Effectiveness Of Non Medical Nurse Prescribing Primary Care
Nurse-led clinics have been increasing for some time and Marsden (1992) identified the benefits of using specialist nurses to compliment services already offered by doctors. Read (1999) defined nurse-led care as being the interface between nursing and medicine. Miles (2003) cited ten individual authors as saying that research shows that nurses are capable of carrying out procedures usually in the domain of doctors, often resulting in greater patient satisfaction.
Patient satisfaction is an important quality indicator. Yellen (2002) felt that the measurement of patient satisfaction with nursing care was particularly important as it provided a good measure of overall satisfaction with services. Ford (1997) agreed with this principle but concentrated more on the competitive edge and financial survival being reflected in patient satisfaction. Cohen (1994) advocated the use of satisfaction questionnaires, but both Avis (1997) and Westbrook (1993) doubted their efficacy, questioning the validity of questionnaires and the way in which they are measured. Westbrook (1993) felt that questionnaires may be limiting and poorly evaluated, giving rise to a poor reputation for satisfaction questionnaires. Duffin (2002) commented that questionnaires with tick boxes appear to have limited use and may include leading questions where there is no scope for the patient to enlarge upon their answers.
Both Robson (1993) and Wiles (1996) warned that the results of surveys can sometimes paint a falsely positive picture and may be difficult to translate into a course of action. However, Backhouse (2000) says that the power of a successful nurse-led user satisfaction survey lies in the immediacy and relevance of the results. This may have enormous potential to transform practice, especially if the staff are able to remain positive about any possible negative feedback. Backhouse (2000) commented that nurses may tend to take praise for granted, as a regular stream of cards and thanks is often the only feedback they receive. This may produce the belief that the service is satisfactory, but it has been found that although there is a great deal of satisfaction, there is also some dissatisfaction, particularly with respect to information (McColl (1996), Backhouse (2000), Byrne (2000), Duffin (2002)).
As a Business Manager in General Practice in an affluent rural environment, the author has found that there are increasing frustrations and limitations with time and resources where a competent healthcare professional could manage a patient’s care more than adequately during one appointment. Additionally, continuity of care and health care management in a more patient centred, balanced way could benefit the patient. Discussion around the management of their medicines and general health education could aid to the patient taking responsibility for their own health care management.
The Welsh Assembly Government (WAG) (WAG 2001, WAG 2005) has prioritised patient access to primary care services for the last few years which has impacted on patient expectation around the need for an urgent appointment. This has caused pressure on appointment systems, and subsequently changes have been made to deal with the demand. One way in which the practice would like to cope with these demands is by enabling the Senior Practice Nurse to give more holistic care, making the consultation seamless for the patient, thus reducing the need for additional appointments, having already consulted with an appropriate healthcare professional (WAG 2001, WAG 2005).
This practice nurse is currently undertaking the Independent Nurse Prescribing (non-medical). When qualified, this will tie in with the nurse-led diabetes clinic and Minor Illness clinics for which she is qualified. The natural progression would be for her to prescribe appropriate medicine or dressings in relation to the competencies she has accumulated following evidence based practice in these disciplines.
A nurse may spend a considerable amount of time dealing with the assessment and management of a patient, then waiting outside a GP’s door for a prescription to be signed. This situation is far from ideal, and with the enhancement of the prescribing qualification, this could be done in a more appropriate way. This literature review looks at aspects of nurse prescribing in primary care, and how this can lead to patient satisfaction, autonomy and job satisfaction for nurse prescribers.
Literature Search Strategy (Method: 10% c350 words) 582
LoBiondo-Wood (2002) describes a literature search as an efficient retrieval of scholarly literature related to the topic of interest, while Cormack (2000) describes a literature search as a review of previously written literature on a related topic in order to provide the researcher and the reader with knowledge of the field being researched.
Research literature can originate from many sources. The volume of literature would be unmanageable if careful selection was not carried out (Cormack 2000, LoBiondo 2002). Polit (2004) recommends using electronic databases to locate relevant research information and points out the limitations of manual and internet sources as being time consuming and inconvenient, internet searching possibly not providing required results and bibliographic information. Polit (2004) likens locating all relevant information on the chosen subject to being like detective work.
Primary research only was sought. CINAHL Plus (Cumulative Index of Nursing and Allied Health Literature) with Full Text and MEDLINE were used to search for key words “non-medical” AND “nurse prescib” AND “primary care” with published dates between January 2004 to present, resulting in 209 “hits”. These were restricted to research, years 2004-2010 and English-only articles in order to reduce the number of articles to 29.
Playle (2000) suggests that the title of a research article is extremely important and should cover focus as well as identifying the research approach used (McCaughan, 1999 & Stevens et al, 1993).
In the author’s case, an informative abstract facilitates the choice of research article.
The abstract or introduction, as Bailey (1991) suggests it should prepare the stage for the problem to be investigated, as well as being brief.
As suggested by Playle (2000) a well written abstract identifies the main points of the study, although the main weakness can be the word restriction as suggested by Burns and Grove (2001). It should represent an accurate picture (Reid, 1993) of the study with concise methodology, sample subject, reported findings and conclusion. This would enable any reader to base a decision to read the article (Reid, 1993).
The rationale for choosing the critique guidelines from Benton & Cormack (2000) is based on the convenience and manageability of a well structured process that enables to author to appraise with ease.
A literature review is an important element of a research question. Rees (2003 p. 17) indicates that ‘a thorough review of the literature is essential to provide the theoretical and conceptual context for the study’. Parahoo (1997) supports this stating a literature search provides the identification and locating up to date material, relevant to the topic under review. It involves the scanning along with critical reading of the literature chosen to assess usefulness to the question under discussion.
The author’s knowledge and prior reading of literature directed at change management in primary care dictated the final choice of research articles to Richards, L.A; Richards, A; Gilead, L; Stessman, J; blab la bla and Raz, I (1999) “title of an article” International Journal of Dermatology 38, 623-627 (appendix 1).
Those chosen for review were three qualitiative and one quantitative research articles relating to the question under evaluation.
All eleven authors have either the appropriate professional qualifications or academic qualifications, for example MD or PhDs. A further research on the authors’ names and using databases CINAHL and Medline xx to present showed that between them they have published xxx articles in various medical journals with different topics. Most have no bearing on the subject of maggots and wounds blab la bla, while most of them have some bearing….
The review (50% c1750 words) 2168
A good literature review draws on a wide range of sources (McCaughan, 1999) and will identify the need for research. Nevertheless, ‘A poor literature does not invalidate the findings but a good one does enhance the status of the research’ (Stevens et al, 1993:135).
A hypothesis is not included and an explanation could be that the aim of this study is to provide new information by utilising a descriptive research method. Burns and Grove (2001) suggested that if there is very little or no research being conducted on a particular question, then researchers state objectives or questions and there is an objective….
Quantitative research should have all terms explained or defined. Stevens et al (1993) refer to common error by researchers in the assumption that readers are knowledgeable about the jargon and terminologies employed.
The research approach is not acknowledged within the article. Howedver, it can be assumed that the approach is quantitative, in that it involves manipulation of the independent variable.. On the other hand, to provide the strongest evidence with a greater degree of …..
Also included are certain qualitative components such as ….. that would indicated possible combination of the two approaches, qualitative and quantitative. Using this combination in approach to research may not appear to be very scientific, however Docherty (2000) suggests that this method may produce a more meaningful and richer data. Even so, there is strength and weakness to both approaches and neither have been stated within this study. On the other hand… but backed up with …. And the author agreed with this type of approach as it enables a reader to scrutinise the data, without having to be familiar with research methodology, data statistics or the terminology.
The subjects are identified as 43xx in five depts. Of xx hospital …. Nevertheless, many potential or suitable candidates for this type of research may be unwilling to participate (burns & Grove, 2001 and Reid & Boore, 1987) due to the xxxx.
The approach to the sample selection is not clearly stated and a good research study should explain the sample selection method as suggested by Baxter (2001b). However…… On the other hand, all the subjects are typically,….
Data collection procedures are….. not acknowledged…..
The validity and reliability are undefined within this study and McCaughan (1999) suggests that if the researcher has not mentioned testing for reliability and validity then it is unlikely that it has been done.
Xxxxx ethical committee ….. In the author’s opinion, ethical consideration should have been an important part of this article…..
Appendix 3 shows/…..
As suggested by Matthews & Venables (1998) every published research report should include a description on how the informed consent is given. On the other hand, lack of acknowledgement of anonymity, confidentiality as well as the description of informed consent does not necessarily mean they have not been considered (Firby, 1995 & McCaughan, 1999), merely that the researchers assumed that the results and method were more interesting to the reader.
The results are presented as xxxxx and backed up by xxx, which showed that xxx. However, quantitative data is limited wtug xxxx. In spite of this, there is sufficient detail that would enable a reader without any research experience to look at the results and understand what they signify and to judge with confidence the findings.
The data analysis is appropriate to the type of data collected that is percentages and for the type of read that xxx was aiming for. In some ways the method employed is simple and easy to replicate. However, there…
Clarke (1999c) suggests that the data analysis relies heacily on the researchers’ skill and judgement to see that it is accurately exeuted, also not reported are values such as test values df and p. In addition, poor quality analysis will render the data anecdotal and unfocused, yet the analysis is focused, credible and to improve upon this, the author would suggest the inclusion of statistical tables.
The discussion is not really balanced, as it only mentions and draws upon xxxx
However, what is discussed is very concise and knowledgeable. There is also no acknowledgement of the limitations or weakness of this particular stify and there is only one reference to disadvantages, THAT IS …..
The aim of the literature review was to find out what the nurses role is in primary care, in relation to providing xxxxx. To assist in the critiquing process, quantitative and qualitative papers were reviewed using the Benton and Cormack (2000) framework. Although the author finds this framework comprehensive and simplistic, it is noted Rees (2003) states qualitative and quantitative research are extremely different, and same method of critiquing cannot be used. This opinion is not upheld by Benton and Cormack (2000) as they promote the use of one framework for both.
Within the articles reviewed the evident themes that emerged are xxx and xxxx.
In order to guide the reader to continue reading a paper, the abstract should set the scene for the rest of the report. Playle (2000) states an abstract that is soundly written will list the main points of a study. It is noted three out of the four articles reviewed have concise detailed abstracts. Although, that by xxx (2006) lacked depth, understanding and did note cite up to date government papers to support the topic of xxxx. Burns and Grove (2001) highlight that a potential weakness noted wihin Gibbs et al (2004b) paper was the difficulty the reader encountered at determining whether the paper was quantitative or qualitative. Parahoo (1997) concedes this should have been obtained within the abstract, as this should briefly summarise the method, sampling and main findings within a study. Within the abstracts of the articles reviewed, the researchers have clearly portrayed and accurate image of all study methodologies, reported findings, sample subjects and conclusions.
Gibbs et al (2004a) initial quantitative research paper tested one hundred and forty-one general practitioners and sixty-six practice nurse opinions relating to xxxx. Results favourably showed that ninety-seven percent of practice nurses raised xxxx but the article concluded xxxx within primary care and mainly relied upon xxxx. Leading on from this study, Gibbs et al (2004b) carried out a quantitative study involving eight general practices and one thousand five hundred and forty-nine kxdffdsdf. The article reports on xxxx. This quantitative paper involved structured interviews where questions were asked in a planned format. A structured interview involves set questions with no deviation from these (Parahoo 1997).
A limitation of the study was the elevated drop-out rate but positively forty percent achieved a five percent or more weight loss at twelve months. It highlights whether the researcher has performed the study in a logical, systematic method, having paid attention to pointers that may influence the accuracy of the results (Rees 2003). Although Burns and Grove (2001) argue that a rigorous study should have exact measurement tools, a representative sample and a tightly controlled design. Audit was conducted in all practices prior to the study, where measurement tools such as weighing scales, height measure and large blood pressure cuffs were assessed. The provided consistency of the tools used at each centre along with evidence of their validity. Validity refers to whether an instrument measures what it stated to be measuring whilst reliability relies upon individuals using the tools and reporting accurate measurments obtained (Carter and Porter 2000).
It was noted those practices participating in this study were self-selected, already having an interest in obesity management, thus possibly weakening representations. It was encouraging that a cross-section of those involved included large practices, rural, urban, single handed and those fro low deprivation areas. This appeared to provide a representative population with no evidence of bias selection. The xxxx project was ethically approved by xxxx.
In contrast Moore et al (2003) in a cluster randomised control studyxxxxxxxx Cluster randomised trual means the sampling frame are geographically spread or the individual elements of the population are not know (Rees 2003). The advantage of this process is achievement of an accessible sample from an almost impossible total population (Rees 2003). Donnan (2000) states experimental research is the gold standard way of representing in a rigorous style that a treatment or intervention is effective. It concludes it si an essential tool for qualitative evaluation of a study’s worth. Greenhalgh (2006) draws attention to the fact that publication of an article does not mean the evidence is robust.
In conclusion as found in xxxx. Rees (2003) states bias is anything that distorts or affects a study, potentially altering or influencing the accuracy of the findings. Results noted that xxxx. They conclude more in=depth training of health professionals is needed xxxx. This would involve further implementation of training progrmmes and additional research. Ethical approval was granted by the xxxx ethics committee.
The research paper by XX (2007) mixes quantitative and qualitative approaches and is known as triangulation,. Docherty (2000) suggests use of triangulation provides richer, more meaningful data. Holloway and Wheeler (2002) support this method stating it to be a way of obtaining rigour in qualitative research. Rees (2003 p. 235) lists this as being ‘the use of more than one method of data collection within the same study in an attempt to produce more accurate information and understanding’.
This was a cross-sectional study with questionnaires being completed by forty General Practitioners and forty-seven practice nurses. A limitation to this study was no indication was made of the total number of initial questionnaires sent out in comparison to the response rate. A cross-sectional study is a survey that gazes at a situation at one point in time (Rees 2003). The qualitative results by xx (2005) were not shown within the report and rigour was disputed on reading the research paper as a full conclusion of the findings could not be made. It is realised word restriction could be the main reason for the results being omitted, but unfortunately it leaves the reading having to guess what they might have concluded. Ethical approval was supported by xxxx.
In comparison with Gibbs et al (2004b) article the outcomes indicated mirror one another, with both papers coming to the conclusion that opportunties for xxxxxx in primary care are often missed or inadequate time given to education and support. Although the report by xx(2—3) shows xxxx, it was indicated this was in accordance with increasing responsibilities in implementation of chronic disease management. It is highlighted in the report that caution regarding results needs to take place. Also this article, although mainly quantitative, has a small sample size. Parahoo (1997) states quantitative research usually involves large numbers in probability samples. The importance of large numbers aims to lessen the chance of bias and correctly achieve statistical procedures (Rees 2003).
A pilot study was not carried out prior to this research. Piloting of a questionnaire increases research validity and reliability as it highlights any anticipated problems accessing data, and ensures the method used to gather data works (Parahoo 1997). Research should be instigated because the researcher wants to extend knowledge base and understanding through rigorous collection of information, answering a question objectively and with accuracy (Rees 2003).
Soanso (2009) article is a qualitative study and deals with support and perceptions of the patient who is obese. This is a primary study that reports research findings first hand (Greenhalgh 2006). Rees (2003) states to have involvement in qualitative research and understand a topic, individuals first have to see it through the eyes of those who experience it. This method aims to summarise perceptions, experiences, behaviour or interpretations. This process included a qualitative study with semi-structured interviews drawing on grounded theory methodology. Grounded theory aims to produce a concept or explanation that is ‘grounded’ in the results and arises inductively by researchers understanding and analysis (Rees 2003). Polit et al (2001) strongly supports interviews stating they by far outweigh questionnaires. The response rate is higher, reaching a wider population than questionnaires, are less likely to mislead those reading the questions and provide wealthier data. Rees (2003) agrees with the above adding, those involved can experience the belief of being in control and positively feeling more valued. It is noted there are disadvantages such as high cost, participants providing socially acceptable answers, affect of interviewer status and difficultly in expressing feelings (Rees 2003). Five general practices from differing socioeconomic backgrounds in Sheffield were involved with interviews conducted at their homes. This provided a varied population adding rigour to the study, and it could be generally assumed an individual would feel more comfortable being interviewed within their own surroundings. Although, it can be argued that interviewers have less power to control the interview within this environment as there is no assurance that the interviewee will maintain a safe place with no interruption, disturbance or being overheard (Pontin & Webb 1995, Webb & Pontin 1996).
Kdfsdfsfhskdfhsd. Ethical approval was sought prior to this study from xxx Ethics Committee.
Application to clinical practice (30% c 1050 words) 1086
APPLICATION TO PRACTICE
At present within the author’s practice setting issues of xxxx are raised xxxx. Since April 2006 the General Medical Service Contract (National Health Service 2006) awarded points for the xxxx.
This critical review of the literature has aimed to answer the question: xxxxxxxxxxxxxxxxxxxxxxxxx? It is well documented that xxxx. Research that has been carried out in an ethical manner and is of robust design can benefit all involved and improve practice (Royal College of Nursing 2004). The document Best Research for Best Health (Department of Health 2006a) states research provides the support and evidence to tackle increasing challenges that disease and ill health have placed on society. This document supports a pilot study within primary care in England to improve evidence based practice of care by facilitating the conduct of clinical trial and other well designed studies. It would hardly be an exaggeration to say, pending successful results in 2014, the use of this structure within primary care in Wales could potentially benefit application of much needed research findings into practice.
Findings of this review showed the counterweight project by Gibbs et al (2004a, 2004b) provided the best evidence of implementation within practice, showing xxxx. The Cochrane Library for Sytematic Reviews (2004) supports the Counterweight Project (2004b) stating ‘The Counterweight Programme is an evidence-based weight managmentxxxx Brown & Psarou (2007) in their literature review also supported this project stating it was rigorously conducted and soundly funded. Presentation of these research findings were undertaking xxxx.
Banning (2005) suggests the management of obesity should focus on xxxx. The National Institue for Clinical Excellence (2001) states that primary care nurses are ideally placed to manage and assess obese individuals. This comprehensive package addresses issues and management of ….. The material is simplistic with the alforithm providing an easy guide for the primary care nurse to follow, The …… pathway opportunistically at routine appointments or reviews.
To implement this in the clinical setting, xxxx.
Successful implementation of this pathway into the practice setting would require change management issues to be addressed. Implementation of change following research can be a difficult process. Resistance, resentment and jealousy can all impede implementation of the change process (Cormack 2000). To overcome resistance to change the key factor is leadership, along with effective communication and a sound understanding of what motivates people (LaMonica 1994). Those involved in the change process must be kept informed and involved at each stage of change. Individuals like equilibrium and are keen to be involved once they know the process will not cause problems or a change of workload (Broome 1998).
A conclusion was included within the abstract, xxxx
As suggested by McCaughan (1999) and Playle (2000), there is a restriction placed on researchers and authors by publications to condense from a much larger and more detailed research report. It can be assumed that this is the case with this research article.
However, as suggested by Baxter (2001c) that in qualitative research to aid the flow and understandings, discussion and conclusion are kept together under one heading. In the author’s opinion, the conclusion should have ……
Stevens et al (1993) suggests the realistic researcher would draw conclusion from the data presented and then make further recommendations on what other research is required. However, there is no heading of recommendation or any indication that one was included. Alternatively, suggestions for further research studies and in the author’s opinion threr should have been a recommendation for future randomised control trial.
There is a possibility as suggested by Playle (2000) that the actual research report is more detailed with recommendations, but this may have been lost when condensed for publication.
In conclusion, this literature review has shown xxxx. To achieve this, implementation of findings along with ongoing research is necessary to sustain the evolving needs of xxxx. It should be noted that a limited number of research articles were used for this review, providing partial evidence. Thus, it is suggested more concrete evidence is needed requiring a further search and review of the literature on xxxx. It would hardly be an exaggeration to say that this review has highlighted the need for further research on the topic of xxxx relating to support and education. It can be said this would potentially emphasise additional studies, which in turn could be applied to practice improving nurse education and support to the obese patient.
APPLICATION TO CLINICAL PRACTICE
The article on …. Appeared to be a concise, informative and innovative piece of research on first perusal. However, what appeared at first glance to be just….. turned out to be more complicated upon closer iinvestigation and mmmmmm. The reader begins to question…
It has a focus and direction, which is to assess the efficacy of maggot therapy and a very concise and informative methodology, which would enable anyone to reproduce a similar type of research. The data collection procedures are not clearly identified, although the simple representation allows it to be easily followed and replicated.
This is further confounded by the entwined discussion and conclusion and as suggested by Baxter (2001c) this often occurs with qualitative research. Nevertheless, the reader must balance the evidence presented and sometimes more than one type of evidence (Roberts, 1999) is needed to determine if the interventions is practicable or efficient, as well as ethical and morally sound (Freak, 1995). Another point is the ethical considerations …. Ethical significance ….
An assumption is the researcher focus on the results or alternative the method, as being more interesting or important (Firby, 1995) to the reader.
As suggested by various authors including Polit & Hungler (1991) all research has limitation and can be imperfect and if this research article has been condensed from a much larger research report, then this critique has been conducted on a published condensed research article and not the actual research report. Therefore, what imperfections or liitations that are identified within this critique, is the ability of the researchers to actually condense their work and the readers have to assume that the researchers have honestly presented their fndings (Firby, 1995).
For all the points highlighted like ethical, operational definitions, qualitative/quantitative approach, this is a very good informative research article that allows anyone to replicate the study.
The author would like to recommend that… Furthermore, it …. However, as reported by XX, the main disadvantage is,,,, nevertheless,
A readonable recommendation in the author’s opinion would be…, In addition, if there is…
INTEGRATING RESEARCH INTO PRACTICE
Sdfhsdkfhshdfhdfh to advocate and support the patient.
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