Table 2 Literature review table of study characteristics (n = 23)
From: Effectiveness of registered nurses on patient outcomes in primary care: a systematic review
Author, Year, Country | Aim | Design | Sample | Intervention and RN Involvement | Primary Care Setting Type | ICROMS Quality Appraisal Score [1] |
|---|---|---|---|---|---|---|
Aubert et al., 1998 [43] 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 and 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 |
Aveyard et al., 2007 [53] UK | To examine whether weekly behavioral support increased smoking quit rate relative to basic support; and to assess whether primary care nurses can deliver effective behavioral support | Randomized controlled trial | Adults who smoked ≥ 10 cigarettes per day (n = 925) were recruited between July 2002 - March 2005 | Smoking cessation support provided by a PN (weekly behavioural support [one additional visit and two additional telephone calls]) v. basic, less frequent support provided by a PN (control) Number of PNs and additional characteristics were not indicated PN provided intervention alone. All PNs were provided with mentoring and training on the application of smoking cessation support, as well as information on the use of nicotine replacement therapies | 26 general practices in two urban counties in the UK | 23 |
Bellary et al., 2008 [44] 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/control [routine PN-led diabetes clinics guided by prescribing algorithm]) 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 |
Byers et al., 2018 [54] USA | To compare smoking cessation rates between nurse-led and physician-led preventative/wellness visits | Observational; retrospective secondary analysis of a de-identified electronic medical record data set | Medicare beneficiaries who received wellness visits or non-Medicare patients who received MD-led annual physicals and identified as smokers (n = 218) between January 2011 - December 2015 | Nurse-led wellness visits focused on smoking cessation carried out by RNs v. same intervention carried out by GPs Nurses in the RN-led group were non-advanced practice RNs. Due to limited resources and competing clinical demands, efforts to implement Medicare annual wellness visits occurred gradually and included RNs in 4 of the 6 clinics RN provided intervention alone, carrying out point-of-care screening and various other preventative wellness activities | Network of 6 primary care clinics in Arkansas, USA | 20 |
Caldow et al., 2006 [64] UK | To assess patients’ satisfaction, attitudes, and preferences regarding PN v. doctor consultations for minor illness as first-line contact | Observational; survey and telephone interviews | Large random sample of registered patients over 18 years of age (n = 2949 questionnaires were mailed out; n = 1343 [45.5%] were returned completed) | National survey of patient satisfaction, attitudes, and preferences regarding PN care v. doctor consultation Number of PNs and additional characteristics were not indicated. Data obtained from postal questionnaire survey including discreet choice experiment, followed by telephone interviews Practices were scored and ranked according to the degree of extended nursing role; the 20 most and 20 least extended practices according to the criteria were invited to participate Organizational-level involvement; practices had PNs with varying roles (traditional and extended) and patients were surveyed about their interactions and attitudes/preferences | 433 general practices, including traditional and extended PN roles in Scotland | 21 |
Cherkin et al., 1996 [57] USA | To evaluate the impact of a proactive and patient-centered educational intervention for low back involving a nurse-intervention group in comparison with two lower impact treatment models | Randomized controlled trial | Patients aged 20–69 years of age 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) v. usual care + educational booklet (intervention arm 1) v. usual care + session with RN + educational booklet (intervention arm 2); 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 alone. 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 |
Coppell et al., 2017 [50] New Zealand | To examine the implementation and feasibility of a six-month multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice for patients with prediabetes | Pragmatic, non-randomized controlled before-after; convergent mixed methods design | Non-pregnant adults aged ≤ 70 years with newly diagnosed prediabetes, a BMI above 25, not prescribed Metformin, and able to communicate in English were sent a study invitation letter between August 2014 -April 2015. One-hundred fifty-seven patients were enrolled and n = 133 patients were retained at the six-month follow-up | Multi-level primary care nurse-led prediabetes lifestyle intervention involving a structured dietary intervention tool v. usual care (control) Study involved 11 RNs and community nurses. Additional characteristics were not indicated RN provided intervention with support of dietician and liaison nurse. RNs delivered the clinic portion of the intervention (30-min dietary session and evaluation using a validated dietary measurement tool at baseline, 2–3 weeks, 3 months, and 6 months) while community nurses carried out the group education sessions outside of the clinic | 4 intervention general practices and 4 control general practices located in 2 neighboring New Zealand cities; all practices employed a primary care nurse | 26 |
Desborough et al., 2016 [62] Australia | To examine the relationships between specific general practice characteristics, nurse consultation characteristics, and patient satisfaction and enablement | Observational; cross-sectional survey | Patients in general practice who had consulted with a nurse, regardless of health condition, and were 16 years or older, or 5 years or younger (n = 678) between September 2013 - March 2014 | Nursing care in general practice based on specific practice characteristics and nurse consultation characteristics (measured by patient surveys and interviews with nurses, patients, and practice managers) Study involved 47 baccalaureate-prepared RNs and 3 diploma-prepared enrolled nurses across all practices (average of 2.5 RNs per practice) with a mean of 3 years of experience RN provided intervention alone. The majority of consultations were for clinical care, preventative health care, and chronic disease management | 21 general practice locations in an Australian capital territory, with an average ratio of 3–4 GPs: 1 nurse per clinic | 22 |
Faulkner et al., 2016 [55] 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 [65] UK | To determine the impact of telephone triage, conducted by a PN, on the management of same day consultations in a general practice | Observational (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 - 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, PNs, and admin staff | 16; 22* |
Halcomb, Davies, & Salamonson, 2015 [63] New Zealand | To understand the relationship between consumer demographics and their satisfaction with PN services | Observational; survey | Patients with sufficient fluency in English to complete the survey form and provide consent (n = 1505) were recruited through email invitation from December 2010 - December 2011 | PN-led care in general practice as assessed by a 64-item self-report survey tool completed by patients Number of PNs not indicated, however each participating practice employed between 1–11. All participating nurses were female and had an average of 22 years of experience, a mean age of 49 years, and worked between 8–44 h/week PN provided intervention alone by performing a range of services within primary care nursing scope of practice- vaccination, blood pressure measurement, cardiovascular assessments, treatment of minor illnesses/injuries, cervical smears and sexual health check-ups, tissue collection, lung function tests, etc | 20 general practices in New Zealand, representing a mixture of urban and rural locations | 21 |
Halcomb, Salamonson, & Cook, 2015 [45] Australia | To evaluate consumer satisfaction and comfort with chronic disease management by nurses in general practice | Observational; survey | A convenience sample of all patients in practice (n = 81) who received services from a participating PN | Chronic disease services delivered by PNs in general practice, as measured by a 33-item survey tool Number of PNs and additional characteristics were not indicated PN provided intervention alone; after services were delivered, patients were provided with an information package containing a survey to evaluate their encounter | 8 general practices that contained GPs and PNs working collaboratively in New South Wales, Australia | 17 |
Harris et al., 2015 [59] UK | To determine whether a primary care nurse-delivered complex intervention increased objectively measured step-counts and moderate to vigorous physical activity 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 - 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 [60] 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 moderate to vigorous physical activity (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 [46] 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 (n =120) v. GP-led (usual care) care model (n =134) 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 [47] 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 PN involvement (high-level PN practice v. low-level PN practice v. physician-only model) | Observational; 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 indicate that high level practices had a non-significantly higher number of FTE PNs than low level practices (0.35 compared to 0.25 for low level practices, p = 0.34); PNs had varying scopes of practice in clinics, which was informed by survey responses which 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 |
Marshall et al., 2011 [51] New Zealand | To assess patients’ experiences and opinions of the Nurse-Led Healthy Lifestyle Clinic Project as well as recorded clinical outcomes, and to assess how successfully the clinics engaged the target populations | Observational; clinical outcome data and cross-sectional surveys | Patients with a specifically diagnosed condition relevant to the nurse-led lifestyle clinics (diabetes, smoking cessation, women’s health, cardiovascular, respiratory, diet/nutrition) (n = 2850) | Nurse-led healthy habits lifestyle clinics for patients with or at risk of chronic disease within targeted populations with known health inequalities 115 RNs in total participated; in each clinic the nurses had their own patient caseload. Clinical outcome data were obtained from individuals who participated in the clinics (n = 2850) and patient satisfaction surveys (n = 424) RN provided intervention alone, however, in some cases patients were referred to other professionals when warranted. RNs delivered care using a holistic health approach defined by the patients’ needs. Clinical outcome data was collected on the first and last day of clinic attendance | 17 practices (3 Hauora, 2 community, and 12 general practices) served by the Primary Healthcare Organization | 20 |
Moher et al., 2001 [52] 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 [48] 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 | Observational; 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 by CPS-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 |
Pearson et al., 2003 [61] USA | To apply the principles from the Kaiser Permanente model for depression treatment towards the development and implementation of a primary care PN telecare program | Uncontrolled before-after | Patients aged 21–64 years, diagnosed with major depressive disorder, depressive disorder NOS with severe symptoms, or dysthymic disorder, were experiencing a first or new episode of depression, and were prescribed an SSRI (n = 177 patients enrolled; n = 102 analyzed at six-month follow-up) | Nurse telecare case management program based on the principles from the Kaiser Permanente model for patients with diagnosed depression Study consisted of 12 RNs and 2 LPNs involved in the telephone follow-up portion; additional characteristics not identified Organizational-level intervention; providers consisted of 39 physicians, 6 NPs and 5 physician assistants. Telephone follow-up was provided by RNs alone, however, they could consult with a supervising psychiatrist on an as-needed basis | 13 primary care practices in Maine’s urban centers of Augusta, Bangor, Lewiston, and Portland | 22 |
Pine et al., 1997 [49] USA | To evaluate the effect of a nurse-based intervention for patients with high total cholesterol levels in a community practice | Non-controlled before-and-after clinical trial (pre-post study) followed by a non-randomized controlled trial (matching study) | One hundred twenty-three patients agreed to participate. Forty-one were excluded from the final analysis. The final sample consisted of n = 82 white patients with total cholesterol higher than 6.21 mmol/L | Counseling provided by nurses to patients diagnosed with hypercholesterolemia using the Eating Pattern Assessment Tool and handouts with food advice Study involved 2 RNs; additional characteristics not identified RN provided intervention alone; in the pre-post study, RNs provided 5 counseling visits (1 month after referral, and at 3, 5, 7, and 12 months) to patients, which were focused on nutritional education and physical activity. In the follow-up matching study, intervention patients who attended 2 or more counseling sessions were matched with other patients in the practice | Large multi-specialty group suburban primary care practice in Minneapolis | 23; 24* |
Waterfield et al., 2021 [58] UK | To determine whether primary care nurses with no prior experience can, after training, provide effective supervised PFMT, when compared to PFMT given by a urogynaecology nurse specialist and that of usual care | Randomized controlled trial | Sample consisted of 337 asymptomatic women with weak pelvic floor muscles (Modified Oxford Score 2 or less) in a randomly sampled survey. Two hundred forty women aged 19 - 76 (median 49) years were recruited | PFMT delivered to patients with weak pelvic floor muscles at three levels: primary care nurse-delivered training (arm 1) v. urogynaecology nurse specialist training (arm 2) v. usual care (no training) Number of primary care nurses involved and additional characteristics were not indicated; at least one primary care nurse from each practice participated Primary care nurse provided intervention alone; the primary care nurse intervention group were provided training materials related to pelvic floor assessment and techniques involved in teaching PFMT. Primary care nurses taught patients a PFMT regimen to perform 3–6 times per day for 3 months and used a perineometer to assess pelvic floor strength at baseline and 3 months | 11 primary care/general practices, covering urban and rural settings in South West England | 27 |
Zwar et al., 2010 [56] Australia | To examine the impact of PN-delivered behavioral support on smoking cessation rates as well as the feasibility and acceptability of this model to patients, PNs, and GPs | Non controlled pre- and post-study using mixed methods | A convenience sample of smokers (n = 498 initial; n = 378 at 6-month follow-up) were recruited during nurse appointment in general practice | Nurse-delivered smoking cessation counseling Study involved 31 PNs and all practices included in study employed at least 1 PN; additional characteristics not identified PNs took a leading role in providing counseling but were supported by the GPs from participating practices; GPs identified smokers interested in quitting and referred them to the PN for a series of weekly counseling visits of approximately 30-min duration over 4 weeks | 19 general practices in South West Sydney and a nearby rural area, representing 2 Divisions of General Practice | 22 |