Nursing in the Community: reviewing the evidence base

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Nursing in the Community reviewing the evidence
base

• Dr Catriona Kennedy
• Senior Lecturer
• Consensus Conference 16th May 2006

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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

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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

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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?

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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

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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

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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
• Patients and carers 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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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.

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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

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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.

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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.

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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

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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

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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 dont 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

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• Thank you for your attention