Journal of Nursing Management, 2015, 23, 920–930
Impact of a quality improvement intervention on nurses’ management of same-day primary care flow JERONI JURADO-CAMPOS P h D , M S c , R N 1, EDURNE ZABALETA-DEL-OLMO M S c , R N 2,3, MARIA TERESA ANGLADA-DILME M N M , R N 4, LAURA SANCHEZ-VILANOVA R N 4, MARGARITA RABASSA-ESTER R N 4, NURIA BARBERI-COSTA R N 4, MAGDA PAGES-PASCUAL A D 5 and MONTSERRAT CANET-PONSA R N 6 1
Researcher, Institut Universitari d’Investigaci o en Atenci o Primaria (IDIAP) Jordi Gol, Girona, 2Researcher, 3 onoma de Barcelona, Bellaterra (Cerdanyola del Valles), IDIAP Jordi Gol, Barcelona, Researcher, Universitat Aut o Primaria Olot, Institut Catala de la Salut (ICS), Olot, Barcelona, 4Primary Care Nurse, Equip d’Atenci 5 Administrative Support Staff, Equip d’Atenci o Primaria Olot, Institut Catala de la Salut (ICS), Olot and 6Nurse Manager, Servei d’Atenci o Prim aria Girona Sud, ICS, Girona, Spain
Correspondence Edurne Zabaleta-del-Olmo Researcher IDIAP Jordi Gol Gran Via de les Corts Catalanes, 587 atic 08007 Barcelona Spain E-mail: [email protected]
JURADO-CAMPOS J., ZABALETA-DEL-OLMO E., ANGLADA-DILME M.T., SANCHEZ-VILANOVA L., RABASSA-ESTER M., BARBERI-COSTA N., PAGES-PASCUAL M. & CANET-PONSA M.
(2015) Journal of Nursing Management 23, 920–930. Impact of a quality improvement intervention on nurses’ management of same-day primary care flow Aim To evaluate the impact of an interdisciplinary intervention designed to improve the capacity of nurses to manage walk-in patient demand for primary health care. Background Implementation of a programme to expand nursing practice is a complex process that requires the application of context-appropriate measures and adaptation when results do not meet expectations. Methods A longitudinal, uncontrolled intervention study with a 3-year follow-up, from 2009 to 2012, was carried out in Catalonia (northeast Spain). The intervention included three training periods focused on clinical and instrumentation topics. The capacity of nurses to manage walk-in patient demand was assessed by determining the number of cases resolved and of return visits for the same complaint within 72 hours. Results In total, 2751 patient care demands were evaluated. Resolved cases increased (v2 = 54.624, df = 1, P < 0.001) and the number of return visits decreased (v2 = 54.585, df = 1, P < 0.001) significantly from baseline to the end of the study period. Conclusions Nurses’ capacity to manage walk-in patient demand improved after an interdisciplinary intervention using a mutually agreed upon, locally adapted approach. Implications for nursing management To improve outcomes, nurses in management positions should systematically consider the need for skills training, specific academic courses, leadership development and, as appropriate, legislative initiatives.
Keywords: health services research, nurse’s role, primary health care, quality improvement, training Accepted for publication: 20 February 2014
920
DOI: 10.1111/jonm.12236 ª 2014 John Wiley & Sons Ltd
Nurses’ management of same-day primary care flow
Introduction Primary care nurses worldwide have demonstrated their capacity to manage and treat patients with chronic diseases and to manage urgent care consultations (Laurant et al. 2005). With proper preparation and training, nurses can take on some of the tasks and functions normally associated with physicians, achieving similar health outcomes and even increased patient satisfaction (Horrocks et al. 2002, Laurant et al. 2005, Delamaire & Lafortune 2010, Iglesias et al. 2013). This demonstration of professional capacity has not, however, led to expansion of nursing practice, roles, or autonomy, except in a few countries (Delamaire & Lafortune 2010, Hoare et al. 2012, Riegel et al. 2012), especially those with advanced practice nursing or nurse practitioners (Horrocks et al. 2002, Delamaire & Lafortune 2010, Arts et al. 2012, Jokiniemi et al. 2012). In Catalonia (an autonomous community in northeast Spain), primary care is organised into geographic entities called basic health care areas (BHAs), staffed by teams of physicians and nurses, with support staff. In general, primary care nursing focuses on follow-up of patients with chronic diseases and on delegated ~ez 2010, Caja L tasks (Hern andez Y an opez 2011). Entry-level nurses have a 3-year diploma (since 1977 a 3-year university degree) with no higher-level accreditations. The new university structure of 4-year degrees, master’s degrees and doctorates (Zabalegui & Cabrera 2009) offers nurses the opportunity to develop additional competencies and expand their nursing roles. However, these more recent graduates have not yet arrived in the primary care setting. The challenges, criticisms and lack of regulation of expanded nursing practice in Spain are similar to those of other European countries (Coombes 2008). The main issues are associated with a limited level of academic preparation, a lack of ad hoc options for advanced accreditations and resistance to the expansion of nurs~ez 2010, Caja L ing practice (Hern andez Y an opez 2011). Along with their limited role in patient education and health promotion, nurses are making progress in case management, liaison nursing and caring for dependent individuals (Caja L opez 2011). However, nurse autonomy and the expansion of nursing functions in the interdisciplinary context clearly continue to be inade~ez 2010, Caja L quate (Hern andez Y an opez 2011).
Overview of the literature The current demographic and social paradigm in Catalonia includes increased life expectancy, which is ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 920–930
associated with more health-care needs and higher expectations that add greatly to the human resource and treatment costs (Zabalegui & Cabrera 2010, Caja L opez 2011). The situation is aggravated by the current economic crisis, making adequate funding even more difficult (Zabalegui & Cabrera 2010). This panorama demands a reorientation of health-care policy (Hoare et al. 2012) to emphasise resource optimisation, efficiency and effectiveness, reinforcing the tasks and functions related to meeting the demand for health care and decreasing the saturation levels of certain services. In February 2009, the Catalan Institute of Health (ICS, Institut Catala de la Salut), a public agency that manages approximately 80% of primary care services in Catalonia, assigned primary care nurses new responsibilities in the management of same-day, walkin patients. The new programme included the implementation of a protocol with algorithms for managing the most common minor illnesses. Various studies have reported positive results from this programme in the ICS primary care centres (Fabrellas et al. 2011) and other similar initiatives (Brugues et al. 2008, Leal Negre et al. 2011, Pascual et al. 2012). Nonetheless, the initial effectiveness of the ICS programme was not equal in all BHAs. In our BHA, the capacity of nurses to manage same-day care (SDC) flow after the initial ICS training process and programme implementation was considered inadequate because the percentage of same-day resolution of those cases was
Impact of a quality improvement intervention on nurses’ management of same-day primary care flow JERONI JURADO-CAMPOS P h D , M S c , R N 1, EDURNE ZABALETA-DEL-OLMO M S c , R N 2,3, MARIA TERESA ANGLADA-DILME M N M , R N 4, LAURA SANCHEZ-VILANOVA R N 4, MARGARITA RABASSA-ESTER R N 4, NURIA BARBERI-COSTA R N 4, MAGDA PAGES-PASCUAL A D 5 and MONTSERRAT CANET-PONSA R N 6 1
Researcher, Institut Universitari d’Investigaci o en Atenci o Primaria (IDIAP) Jordi Gol, Girona, 2Researcher, 3 onoma de Barcelona, Bellaterra (Cerdanyola del Valles), IDIAP Jordi Gol, Barcelona, Researcher, Universitat Aut o Primaria Olot, Institut Catala de la Salut (ICS), Olot, Barcelona, 4Primary Care Nurse, Equip d’Atenci 5 Administrative Support Staff, Equip d’Atenci o Primaria Olot, Institut Catala de la Salut (ICS), Olot and 6Nurse Manager, Servei d’Atenci o Prim aria Girona Sud, ICS, Girona, Spain
Correspondence Edurne Zabaleta-del-Olmo Researcher IDIAP Jordi Gol Gran Via de les Corts Catalanes, 587 atic 08007 Barcelona Spain E-mail: [email protected]
JURADO-CAMPOS J., ZABALETA-DEL-OLMO E., ANGLADA-DILME M.T., SANCHEZ-VILANOVA L., RABASSA-ESTER M., BARBERI-COSTA N., PAGES-PASCUAL M. & CANET-PONSA M.
(2015) Journal of Nursing Management 23, 920–930. Impact of a quality improvement intervention on nurses’ management of same-day primary care flow Aim To evaluate the impact of an interdisciplinary intervention designed to improve the capacity of nurses to manage walk-in patient demand for primary health care. Background Implementation of a programme to expand nursing practice is a complex process that requires the application of context-appropriate measures and adaptation when results do not meet expectations. Methods A longitudinal, uncontrolled intervention study with a 3-year follow-up, from 2009 to 2012, was carried out in Catalonia (northeast Spain). The intervention included three training periods focused on clinical and instrumentation topics. The capacity of nurses to manage walk-in patient demand was assessed by determining the number of cases resolved and of return visits for the same complaint within 72 hours. Results In total, 2751 patient care demands were evaluated. Resolved cases increased (v2 = 54.624, df = 1, P < 0.001) and the number of return visits decreased (v2 = 54.585, df = 1, P < 0.001) significantly from baseline to the end of the study period. Conclusions Nurses’ capacity to manage walk-in patient demand improved after an interdisciplinary intervention using a mutually agreed upon, locally adapted approach. Implications for nursing management To improve outcomes, nurses in management positions should systematically consider the need for skills training, specific academic courses, leadership development and, as appropriate, legislative initiatives.
Keywords: health services research, nurse’s role, primary health care, quality improvement, training Accepted for publication: 20 February 2014
920
DOI: 10.1111/jonm.12236 ª 2014 John Wiley & Sons Ltd
Nurses’ management of same-day primary care flow
Introduction Primary care nurses worldwide have demonstrated their capacity to manage and treat patients with chronic diseases and to manage urgent care consultations (Laurant et al. 2005). With proper preparation and training, nurses can take on some of the tasks and functions normally associated with physicians, achieving similar health outcomes and even increased patient satisfaction (Horrocks et al. 2002, Laurant et al. 2005, Delamaire & Lafortune 2010, Iglesias et al. 2013). This demonstration of professional capacity has not, however, led to expansion of nursing practice, roles, or autonomy, except in a few countries (Delamaire & Lafortune 2010, Hoare et al. 2012, Riegel et al. 2012), especially those with advanced practice nursing or nurse practitioners (Horrocks et al. 2002, Delamaire & Lafortune 2010, Arts et al. 2012, Jokiniemi et al. 2012). In Catalonia (an autonomous community in northeast Spain), primary care is organised into geographic entities called basic health care areas (BHAs), staffed by teams of physicians and nurses, with support staff. In general, primary care nursing focuses on follow-up of patients with chronic diseases and on delegated ~ez 2010, Caja L tasks (Hern andez Y an opez 2011). Entry-level nurses have a 3-year diploma (since 1977 a 3-year university degree) with no higher-level accreditations. The new university structure of 4-year degrees, master’s degrees and doctorates (Zabalegui & Cabrera 2009) offers nurses the opportunity to develop additional competencies and expand their nursing roles. However, these more recent graduates have not yet arrived in the primary care setting. The challenges, criticisms and lack of regulation of expanded nursing practice in Spain are similar to those of other European countries (Coombes 2008). The main issues are associated with a limited level of academic preparation, a lack of ad hoc options for advanced accreditations and resistance to the expansion of nurs~ez 2010, Caja L ing practice (Hern andez Y an opez 2011). Along with their limited role in patient education and health promotion, nurses are making progress in case management, liaison nursing and caring for dependent individuals (Caja L opez 2011). However, nurse autonomy and the expansion of nursing functions in the interdisciplinary context clearly continue to be inade~ez 2010, Caja L quate (Hern andez Y an opez 2011).
Overview of the literature The current demographic and social paradigm in Catalonia includes increased life expectancy, which is ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 920–930
associated with more health-care needs and higher expectations that add greatly to the human resource and treatment costs (Zabalegui & Cabrera 2010, Caja L opez 2011). The situation is aggravated by the current economic crisis, making adequate funding even more difficult (Zabalegui & Cabrera 2010). This panorama demands a reorientation of health-care policy (Hoare et al. 2012) to emphasise resource optimisation, efficiency and effectiveness, reinforcing the tasks and functions related to meeting the demand for health care and decreasing the saturation levels of certain services. In February 2009, the Catalan Institute of Health (ICS, Institut Catala de la Salut), a public agency that manages approximately 80% of primary care services in Catalonia, assigned primary care nurses new responsibilities in the management of same-day, walkin patients. The new programme included the implementation of a protocol with algorithms for managing the most common minor illnesses. Various studies have reported positive results from this programme in the ICS primary care centres (Fabrellas et al. 2011) and other similar initiatives (Brugues et al. 2008, Leal Negre et al. 2011, Pascual et al. 2012). Nonetheless, the initial effectiveness of the ICS programme was not equal in all BHAs. In our BHA, the capacity of nurses to manage same-day care (SDC) flow after the initial ICS training process and programme implementation was considered inadequate because the percentage of same-day resolution of those cases was
