WORKFORCE CSIRO PUBLISHING
Australian Health Review, 2015, 39, 220–227 http://dx.doi.org/10.1071/AH14040
Scoping study into wound management nurse practitioner models of practice Michelle A. Gibb1,4 BN, M Wound Care, M NsgSci(NP), PhD candidate, Nurse Practitioner Wound Management
Helen E. Edwards2 OAM, RN, DipAppSc, BA(Hons), PhD, Assistant Dean International and Engagement
Glenn E. Gardner3 RN, PhD, MEd Studies, BAppSci(Adv Nrsg), Director of the Centre for Clinical Nursing 1
Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia. 2 Faculty of Health, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia. Email: [email protected] 3 Queensland University of Technology and Royal Brisbane and Women’s Hospital, Level 3 N Block, Kelvin Grove, Qld 4059, Australia. Email: [email protected] 4 Corresponding author. Email: [email protected]
Abstract Objectives. The primary objective of this research was to investigate wound management nurse practitioner (WMNP) models of service for the purposes of identifying parameters of practice and how patient outcomes are measured. Methods. A scoping study was conducted with all authorised WMNPs in Australia from October to December 2012 using survey methodology. A questionnaire was developed to obtain data on the role and practice parameters of authorised WMNPs in Australia. The tool comprised seven sections and included a total of 59 questions. The questionnaire was distributed to all members of the WMNP Online Peer Review Group, to which it was anticipated the majority of WMNPs belonged. Results. Twenty-one WMNPs responded (response rate 87%), with the results based on a subset of respondents who stated that, at the time of the questionnaire, they were employed as a WMNP, therefore yielding a response rate of 71% (n = 15). Most respondents (93%; n = 14) were employed in the public sector, with an average of 64 occasions of service per month. The typical length of a new case consultation was 60 min, with 32 min for follow ups. The most frequently performed activity was wound photography (83%; n = 12), patient, family or carer education (75%; n = 12), Doppler ankle–brachial pressure index assessment (58%; n = 12), conservative sharp wound debridement (58%; n = 12) and counselling (50%; n = 12). The most routinely prescribed medications were local anaesthetics (25%; n = 12) and oral antibiotics (25%; n = 12). Data were routinely collected by 91% of respondents on service-related and wound-related parameters to monitor patient outcomes, to justify and improve health services provided. Conclusion. This study yielded important baseline information on this professional group, including data on patient problems managed, the types of interventions implemented, the resources used to accomplish outcomes and how outcomes are measured. What is known about the topic? The nurse practitioner (NP) is an established and legitimised entity of health service in Australia, with NPs in a range of specialities. To date, there is a paucity of research on the role and practice parameters of WMNP in the Australian context. What does this paper add? This paper provides important baseline information on WMNP models of practice in the Australian context, including data on patient problems managed, the types of interventions implemented, the resources used to accomplish outcomes and how outcomes are currently measured. This information will help inform the development of WMNP roles and highlights potential areas of evaluation for WMNP models of care. What are the implications for practitioners? Measurement of outcomes is essential to demonstrate efficacy of NP service. Yet, there is no way currently to measure these outcomes for WMNP service. Nationally consistent data collection on processes of care and patient outcomes supports ongoing development of the WMNP role. Received 21 February 2014, accepted 6 October 2014, published online 11 December 2014 Journal compilation AHHA 2015
www.publish.csiro.au/journals/ahr
Nurse practitioner models of practice
Introduction Although the wound management nurse practitioner (WMNP) model is an important strategy for the management of increased service demands, little is known about the distribution of WMNPs throughout Australia, their parameters of practice or their outcomes. This makes direct comparisons between services and evaluation of these models extremely difficult. Further research is needed to better understand WMNP models so the contribution they make to the healthcare system can be quantified accurately. This paper presents the results of a scoping study conducted on all authorised WMNPs in Australia. Background Wounds are a major problem affecting a significant proportion of the population. In Australia alone, it is estimated that more than 433 000 people suffer from chronic wounds, such as leg ulcers, pressure injuries or non-healing surgical wounds, at any one time.1 Wounds are frequently long term, painful and debilitating, resulting in extreme loss of quality of life for sufferers. Wounds can affect people of any age, yet, unfortunately, prevalence increases with age.2 In Australia, it is conservatively estimated that the problem of wounds costs the healthcare system more than A$2.6 billion per year.1 The Australian health system is under increasing pressure, particularly as the health needs of our population change. There are significant challenges, including a growing demand for, and expenditure on, health care, inequities in health outcomes and access to services, increasing concerns about safety and quality, workforce shortages and inefficiencies in health service delivery.1,3,4 Redesigning our health system so that it is better positioned to respond to these emerging challenges is a matter of urgency. The nurse practitioner (NP) has been identified as a key strategy in the development of a sustainable and responsive health workforce to improve timely access to clinical care for specific populations.5,6 An NP is a registered nurse with advanced educational preparation that allows autonomous function in an expanded clinical role while working collaboratively with healthcare professionals.7 This extended role includes assessment and management of patients using nursing knowledge and skills, prescribing medications and ordering diagnostic investigations.7 In Australia, the title of ‘nurse practitioner’ is protected under national law.8 The title of NP can only be used by those endorsed by the Nursing and Midwifery Board of Australia (NMBA).8 NPs are now an established and legitimised entity of health service in Australia, with clinical expertise in a range of specialities, including primary health, aged care, emergency and wound management.8–10 NPs deliver service at lower costs and improve access to health care for under-serviced populations; they provide safe, cost-effective care and outcomes that are at a level at least similar to that of medical practitioners.11–16 To date, there is a paucity of research on the role of the WMNP; however, what little literature there is indicates that WMNP service is safe, efficacious and valued by patients.17 Now that WMNPs are established in a variety of health service settings throughout Australia, further
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research on WMNP service, processes and outcomes is needed.18,19 Measurement of outcomes of NP service is essential to demonstrate efficacy of NP service.19–21 The Australian Nurse Practitioner Study (AUSPRAC) was the first national research project on NP service and involved three phases over a 3-year period to investigate the profile, work processes and practice outcomes of Australian NPs.22 The study developed a range of validated tools for researching NP service and clinical outcomes.23 Although examining the work activities of NPs can provide detailed information on their role in providing health service, clinical care and baseline data for analysis of scope of practice and barriers to practice, there is a need to evaluate speciality areas of practice.12,22 Aggregate data for ongoing quality assessment of NP care is scarce24 and, at present, there is no internationally agreed tool for evaluating systems of care for patients with wounds.25,26 Evaluation of wound services is mostly clinically focused, with little attention to the broader needs of patients and health services. The literature indicates that the wound nurse is pivotal in the care and treatment of patients with loss of skin integrity and can influence health outcomes for patients with wounds more than any other health professional.17,27–29 Furthermore, specialist nurses are recognised as demonstrating higher levels of clinical decision making, focused on evidence-based practice, leadership, collaboration among team members, continuity of care, counselling, education and development while being able to act as a clinical resource and change agent.28–30 Research on the role of the WMNP in wound care indicates that one of the key characteristics is their advanced educational preparation, expanded role and autonomy.17 Unfortunately, however, data are not available to describe how patient problems are managed by WMNPs, the types of interventions WMNPs implement to prevent or resolve problems or the resources used to accomplish patient outcomes. Therefore, these outcomes are often untracked, undocumented and essentially unknown. There is a need to evaluate services over a long period to understand the changing nature of this group, particularly the effect of aging and changes in the aetiological profile of the patient population.31 The purpose of conducting a scoping study was to investigate the role of WMNPs in different health service settings in order to identify core elements of practice and how their practice outcomes are measured. This scoping study sought to address the following research questions: how are WMNPs services structured in different health service contexts; what are the methods by which health care is provided for patients with wounds; and how are patient outcomes of WMNP care measured? It is recommended that evaluation of the service that NPs provide and the associated health outcomes of patients be based on the use of developed and tested tools.32 Data should be collected on service measures such as the utilisation of different healthcare professionals and the number of times patients access the service over a specified period of time.32 The present scoping study draws on a range of tools for researching NP service developed in the AUSPRAC study that were designed to capture data on models of health service delivery.22,23,32
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Methods This scoping study involved a survey conducted from October to December 2012 of WMNPs who were members of the WMNP Online Peer Support Group in Australia. Sample As of March 2014, there were 1058 authorised NPs in Australia with clinical expertise in a range of specialities, including primary health, aged care, emergency and wound management.33 At present, there is no way to identify the number of WMNPs in Australia because the area of speciality is not compulsorily recorded by the Australian Health Practitioners Regulation Agency (AHPRA). Contact was made with the WMNP Online Peer Review Group, to which it was anticipated the majority of WMNPs belonged. Based on membership of this group, it was estimated that there were between 25 and 30 WMNPs in Australia. Participants and recruitment Ethics approval was obtained from the Human Research Ethics Committee, Queensland University of Technology. Following ethics approval, members of the WMNP Online Peer Support Group were contacted by email by the researchers. The questionnaire distribution process included an email explaining the purpose of the study, a plain language statement and an electronic link to the questionnaire. The original mail out was followed by one reminder email. Completion of the questionnaires was taken as consent to participate in the study. Instrument An online questionnaire (entitled ‘Wound Management Nurse Practitioner Survey 2012’) was delivered via SurveyMonkey. The questionnaire was comprised of seven sections and included a total of 59 questions. The questions were based on the national census questionnaire developed by the AUSPRAC study and the Nursing and Midwifery Labour Force Census administered annually by AHPRA and reported by the Australian Institute of Health and Welfare (AIHW).34,35 The first section related to demographic information (two questions). The second section asked questions about general nursing registration and NP authorisation processes (four questions). The third section sought information on formal education and professional development activities relevant to their role (seven questions). The fourth section related to the employment profile of the NP (eight questions). Respondents were asked to identify the amount of time since authorisation they had spent working as an NP whose primary role involved management of wounds. Section five related to clinical service patterns and elicited information on current clinical work as a NP (six questions). This section included questions on the number of patients present with a wound in their health service in general and the number of patients admitted to their health service for treatment of a wound (including those they did not treat). The following questions then focused on WMNP practice specifically by asking respondents to identify within the last 4 weeks of working the occasions of service or episodes of care they performed for a patient with a wound, the number of people they had treated for wound care in the past year, the length of a typical
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new case and review consultation. The sixth section asked questions on the NPs model of care (10 questions) and sought to elicit information on how the respondent’s health service and model of care operated by asking them to describe their target population and the types of clinical presentations that are the focus of their service, how they managed their service, to describe how they collaborated with other health professionals in their service and to describe how their service was funded. The final section elicited information on clinical service patterns (22 questions) and asked respondents whether they had clinical pathways for management of wounds, if they had locally agreed assessment protocols for specific wound types and the types of tools and/or classification systems they used, the types and frequency of activities they routinely performed and medications that they prescribed. Sources of referral to their health service and the number and types of referrals the respondent had initiated within the last 4 weeks were requested. Respondents were asked to indicate whether they had patient information available on differing wound aetiologies, whether they conducted patient satisfaction surveys and the types of data they collected. In the questionnaire, the term ‘health service’ referred to the primary place of work. For example, if the WMNP worked in a hospital but spent the majority of time in an outpatient clinic, the health service was considered the outpatient clinic. Data analysis Data were analysed using IBM SPSS Statistics version 21.0 (IBM, Armonk, NY, USA). Frequencies for questionnaire responses were calculated for all variables. Descriptive analyses were conducted consistent with the structure of items in the questionnaire. Unless indicated otherwise, data are presented as the mean s.d. Results Demographics Twenty-one WMNPs belonging to the WMNPs Online Peer Support Group completed the questionnaire within the allotted time frame (response rate 87%), with the remaining results based on the subset of 15 respondents who stated that, at the time of the questionnaire, they were employed as WMNPs, yielding a response rate of 71% (there are missing data for some items on the questionnaire where respondents failed to answer the question). All 15 respondents were female. Respondents ranged in age from 39 to 60 years, with a mean age of 51 6 years. WMNP authorisation process For WMNPs, the mean duration of experience as a registered nurse was 27 7 years (range 15–40 years). For all respondents (n = 21), the mean length of time WMNPs were authorised was 5 3 years (range 0–12 years). For most respondents (n = 11; 52.4%), the pathway to authorisation was through completion of a Board or Council accredited NP postgraduate degree. The remaining WMNPs had completed an accredited degree and presentation of a portfolio and/or case study (n = 6; 28.6%) or presentation of a portfolio and/or case study and interview by an expert panel (n = 4; 19%). Since authorisation, the average time worked as a WMNP was 47 31 months (range 3–105 months; n = 15).
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Professional development (education) Most WMNPs (80%; n = 15) had completed postgraduate courses related to their practice as an NP, including a Masters (53.3%; n = 8), Graduate Certificate (33.3%; n = 5), or both (20%, n = 3). At least 20% of WMNPs were currently undertaking study relevant to their role as an NP, with 66.7% undertaking a doctoral degree. For those not studying at the time of the questionnaire, the main reason for not studying was attributed to workload (66.7%; n = 10), followed by lack of interest (26.7%) and financial constraint (20%). Employment profile Position before authorisation Immediately before authorisation as a WMNP, 66.7% of participants (n = 10) had worked as clinical nurse consultants (CNCs) and 13.3% (n = 2) had worked as nurse unit managers (NUMs). The remainder of participants had worked as either advanced clinical practice consultants (6.7%), clinical nurse specialists (6.7%) or as an NP candidate (6.7%). Hours of work and roles performed Most WMNPs were employed in a full-time capacity (n = 14; 93%). As indicated in Table 1, respondents stated that the majority of their time was spent delivering direct patient care (49.6%), followed by administration (17.2%), research (13%) and then education of patients and/or carers (7.6%), nurses (7.4%), medical or allied health colleagues (4%). Location of workplace Service setting Most respondents (n = 15; 93%) were employed in the public sector. Almost half (46.7%) worked in either tertiary referral, metropolitan or regional hospitals; 26.7% worked for community nursing organisations or community health centres; 6.7% worked in residential aged care; and 20% worked in other settings (on project work). Service profile Numbers of patients with wounds In the last continuous 4 weeks of working, the WMNPs indicated that there were approximately 244 patients with a wound and 301 patients admitted to their health service, including those they did not treat. Occasions of service In the last continuous 4 weeks of working, there was an average of 64 occasions of service or Table 1. Mean (þs.d.) percentage of time allocated to tasks (n = 15) Task allocation Direct patient care Administration & management Research Patient/carer education Education of nurses Education of medical and/or allied health Other activities Total
% Time allocated 49.7 ± 25.1 17.2 ± 14.4 13.0 ± 27.7 7. 7 ± 8.4 7.5 ± 4.7 4.0 ± 3.3 1.0 ± 3.8 100
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episodes of care performed per patient with a wound by the WMNP. The average number of patients treated with a wound in the past year by the WMNPs was 578 patients (range 0–1560 patients). Length of consultations The typical length of a new case consultation was 60 min, whereas a follow-up consultation was 32 min in length. Model of care Target population The WMNPs were asked to describe their model of care to elicit information on their target population and the types of clinical presentations that are the focus of their service. All WMNPs stated that they mostly treat adults over 60 years of age. Types of wounds treated The WMNPs were asked to describe the main types of wounds they treated. The types of wounds identified included chronic wounds, such as leg ulcers, diabetic foot ulcers, pressure injuries, malignant fungating wounds, complicated surgical wounds and sinuses. Appointment scheduling and referrals For 73.3% of WMNPs, an appointment scheduling system was used to arrange appointments, but they also had capacity for ad hoc consultations if requested. Although the WMNPs indicated they did not require a referral to access their services, they mostly request one, citing that it is their way of ensuring collaboration with the patient’s general practitioner (GP) or other health professionals involved in the patient’s care. The most common source of referrals to the WMNPs was a GP (80%), followed by allied health professionals (73%), registered nurses (73%), community nursing services (73%) and medical specialists (66%). A high number of WMNPs indicated that they accepted patients who were self-referrals (75%). The most common referrals that WMNPs initiated were to GPs (80%), followed by community nursing services (50%), medical specialists (33%), high risk foot (specialist high risk foot clinics for patients with neuropathic foot ulceration) (33%) and allied health professionals (25%). For the WMNPs working in the acute sector, they attended ward rounds for the purposes of identifying patients with wounds and to provide opportunistic wound management education to patients and/or carers and other health professionals. Just over half the WMNPs (53.4%) ran clinics several days per week. Collaboration with other health professionals The WMNPs were asked to describe how they collaborated with other health professionals in their health service. Responses included a combination of meetings, attendance at NP support groups, steering groups or that they attended multidisciplinary team meetings. Most demonstrated their collaborative relationships through correspondence or other forms of communication. Some WMNPs indicated that they worked independently and were required to develop collaborative arrangements with health professionals external to their service. Sources of funding WMNPs working in the public hospital setting do not have access to the Medicare Benefits Schedule (MBS). Those WMNPs working for community nursing organisations received their funding through other government sources. Most WMNPs (n = 13; 60%) did not have access to the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS).
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Clinical service patterns
Types of data collected
Clinical pathways
Patient satisfaction surveys were conducted regularly by nearly half the respondents (n = 12; 41%) and 91% of the 12 WMNPs who answered this question routinely collected data on their health service. The type of data that the WMNPs collected included a wide range of service-related and wound-related parameters (see Fig. 1). The most commonly collected servicerelated parameter was on sources of referral to their services and occasions of service. The least routinely collected information was on patient health-related quality of life. A wound assessment tool capturing data on wound-specific parameters and interventions performed was administered by 83% of WMNPs. The most commonly collected wound assessment parameter was ABPI (n = 12; 100%).
Most respondents (80%; n = 12) indicated that they had clinical pathways and protocols for the management of wounds. The most common type of tool used by respondents was a wound assessment tool (80%). Other types of tools used included a pressure injury risk assessment (80%), followed by a diabetic foot assessment tool (80%) and a skin tear classification (73.3%) tool. Activities performed The most commonly performed activities by WMNPs were wound photography (83%), followed by patient, family and/or carer education (75%), performing Doppler ankle–brachial pressure index assessment (ABPI; 58%), conservative sharp wound debridement (58%), counselling (50%) and a range of other activities, such as monofilament testing, ultrasonic debridement, education of nursing, medical, allied health professionals and/or students and monitoring and/or follow up.
Methods of data collection In terms of data collection methods, of the 12 who reported collecting data, 83% recorded the data in a database. Of these, 41% used a paper-based audit tool and 25% used other methods, including medical charts or an electronic medical record. Of the 11 WMNPs who answered this question, 83% indicated that they were the person most likely to be responsible for collecting information. Data were recorded on a daily basis by 55% (n = 11) of respondents and either weekly or monthly by 18% of respondents, with the remaining 9% recording data on a quarterly basis. Of the WMNPs who collected data, 67% analysed and reported on their data. The main barriers to analysis and reporting of data were insufficient time (50%), followed by a lack of common tools (41.7%), the lack of a requirement to undertake routine data analysis and reporting (16.7%) and uncertainty about how the data would be used (8.3%).
Medications prescribed The most routinely prescribed medications were local anaesthetic (25%), followed by topical corticosteroids (16%). The least commonly prescribed medication was intravenous antibiotics, with 81% (n = 12) of respondents indicating that they never prescribe this type of medication. Oral antibiotics were frequently prescribed by 25% of WMNPs. Admission and discharge privileges In terms of hospital admission privileges, 60% of WMNPs did not have admission privileges, although 33% had hospital discharge privileges.
Purposes of data collection Patient education
The 12 WMNPs who collected data, reported that these data were used for a range of purposes, such as to monitor patient outcomes (91%), to justify their health service (75%) and to improve the health services they provide (66%). Half these WMNPs reported using the data to change practices or for their personal use and/or interest, whereas only 17% used the data
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The WMNPs routinely offered patient information literature on a range of topics. The most common type of patient information that WMNPs provided to patients was on pressure injury prevention (83%), followed by literature on leg ulcer prevention (67%).
Type of wound data Fig. 1. Types of wound related data collected (n = 12). ABPI, ankle–brachial pressure index.
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they collected to benchmark between services or for research purposes. Discussion One of the key characteristics of a WMNP is their advanced educational preparation, expanded role and autonomy.17 Like other groups of the nursing workforce, most WMNPs in the present study were female and aged >30 years.34,35 This is reflective of the years of advanced clinical practice required for authorisation.34 There is general agreement in the literature that wound care nurses, like the WMNPs in the present study, educated to the Master’s degree level practice autonomously, collaborate with medical and allied health colleagues to coordinate care of patients and have high level clinical and decisionmaking skills, as well as a commitment to life-long learning.36,37 In fact, Rece Mitchell38 argues that Masters-prepared nurses with speciality certification in wound management have a unique opportunity to integrate the role components of clinician, consultant, educator, researcher and manager and are able to provide excellent care in a cost-effective manner. The results of the present study indicate that the WMNPs in this sample are very experienced in the speciality area, having worked in the area of wound management before authorisation. Furthermore, at least one-quarter were currently undertaking study relevant to their role as an NP. Health care depends heavily on access to a skilled workforce.34 Consistent with findings reported in the literature on NPs in Australia, most WMNPs in the present study stated that the greater part of their time was spent delivering direct patient care, followed by administration, research and then education of patients or carers, nurses, medical or allied health colleagues.12,22 The amount of time NPs spend on administrative and coordinating activities reduces the time they spend providing direct patient care.12 Having information about the time spent on activities not directly related to provision of clinical service enables nurses and managers to improve the utilisation of NP services.12 It is interesting that 13% of respondents indicated that they were engaged in research when in previous studies on NPs this figure has been as low as 1.5% (n = 205) of the entire sample were engaged in research.12,22 Perhaps this is reflective of an increasing awareness of the need to meet competency standards for NPs where research is an explicit requirement of the competency standards.7,39 Another reason may be the drive for NP workforce development and the need to improve frontline patient care from prevention to chronic disease management, an area where NPs are ideally placed to achieve these objectives.12,22,40 A definition of what constituted ‘research’ was not included in the present study, which may also account for the higher proportion of NPs indicating that they were engaged in research activities. There is evidence to suggest that research activities, such as participation, dissemination and utilisation of research evidence, are still not perceived favourably or used proactively by the majority of nurses.41,42 Furthermore, there is increasing recognition of gaps between best scientific evidence and clinical practice in many fields of health care.3,43 A recent study estimated that in wound care up to 70% of patients with venous leg ulcers fail to receive evidence-based treatment.3
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However, the same study demonstrated that following admission to a specialist wound clinic, including a WMNP-led clinic, implementation of key indicators of evidence-based care increased.3 The majority of respondents in the present study (93%) were employed in the public sector.8 Although the numbers of WMNPs working in settings apart from the public sector is relatively low, it is anticipated that this number will increase with access to MBS and PBS becoming increasingly available, enabling NPs to work in a private capacity.8 Despite legislative changes in November 2010 providing NPs with access to the MBS and PBS, the context in which health care is delivered, such as in public hospitals, means that some NPs do not have the authority to access MBS provider number or the authority to prescribe through the PBS.22 These restrictions mean that the full potential of the NP role is yet to be realised (i.e. NPs are not being used to their full clinical capacity) and this will inhibit the development of NP services.44 Increasingly, treatment for chronic wounds, such as leg ulcers, has moved away from the acute sector and is becoming community based in an attempt by the healthcare system to improve cost-effectiveness.45–47 Unfortunately, the costs and responsibility for chronic wounds has shifted from the healthcare system to the patient.45 The limited MBS rebates currently available to NPs are a disincentive for them to deliver more efficient and streamlined services for patients and reduces patient demand for allowable (but nonMBS supported) services because of the resulting financial impost on the patient.48 In keeping with the literature, the present study highlights that WMNPs, like other NPs across a wide range of speciality areas, spend more time with patients, providing longer consultations; that they carry out more investigations than doctors; and that patients were generally more satisfied with care from an NP than from a doctor.48–50 Furthermore, evidence suggests that patients are more likely to be involved in their care if they are given oral and written information.17,51,52 As the results from the present study demonstrate, the WMNPs are actively providing both oral and written information to patients. There is good evidence to demonstrate that when patients are actively involved in their treatment, outcomes improve.53,54 In terms of the types of activities that WMNPs routinely performed, there was a wide range of activities that was undertaken. These findings are consistent with previous research in the area and are indicative of the complex nature of wound care.17 With wound prevalence increasing with age,3 the number of patients WMNPs treat is anticipated to increase exponentially in the future. Given the complexity of wounds and the fact that many patients suffer from multiple comorbid conditions, it is essential that the WMNP works collaboratively with other health professionals. In the present study, the WMNPs, like other NPs, collaborated with a wide range of health professionals, demonstrating the interdisciplinary nature of wound management. Numerous studies have indicated that access to skilled care is an important issue for patients with wounds and that NP service improves access for patients.3,17 The WMNP is in an ideal position to facilitate and enhance communication and collaboration within and between specialist consultants, other nurses and allied health professionals. In keeping with the literature,31,46,55 the results of the present study demonstrate
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that NPs complement services and ensure integrated continuity of care and effective communication through the collaborative development of referral pathways, clinical practice guidelines and protocols. Given that wound assessment is a routine component of caring for patients with any type of wound, it is not surprising that the WMNPs use a wound assessment tool. The use of standardised wound assessment tools and other data collection measures, such as patient satisfaction surveys and periodic audits of service utilisation, provides benchmarks for measuring patient outcomes.56 However, the present study found that for almost half the respondents, insufficient time and the lack of common tools was a barrier to data collection and that they were the person most likely to be responsible for collecting this information, thereby further reducing the amount of time they have for direct patient care. Measurement of outcomes of WMNP service is essential and further highlights the need for a tool that WMNPs can use for benchmarking and articulating the benefits and outcomes of their models of practice. Limitations It is acknowledged that this study has a small sample size because, in Australia, there is no way to identify the number of authorised WMNPs: the area of speciality is not captured by AHPRA. Although contact was made with the WMNP Online Peer Review Group, to which most WMNPs belong, and it was estimated that there are between 25 and 30 WMNPs in Australia based on membership of this group, it is possible that some authorised WMNPs were not included in this study. Although online survey methods have found that response rates to email surveys are equal to or better than those for traditional mailed surveys, the response rate in the present study was low, thereby introducing the possibility of selection bias and limiting the sampling frame.57 The results may not be representative or generalisable for all WMNPs. Conclusion The results of the present scoping study indicate that WMNPs practice in a range of health service settings throughout Australia and yet have similar patterns of practice. This information has yielded important baseline information on this emergent professional group. However, it is clear that more research is needed on WMNP service, processes and patient outcomes to enable health service planners, other health professionals and consumers to understand more about these models and to realise the full potential of the WMNP role.22 Competing interests
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The authors declare that no conflicts of interest exist. 19
Acknowledgements The authors acknowledge the WMNPs for their participation in the study. This study was undertaken as part of a PhD degree by MAG at Queensland University of Technology. This study was supported by the Wound Management Innovation Cooperative Research Centre (WMI CRC; Project no. 3–18).
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Australian Institute of Health and Welfare (AIHW). Australia’s health 2012. Australia’s health series no. 13. Catalogue no. AUS 156. Canberra: AIHW; 2012. Australian Bureau of Statistics (ABS). Population projections. Canberra: ABS; 2008. Edwards H, Finlayson K, Courtney M, Graves N, Gibb M, Parker C. Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence based wound care. BMC Health Serv Res 2013; 13: 86. doi:10.1186/1472-6963-13-86 Coyer F, Edwards H, Courtney M. Best practice community care for clients with chronic venous leg ulcers: National Institute of Clinical Studies (NICS) report for Phase 1 evidence uptake network. Brisbane: Queensland University of Technology; 2005. Considine J, Fielding K. Sustainable workforce reform: case study of Victorian nurse practitioner roles. Aust Health Rev 2010; 34: 297–303. doi:10.1071/AH08727 Gardner G, Gardner A, O’Connell J. Using the Donabedian framework to examine the quality and safety of nursing service innovation. J Clin Nurs 2014; 23: 145–55. doi:10.1111/jocn.12146 Australian Nursing and Midwifery Council. National competency standards for the nurse practitioner. Dickson, ACT: Australian Nursing and Midwifery Council; 2013. Australian Nursing Federation. A snapshot of nurse practitioners in Australia. Kingston, ACT: Australian Nursing Federation; 2011. Australian Health Practitioner Regulation Agency. Annual report 2011/ 12. Brisbane: Australian Health Practitioner Regulation Agency; 2012. Nursing and Midwifery Board of Australia. Nurse and midwife registrant data: March 2013. Melbourne: Australian Health Practitioner Regulation Agency; 2013. Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000; 320: 1048–53. doi:10.1136/bmj.320.7241.1048 Gardner G, Gardner A, Middleton S, Della P, Kain V, Doubrovsky A. The work of nurse practitioners. J Adv Nurs 2010; 66: 2160–9. doi:10.1111/j.1365-2648.2010.05379.x Gardner G, Carryer J, Gardner A, Dunn S. Nurse practitioner competency standards: findings from collaborative Australian and New Zealand research. Int J Nurs Stud 2006; 43: 601–10. doi:10.1016/j.ijnurstu.2005.09.002 Harrington J. Nurse practitioners: a safe and competent choice for primary care. Int Nurs Rev 2010; 17: 66–7. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting ‘same day’ consultations in primary care. BMJ 2000; 320: 1043–8. doi:10.1136/bmj.320.7241.1043 Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: twoyear follow-up. Med Care Res Rev 2004; 61: 332–51. doi:10.1177/ 1077558704266821 MacLellan L, Gardner A, Gardner G. Designing the future in wound care: the role of the nurse practitioner. Primary Intention: Aust J Wound Manage 2002; 10: 97–112. Lowe G. Scope of emergency nurse practitioner practice: where to beyond clinical practice guidelines? Aust J Adv Nurs 2010; 28: 74–82. Queensland Government. Clinical governance for nurse practitioners in Queensland: a guide. Brisbane: Queensland Government; 2011. Carryer J, Gardner G, Dunn S, Gardner A. The core role of the nurse practitioner: practice, professionalism and clinical leadership. J Clin Nurs 2007; 16: 1818–25. doi:10.1111/j.1365-2702.2007.01823.x Lowe G, Plummer V, O’Brien AP, Boyd L. Time to clarify: the value of advanced practice nursing roles in health care. J Adv Nurs 2012; 68: 677–85. doi:10.1111/j.1365-2648.2011.05790.x
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22 Middleton S, Gardner A, Gardner G, Della P. The status of Australian nurse practitioners: the second national census. Aust Health Rev 2011; 35: 448–54. 23 Gardner A, Gardner G, Middleton S, Della PR. The status of Australian nurse practitioners: the first national census. Aust Health Rev 2009; 33: 679–89. doi:10.1071/AH090679 24 Jenkins ML. Toward national comparable nurse practitioner data: proposed data elements, rationale, and methods. J Biomed Inform 2003; 36: 342–50. doi:10.1016/j.jbi.2003.09.016 25 Harding K, Queen D. Wound registries: a new emerging evidence resource. Int Wound J 2011; 8: 325. doi:10.1111/j.1742-481X.2011. 00827.x 26 Keast DH, Bowering CK, Evans AW, Mackean GL, Burrows C, D’Souza L. MEASURE: a proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair Regen 2004; 12(Suppl): S1–17. doi:10.1111/j.1067-1927.2004. 0123S1.x 27 Capasso V, Collins J, Griffith C, Lasala CA, Kilroy S, Martin AT, Pedro J, Wood SL. Outcomes of a clinical nurse specialist-initiated wound care education program: using the promoting action on research implementation in health services framework. Clin Nurse Spec 2009; 23: 252–7. doi:10.1097/NUR.0b013e3181b207f5 28 Bale S. The contribution of the wound care nurse in developing a diabetic foot clinic. Br J Clin Govern 2002; 7: 22–6. doi:10.1108/ 14664100210417995 29 Cowman S, Gethin G, Clarke E, Moore Z, Craig G, Jordan-O’Brien J, McLain N, Strapp H. An international eDelphi study identifying the research and education priorities in wound management and tissue repair. J Clin Nurs 2012; 21: 344–53. doi:10.1111/j.1365-2702.2011. 03950.x 30 Appleby SL. Role of the wound ostomy continence nurse in the home care setting: a patient case study. Home Healthc Nurse 2011; 29: 169–77. doi:10.1097/NHH.0b013e3181fe438b 31 Moffatt C, Franks P, Morison M. Models of service provision. In Morison M, Moffatt C, Franks P, editors. Leg ulcers: a problem-based learning approach. Edinburgh: Mosby Elsevier; 2007. pp. 99–118. 32 Gardner G, Gardner A, Middleton S, Della P. The nurse practitioner research toolkit. Brisbane: Australian College of Nurse Practitioners; 2009. 33 Nursing and Midwifery Board of Australia. Nurse and midwife registrant data: March 2014. Melbourne: Nursing and Midwifery Board of Australia; 2014. 34 Australian Institute of Health and Welfare (AIHW). Nursing and midwifery workforce 2011. National health workforce series no. 2. Catalogue no. HWL 48. Canberra: AIHW; 2012. 35 Gardner A, Gardner G, Middleton S, Della P. The status of Australian nurse practitioners: the first national census. Aust Health Rev 2009; 33: 679–89. doi:10.1071/AH090679 36 Doughty D. Integrating advanced practice and WOC nursing education. J Wound Ostomy Continence Nurs 2000; 27: 65–8. 37 Gray M, Ratliff C, Mawyer R. A brief history of advanced practice nursing and its implications for WOC advanced nursing practice. J Wound Ostomy Continence Nurs 2000; 27: 48–54. 38 Mitchell JR. Development of the advanced practice nurse role in wound management. Top Spinal Cord Inj Rehabil 2003; 9: 1–7. doi:10.1310/ N833-C8D9-R7B0-J14N 39 Nursing and Midwifery Board of Australia. Nurse practitioner standards for practice. Melbourne: Nursing and Midwifery Board of Australia; 2014.
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40 National Health and Hospitals Reform Commission. A healthier future for all Australians: final report of the National Health and Hospitals Reform Commission. Barton, ACT: Commonwealth of Australia; 2009. 41 Edwards H, Chapman H, Davis LM. Utilization of research evidence by nurses. Nurs Health Sci 2002; 4: 89–95. doi:10.1046/j.1442-2018. 2002.00111.x 42 Squires JE, Hutchinson AM, Bostrom AM, O’Rourke HM, Cobban SJ, Estabrooks CA. To what extent do nurses use research in clinical practice? A systematic review. Implement Sci 2011; 6: 21. doi:10.1186/1748-5908-6-21 43 Bryant J, Boyes A, Jones K, Sanson-Fisher R, Carey M, Fry R. Examining and addressing evidence-practice gaps in cancer care: a systematic review. Implement Sci 2014; 9: 37. doi:10.1186/1748-5908-9-37 44 Barton AJ, Baramee J, Sowers D, Robertson KJ. Articulating the valueadded dimension of NP care. Nurse Pract 2003; 28: 34–40. doi:10.1097/ 00006205-200312000-00006 45 Smith E, McGuiness W. Managing venous leg ulcers in the community: personal financial cost to sufferers. Wound Pract Res: Aust J Wound Manage 2010; 18: 134–9. 46 Graham ID, Harrison MB, Moffatt C, Franks P. Leg ulcer care: nursing attitudes and knowledge. Can Nurse 2001; 97: 19–24. 47 Simon DA, Freak L, Kinsella A, Walsh J, Lane C, Groarke L, McCollum C. Community leg ulcer clinics: treatment comparative study in two health authorities. British Medical Journal 1996; 312: 1648–1651. 48 Centre for International Economics (CIE). The CIE final report. Responsive patient centred care. The economic value and potential of nurse practitioners in Australia. Canberra: CIE; 2013. 49 Horrocks S, Anderson E, Salisbury C. Systemic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002; 324: 819–23. doi:10.1136/bmj.324.7341.819 50 Laurant MG, Hermens RP, Braspenning JC, Akkermans RP, Sibbald B, Grol RP. An overview of patients’ preference for, and satisfaction with, care provided by general practitioners and nurse practitioners. J Clin Nurs 2008; 17: 2690–8. doi:10.1111/j.1365-2702.2008.02288.x 51 Edwards H, Courtney M, Finlayson K, Lindsay E, Lewis C, Shuter P. Chronic venous leg ulcers: effect of a community nursing intervention on pain and healing. Nurs Stand 2005; 19: 47–54. doi:10.7748/ns2005. 09.19.52.47.c3950 52 Agosta LJ. Patient satisfaction with nurse practitioner-delivered primary healthcare services. J Am Acad Nurse Pract 2009; 21: 610–17. doi:10.1111/j.1745-7599.2009.00449.x 53 Edwards H, Courtney M, Finlayson K, Shuter P, Lindsay E. A randomised controlled trial of a community nursing intervention: improved quality of life and healing for clients with chronic leg ulcers. J Clin Nurs 2009; 18: 1541–9. doi:10.1111/j.1365-2702.2008.02648.x 54 Finlayson K, Edwards H, Courtney M. The impact of psychosocial factors on adherence to compression therapy to prevent recurrence of venous leg ulcers. J Clin Nurs 2010; 19: 1289–97. doi:10.1111/j.13652702.2009.03151.x 55 van Offenbeek MAG, Knip M. The organizational and performance effects of nurse practitioner roles. J Adv Nurs 2004; 47: 672–81. doi:10.1111/j.1365-2648.2004.03156.x 56 Bolton L. Wounds: A compendium of clinical research and practice. Wounds 2012; 24: 18–24.
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Australian Health Review, 2015, 39, 220–227 http://dx.doi.org/10.1071/AH14040
Scoping study into wound management nurse practitioner models of practice Michelle A. Gibb1,4 BN, M Wound Care, M NsgSci(NP), PhD candidate, Nurse Practitioner Wound Management
Helen E. Edwards2 OAM, RN, DipAppSc, BA(Hons), PhD, Assistant Dean International and Engagement
Glenn E. Gardner3 RN, PhD, MEd Studies, BAppSci(Adv Nrsg), Director of the Centre for Clinical Nursing 1
Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia. 2 Faculty of Health, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia. Email: [email protected] 3 Queensland University of Technology and Royal Brisbane and Women’s Hospital, Level 3 N Block, Kelvin Grove, Qld 4059, Australia. Email: [email protected] 4 Corresponding author. Email: [email protected]
Abstract Objectives. The primary objective of this research was to investigate wound management nurse practitioner (WMNP) models of service for the purposes of identifying parameters of practice and how patient outcomes are measured. Methods. A scoping study was conducted with all authorised WMNPs in Australia from October to December 2012 using survey methodology. A questionnaire was developed to obtain data on the role and practice parameters of authorised WMNPs in Australia. The tool comprised seven sections and included a total of 59 questions. The questionnaire was distributed to all members of the WMNP Online Peer Review Group, to which it was anticipated the majority of WMNPs belonged. Results. Twenty-one WMNPs responded (response rate 87%), with the results based on a subset of respondents who stated that, at the time of the questionnaire, they were employed as a WMNP, therefore yielding a response rate of 71% (n = 15). Most respondents (93%; n = 14) were employed in the public sector, with an average of 64 occasions of service per month. The typical length of a new case consultation was 60 min, with 32 min for follow ups. The most frequently performed activity was wound photography (83%; n = 12), patient, family or carer education (75%; n = 12), Doppler ankle–brachial pressure index assessment (58%; n = 12), conservative sharp wound debridement (58%; n = 12) and counselling (50%; n = 12). The most routinely prescribed medications were local anaesthetics (25%; n = 12) and oral antibiotics (25%; n = 12). Data were routinely collected by 91% of respondents on service-related and wound-related parameters to monitor patient outcomes, to justify and improve health services provided. Conclusion. This study yielded important baseline information on this professional group, including data on patient problems managed, the types of interventions implemented, the resources used to accomplish outcomes and how outcomes are measured. What is known about the topic? The nurse practitioner (NP) is an established and legitimised entity of health service in Australia, with NPs in a range of specialities. To date, there is a paucity of research on the role and practice parameters of WMNP in the Australian context. What does this paper add? This paper provides important baseline information on WMNP models of practice in the Australian context, including data on patient problems managed, the types of interventions implemented, the resources used to accomplish outcomes and how outcomes are currently measured. This information will help inform the development of WMNP roles and highlights potential areas of evaluation for WMNP models of care. What are the implications for practitioners? Measurement of outcomes is essential to demonstrate efficacy of NP service. Yet, there is no way currently to measure these outcomes for WMNP service. Nationally consistent data collection on processes of care and patient outcomes supports ongoing development of the WMNP role. Received 21 February 2014, accepted 6 October 2014, published online 11 December 2014 Journal compilation AHHA 2015
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Introduction Although the wound management nurse practitioner (WMNP) model is an important strategy for the management of increased service demands, little is known about the distribution of WMNPs throughout Australia, their parameters of practice or their outcomes. This makes direct comparisons between services and evaluation of these models extremely difficult. Further research is needed to better understand WMNP models so the contribution they make to the healthcare system can be quantified accurately. This paper presents the results of a scoping study conducted on all authorised WMNPs in Australia. Background Wounds are a major problem affecting a significant proportion of the population. In Australia alone, it is estimated that more than 433 000 people suffer from chronic wounds, such as leg ulcers, pressure injuries or non-healing surgical wounds, at any one time.1 Wounds are frequently long term, painful and debilitating, resulting in extreme loss of quality of life for sufferers. Wounds can affect people of any age, yet, unfortunately, prevalence increases with age.2 In Australia, it is conservatively estimated that the problem of wounds costs the healthcare system more than A$2.6 billion per year.1 The Australian health system is under increasing pressure, particularly as the health needs of our population change. There are significant challenges, including a growing demand for, and expenditure on, health care, inequities in health outcomes and access to services, increasing concerns about safety and quality, workforce shortages and inefficiencies in health service delivery.1,3,4 Redesigning our health system so that it is better positioned to respond to these emerging challenges is a matter of urgency. The nurse practitioner (NP) has been identified as a key strategy in the development of a sustainable and responsive health workforce to improve timely access to clinical care for specific populations.5,6 An NP is a registered nurse with advanced educational preparation that allows autonomous function in an expanded clinical role while working collaboratively with healthcare professionals.7 This extended role includes assessment and management of patients using nursing knowledge and skills, prescribing medications and ordering diagnostic investigations.7 In Australia, the title of ‘nurse practitioner’ is protected under national law.8 The title of NP can only be used by those endorsed by the Nursing and Midwifery Board of Australia (NMBA).8 NPs are now an established and legitimised entity of health service in Australia, with clinical expertise in a range of specialities, including primary health, aged care, emergency and wound management.8–10 NPs deliver service at lower costs and improve access to health care for under-serviced populations; they provide safe, cost-effective care and outcomes that are at a level at least similar to that of medical practitioners.11–16 To date, there is a paucity of research on the role of the WMNP; however, what little literature there is indicates that WMNP service is safe, efficacious and valued by patients.17 Now that WMNPs are established in a variety of health service settings throughout Australia, further
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research on WMNP service, processes and outcomes is needed.18,19 Measurement of outcomes of NP service is essential to demonstrate efficacy of NP service.19–21 The Australian Nurse Practitioner Study (AUSPRAC) was the first national research project on NP service and involved three phases over a 3-year period to investigate the profile, work processes and practice outcomes of Australian NPs.22 The study developed a range of validated tools for researching NP service and clinical outcomes.23 Although examining the work activities of NPs can provide detailed information on their role in providing health service, clinical care and baseline data for analysis of scope of practice and barriers to practice, there is a need to evaluate speciality areas of practice.12,22 Aggregate data for ongoing quality assessment of NP care is scarce24 and, at present, there is no internationally agreed tool for evaluating systems of care for patients with wounds.25,26 Evaluation of wound services is mostly clinically focused, with little attention to the broader needs of patients and health services. The literature indicates that the wound nurse is pivotal in the care and treatment of patients with loss of skin integrity and can influence health outcomes for patients with wounds more than any other health professional.17,27–29 Furthermore, specialist nurses are recognised as demonstrating higher levels of clinical decision making, focused on evidence-based practice, leadership, collaboration among team members, continuity of care, counselling, education and development while being able to act as a clinical resource and change agent.28–30 Research on the role of the WMNP in wound care indicates that one of the key characteristics is their advanced educational preparation, expanded role and autonomy.17 Unfortunately, however, data are not available to describe how patient problems are managed by WMNPs, the types of interventions WMNPs implement to prevent or resolve problems or the resources used to accomplish patient outcomes. Therefore, these outcomes are often untracked, undocumented and essentially unknown. There is a need to evaluate services over a long period to understand the changing nature of this group, particularly the effect of aging and changes in the aetiological profile of the patient population.31 The purpose of conducting a scoping study was to investigate the role of WMNPs in different health service settings in order to identify core elements of practice and how their practice outcomes are measured. This scoping study sought to address the following research questions: how are WMNPs services structured in different health service contexts; what are the methods by which health care is provided for patients with wounds; and how are patient outcomes of WMNP care measured? It is recommended that evaluation of the service that NPs provide and the associated health outcomes of patients be based on the use of developed and tested tools.32 Data should be collected on service measures such as the utilisation of different healthcare professionals and the number of times patients access the service over a specified period of time.32 The present scoping study draws on a range of tools for researching NP service developed in the AUSPRAC study that were designed to capture data on models of health service delivery.22,23,32
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Methods This scoping study involved a survey conducted from October to December 2012 of WMNPs who were members of the WMNP Online Peer Support Group in Australia. Sample As of March 2014, there were 1058 authorised NPs in Australia with clinical expertise in a range of specialities, including primary health, aged care, emergency and wound management.33 At present, there is no way to identify the number of WMNPs in Australia because the area of speciality is not compulsorily recorded by the Australian Health Practitioners Regulation Agency (AHPRA). Contact was made with the WMNP Online Peer Review Group, to which it was anticipated the majority of WMNPs belonged. Based on membership of this group, it was estimated that there were between 25 and 30 WMNPs in Australia. Participants and recruitment Ethics approval was obtained from the Human Research Ethics Committee, Queensland University of Technology. Following ethics approval, members of the WMNP Online Peer Support Group were contacted by email by the researchers. The questionnaire distribution process included an email explaining the purpose of the study, a plain language statement and an electronic link to the questionnaire. The original mail out was followed by one reminder email. Completion of the questionnaires was taken as consent to participate in the study. Instrument An online questionnaire (entitled ‘Wound Management Nurse Practitioner Survey 2012’) was delivered via SurveyMonkey. The questionnaire was comprised of seven sections and included a total of 59 questions. The questions were based on the national census questionnaire developed by the AUSPRAC study and the Nursing and Midwifery Labour Force Census administered annually by AHPRA and reported by the Australian Institute of Health and Welfare (AIHW).34,35 The first section related to demographic information (two questions). The second section asked questions about general nursing registration and NP authorisation processes (four questions). The third section sought information on formal education and professional development activities relevant to their role (seven questions). The fourth section related to the employment profile of the NP (eight questions). Respondents were asked to identify the amount of time since authorisation they had spent working as an NP whose primary role involved management of wounds. Section five related to clinical service patterns and elicited information on current clinical work as a NP (six questions). This section included questions on the number of patients present with a wound in their health service in general and the number of patients admitted to their health service for treatment of a wound (including those they did not treat). The following questions then focused on WMNP practice specifically by asking respondents to identify within the last 4 weeks of working the occasions of service or episodes of care they performed for a patient with a wound, the number of people they had treated for wound care in the past year, the length of a typical
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new case and review consultation. The sixth section asked questions on the NPs model of care (10 questions) and sought to elicit information on how the respondent’s health service and model of care operated by asking them to describe their target population and the types of clinical presentations that are the focus of their service, how they managed their service, to describe how they collaborated with other health professionals in their service and to describe how their service was funded. The final section elicited information on clinical service patterns (22 questions) and asked respondents whether they had clinical pathways for management of wounds, if they had locally agreed assessment protocols for specific wound types and the types of tools and/or classification systems they used, the types and frequency of activities they routinely performed and medications that they prescribed. Sources of referral to their health service and the number and types of referrals the respondent had initiated within the last 4 weeks were requested. Respondents were asked to indicate whether they had patient information available on differing wound aetiologies, whether they conducted patient satisfaction surveys and the types of data they collected. In the questionnaire, the term ‘health service’ referred to the primary place of work. For example, if the WMNP worked in a hospital but spent the majority of time in an outpatient clinic, the health service was considered the outpatient clinic. Data analysis Data were analysed using IBM SPSS Statistics version 21.0 (IBM, Armonk, NY, USA). Frequencies for questionnaire responses were calculated for all variables. Descriptive analyses were conducted consistent with the structure of items in the questionnaire. Unless indicated otherwise, data are presented as the mean s.d. Results Demographics Twenty-one WMNPs belonging to the WMNPs Online Peer Support Group completed the questionnaire within the allotted time frame (response rate 87%), with the remaining results based on the subset of 15 respondents who stated that, at the time of the questionnaire, they were employed as WMNPs, yielding a response rate of 71% (there are missing data for some items on the questionnaire where respondents failed to answer the question). All 15 respondents were female. Respondents ranged in age from 39 to 60 years, with a mean age of 51 6 years. WMNP authorisation process For WMNPs, the mean duration of experience as a registered nurse was 27 7 years (range 15–40 years). For all respondents (n = 21), the mean length of time WMNPs were authorised was 5 3 years (range 0–12 years). For most respondents (n = 11; 52.4%), the pathway to authorisation was through completion of a Board or Council accredited NP postgraduate degree. The remaining WMNPs had completed an accredited degree and presentation of a portfolio and/or case study (n = 6; 28.6%) or presentation of a portfolio and/or case study and interview by an expert panel (n = 4; 19%). Since authorisation, the average time worked as a WMNP was 47 31 months (range 3–105 months; n = 15).
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Professional development (education) Most WMNPs (80%; n = 15) had completed postgraduate courses related to their practice as an NP, including a Masters (53.3%; n = 8), Graduate Certificate (33.3%; n = 5), or both (20%, n = 3). At least 20% of WMNPs were currently undertaking study relevant to their role as an NP, with 66.7% undertaking a doctoral degree. For those not studying at the time of the questionnaire, the main reason for not studying was attributed to workload (66.7%; n = 10), followed by lack of interest (26.7%) and financial constraint (20%). Employment profile Position before authorisation Immediately before authorisation as a WMNP, 66.7% of participants (n = 10) had worked as clinical nurse consultants (CNCs) and 13.3% (n = 2) had worked as nurse unit managers (NUMs). The remainder of participants had worked as either advanced clinical practice consultants (6.7%), clinical nurse specialists (6.7%) or as an NP candidate (6.7%). Hours of work and roles performed Most WMNPs were employed in a full-time capacity (n = 14; 93%). As indicated in Table 1, respondents stated that the majority of their time was spent delivering direct patient care (49.6%), followed by administration (17.2%), research (13%) and then education of patients and/or carers (7.6%), nurses (7.4%), medical or allied health colleagues (4%). Location of workplace Service setting Most respondents (n = 15; 93%) were employed in the public sector. Almost half (46.7%) worked in either tertiary referral, metropolitan or regional hospitals; 26.7% worked for community nursing organisations or community health centres; 6.7% worked in residential aged care; and 20% worked in other settings (on project work). Service profile Numbers of patients with wounds In the last continuous 4 weeks of working, the WMNPs indicated that there were approximately 244 patients with a wound and 301 patients admitted to their health service, including those they did not treat. Occasions of service In the last continuous 4 weeks of working, there was an average of 64 occasions of service or Table 1. Mean (þs.d.) percentage of time allocated to tasks (n = 15) Task allocation Direct patient care Administration & management Research Patient/carer education Education of nurses Education of medical and/or allied health Other activities Total
% Time allocated 49.7 ± 25.1 17.2 ± 14.4 13.0 ± 27.7 7. 7 ± 8.4 7.5 ± 4.7 4.0 ± 3.3 1.0 ± 3.8 100
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episodes of care performed per patient with a wound by the WMNP. The average number of patients treated with a wound in the past year by the WMNPs was 578 patients (range 0–1560 patients). Length of consultations The typical length of a new case consultation was 60 min, whereas a follow-up consultation was 32 min in length. Model of care Target population The WMNPs were asked to describe their model of care to elicit information on their target population and the types of clinical presentations that are the focus of their service. All WMNPs stated that they mostly treat adults over 60 years of age. Types of wounds treated The WMNPs were asked to describe the main types of wounds they treated. The types of wounds identified included chronic wounds, such as leg ulcers, diabetic foot ulcers, pressure injuries, malignant fungating wounds, complicated surgical wounds and sinuses. Appointment scheduling and referrals For 73.3% of WMNPs, an appointment scheduling system was used to arrange appointments, but they also had capacity for ad hoc consultations if requested. Although the WMNPs indicated they did not require a referral to access their services, they mostly request one, citing that it is their way of ensuring collaboration with the patient’s general practitioner (GP) or other health professionals involved in the patient’s care. The most common source of referrals to the WMNPs was a GP (80%), followed by allied health professionals (73%), registered nurses (73%), community nursing services (73%) and medical specialists (66%). A high number of WMNPs indicated that they accepted patients who were self-referrals (75%). The most common referrals that WMNPs initiated were to GPs (80%), followed by community nursing services (50%), medical specialists (33%), high risk foot (specialist high risk foot clinics for patients with neuropathic foot ulceration) (33%) and allied health professionals (25%). For the WMNPs working in the acute sector, they attended ward rounds for the purposes of identifying patients with wounds and to provide opportunistic wound management education to patients and/or carers and other health professionals. Just over half the WMNPs (53.4%) ran clinics several days per week. Collaboration with other health professionals The WMNPs were asked to describe how they collaborated with other health professionals in their health service. Responses included a combination of meetings, attendance at NP support groups, steering groups or that they attended multidisciplinary team meetings. Most demonstrated their collaborative relationships through correspondence or other forms of communication. Some WMNPs indicated that they worked independently and were required to develop collaborative arrangements with health professionals external to their service. Sources of funding WMNPs working in the public hospital setting do not have access to the Medicare Benefits Schedule (MBS). Those WMNPs working for community nursing organisations received their funding through other government sources. Most WMNPs (n = 13; 60%) did not have access to the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS).
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Clinical service patterns
Types of data collected
Clinical pathways
Patient satisfaction surveys were conducted regularly by nearly half the respondents (n = 12; 41%) and 91% of the 12 WMNPs who answered this question routinely collected data on their health service. The type of data that the WMNPs collected included a wide range of service-related and wound-related parameters (see Fig. 1). The most commonly collected servicerelated parameter was on sources of referral to their services and occasions of service. The least routinely collected information was on patient health-related quality of life. A wound assessment tool capturing data on wound-specific parameters and interventions performed was administered by 83% of WMNPs. The most commonly collected wound assessment parameter was ABPI (n = 12; 100%).
Most respondents (80%; n = 12) indicated that they had clinical pathways and protocols for the management of wounds. The most common type of tool used by respondents was a wound assessment tool (80%). Other types of tools used included a pressure injury risk assessment (80%), followed by a diabetic foot assessment tool (80%) and a skin tear classification (73.3%) tool. Activities performed The most commonly performed activities by WMNPs were wound photography (83%), followed by patient, family and/or carer education (75%), performing Doppler ankle–brachial pressure index assessment (ABPI; 58%), conservative sharp wound debridement (58%), counselling (50%) and a range of other activities, such as monofilament testing, ultrasonic debridement, education of nursing, medical, allied health professionals and/or students and monitoring and/or follow up.
Methods of data collection In terms of data collection methods, of the 12 who reported collecting data, 83% recorded the data in a database. Of these, 41% used a paper-based audit tool and 25% used other methods, including medical charts or an electronic medical record. Of the 11 WMNPs who answered this question, 83% indicated that they were the person most likely to be responsible for collecting information. Data were recorded on a daily basis by 55% (n = 11) of respondents and either weekly or monthly by 18% of respondents, with the remaining 9% recording data on a quarterly basis. Of the WMNPs who collected data, 67% analysed and reported on their data. The main barriers to analysis and reporting of data were insufficient time (50%), followed by a lack of common tools (41.7%), the lack of a requirement to undertake routine data analysis and reporting (16.7%) and uncertainty about how the data would be used (8.3%).
Medications prescribed The most routinely prescribed medications were local anaesthetic (25%), followed by topical corticosteroids (16%). The least commonly prescribed medication was intravenous antibiotics, with 81% (n = 12) of respondents indicating that they never prescribe this type of medication. Oral antibiotics were frequently prescribed by 25% of WMNPs. Admission and discharge privileges In terms of hospital admission privileges, 60% of WMNPs did not have admission privileges, although 33% had hospital discharge privileges.
Purposes of data collection Patient education
The 12 WMNPs who collected data, reported that these data were used for a range of purposes, such as to monitor patient outcomes (91%), to justify their health service (75%) and to improve the health services they provide (66%). Half these WMNPs reported using the data to change practices or for their personal use and/or interest, whereas only 17% used the data
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The WMNPs routinely offered patient information literature on a range of topics. The most common type of patient information that WMNPs provided to patients was on pressure injury prevention (83%), followed by literature on leg ulcer prevention (67%).
Type of wound data Fig. 1. Types of wound related data collected (n = 12). ABPI, ankle–brachial pressure index.
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they collected to benchmark between services or for research purposes. Discussion One of the key characteristics of a WMNP is their advanced educational preparation, expanded role and autonomy.17 Like other groups of the nursing workforce, most WMNPs in the present study were female and aged >30 years.34,35 This is reflective of the years of advanced clinical practice required for authorisation.34 There is general agreement in the literature that wound care nurses, like the WMNPs in the present study, educated to the Master’s degree level practice autonomously, collaborate with medical and allied health colleagues to coordinate care of patients and have high level clinical and decisionmaking skills, as well as a commitment to life-long learning.36,37 In fact, Rece Mitchell38 argues that Masters-prepared nurses with speciality certification in wound management have a unique opportunity to integrate the role components of clinician, consultant, educator, researcher and manager and are able to provide excellent care in a cost-effective manner. The results of the present study indicate that the WMNPs in this sample are very experienced in the speciality area, having worked in the area of wound management before authorisation. Furthermore, at least one-quarter were currently undertaking study relevant to their role as an NP. Health care depends heavily on access to a skilled workforce.34 Consistent with findings reported in the literature on NPs in Australia, most WMNPs in the present study stated that the greater part of their time was spent delivering direct patient care, followed by administration, research and then education of patients or carers, nurses, medical or allied health colleagues.12,22 The amount of time NPs spend on administrative and coordinating activities reduces the time they spend providing direct patient care.12 Having information about the time spent on activities not directly related to provision of clinical service enables nurses and managers to improve the utilisation of NP services.12 It is interesting that 13% of respondents indicated that they were engaged in research when in previous studies on NPs this figure has been as low as 1.5% (n = 205) of the entire sample were engaged in research.12,22 Perhaps this is reflective of an increasing awareness of the need to meet competency standards for NPs where research is an explicit requirement of the competency standards.7,39 Another reason may be the drive for NP workforce development and the need to improve frontline patient care from prevention to chronic disease management, an area where NPs are ideally placed to achieve these objectives.12,22,40 A definition of what constituted ‘research’ was not included in the present study, which may also account for the higher proportion of NPs indicating that they were engaged in research activities. There is evidence to suggest that research activities, such as participation, dissemination and utilisation of research evidence, are still not perceived favourably or used proactively by the majority of nurses.41,42 Furthermore, there is increasing recognition of gaps between best scientific evidence and clinical practice in many fields of health care.3,43 A recent study estimated that in wound care up to 70% of patients with venous leg ulcers fail to receive evidence-based treatment.3
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However, the same study demonstrated that following admission to a specialist wound clinic, including a WMNP-led clinic, implementation of key indicators of evidence-based care increased.3 The majority of respondents in the present study (93%) were employed in the public sector.8 Although the numbers of WMNPs working in settings apart from the public sector is relatively low, it is anticipated that this number will increase with access to MBS and PBS becoming increasingly available, enabling NPs to work in a private capacity.8 Despite legislative changes in November 2010 providing NPs with access to the MBS and PBS, the context in which health care is delivered, such as in public hospitals, means that some NPs do not have the authority to access MBS provider number or the authority to prescribe through the PBS.22 These restrictions mean that the full potential of the NP role is yet to be realised (i.e. NPs are not being used to their full clinical capacity) and this will inhibit the development of NP services.44 Increasingly, treatment for chronic wounds, such as leg ulcers, has moved away from the acute sector and is becoming community based in an attempt by the healthcare system to improve cost-effectiveness.45–47 Unfortunately, the costs and responsibility for chronic wounds has shifted from the healthcare system to the patient.45 The limited MBS rebates currently available to NPs are a disincentive for them to deliver more efficient and streamlined services for patients and reduces patient demand for allowable (but nonMBS supported) services because of the resulting financial impost on the patient.48 In keeping with the literature, the present study highlights that WMNPs, like other NPs across a wide range of speciality areas, spend more time with patients, providing longer consultations; that they carry out more investigations than doctors; and that patients were generally more satisfied with care from an NP than from a doctor.48–50 Furthermore, evidence suggests that patients are more likely to be involved in their care if they are given oral and written information.17,51,52 As the results from the present study demonstrate, the WMNPs are actively providing both oral and written information to patients. There is good evidence to demonstrate that when patients are actively involved in their treatment, outcomes improve.53,54 In terms of the types of activities that WMNPs routinely performed, there was a wide range of activities that was undertaken. These findings are consistent with previous research in the area and are indicative of the complex nature of wound care.17 With wound prevalence increasing with age,3 the number of patients WMNPs treat is anticipated to increase exponentially in the future. Given the complexity of wounds and the fact that many patients suffer from multiple comorbid conditions, it is essential that the WMNP works collaboratively with other health professionals. In the present study, the WMNPs, like other NPs, collaborated with a wide range of health professionals, demonstrating the interdisciplinary nature of wound management. Numerous studies have indicated that access to skilled care is an important issue for patients with wounds and that NP service improves access for patients.3,17 The WMNP is in an ideal position to facilitate and enhance communication and collaboration within and between specialist consultants, other nurses and allied health professionals. In keeping with the literature,31,46,55 the results of the present study demonstrate
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that NPs complement services and ensure integrated continuity of care and effective communication through the collaborative development of referral pathways, clinical practice guidelines and protocols. Given that wound assessment is a routine component of caring for patients with any type of wound, it is not surprising that the WMNPs use a wound assessment tool. The use of standardised wound assessment tools and other data collection measures, such as patient satisfaction surveys and periodic audits of service utilisation, provides benchmarks for measuring patient outcomes.56 However, the present study found that for almost half the respondents, insufficient time and the lack of common tools was a barrier to data collection and that they were the person most likely to be responsible for collecting this information, thereby further reducing the amount of time they have for direct patient care. Measurement of outcomes of WMNP service is essential and further highlights the need for a tool that WMNPs can use for benchmarking and articulating the benefits and outcomes of their models of practice. Limitations It is acknowledged that this study has a small sample size because, in Australia, there is no way to identify the number of authorised WMNPs: the area of speciality is not captured by AHPRA. Although contact was made with the WMNP Online Peer Review Group, to which most WMNPs belong, and it was estimated that there are between 25 and 30 WMNPs in Australia based on membership of this group, it is possible that some authorised WMNPs were not included in this study. Although online survey methods have found that response rates to email surveys are equal to or better than those for traditional mailed surveys, the response rate in the present study was low, thereby introducing the possibility of selection bias and limiting the sampling frame.57 The results may not be representative or generalisable for all WMNPs. Conclusion The results of the present scoping study indicate that WMNPs practice in a range of health service settings throughout Australia and yet have similar patterns of practice. This information has yielded important baseline information on this emergent professional group. However, it is clear that more research is needed on WMNP service, processes and patient outcomes to enable health service planners, other health professionals and consumers to understand more about these models and to realise the full potential of the WMNP role.22 Competing interests
M. A. Gibb et al.
References 1
2 3
4
5
6
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8 9 10
11
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The authors declare that no conflicts of interest exist. 19
Acknowledgements The authors acknowledge the WMNPs for their participation in the study. This study was undertaken as part of a PhD degree by MAG at Queensland University of Technology. This study was supported by the Wound Management Innovation Cooperative Research Centre (WMI CRC; Project no. 3–18).
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Australian Institute of Health and Welfare (AIHW). Australia’s health 2012. Australia’s health series no. 13. Catalogue no. AUS 156. Canberra: AIHW; 2012. Australian Bureau of Statistics (ABS). Population projections. Canberra: ABS; 2008. Edwards H, Finlayson K, Courtney M, Graves N, Gibb M, Parker C. Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence based wound care. BMC Health Serv Res 2013; 13: 86. doi:10.1186/1472-6963-13-86 Coyer F, Edwards H, Courtney M. Best practice community care for clients with chronic venous leg ulcers: National Institute of Clinical Studies (NICS) report for Phase 1 evidence uptake network. Brisbane: Queensland University of Technology; 2005. Considine J, Fielding K. Sustainable workforce reform: case study of Victorian nurse practitioner roles. Aust Health Rev 2010; 34: 297–303. doi:10.1071/AH08727 Gardner G, Gardner A, O’Connell J. Using the Donabedian framework to examine the quality and safety of nursing service innovation. J Clin Nurs 2014; 23: 145–55. doi:10.1111/jocn.12146 Australian Nursing and Midwifery Council. National competency standards for the nurse practitioner. Dickson, ACT: Australian Nursing and Midwifery Council; 2013. Australian Nursing Federation. A snapshot of nurse practitioners in Australia. Kingston, ACT: Australian Nursing Federation; 2011. Australian Health Practitioner Regulation Agency. Annual report 2011/ 12. Brisbane: Australian Health Practitioner Regulation Agency; 2012. Nursing and Midwifery Board of Australia. Nurse and midwife registrant data: March 2013. Melbourne: Australian Health Practitioner Regulation Agency; 2013. Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000; 320: 1048–53. doi:10.1136/bmj.320.7241.1048 Gardner G, Gardner A, Middleton S, Della P, Kain V, Doubrovsky A. The work of nurse practitioners. J Adv Nurs 2010; 66: 2160–9. doi:10.1111/j.1365-2648.2010.05379.x Gardner G, Carryer J, Gardner A, Dunn S. Nurse practitioner competency standards: findings from collaborative Australian and New Zealand research. Int J Nurs Stud 2006; 43: 601–10. doi:10.1016/j.ijnurstu.2005.09.002 Harrington J. Nurse practitioners: a safe and competent choice for primary care. Int Nurs Rev 2010; 17: 66–7. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting ‘same day’ consultations in primary care. BMJ 2000; 320: 1043–8. doi:10.1136/bmj.320.7241.1043 Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: twoyear follow-up. Med Care Res Rev 2004; 61: 332–51. doi:10.1177/ 1077558704266821 MacLellan L, Gardner A, Gardner G. Designing the future in wound care: the role of the nurse practitioner. Primary Intention: Aust J Wound Manage 2002; 10: 97–112. Lowe G. Scope of emergency nurse practitioner practice: where to beyond clinical practice guidelines? Aust J Adv Nurs 2010; 28: 74–82. Queensland Government. Clinical governance for nurse practitioners in Queensland: a guide. Brisbane: Queensland Government; 2011. Carryer J, Gardner G, Dunn S, Gardner A. The core role of the nurse practitioner: practice, professionalism and clinical leadership. J Clin Nurs 2007; 16: 1818–25. doi:10.1111/j.1365-2702.2007.01823.x Lowe G, Plummer V, O’Brien AP, Boyd L. Time to clarify: the value of advanced practice nursing roles in health care. J Adv Nurs 2012; 68: 677–85. doi:10.1111/j.1365-2648.2011.05790.x
Nurse practitioner models of practice
Australian Health Review
22 Middleton S, Gardner A, Gardner G, Della P. The status of Australian nurse practitioners: the second national census. Aust Health Rev 2011; 35: 448–54. 23 Gardner A, Gardner G, Middleton S, Della PR. The status of Australian nurse practitioners: the first national census. Aust Health Rev 2009; 33: 679–89. doi:10.1071/AH090679 24 Jenkins ML. Toward national comparable nurse practitioner data: proposed data elements, rationale, and methods. J Biomed Inform 2003; 36: 342–50. doi:10.1016/j.jbi.2003.09.016 25 Harding K, Queen D. Wound registries: a new emerging evidence resource. Int Wound J 2011; 8: 325. doi:10.1111/j.1742-481X.2011. 00827.x 26 Keast DH, Bowering CK, Evans AW, Mackean GL, Burrows C, D’Souza L. MEASURE: a proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair Regen 2004; 12(Suppl): S1–17. doi:10.1111/j.1067-1927.2004. 0123S1.x 27 Capasso V, Collins J, Griffith C, Lasala CA, Kilroy S, Martin AT, Pedro J, Wood SL. Outcomes of a clinical nurse specialist-initiated wound care education program: using the promoting action on research implementation in health services framework. Clin Nurse Spec 2009; 23: 252–7. doi:10.1097/NUR.0b013e3181b207f5 28 Bale S. The contribution of the wound care nurse in developing a diabetic foot clinic. Br J Clin Govern 2002; 7: 22–6. doi:10.1108/ 14664100210417995 29 Cowman S, Gethin G, Clarke E, Moore Z, Craig G, Jordan-O’Brien J, McLain N, Strapp H. An international eDelphi study identifying the research and education priorities in wound management and tissue repair. J Clin Nurs 2012; 21: 344–53. doi:10.1111/j.1365-2702.2011. 03950.x 30 Appleby SL. Role of the wound ostomy continence nurse in the home care setting: a patient case study. Home Healthc Nurse 2011; 29: 169–77. doi:10.1097/NHH.0b013e3181fe438b 31 Moffatt C, Franks P, Morison M. Models of service provision. In Morison M, Moffatt C, Franks P, editors. Leg ulcers: a problem-based learning approach. Edinburgh: Mosby Elsevier; 2007. pp. 99–118. 32 Gardner G, Gardner A, Middleton S, Della P. The nurse practitioner research toolkit. Brisbane: Australian College of Nurse Practitioners; 2009. 33 Nursing and Midwifery Board of Australia. Nurse and midwife registrant data: March 2014. Melbourne: Nursing and Midwifery Board of Australia; 2014. 34 Australian Institute of Health and Welfare (AIHW). Nursing and midwifery workforce 2011. National health workforce series no. 2. Catalogue no. HWL 48. Canberra: AIHW; 2012. 35 Gardner A, Gardner G, Middleton S, Della P. The status of Australian nurse practitioners: the first national census. Aust Health Rev 2009; 33: 679–89. doi:10.1071/AH090679 36 Doughty D. Integrating advanced practice and WOC nursing education. J Wound Ostomy Continence Nurs 2000; 27: 65–8. 37 Gray M, Ratliff C, Mawyer R. A brief history of advanced practice nursing and its implications for WOC advanced nursing practice. J Wound Ostomy Continence Nurs 2000; 27: 48–54. 38 Mitchell JR. Development of the advanced practice nurse role in wound management. Top Spinal Cord Inj Rehabil 2003; 9: 1–7. doi:10.1310/ N833-C8D9-R7B0-J14N 39 Nursing and Midwifery Board of Australia. Nurse practitioner standards for practice. Melbourne: Nursing and Midwifery Board of Australia; 2014.
227
40 National Health and Hospitals Reform Commission. A healthier future for all Australians: final report of the National Health and Hospitals Reform Commission. Barton, ACT: Commonwealth of Australia; 2009. 41 Edwards H, Chapman H, Davis LM. Utilization of research evidence by nurses. Nurs Health Sci 2002; 4: 89–95. doi:10.1046/j.1442-2018. 2002.00111.x 42 Squires JE, Hutchinson AM, Bostrom AM, O’Rourke HM, Cobban SJ, Estabrooks CA. To what extent do nurses use research in clinical practice? A systematic review. Implement Sci 2011; 6: 21. doi:10.1186/1748-5908-6-21 43 Bryant J, Boyes A, Jones K, Sanson-Fisher R, Carey M, Fry R. Examining and addressing evidence-practice gaps in cancer care: a systematic review. Implement Sci 2014; 9: 37. doi:10.1186/1748-5908-9-37 44 Barton AJ, Baramee J, Sowers D, Robertson KJ. Articulating the valueadded dimension of NP care. Nurse Pract 2003; 28: 34–40. doi:10.1097/ 00006205-200312000-00006 45 Smith E, McGuiness W. Managing venous leg ulcers in the community: personal financial cost to sufferers. Wound Pract Res: Aust J Wound Manage 2010; 18: 134–9. 46 Graham ID, Harrison MB, Moffatt C, Franks P. Leg ulcer care: nursing attitudes and knowledge. Can Nurse 2001; 97: 19–24. 47 Simon DA, Freak L, Kinsella A, Walsh J, Lane C, Groarke L, McCollum C. Community leg ulcer clinics: treatment comparative study in two health authorities. British Medical Journal 1996; 312: 1648–1651. 48 Centre for International Economics (CIE). The CIE final report. Responsive patient centred care. The economic value and potential of nurse practitioners in Australia. Canberra: CIE; 2013. 49 Horrocks S, Anderson E, Salisbury C. Systemic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002; 324: 819–23. doi:10.1136/bmj.324.7341.819 50 Laurant MG, Hermens RP, Braspenning JC, Akkermans RP, Sibbald B, Grol RP. An overview of patients’ preference for, and satisfaction with, care provided by general practitioners and nurse practitioners. J Clin Nurs 2008; 17: 2690–8. doi:10.1111/j.1365-2702.2008.02288.x 51 Edwards H, Courtney M, Finlayson K, Lindsay E, Lewis C, Shuter P. Chronic venous leg ulcers: effect of a community nursing intervention on pain and healing. Nurs Stand 2005; 19: 47–54. doi:10.7748/ns2005. 09.19.52.47.c3950 52 Agosta LJ. Patient satisfaction with nurse practitioner-delivered primary healthcare services. J Am Acad Nurse Pract 2009; 21: 610–17. doi:10.1111/j.1745-7599.2009.00449.x 53 Edwards H, Courtney M, Finlayson K, Shuter P, Lindsay E. A randomised controlled trial of a community nursing intervention: improved quality of life and healing for clients with chronic leg ulcers. J Clin Nurs 2009; 18: 1541–9. doi:10.1111/j.1365-2702.2008.02648.x 54 Finlayson K, Edwards H, Courtney M. The impact of psychosocial factors on adherence to compression therapy to prevent recurrence of venous leg ulcers. J Clin Nurs 2010; 19: 1289–97. doi:10.1111/j.13652702.2009.03151.x 55 van Offenbeek MAG, Knip M. The organizational and performance effects of nurse practitioner roles. J Adv Nurs 2004; 47: 672–81. doi:10.1111/j.1365-2648.2004.03156.x 56 Bolton L. Wounds: A compendium of clinical research and practice. Wounds 2012; 24: 18–24.
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