Advanced practice nurse outcomes 1990-2008: a systematic review.

Advanced practice registered nurses have assumed an increasing role as providers in the health care system, particularly for underserved populations. The aim of this systematic review was to answer the following question: Compared to other providers (physicians or teams without APRNs) are APRN patient outcomes of care similar? This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included. Use of clinical nurse specialists in acute care settings can reduce length of stay and cost of care for hospitalized patients. These results extend what is known about APRN outcomes from previous reviews by assessing all types of APRNs over a span of 18 years, using a systematic process with intentionally broad inclusion of outcomes, patient populations, and settings. The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help to address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.

Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008.

BACKGROUND: Advanced practice nurses (APNs) in the United States could expand access to high-quality health care, particularly for underserved populations. Yet, there has been limited synthesis of the evidence related to their effectiveness as compared with other providers. The study reported here, part of a larger study that examined all four types of APNs, compares the labor and delivery care outcomes of certified nurse-midwives (CNMs) and physicians. DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Proquest (for dissertations), were searched for the years 1990 through 2008. STUDY ELIGIBILITY CRITERIA: Only those articles where processes or outcomes of care were quantitatively compared between CNMs and physicians were included. For all APNs, 27,993 citations were reviewed. For CNMs, 21 articles representing 18 unique studies reported either infant or maternal outcomes. METHODS: The systematic review followed established procedures (replicable search of relevant databases, sequential review to identify eligible studies, abstraction by two reviewers, assessment of quality, and grading of evidence). RESULTS: For measures that relate to the processes of care (e.g., epidural, labor induction, episiotomy), lower use was found for CNMs. For many of the infant outcomes (e.g., low Apgar, low birth weight, neonatal intensive care unit admission), there were no differences between physicians and CNMs. Perineal lacerations were lower and breastfeeding was higher among women cared for by CNMs compared with physicians. LIMITATIONS: The review addressed only CNMs practicing in the United States and outcomes measured during labor and delivery. The majority of study designs were observational and the models of care ranged from independent to shared, limiting the control for bias. Moreover, all reviewers were nurses. CONCLUSION: Differences in practice between CNMs and MDs seem to be well documented, particularly in the use of technology. Yet, the findings provide evidence that care by CNMs is safe and effective. CNMs should be better utilized to address the projected health care workforce shortages.