Integrating nurse practitioners into primary healthcare to advance health equity through a social justice lens: An integrative review.

AIM: To develop a framework to guide the successful integration of nurse practitioners (NPs) into practice settings and, working from a social justice lens, deliver comprehensive primary healthcare which advances health equity. DESIGN: Integrative review. METHODS: The integrative review was informed by the Whittemore and Knafl's framework and followed the Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines. Quality was assessed using the Johns Hopkins Research Evidence Appraisal Tool. Findings were extracted and thematically analysed using NVivo. A social justice lens informed all phases. DATA SOURCES: Databases, including CINAHL, PubMed, Scopus and Web of Science, were searched for peer-reviewed literature published in English between 2005 and April 2022. RESULTS: Twenty-eight articles were included. Six themes were identified at the individual (micro), local health provider (meso), and national systems and structures (macro) levels of the health sector: (1) autonomy and agency; (2) awareness and visibility; (3) shared vision; (4) leadership; (5) funding and infrastructure; and (6) intentional support and self-care. The evidence-based framework is explicitly focused on the components required to successfully integrate NPs into primary healthcare to advance health equity. CONCLUSION: Integrating NPs into primary healthcare is complex and requires a multilevel approach at macro, meso and micro levels. NPs offer the potential to transform primary healthcare delivery to meet the health needs of local communities. Health workforce and integration policies and strategies are essential if the contribution of NPs is to be realized. The proposed framework offers an opportunity for further research to inform NP integration. IMPACT STATEMENT: Nurse practitioners (NPs) offer the potential to transform primary healthcare services to meet local community health needs and advance health equity. Globally, there is a lack of guidance and health policy to support the integration of the NP workforce. The developed framework provides guidance to successfully integrate NPs to deliver comprehensive primary healthcare grounded in social justice. Integrating NPs into PHC is complex and requires a multilevel approach at macro, meso and micro levels. The framework offers an opportunity for further research to inform NP integration, education and policy. SUMMARY STATEMENT: What problem did the study address: The challenges of integrating nurse practitioners (NPs) into primary healthcare (PHC) are internationally recognized. Attempts to establish NP roles in New Zealand have been ad hoc with limited research, evidence-informed frameworks or policy to guide integration initiatives. Our review builds on existing international literature to understand how NPs are successfully integrated into PHC to advance health equity and provide a guiding framework. What were the main findings: Six themes were identified across individual (micro), local health provider (meso) and national systems and structures (macro) levels as fundamental to NP integration: autonomy and agency; awareness and visibility of the NP and their role; a shared vision for the direction of primary healthcare utilizing NP scope of practice; leadership in all spaces; necessary funding and infrastructure; and intentional support and self-care. Where and on whom will the research have an impact: Given extant health workforce challenges together with persisting health inequities, NPs provide a solution to delivering comprehensive primary healthcare from a social justice lens to promote healthcare access and health equity. The proposed evidence-informed framework provides guidance for successful integration across the health sector, training providers, as well as the NP profession, and is a platform for future research. REPORTING METHOD: This integrative review adhered to the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) method. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Developing discipline-specific online pedagogies for nursing education.

BACKGROUND: Many nurse educators have pivoted their teaching to online formats since the COVID-19 pandemic began. Nurse educators face the dilemma that person-centred approaches are particularly challenging to replicate online. Current research provides general recommendations for designing and delivering online learning, but less is known about the usefulness of discipline-specific pedagogies for nursing education. AIM: This study explores the value of creating discipline-specific pedagogies for online learning in baccalaureate nursing education. METHOD: Using an action research approach, the authors document their lived experience of designing and delivering a course in two different formats - blended and entirely online. Drawing on existing and new educational models related to online learning, we explore how practice can inform the development of emergent frameworks to guide online education. RESULTS: Using reflective practice, the authors developed an emergent framework that draws on embodied learning theory to enhance the online delivery of a disability and enablement course for nursing students. CONCLUSIONS: The concept of embodied pedagogies may offer a starting point for developing guidelines for person-centred and student-centred nursing education online.

What determinants impact deceased organ donation consent in the adult intensive care unit? An integrative review exploring the perspectives of staff and families.

BACKGROUND: Deceased organ donation saves lives. Donation processes in New Zealand operate under an opt-in system, which requires consent from families of patients diagnosed with brain death or circulatory death while in the intensivecare unit. The donation demand and supply mismatch is a global phenomenon. OBJECTIVES: The objective of this study was to understand the determinants of deceased organ donation decisions in the adult intensive care setting from the perspectives of staff and families. METHODS: An integrative review based on Whittemore and Knafl's approach searched literature through databases CINAHL Plus, SCOPUS, Proquest Medline Ovid, and manual ancestry searches. Inclusion/exclusion criteria screened for pertinent literature, which were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Selected studies were appraised using a generic scoring tool, and data were systematically extracted and coded onto spreadsheets using inductive, thematic analysis. RESULTS: A total of 21 studies (12 qualitative, seven quantitative, two mixed methods) were included. Publication dates ranged from 1993 to 2021 from multiple countries (18 opt-in, three opt-out systems). Four overarching themes pertaining to families and staff were generated. Important knowledge related to families' knowledge deficits around brain death, the purpose of ventilation, donation procedures, patients' wishes, and staffs' lack of training. Challenging communication highlighted miscommunications due to language choices and interrupted continuity of care during staff-family interactions. Internal determinants explored the cultural, spiritual, and emotional perspectives of families, while staff faced a sense of burden and conflicting values in delivering care between donors and recipients. External determinants related to the clinical environment impacting on grieving families, while for the staff, it explained concerns around resources and organisational processes. CONCLUSIONS: Factors underpinning deceased organ donation are multifaceted and complex. Staff actions and families' decisions are inextricably intertwined. Modifiable factors include a lack of formal training and communicational skills and environmental limitations of an intensive care setting.

Incidence and predictors of new-onset atrial fibrillation after cardiac surgery at Auckland City Hospital.

AIM: To describe the incidence, ethnic differences in incidence, and predictors of post-operative atrial fibrillation (POAF) after cardiac surgery in a New Zealand hospital. METHOD: Analysis of registry data on 1,630 adults without previous atrial fibrillation having coronary artery bypass grafting and/or valve surgery was used to determine the incidence of POAF. Univariate analysis identified risk factors and stepwise logistic regression was used to create the most parsimonious model to predict POAF. RESULTS: Overall POAF incidence was 29% (n=465) and differed by surgery type (25% after isolated coronary artery bypass surgery (CABG) vs 42% after combined CABG+valve). Incidence was highest in Maori (35%) and NZ/Other Europeans (32%). Maori and Pasifika with POAF were on average ten years younger than NZ/Other Europeans. Independent risk factors were age (OR 1.05, 95%CI 1.04-1.06), body mass index (OR 1.04, 95%CI 1.02-1.06), history of heart failure (OR 2.08, 95%CI 1.47-2.95), and valve surgeries (isolated valve OR 1.51, 95%CI 1.16-1.95; CABG+valve OR 1.59, 95%CI 1.11-2.28), but the model had poor discrimination (AUC 0.67). CONCLUSION: POAF in a New Zealand hospital occurs at comparable rates to international settings. Risk models using routinely measured factors offer poor predictive accuracy, meaning risk stratification is unlikely to adequately inform targeted POAF prevention in clinical practice.

Attitudinal Factors Influencing Quality Nurse-Led Mental Health Interventions in Primary Care Settings: An Integrative Literature Review.

The World Health Organization's Comprehensive Mental Health Action Plan, 2013-2020 identified mental health as a global priority. Preventive measures include provision of mental health interventions by nurses in primary care settings. The success of these interventions may be influenced by the attitudes of the practice nurses involved. The current integrative review explored how attitudinal factors influence quality nurse-led mental health interventions in primary care settings. A systematic search in five electronic databases identified 10 studies eligible for inclusion. Study design, method, population characteristics, and data relevant to the research question were extracted, coded, and analyzed. Themes created from the data were: Stigma Impacts Patients' Experiences of Care; Imperative of the Right Attitude, the Right Person; and Need to Apply a Holistic Framework. Results highlight the need to ensure nurses maintain clinical currency and competence in the delivery of holistic person-centered mental health care. [Journal of Psychosocial Nursing and Mental Health Services, 61(6), 25-32.].

Health promotion interventions post-stroke for improving self-management: A systematic review.

BACKGROUND: It is well-documented that women tend to be worse off post-stroke. They are often frailer, have less independence, lower functionality, increased rates of depression, and overall a lower quality of life. People who have had strokes benefit from rehabilitative support to increase their independence and reduce the risk of stroke reoccurrence. Despite the gender differences in the effects of stroke, interventions explicitly aimed at helping women have not been identified. PURPOSE: This systematic review aimed to summarize the effectiveness of the health promoting behavioural interventions for reducing risk factors and improved self-management in women post-stroke, compared to usual care. METHOD: Seven databases, Medline (Ovid), CINAHL, PsychInfo, Embase, PubMed, Scopus, and Google Scholar, were reviewed for randomized controlled trials covering post-stroke interventions. The following keywords were used: health promotion, secondary prevention, woman, women, female, sex difference, gender difference, after stroke, and post-stroke. RESULTS: Ten randomised controlled trials were found. These demonstrated common successful approaches for rehabilitation, but none specifically described health promotion strategies for women. Core components of successful programs appeared to be a structured approach, tailored to clientele and formalised support systems through their carer, family networks, or community engagement. Comprehensive reminder systems were successful for stroke risk reduction. CONCLUSION: Women are disproportionately affected by stroke and are often in the frail category. Tailored structured health promotion programs with family and caregiver support combined with a comprehensive reminder system would appear to enable women post-stroke.

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings.

OBJECTIVE: To develop a multidimensional framework representing patients' perspectives on comfort to guide practice and quality initiatives aimed at improving patients' experiences of care. DESIGN: Two-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients' perspectives of comfort in an acute care setting. SETTING: Cardiac surgical unit in New Zealand. PARTICIPANTS: Culturally diverse patients in hospital undergoing heart surgery. MAIN OUTCOMES: A definition of comfort. The Comfort ALways Matters (CALM) framework describing factors influencing comfort. RESULTS: Comfort is transient and multidimensional and, as defined by patients, incorporates more than the absence of pain. Factors influencing comfort were synthesised into 10 themes within four inter-related layers: patients' personal (often private) strategies; the unique role of family; staff actions and behaviours; and factors within the clinical environment. CONCLUSIONS: These findings provide new insights into what comfort means to patients, the care required to promote their comfort and the reasons for which doing so is important. We have developed a definition of comfort and the CALM framework, which can be used by healthcare leaders and clinicians to guide practice and quality initiatives aimed at maximising comfort and minimising distress. These findings appear applicable to a range of inpatient populations. A focus on comfort by individuals is crucial, but leadership will be essential for driving the changes needed to reduce unwarranted variability in care that affects comfort.

A framework of comfort for practice: An integrative review identifying the multiple influences on patients' experience of comfort in healthcare settings.

PURPOSE: Comfort is central to patient experience but the concept of comfort is poorly defined. This review aims to develop a framework representing patients' complex perspective of comfort to inform practice and guide initiatives to improve the quality of healthcare. DATA SOURCES: CINAHL, MEDLINE Complete, PsycINFO and Google Scholar (November 2016); reference lists of included publications. STUDY SELECTION: Qualitative and theoretical studies advancing knowledge about the concept of comfort in healthcare settings. Studies rated for methodological quality and relevance to patients' perspectives. DATA EXTRACTION: Data on design, methods, features of the concept of comfort, influences on patients' comfort. Data were systematically coded and categorized using Framework method. RESULTS OF DATA SYNTHESIS: Sixty-two studies (14 theoretical and 48 qualitative) were included. Qualitative studies explored patient and staff perspectives in varying healthcare settings including hospice, emergency departments, paediatric, medical and surgical wards and residential care for the elderly. From patients' perspective, comfort is multidimensional, characterized by relief from physical discomfort and feeling positive and strengthened in one's ability to cope with the challenges of illness, injury and disability. Different factors are important to different individuals. We identified 10 areas of influence within four interrelated levels: patients' use of self-comforting strategies; family presence; staff actions and behaviours; and environmental factors. CONCLUSION: Our data provide new insights into the nature of comfort as a highly personal and contextual experience influenced in different individuals by different factors that we have classified into a framework to guide practice and quality improvement initiatives.

Patient experience in the emergency department: inconsistencies in the ethic and duty of care.

AIMS AND OBJECTIVES: To understand how people who present on multiple occasions to the emergency department experience their health professionals' moral comportment (ethic of care and duty of care); and to understand the consequences of this for 'people who present on multiple occasions' ongoing choices in care. BACKGROUND: People (n = 34) with chronic illness who had multiple presentations were interviewed about the role that emergency departments played within their lives and health-illness journey. Unprompted, all participants shared views about the appropriateness or inappropriateness of the care they received from the health professionals in the emergency departments they had attended. These responses raised the imperative for specific analysis of the data regarding the need for and experience of an ethic of care. DESIGN: Qualitative description of interview data (stage 3 of a multimethod study). METHODS: The methods included further analysis of existing interviews, exploration of relevant literature, use of Tronto's ethic of care as a theoretical framework for analysis, thematic analysis of people who present on multiple occasions' texts and explication of health professionals' moral positions in relation to present on multiple occasions' experiences. RESULTS: Four moral comportment positions attributed by the people who present on multiple occasions to the health professionals in emergency department were identified: 'sustained and enmeshed ethic and duty of care', 'consistent duty of care', 'interrupted or mixed duty and ethic of care', and 'care in breach of both the ethic and duty of care'. CONCLUSIONS: People who present on multiple occasions are an important group of consumers who attend the emergency department. Tronto's phases/moral elements in an ethic of care are useful as a framework for coding qualitative texts. Investigation into the bases, outcomes and contextual circumstances that stimulate the different modes of moral comportment is needed. RELEVANCE TO CLINICAL PRACTICE: Findings carry implications for emergency department care of people who present on multiple occasions and for emergency department health professionals to increase awareness of their moral comportment in care.

Review article: People who present on multiple occasions to emergency departments.

Research about people who present on multiple occasions to the ED began in the 1980s. Despite this, little is known of their journey as patients. Understanding ED use as a journey can help clinicians improve how they meet the needs of this patient group. Multiple terms were used to identify research on the use of the ED. Papers were included if they had a primary focus on multiple presentations by the general ED population. Integrative review methods were used to extract findings related to the patients' journeys. The findings confirm a sequence of events and processes that provide an outline of the journey through the experience of people who present on multiple occasions. The journey concerns people's decisions to present and re-present to the ED, their assessments on arrival, dilemmas of treatment, outcomes of care and long-term health outcomes. This patient group often have high and complex health needs, engage extensively with other health services and have poor long-term health outcomes. The issue of multiple presentations to the ED is complex and ongoing because of the morbidity of the people concerned, the preference of patients to attend, the purpose of the ED and preparation and role of the personnel and the difficulties with continuity of care. The provision of care for people who present on multiple occasions can be improved within the ED and health services generally through a better understanding of presentations.

Nursing clinical practice guidelines to improve care for people undergoing percutaneous coronary interventions.

AIM: The aim of this paper is to present a set of nursing clinical practice guidelines for individuals undergoing percutaneous coronary interventions (PCIs) together with a summary of the evidence to support these recommendations. BACKGROUND: Percutaneous coronary intervention is a common procedure requiring expert nursing care delivered within an interdisciplinary team. Although evidence-based medical practice guidelines exist, they include minimal information to guide nursing-specific care. GUIDELINES DEVELOPMENT: The guidelines development process used a framework of the patient journey. Three steps leading up to this paper were undertaken: (1) a comprehensive literature review; (2) a consensus development workshop; and (3) a modified Delphi technique to refine the guideline recommendations. SUMMARY: Clinical practice guidelines to support interventional cardiology nursing care are limited. This paper represents an important contribution toward meeting this need. IMPLICATIONS FOR PRACTICE: These guidelines, developed within a context of Australian and New Zealand nursing practice, provide an important foundation to enable benchmarking and ongoing developing clinical practice standards.

Pain relief for the removal of femoral sheath in interventional cardiology adult patients.

BACKGROUND: There is considerable variation in use of pain relief for managing pain or discomfort of femoral sheath removal. Efficacy of pain relief to promote comfort during this procedure or to reduce the incidence of vascular and procedural complications has not been established. OBJECTIVES: Assess efficacy of pain relief used to manage pain of femoral sheath removal in adults after interventional cardiology.Determine if pain relief influences rate of complications associated with this procedure. SEARCH STRATEGY: Databases searched in August 2007: Cochrane Pain, Palliative and Supportive Care Group Trials Register, Cochrane Heart Group Trials Register, Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL, PubMed, Australia's Australasian Medical Index, National Research Centre, Web of Knowledge and Digital Dissertations. SELECTION CRITERIA: Randomised studies comparing opioid, local anaesthetic, anxiolytic, no treatment or placebo administered for alleviation of pain or discomfort of the femoral sheath removal procedure, were sought. DATA COLLECTION AND ANALYSIS: Two review authors assessed trial quality and extracted data. Weighted mean differences (WMD) were calculated where meta-analysis of pain score data was feasible. Adverse effects information was collected. MAIN RESULTS: Four trials involving 971 participants were included. All results were reported using a zero to ten pain scale. Three trials (four treatment arms) involving 498 participants compared subcutaneous lignocaine with control; with no significant difference between pain scores; WMD 0.12 (95% CI -0.46 to 0.69). Two trials (three treatment arms) involving 399 participants compared intravenous pain regimens with control. A significant reduction in pain score with an intravenous pain regimen (opioid and anxiolytic) was observed when compared with placebo; WMD -0.90 (95% CI -1.54 to -0.27). One study involving 60 participants compared levobupivacaine with placebo. Longer-acting local anaesthetic significantly lowered pain score by -1.10 (95% CI -1.26 to -0.94). Data is insufficient to identify any influence of pain regimens on incidence of vascular and procedural complications. No trials reported appropriate blinding for treatment arms. The largest trial, comprising 661 participants was unblinded with a quality score of two out of five. AUTHORS' CONCLUSIONS: Intravenous pain regimens and levobupivacaine may have greater efficacy when compared to control for the management of pain related to femoral sheath removal. However, a definitive study is still required because the clinical difference is small. There is no evidence to support the use of subcutaneous lignocaine for the relief of femoral sheath removal related pain. There is insufficient evidence to determine if pain relief influences the rate of complications.