioner–Led Clinic

A unique and innovative model of primary healthcare (PHC) delivery began at the Sudbury District Nurse Practitioner Clinics (SDNPC) in 2007. Significant growth and development has taken place since the opening of this new model of PHC delivery. Now that SDNPC is operating at full capacity, an evaluation was warranted of patient experiences with clinic services and the level of overall patient satisfaction. A survey of clinic patients was conducted in the spring of 2011. Results demonstrated high satisfaction with clinic services. Some areas were identified for review, including the level of accessibility to same-day appointments and rationale for patient use of walk-in clinics and emergency department care. One of the strengths and benefits of this model of NP care was demonstrated in this evaluation, whereby a majority of patients identified that they had received counselling about a lifestyle issue and, of those patients, most reported a resulting positive health-related behavioural change. Ongoing comprehensive evaluation is important to ensure that services are efficient and directed to optimal patient health outcomes.

Canada's First Nurse Practitioner-Led Clinic: A Case Study in Healthcare Innovation.

Canada's first nurse practitioner-led clinic opened in 2007 after a period of intense lobbying. The development of this clinic has received a great deal of attention in the nursing world and among the general public, but the factors that enabled it have not been examined. The antecedents outlined in healthcare innovation concept analysis - including leadership, financial considerations, idea generation, teamwork, culture and demand - provide a framework for examination of the campaign for the nurse practitioner-led clinic. This review demonstrates the complex interplay of factors that drive healthcare innovation and expands understanding of the leadership and change competencies of the advanced practice nurse.