Nurse-led clinic

A nurse-led clinic is any outpatient clinic that is run or managed by registered nurses, usually nurse practitioners or Clinical Nurse Specialists in the UK. Nurse-led clinics have assumed distinct roles over the years, and examples exist within hospital outpatient departments,<ref>Rudra, N. (2009, May). Heat on nurse-led clinic to succeed, in Canberra Times [1]</ref> public health clinics<ref>Sussex County, New Jersey (2002). Public Health Nursing Page</ref> and independent practice environments.<ref>Ontario Ministry of Health and Long-Term Care (2009, June). Introduction to nurse practitioner-led clinics. [2]</ref>

Definition

A broad definition of a nurse-led clinic defines these clinics based on what nursing activities are performed at the site.<ref name='NLCPI'>Hatchett, R. (2003). Nurse-Led Clinics: Practice Issues. New York, NY: Routledge.</ref> Nurses within a nurse-led clinic assume their own patient case-loads, provide an educative role to patients to promote health, provide psychological support, monitor the patient's condition and perform nursing interventions.<ref name='NLCPI'/> Advanced practice registered nurses, usually nurse practitioners, may have expanded roles within these clinics, depending on the scope of practice defined by their state, provincial or territorial government.

Overview

The recent growth of nurse-led clinics is considered an emerging area of nursing practice; they were originally discussed in nursing journals in the 1980s, and developed over the 1990s into practice areas that have generated financial, legal and professional challenges over the years.<ref name='NLCPI'/> There has been recent growth of nurse-led clinics both within hospitals and in the community.<ref name='NLCPI'/> However, that growth has been unequal across different legislative regions. As an example, Canada's only known nurse-led clinics exist in Ontario.<ref name='OMA'>Hodges, D. (2009, July). Ontario docs concerned by nurse-led clinics. Retrieved from --~~~~www.everbetter.ca, originally published in The Medical Post. [3]</ref> Unlike many clinics which exist in the United States, Ontario's clinics have been met with some criticism from the Ontario Medical Association and some family physicians who view nurse-led clinics to be unproven innovations in primary care.<ref name='OMA'/>

In the UK, advanced nursing practice developed in the 1980s in response to increased health needs and cost, and in keeping with health policy. A later impetus came from the “New deal for junior doctors” which was a government response to the European Community directive to reduce junior doctors' hours of work.<ref>Pickersgill, Trevor,

 The European working time directive for doctors in training, 
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Nurse-led clinics typically focus on chronic disease management: conditions where regular follow-up and expertise is required, but also where a patient may not necessarily need to see a physician at every visit.<ref name='NLCPI'/> Most nurse-led clinics use nursing theory and knowledge to educate patients and form care plans to manage their conditions.<ref name='NLCPI'/>

Nursing consultations

In their consultations, nurses undertake a range of activities.<ref name="pmid22039168">van Eijk-Hustings, Yvonne,

 EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis, 
 Annals of the Rheumatic Diseases, 
 
 Vol. 71(Issue: 1),
 pp. 13–19,
 DOI: 10.1136/annrheumdis-2011-200185,
 PMID: 22039168,</ref> This may include a specific task such as giving patient education,<ref>Ndosi, M., 
 Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial, 
 Annals of the Rheumatic Diseases, 
 
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 Full text,</ref> managing blood pressure,<ref>Clark, Christopher E., 
 Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis, 
 BMJ, 
 
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 Full text,</ref> exacerbations of COPD and overall disease management.<ref>Mora, Kathlyen, 
 Nurse practitioner-led transitional care interventions: An integrative review, 
 Journal of the American Association of Nurse Practitioners, 
 
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Review of evidence

Nurse-led clinics have a brief history of evaluation in scientific literature.<ref name="NLCPI" /> Not only is there a large amount of heterogeneity between nurse-led clinics, but there are also different educational backgrounds for nurses who wish to enter these roles.

In a partially blind randomized controlled trial, adult patients with Type II Diabetes were found to have better control of hypertension and hyperlipidemia in a nurse-led clinic when compared to conventional follow-up care.<ref>,

 Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled trial, 
 Diabetes Care, 
 2003,
 Vol. 26(Issue: 8),
 pp. 2250–2255,
 DOI: 10.2337/diacare.26.8.2250,
 PMID: 12882844,</ref>  A related study also found that nurse-led clinics were more effective than conventional care in controlling hypertension for adult patients with Type II Diabetes and uncontrolled hypertension.<ref>, 
 Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes, 
 Diabetes Care, 
 2003,
 Vol. 26(Issue: 8),
 pp. 2256–2260,
 DOI: 10.2337/diacare.26.8.2256,
 PMID: 12882845,</ref>  Generally, it was found that most patients experienced improved outcomes following nurse-led clinic consultation, with the best improvement rates found for wound care and continence clinics.<ref name='JAN'>, 
 Establishing a definition for a nurse-led clinic: structure, process, and outcome, 
 Journal of Advanced Nursing, 
 2006,
 Vol. 53(Issue: 3),
 pp. 358–369,
 DOI: 10.1111/j.1365-2648.2006.03730.x,
 PMID: 16441541,</ref>

Randomised controlled trials in rheumatology have demonstrated that nurse-led clinics are effective in controlling disease activity in people with rheumatoid arthritis.<ref>Primdahl, Jette,

 Shared care or nursing consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis outpatients with low disease activity--patient outcomes from a 2-year, randomised controlled trial, 
 Annals of the Rheumatic Diseases, 
 
 Vol. 73(Issue: 2),
 pp. 357–364,
 DOI: 10.1136/annrheumdis-2012-202695,
 PMID: 23385306,</ref><ref>Koksvik, Hege Svean, 
 Patient satisfaction with nursing consultations in a rheumatology outpatient clinic: a 21-month randomised controlled trial in patients with inflammatory arthritides, 
 Annals of the Rheumatic Diseases, 
 
 Vol. 72(Issue: 6),
 pp. 836–843,
 DOI: 10.1136/annrheumdis-2012-202296,
 PMID: 23393144,</ref><ref>Larsson, Ingrid, 
 Randomized controlled trial of a nurse-led rheumatology clinic for monitoring biological therapy, 
 Journal of Advanced Nursing, 
 
 Vol. 70(Issue: 1),
 pp. 164–175,
 DOI: 10.1111/jan.12183,
 PMID: 23772698,
 PMC: 4285750,</ref><ref name=":0">Ndosi, Mwidimi, 
 The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial, 
 Annals of the Rheumatic Diseases, 
 
 Vol. 73(Issue: 11),
 pp. 1975–1982,
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 Full text,</ref><ref>Tijhuis, Gerhardus J., 
 Two-year follow-up of a randomized controlled trial of a clinical nurse specialist intervention, inpatient, and day patient team care in rheumatoid arthritis, 
 Journal of Advanced Nursing, 
 
 Vol. 41(Issue: 1),
 pp. 34–43,
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 Full text,</ref> In addition, three studies have demonstrated cost effectiveness on this model of care in Denmark,<ref>Sørensen, J., 
 Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial, 
 Scandinavian Journal of Rheumatology, 
 
 Vol. 44(Issue: 1),
 pp. 13–21,
 DOI: 10.3109/03009742.2014.928945,
 PMID: 25380077,</ref> the Netherlands<ref>van den Hout, W. B., 
 Cost effectiveness and cost utility analysis of multidisciplinary care in patients with rheumatoid arthritis: a randomised comparison of clinical nurse specialist care, inpatient team care, and day patient team care, 
 Annals of the Rheumatic Diseases, 
 
 Vol. 62(Issue: 4),
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 The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial, 
 Annals of the Rheumatic Diseases, 
 
 Vol. 73(Issue: 11),
 pp. 1975–1982,
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Many nurse-led clinics have also been associated with enhanced patient satisfaction with care.<ref name="JAN" /> A nurse-led clinic for intractable constipation in paediatric populations was compared to a paediatric gastroenterology clinic, illustrating that parent satisfaction was significantly higher for those who attended the nurse-led clinic.<ref>,

 Parent satisfaction in a nurse led clinic compared with a paediatric gastroenterology clinic for the management of intractable, functional constipation, 
 Archives of Disease in Childhood, 
 2006,
 Vol. 91(Issue: 6),
 pp. 499–501,
 DOI: 10.1136/adc.2005.087486,
 PMID: 16531455,
 PMC: 2082804,</ref> This has also been shown in rheumatology nurse-led clinics.<ref>, 
 Patient satisfaction with nursing consultations in a rheumatology outpatient clinic: a 21-month randomised controlled trial in patients with inflammatory arthritides, 
 Annals of the Rheumatic Diseases, 
 2013,
 Vol. 55(Issue: 6),
 
 DOI: 10.1136/annrheumdis-2012-202296,
 PMID: 23393144,</ref><ref name=":0" />

In areas where nursing practice may require additional support to maintain patient safety, some nurse-led clinics have implemented decision support tools, computerized systems and evidence-based algorithms to support their practice. Nurse-led clinics which utilize computerized decision support tools to manage oral anticoagulation dosages were found be to as effective as hospital-based clinics for INR control and stability.<ref>,

 Oral anticoagulation management in primary care with the use of computerized decision support and near-patient testing: a randomized, controlled trial, 
 Archives of Internal Medicine, 
 2000,
 Vol. 160(Issue: 15),
 pp. 2343–2348,
 DOI: 10.1001/archinte.160.15.2343,
 PMID: 10927732,</ref>

In the UK, nurse-led care has been established in many chronic conditions such as diabetes, COPD and musculoskeletal disorders. Treatment guidelines in rheumatoid arthritis for example, specify the role of the nurse in managing the disease<ref name="pmid22039168" /> and coordinating care.<ref>NICE. Rheumatoid arthritis: The management of rheumatoid arthritis in adults. Secondary Rheumatoid arthritis: The management of rheumatoid arthritis in adults [Online] August 2013 2009. http://www.nice.org.uk/nicemedia/pdf/CG79NICEGuideline.pdf</ref>

The evidence for the effectiveness of nurse-led intervention is growing and increasingly supported by randomised controlled trials and systematic reviews.<ref>Primdahl, Jette,

 Nurses' Role in Cardiovascular Risk Assessment and Management in People with Inflammatory Arthritis: A European Perspective, 
 Musculoskeletal Care, 
 
 Vol. 14(Issue: 3),
 pp. 133–151,
 DOI: 10.1002/msc.1121,
 PMID: 26549188,
 
 
 Full text,</ref><ref>Thurah, Annette de, 
 Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis, 
 RMD Open, 
 
 Vol. 3(Issue: 2),
 pp. e000481,
 DOI: 10.1136/rmdopen-2017-000481,
 PMID: 28879053,
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 Full text,</ref><ref>Garner, Stephanie, 
 Nurse-led Care for Patients with Rheumatoid Arthritis: A Systematic Review of the Effect on Quality of Care, 
 The Journal of Rheumatology, 
 
 Vol. 44(Issue: 6),
 pp. 757–765,
 DOI: 10.3899/jrheum.160535,
 PMID: 28202747,</ref><ref>Horrocks, Sue, 
 Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors, 
 BMJ: British Medical Journal, 
 
 Vol. 324(Issue: 7341),
 pp. 819–823,
 DOI: 10.1136/bmj.324.7341.819,
 PMID: 11934775,
 PMC: 100791,</ref><ref>Clark, Christopher E., 
 Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis, 
 BMJ (Clinical Research Ed.), 
 
 Vol. 341,
 pp. c3995,
 DOI: 10.1136/bmj.c3995,
 PMID: 20732968,
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 The effectiveness of nurse-led care in people with rheumatoid arthritis: a systematic review, 
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See also

• Walk-in clinic

References

1. Department of Health Nursing Division. A Strategy for Nursing: a report of the steering committee. London: HMSO; 1989.
2. NHS Management Executive. Junior Doctors: The New Deal. London: HMSO; 1991.
3. Department of Health. A Compendium of Solutions to Implementing the Working Time Directive for Doctors in Training from August 2004. London: Department of Health; 2004.

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