Overview of the uptake and implementation of non-medical prescribing in Wales: a national survey.

OBJECTIVES: To identify (1) the non-medical healthcare professionals in Wales qualified to prescribe medicines (including job title, employer, where the prescribing qualification is used, care setting and service provided); (2) the mode of prescribing used by these healthcare professionals, the frequency with which medicines are prescribed and the different ways in which the prescribing qualification is used; and (3) the safety and clinical governance systems within which these healthcare professionals practise. DESIGN: National questionnaire survey. SETTING: All three National Health Service (NHS) Trusts and seven Health Boards (HB) in Wales. PARTICIPANTS: Non-medical prescribers. RESULTS: 379 (63%) participants responded to the survey. Most of these prescribers (41.1%) were specialist nurses who work in a variety of healthcare settings (primarily in secondary care) within each HB/NHS Trust, and regularly use independent prescribing to prescribe for a broad range of conditions. Nearly a quarter of the sample (22%) reported that prior to undertaking the prescribing programme, they had completed master's level specialist training and 65.5% had 5 years qualified experience. Over half (55.8%) reported that there were plans to increase non-medical prescriber numbers within the team in which they worked. Only 7.1% reported they did not prescribe and the median number of items prescribed per week was between 21 and 30. Nearly all (87.8%) of the sample reported that they perceived prescribing to have ensured better use of their skills and 91.5% indicated that they believed it had improved the quality of care they were able to provide. CONCLUSION: Non-medical prescribing has been implemented across the whole of Wales; however, its uptake within HBs and NHS Trusts has been inconsistent, and it has not been considered across all services, particularly those in primary care. Opportunities therefore exist to share learning across organisations.

Refining and validating a conceptual model of Clinical Nurse Leader integrated care delivery.

AIMS: To empirically validate a conceptual model of Clinical Nurse Leader integrated care delivery. BACKGROUND: There is limited evidence of frontline care delivery models that consistently achieve quality patient outcomes. Clinical Nurse Leader integrated care delivery is a promising nursing model with a growing record of success. However, theoretical clarity is necessary to generate causal evidence of effectiveness. DESIGN: Sequential mixed methods. METHODS: A preliminary Clinical Nurse Leader practice model was refined and survey items developed to correspond with model domains, using focus groups and a Delphi process with a multi-professional expert panel. The survey was administered in 2015 to clinicians and administrators involved in Clinical Nurse Leader initiatives. Confirmatory factor analysis and structural equation modelling were used to validate the measurement and model structure. RESULTS: Final sample n = 518. The model incorporates 13 components organized into five conceptual domains: 'Readiness for Clinical Nurse Leader integrated care delivery'; 'Structuring Clinical Nurse Leader integrated care delivery'; 'Clinical Nurse Leader Practice: Continuous Clinical Leadership'; 'Outcomes of Clinical Nurse Leader integrated care delivery'; and 'Value'. Sample data had good fit with specified model and two-level measurement structure. All hypothesized pathways were significant, with strong coefficients suggesting good fit between theorized and observed path relationships. CONCLUSIONS: The validated model articulates an explanatory pathway of Clinical Nurse Leader integrated care delivery, including Clinical Nurse Leader practices that result in improved care dynamics and patient outcomes. The validated model provides a basis for testing in practice to generate evidence that can be deployed across the healthcare spectrum.

Clinical Nurse Leader Integrated Care Delivery to Improve Care Quality: Factors Influencing Perceived Success.

PURPOSE: Clinical nurse leader(TM) (CNL)-integrated care delivery is a new model for organizing master's-level nursing clinical leadership at the microsystem level. While there is growing evidence of improved patient care quality and safety outcomes associated with CNL practice, organizational and implementation characteristics that influence CNL success are not well characterized. The purpose of this study was to identify organization and implementation factors associated with perceived success of CNL integration into microsystem care delivery models. METHODS: A survey was developed and administered to a nationwide sample of certified CNLs and managers, leaders, educators, clinicians, and change agents involved in planning or integrating CNLs into a health system's nursing care delivery model. Items addressed organizational and implementation characteristics and perceived level of CNL initiative success. Generalized linear modeling was used to analyze data. RESULTS: The final sample included 585 respondents. The final model accounted for 35% of variance in perceived CNL initiative success, and included five variables: phase of CNL initiative, CNL practice consistency, CNL instructor or preceptor involvement, CNL reporting structure, and CNL setting ownership status. CONCLUSIONS: CNL initiative success is associated with modifiable organizational and implementation factors. CLINICAL RELEVANCE: Study findings can be used to inform the development of successful implementation strategies for CNL practice integration into care delivery models to improve care quality outcomes.

Clinical Nurse Specialists' Perceptions of Care for Vulnerable Patients.

The vulnerable and underserved are populations that have higher risks in health care. A clinical nurse specialist is an advanced practice registered nurse who can help mitigate risks and provide holistic care for these patients. Researching clinical nurse specialists' perceptions of their role in caring for the vulnerable populations is important to ensuring quality care and filling in current practice weaknesses.

Impact of formal educational level on clinical specialist role activity.

AIMS: This study, set in Ireland, aimed to explore demographics of the clinical nurse specialist and clinical midwife specialist population and their role activity, particularly in the educational role. BACKGROUND: The clinical nurse/midwife specialist is recognised as an important part of nursing today. In Ireland, formal recognition of the specialist role occurred as recently as 2001. METHODS: Following ethical approval, a questionnaire was circulated to the total population of specialist nurses and midwives in Ireland. The questionnaire captured the formal educational level held and individual educational role activity. RESULTS: The study articulates the individual educational role elements (e.g. patient education, peer education) and captures the level of activity but the level varies between different educational role elements. Formal education level held has an impact on role activity, with higher education levels resulting in greater activity levels. CONCLUSIONS: The clinical specialist has tremendous potential for a positive impact on patient care in his or her education role. The majority are active in this role but the analysis shows there is room for growth. Combined with the finding that the level of activity rises with the level of formal education, this gives a strong reason why there should be continuing focus on further education and life-long learning.

Perspectives on specialist nursing in Saudi Arabia: a national model for success.

In many parts of the world, vulnerable patient populations may be cared for by a clinical nurse specialist (CNS). Nurses desiring to develop themselves professionally in the clinical arena, within the specialty of their choice, have the opportunity to obtain the knowledge, skills, experience and qualifications necessary to attain advanced practice positions such as CNS or nurse consultant (NC). Although studies have demonstrated the benefits of such roles and while the World Health Organization (WHO) recommends it, advanced nursing practice is not yet integrated into the health care culture in Saudi Arabia. The reasons for this are multiple, but the most important is the poor image of clinical nursing throughout the country. This article aims to share a perspective on CNS practice, while casting light on some of the obstacles encountered within Saudi Arabia. A model is proposed representing specialist nurse-physician collaborative practice for implementation nationally. The model has been implemented in the care of the colorectal and stoma patient populations while taking into consideration patient population needs and local health care culture. This model is based on the concepts of holistic "patient-centered care", specialist nurse-physician collaborative practice, and the four practice domains for NCs (expert practice, leadership, research and education) as indicated by the Department of Health in the United Kingdom. We suggest this model will enable the introduction of advanced specialist nursing and collaborative partnerships in Saudi Arabia with benefits for patients, physicians, health care organizations and the nursing profession as a whole.

Harsh humour: a therapeutic discourse.

Humour research in healthcare has tended to focus on rehearsed as opposed to spontaneous humour. This paper reports an empirical example of spontaneous humour in healthcare interactions: a negative case analysis from a constructivist grounded theory study. Twenty Clinical Nurse Specialist (CNS)-patient interactions and CNS pre- and postinteraction audio diaries provided the baseline data corpus. Follow-up interviews, field notes, focus groups and observations serviced theory generation with a constant comparison approach to data collection and analyses. Interpretative and illustrative frameworks incorporating humour theories, non-laughter humour support, discursive features and prosodical features of speech were applied to all data. This paper is based upon the negative case comprising a 90-minute follow-up interview and 10 hours of field note observations. The negative case - a CNS working with female drug users' sexual and reproductive health needs - contradicted emerging findings from the baseline data corpus. First, the negative case had greater awareness of humour, deliberately initiated humour and recognised parameters and exclusion zones. Second, a good patient personal was evident in the baseline data corpus but the negative case worked with 'bad' patients. Accordingly, a specific type of humour - harsh humour - was evident in the negative case. Harsh humour used areas of potential discord (e.g. drug use) as a focus of humour creation and maintenance. The deliberate initiation of harsh humour enabled the negative case and her colleagues to achieve their aims by engaging effectively with unpredictable, reluctant and recalcitrant patients. The negative case demonstrates how humour can be used to therapeutically enhance healthcare interactions with disenfranchised individuals. Humour is not superficial but integral to the accomplishment of key aspects of interactions. Health and social care workers should consider the potential for therapeutic humour to engage and maintain all patients - disenfranchised or otherwise - in healthcare interactions.

Herbs and other dietary supplements: healthcare professionals' knowledge, attitudes, and practices.

CONTEXT: Herbs and other dietary supplements (H/DS) are frequently used by the public. They have significant health implications, yet little is known about health professionals' knowledge, attitudes, or clinical practices related to H/DS. DESIGN: Cross-sectional survey of clinicians prior to participation in an Internet-based educational program on herbs and dietary supplements. PARTICIPANTS: The 537 participants included 111 physicians (MD), 30 advanced practice nurses (RN), 46 pharmacists (PharmD), and 350 dietitians (RD). In addition to demographic information, participants were asked about their knowledge, attitudes, and practices related to H/DS. RESULTS: Most participants were involved in direct patient care (85%), in practice or on faculty (84%), and from outside our local institutions (76%); 66% reported receiving professional education about H/DS in the past year. There were statistically significant differences between professional groups, with RDs scoring better than others, but even their average scores were less than 60% of possible. The average score on knowledge questions was 10/20; the average confidence score was 4 out of 10 possible, and the average communication score was 1.4 out of 4 possible. Most respondents knew the most common clinical uses of echinacea and St. John's wort, and felt confident that they knew more than their colleagues about H/DS. Key deficits were in knowledge about adverse effects, confidence in reporting side effects, routinely communicating with patients about H/DS, and recording H/DS information in the medical record. CONCLUSIONS: Despite significant interest and previous training in H/DS, these clinicians had substantial room for improvement in knowledge, attitudes, and clinical practices about H/DS. Educational interventions and institutional policies are needed to improve the quality of patient care regarding H/DS, and such interventions should be rigorously evaluated to ensure that continuous improvements occur.

Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group.

OBJECTIVE: To assess the effectiveness of a programme to coordinate and support follow up care in general practice after a hospital diagnosis of myocardial infarction or angina. DESIGN: Randomised controlled trial; stratified random allocation of practices to intervention and control groups. SETTING: All 67 practices in Southampton and south west Hampshire, England. SUBJECTS: 597 adult patients (422 with myocardial infarction and 175 with a new diagnosis of angina) who were recruited during hospital admission or attendance at a chest pain clinic between April 1995 and September 1996. INTERVENTION: Programme to coordinate preventive care led by specialist liaison nurses which sought to improve communication between hospital and general practice and to encourage general practice nurses to provide structured follow up. MAIN OUTCOME MEASURES: Serum total cholesterol concentration, blood pressure, distance walked in 6 minutes, confirmed smoking cessation, and body mass index measured at 1 year follow up. RESULTS: Of 559 surviving patients at 1 year, 502 (90%) were followed up. There was no significant difference between the intervention and control groups in smoking (cotinine validated quit rate 19% v 20%), lipid concentrations (serum total cholesterol 5.80 v 5.93 mmol/l), blood pressure (diastolic pressure 84 v 85 mm Hg), or fitness (distance walked in 6 minutes 443 v 433 m). Body mass index was slightly lower in the intervention group (27.4 v 28.2; P=0.08). CONCLUSIONS: Although the programme was effective in promoting follow up in general practice, it did not improve health outcome. Simply coordinating and supporting existing NHS care is insufficient. Ischaemic heart disease is a chronic condition which requires the same systematic approach to secondary prevention applied in other chronic conditions such as diabetes mellitus.