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Table 1 Literature Review Table of Study Characteristics (n = 17)

From: Effectiveness of registered nurses on system outcomes in primary care: a systematic review

Author, Year, Country

Aim

Design

Sample

Intervention and Primary Care RN Involvement

Primary Care Setting Type

ICROMS Quality Appraisal Score1

Aubert et al., 1998 [50]

USA

To compare diabetes control in patients receiving nurse case management and patients receiving usual diabetes management in a primary care setting

Randomized controlled trial

Prudential HealthCare health maintenance organization members with diabetes (n = 138 patients were randomized, n = 100 provided 12-month follow-up data)

Nurse case management for patient diabetes control (diabetes management delivered by a RN case manager) v. usual diabetes care (control)

One RN provided the intervention for this study; RN had 14 years of clinical experience and was a certified diabetes educator

RN provided intervention with support- met at least biweekly with the family medicine physician and the endocrinologist to review patient progress, medication adjustments. RN was trained in the delivery of care while primary care providers oversaw clinical decisions.

2 primary care clinics within a group-model health maintenance organization in Jacksonville, Florida

25

Azariah et al., 2013 [51]

New Zealand

To increase opportunistic testing for chlamydia in under 25-year-olds and to improve documentation of partner notification in primary care using a nurse-led approach

Uncontrolled before-after

All sexually active under 25-year-olds (n = 760) that consented to a chlamydia test during the 4-month pilot project period

Chlamydia management guidelines regarding opportunistic testing and partner notification (analysis of laboratory testing data and diagnostic information) compared to pre-study testing levels

Number of RNs and additional characteristics were not indicated

RN provided intervention independently. During routine patient visits, RNs recommended chlamydia tests to all patients meeting study criteria; those that tested positive were recalled by the RN for treatment and to discuss partner notification. RNs then provided follow-up call one week after treatment

10 primary care practices in urban South Auckland that operate by a nurse-triage process

22

Bellary et al., 2008 [52]

UK

To investigate the effectiveness of a culturally sensitive, enhanced care package for improvement of cardiovascular risk factors in patients of South Asian origin with type 2 diabetes

Cluster randomized controlled trial

Adult patients of South Asian origin with type 2 diabetes (n = 1486)

Enhanced management care for type 2 diabetes tailored to the needs of the South Asian community (enhanced care [additional time with PN + support with link worker and diabetes-specialist nurse]) v. standard care [routine PN-led diabetes clinics guided by prescribing algorithm] (control)

Number of PNs not indicated; all were formally trained in diabetes management

PN provided intervention with support of diabetes nurse specialist, link worker and physician. PNs worked with primary care physicians to implement the protocol and encourage appropriate prescribing, provide patient education, and achieve health targets

21 inner-city practices in 2 cities in the UK with a high-population of South Asian patients. Patients were randomly allotted to the intervention or the control group between March 2004–April 2005

24

Cherkin et al., 1996 [53]

USA

To evaluate the impact of a proactive and patient-centered educational intervention for low back pain involving a nurse-intervention group in comparison with two lower impact treatment models

Randomized controlled trial

Patients aged 20–69 years visiting the clinic for back pain, low back pain, hip pain or sciatica (n = 294) were randomly allocated to one of 3 groups; n = 286 provided complete follow-up data

Educational intervention for back pain carried out by a RN. Usual care (control) v. usual care + educational booklet (booklet intervention) v. usual care + session with RN + educational booklet (nurse intervention); outcomes assessed at 1, 3, 7, and 52 weeks

Study involved 6 female RNs with at least 20 years of clinical experience. Study RNs received 9 h of training on the management of back pain

RN provided intervention indepdendently. The intervention involved a 15–20-min educational session, including the booklet and a follow-up telephone call 1–3 days later

Suburban primary care clinic in western Washington state, belonging to a staff model Health Maintenance Organization

24

Daly et al., 2000 [54]

New Zealand

To evaluate trends in foot examinations for people with diabetes by PNs, district nurses, and specialized nurses between 2006–2008 and 2016 and to determine whether the diabetes education of nurses is related to their management of foot diseases

Quasi-experimental; two cross-sectional surveys

287 randomly selected PNs were surveyed in 2006–2008 and 336 PNs were surveyed in 2016. Nurses provided consulting information for 265 and 166 patients for 2006–2008 and 2016, respectively.

PN-provided examinations and education provision for patients with diabetes foot disease in 2006–2008 and in 2016

Survey was completed by 210 PNs in 2006–2008 and 274 PNs in 2016. Level of diabetes education and years since graduation varied

No specific nurse intervention; study examined PN activities and assessments routinely performed during a diabetes consultation on a randomly selected day. Nurses who had consulted at least one person with diabetes on this day were asked about assessments and care provided for these patients, specifically in regards to foot care

General practices that employed a PN across three district health boards in Auckland, NZ

21

Farford et al., 2021 [55]

USA

To evaluate the impact of a RN-led Medicare annual wellness visit on preventive services in a family medicine clinic

Quasi-experimental; retrospective chart review

A total of 630 patients (330 undergoing annual wellness visits and 300 undergoing standard assessments) aged 68–72 years who were Medicare beneficiaries

RN-led annual wellness visits of Medicare beneficiaries compared to standard assessment (defined as a 30-min office visit with the primary care physician)

The annual wellness visits were conducted by 3 care team RNs (one at each location). Each RN received a 1-h lecture on annual wellness visits and was required to observe a previously trained RN perform annual wellness visits on live patients before offering the service

RNs provided intervention independently; during the annual wellness visits, the RNs ordered needed preventive imaging, labs, and vaccinations. The preventive services that were evaluated included mammography, colon cancer screening, bone mineral analysis, pneumococcal vaccination, influenza vaccination, screening for hepatitis C, and screening for depression in a 12-month period.

3 satellite community-based practices connected with the Department of Family Medicine at the Mayo Clinic in Florida

19

Faulkner et al., 2016 [56]

UK

To compare differences in smoking cessation treatment delivered by PNs or HCAs on short and long-term abstinence rates from smoking

Cohort study using longitudinal data from a previously conducted randomized controlled trial

Current smokers aged 18–75 years who are fluent in English, not enrolled in another formal smoking cessation study or program and not using smoking cessation medications (n = 602)

Smoking cessation support provided by PNs v. HCAs, to compare and assess effects on short and long-term smoking abstinence rates on patients

Number of PNs and additional characteristics were not indicated

PNs provided intervention alone (and were compared to same intervention provided by HCAs). Patients in both groups received an initial consultation, followed by a program-generated cessation advise report tailored to the smoker and a 3-month program of tailored text messages sent to their mobile phone

32 general practices in East England; 8 of which were in the top 50% of deprived small geographical areas in England

21

Gallagher et al., 1998 [57]

UK

To determine the impact of telephone triage, conducted by a PN, on the management of same day consultations in a general practice

Quasi-experimental (cross-sectional) and uncontrolled before-after using prospective telephone and practice consultation data + patient postal questionnaire

All patients in practice (n = 1250 consultations with diagnosis), in which consultations were recorded between August 1995–October 1995

Nurse operated telephone consultations/ triage

There was a total of 4 PNs working in the practice; the telephone consultation/triage service was managed by a single nurse who had 15 years of experience and was familiar with managing acute illnesses and conducting telephone consultations

PN provided intervention with support of physician and receptionist. Patients who telephoned requesting to see a doctor on the same day were put through to the PN, where they would manage the patient’s problem over the phone or arrange for a same-day appointment with either themselves or the GP

Individual general practice in an urban city in England that contains physicians, practice nurses and admin staff

16

22a

Harris et al., 2015 [58]

UK

To determine whether a primary care nurse-delivered complex intervention increased objectively measured step-counts and MVPA when compared to usual care

Cluster randomized controlled trial

60–75-year-olds who could walk outside and had no contraindications to increasing physical activity (n = 298 patients from n = 250 households) were recruited between 2011 and 2012 from a random sample of eligible households

Individually-tailored PN consultations centered around physical activity (four physical activity consultations with nurse) v. usual care (no trial contacts other than for data collection at baseline, 3 months and 12 months) (control)

Number of PNs and additional characteristics were not indicated

PN provided intervention alone; physical activity consultations incorporated behavioural change techniques, step-count and accelerometer feedback, and an individual physical activity plan

3 general practices located in Oxfordshire and Berkshire, UK

28

Harris et al., 2017 [59]

UK

To evaluate and compare the effectiveness of pedometer-based and nurse-supported interventions v. postal delivery intervention or usual care on objectively measured physical activity in predominantly inactive primary care patients

Cluster randomized controlled trial

A random sample of 45–75-year-olds without contraindications to increasing MVPA (n = 956 with at least one follow-up) were sent postal invitations between September 2012–October 2013

Nurse-supported individually-tailored physical activity consultations as measured by patient pedometer activity (nurse-supported pedometer intervention [arm 1]) v. postal pedometer intervention (arm 2) v. usual care (control)

Number of PNs and additional characteristics were not indicated

PN provided intervention alone; nurse-supported intervention group involved a pedometer, patient handbook, physical activity diary, and three individually tailored PN consultations offered at 1, 5, and 9 weeks

7 general family practices with an ethnically and socioeconomically diverse population in South London

26

Iles et al., 2014 [60]

Australia

To determine the economic feasibility of using a PN-led care model of chronic disease management in Australian general practices in comparison to GP-led care

Randomized controlled trial; cost-analysis

Patients > 18 years of age with one or more stable chronic diseases (type 2 diabetes, ischemic heart disease, hypertension) (n = 254)

PN-led care model of chronic disease management v. GP-led care model (usual care)

There were 2 PNs and 1–4 GPs involved in each practice over the 2-year study period

PN provided intervention alone, working within their scope of practice and from protocols, rather than under supervision of GP; if patients in the PN-led group became unstable, they could be referred back to the GP-led group until their health re-stabilized

3 general practices (urban, regional, rural)

22

Karnon et al., 2013 [61]

Australia

To conduct a risk adjusted cost-effectiveness analysis of alternative applied models of primary health care for management of obese adult patients based on level of practice nurse involvement (high-level PN practice v. low-level PN practice v. physician-only model)

Quasi-experimental; risk-adjusted cost-effectiveness analysis

Patients with BMI < 30 prior to October 1, 2009, had at least three visits within the last 2 years, at least two recorded measures of BMI, and aged 18–75 years (n = 383 patients were recruited, n = 208 were excluded, n = 150 patients included in the analysis) who gave consent for researchers to access their medical data

PN involvement in the provision of clinical-based obesity care. Models of care classification were based on percentage of time spent on clinical activities: high-level model (n = 4), low-level model (n = 6), physician-only model (n = 5; due to low number of eligible patients in the physician-only model, data were not presented)

Number of PNs were not indicated, although results suggest that high-level practices had a non-significantly higher number of full-time equivalent PNs than low-level practices (0.35 to 0.25, p = 0.34); PNs had varying scopes of practice in clinics, which was informed by survey responses that assessed their clinical-based activities

No specific nurse intervention; study examined nursing care related to obesity in general (e.g., education, self-management advice, monitoring clinical progress, assessing treatment adherence)

15 of 66 general practices within the Adelaide Northern Division of General Practice with varying levels of PN involvement

22

Katz et al., 2004 [62]

USA

To compare medical assistants’ and LPNs’ performance of recommended smoking-cessation guidelines with that of RNs

Secondary analysis of data from a randomized controlled trial

Patients aged 18+ years who had an appointment with a primary care provider for routine care, and reported smoking at least one cigarette per day on average (n = 1221)

Smoking cessation clinical practice guidelines implemented by either medical assistants, LPNs, or RNs

Number of RNs and additional characteristics were not indicated

RNs (and other health professionals in the study) were paired with a primary care clinician but provided the intervention alone and separate. Intervention involved using guideline algorithms and motivational interviewing

9 community-based, primary care practices

27

Low et al., 2005 [63]

UK

To evaluate the effectiveness of a PN-led strategy to improve the notification and treatment of partners of people with chlamydia infection compared to standardized protocols for patient referral

Randomized controlled trial

Patients who had received a positive chlamydia test result at their general practice (n = 140) from March 2001–October 2002

PN-led strategy to improve the notification and treatment of partners of people diagnosed with chlamydia v. standard protocols, which involve referral to a specialist health advisor at a genitourinary clinic (control)

Study involved 36 PNs; additional characteristics not identified

PNs provided intervention with support of health advisors; PNs carried out partner notification at the time of diagnosis, followed by telephone follow-up by health advisors. The intervention included a partner notification interview, patient partner referral, and advise on sexual health and sexually transmitted infections

27 general practices in the urban cities of Bristol and Birmingham

27

Moher et al., 2001 [64]

UK

To assess the effectiveness of three different methods for improving the secondary prevention of coronary heart disease in primary care (audit and feedback; recall to a GP; recall to a nurse clinic)

Pragmatic, unblinded, cluster randomized controlled trial comparing three intervention arms

Patients aged 55–75 years with established coronary heart disease (n = 1906) as identified by computer and paper health records were recruited from 1997-1999

Secondary prevention care of patients with coronary heart disease delivered at three levels (i.e., audit and feedback; GP recall; nurse recall)

Number of PNs in study unknown- all practices employed at least 1 PN; additional characteristics not identified

PN provided intervention with support of the trial’s nurse facilitator, who gave ongoing support to the practices in setting up a recall system for review of patients with coronary heart disease. The nurse recall and GP recall groups employed the same intervention

21 general practices in Warwickshire that employed PNs, but were not already running nurse-led clinics

26

O’Neill et al., 2014 [65]

USA

To assess expanded CPS and RN roles by comparing blood pressure case management between CPS and physician-directed RN care in patients with poorly controlled hypertension

Quasi-experimental; non-randomized, retrospective comparison of a natural experiment

Patients that had face-to-face or telephone appointments with a RN case manager for poorly controlled hypertension with either physician-directed or CPS-directed clinical decision making at the index encounter (n = 126)

Patient hypertension care delivered interdependently by clinical pharmacy specialist-directed RN case management as an alternative to physician-directed RN case management

Number of RNs and additional characteristics were not indicated

RN provided intervention with support of either CPs or physician; RNs assessed patients independently and presented the case to either a CPS or a physician, if the hypertension continued to be poorly controlled. The RN communicated any changes in the plan to the patient

A large Midwestern Veteran’s Affairs Medical Center that utilizes team-based care

18

Plummer et al., 2000 [66]

UK

To determine the ability of a PN to identify psychiatric morbidity in patients attending their clinics, before the implementation training interventions

Quasi-experimental

All patients in practice aged 16 years and over and not suffering from a disorder causing a cognitive impairment (n = 1768 approached, n = 1710 completed the survey)

Use of data collection and patient questionnaires to determine the abilities of PNs to identify patient psychological distress levels and psychiatric morbidity during nurse consultations with patients

One PN from each practice location took part in the study (n = 24); additional nurse characteristics not identified

PN provided intervention alone; after initial consultation, patients completed a 12-item questionnaire. PN was asked to rate patient’s level of psychological distress on a scale of 0–4. Level of agreement between patient general health questionnaire classification and PN’s assessment was then assessed

24 general practices randomly selected from 41 practices in South London and Kent

19

  1. aMixed methods study consisting of multiple designs; separate ICROMS quality appraisal scores were generated for each study type; RN registered nurse, PN practice nurse, HCA health care assistant, GP general practitioner, MVPA moderate to vigorous physical activity, BMI body mass index, LPN licensed practical nurse, CPS clinical pharmacy specialist