Nursing in the Community: reviewing the evidence base

Dr Catriona Kennedy

Senior Lecturer

Consensus Conference 16th May 2006

Review Team

• Moira Mitchell, Library Information Services Napier University

• Dr Catriona Kennedy, NU• Jane Christie, NU• Dr Fiona Maxton, NU• Dawn Moss, NU• Ishbel Rutherford, QMUC• Jean Harbison, QMUC

Aims of the review:• To determine the contribution of nurses in

the community working within the following areas:

• Anticipatory care• Managing long term conditions• Managing hospital admission and discharge• Supporting unpaid carers• Reducing health inequalities• The impact on patient outcomes when nurses

use IT

In addition…….

• What is the context of nursing in the community?• What do nurses in the community do?• Are there core values that are evident?• What is needed to meet ‘Delivering Health’ in

terms of improving effectiveness and outcomes?• Is there enough evidence to indicate what

developments are required?• If not, what evidence is needed?

So how did we answer these questions?

• Systematic review – gold standard?

• Comprehensive analysis of systematic reviews and primary research of nursing interventions

• Subsequently refined to research from last 5 years – UK, North America, Europe and Australia

Search strategy………

• CINAHL, EMBASE, British Nursing Index, MEDLINE 1999 – present

• Comprehensive search using range of keywords in combination – top down and bottom up!

• 3881 titles screened by 2 members – CK & JC

• 154 titles to screen and quality assess

Key messages• Nursing in the community is

largely hidden and buried• There is insufficient evidence

in some areas to determine impact on patient outcomes BUT:

• Patient’s and carer’s value the humanistic approach of nurses

• Nurses need to take on the challenge of making the ‘invisible’ visible – more research using appropriate research methods is crucial

Anticipatory care

• … a proactive approach to improving health and wellbeing – some evidence this works

• Surveillance, support and health promotion and prevention of illness can reduce mortality and admission to long term care in the elderly

• Work is often hidden as it is integrated with routine care

• Requires: identifying risks and problems early getting to know people and their families

Anticipatory care – key messages

• To anticipate and prevent health problems nurses in the community need to know their population and community and be properly resourced to carry out health assessments and preventative interventions with the ‘healthy’ population.

• Evidence needs to identify the relationship between costs and outcomes

Managing long term conditions

• Evidence the nurses’ role encompasses both human qualities and specific clinical skills

• Patients value interactions with nurses: information giving, time spent and education some of the reasons

• Insufficient evidence to demonstrate differences in morbidity, mortality, hospital readmissions or cost savings

Managing long term conditions – key messages

• Evidence to support a three pronged approach by ensuring that interventions:

• Are delivered over a prolonged period of time supporting self care management by patients and their families

• Monitor measurable indicators of wellbeing as well as disease progression

• Have strategies for structured recall and patient tracking

Managing hospital admission and discharge

• Insufficient evidence to demonstrate that nursing in the community reduces hospital admissions or readmissions

• Some evidence hospital at home improves patient satisfaction

• Early discharge schemes may increase overall days of care

• Further research is needed evaluating the effectiveness of community based admission avoidance schemes

Managing hospital admissions – key message

• Nurses in the community need to be proactive in identifying the needs of people who are at risk of being admitted to hospital, those at risk when coming out of hospital, and in recognising risks that may lead to readmission. Anticipating care needs and promoting self care would contribute positively to this.

Supporting carers• Some evidence nurses offer different interventions for

carers which are complex and responsive to illness and the situation:

• Nurse - helper role – nurse takes time to provide and coordinate care with carers in a supportive role

• Manager-worker role – nurse transfers caring role to family, nurse increases supervision and monitoring role, acts as resource and provides emotional support

• Worker-worker role - nurse tries to co-opt care givers in order to reduce nursing visits but this could result in tension and conflict as carers may feel overwhelmed

• Nurse-patient- demands of caring means carers could become patients

Supoorting carers – key messages

• This is an invisible area of nursing work; hidden, rarely documented and so often unrecognized even by nurses themselves. The tacit nature of work with carers needs to be recognized and recorded.

• Nurses in the community need to identify their role and relationship with family carers and evaluate the nursing contribution to supporting lay carers at home

Reducing health inequalities

• Some evidence focussed and prolonged interventions can improve health or at least prevent them from getting worse

• Evidence that although HCPs may change their interventions this might not result in improvements in outcomes

• Requires substantial investment of resources and no systematic evaluation of the nursing contribution

Reducing health inequalities – key messages

• Evaluating the contribution of nurses in the community to reducing health inequalities is important however alternative ways of collecting and assessing evidence, involving key stakeholders in the community, are necessary.

• Qualitative and participative approaches to data gathering, analysis and research synthesis may help to provide evidence of change and development in this area.

The impact on patient outcomes when nurses use IT

• Insufficient evidence to draw substantive conclusions about the impact of nurse decision making with or without IT support

• Some evidence that nurses can increase participation in health promotion by incorporating into visits

• Online interventions may be useful in managing long term illness, managing social isolation in rural communities

• Telehealth is a useful adjunct to nursing care

Impact of IT – key messages

• Evidence suggests outcomes for community nurses such as increasing patient satisfaction or stopping a condition getting worse may not always be valued as an effective intervention by managers and organizations.

• Urgent need for research evaluating the impact of decision making by nurses in the community, with or without IT support, on patient outcomes. Anticipatory care and management of chronic illness can be enhanced by effective IT systems for monitoring and tracking patients.

Nursing in the community – key messages

• The context and power base of nursing in the community is challenging and complex. Nursing work may be buried in doctor or other health care professionals work making it difficult to identify their contribution.

• In order to anticipate health needs, nurses in the community need to know their population and community, its’ needs and resources.

• Inequalities in health may not improve as a result of changed interventions by health professionals; they need to work with communities and changes need to be driven by communities themselves.

What nurses in the community do

• Holistic assessment, which involves getting to know and the patient, family and their community, establishing trusting and reciprocal relationships.

• Anticipate needs and prevent risks through health promotion and early, prolonged, individualised interventions.

• Establish collaborative working relationships with other health and social care providers

Core values of nursing in the community

• Getting to know the patient, family and community

• Building a relationship based on mutual respect, trust and rapport

• Giving patients and families time • Helping people to achieve the best they can

And finally………..• The ‘invisibility’ of nursing work is challenging for nursing research. • There is a need for further research examining the outcomes for

patient and carers of interventions. Service users and carers value the humanistic contribution of nurse to their care consequently patient satisfaction and user perspective is an important outcome of nursing interventions.

• There is a need to clarify the range of roles in nursing in the community

• Nurses in the community must become more involved and skilled in conducting and leading research using a range of methods including RCTs to establish the efficacy of their interventions.

• Current methodologies such as systematic reviews of randomized controlled trials don’t fit especially well with all aspects of nursing work in the community. Alternative, but equally rigorous, ways of collecting and assessing evidence are necessary.

• Nurses in the community should be at the forefront of developing and evaluating emerging health technology

• Thank you for your attention