The Experience and Effectiveness of Nurse Practitioners in Orthopaedic Settings: A Comprehensive Systematic Review

Abstract

Review question/objective 

This review asks “What is the experience and effectiveness of nurse practitioners in orthopaedic settings”?

The objective of the quantitative component of this review is to synthesise the best available evidence on effectiveness of orthopaedic nurse practitioner specific care on patient outcomes and process indicators.

The objective of the qualitative component of this review is to synthesise the best available evidence on the experience of becoming or being an orthopaedic nurse practitioner in relation to role development, role implementation and (ongoing) role evaluation.

The objective of the text and opinion component of this review is to synthesise the best available evidence of the contemporary discourse on the effectiveness and experience of nurse practitioners in orthopaedic settings.

Background 

Nurse practitioner roles have emerged in response to areas of unmet healthcare needs in a variety of settings.^1,2 Nurse practitioners first evolved in the United States 40 years ago in response to a shortage of primary health care physicians. Nurse practitioners filled the void by providing access to primary health care services where otherwise there was none. Nurse practitioners comprise one branch of advanced nursing practice in the US along with Nurse Anaesthetists (NA), Clinical Nurse Specialists (CNS) and Nurse Midwives (NM).^3,4 Canada soon followed America's lead by establishing the nurse practitioner role in 1967. Canada has two areas of advanced nursing practice, namely nurse practitioner and clinical nurse specialist; they are moving towards introducing nurse anaesthetists currently.⁵ The nurse practitioner role was introduced into the United Kingdom 20 years ago.

There is commonality amongst the definition and characteristics of Nurse Practitioner (NP)/Advanced Practice Nurse (APN) role and practice internationally in terms of education, practice standards and regulation; operationally there is variability however.⁶ Australia's progress with nurse practitioners is very much informed by the experiences of the United States and United Kingdom⁶ and for the most part there exists a parallel between the international experience and the Australian experience of nurse practitioners.

This review will focus on orthopaedic nurse practitioners in an international context. However the local context of the primary reviewer which informs this review is Australian. Australia has mirrored the trends around nurse practitioner practice found elsewhere. In the last 20 years (post implementation of the 1986 Australian nursing career structure), the debate around advanced nursing practice and nurse practitioners, in an Australian context, has developed. The inaugural ‘legal & policy’ nurse practitioner framework was developed in New South Wales (NSW) in 1998, with the first Australian nurse practitioner authorised to practise in NSW in 2000.⁷ It is posited that evaluation of emerging roles began to be seen in the research literature from 1990 onwards. In response to a need for creative workforce re-engineering and against a context of limited health resources, nurse practitioners in Australia over the last 20 years have emerged as an alternative model of health care delivery. For the last 10 years there has been a proliferation of influential ‘reports’ written by nurse researchers, generated to review the progress of Australia's nurse practitioners, commissioned by the health departments of respective state governments and other service planners to guide health workforce planning.^2,3,6–11

In a national context the Australian Nursing & Midwifery Council (ANMC) as the peak national nursing body, defines a nurse practitioner as a Registered Nurse (RN) who is educated and authorised to practice autonomously and collaboratively in an advanced and extended clinical role.¹² The ANMC Competency Standards for the Nurse Practitioner encompass three generic standards which are further defined by nine competencies. The competency standards provide a framework for practice and licensure of nurse practitioners in Australia. In order for the nurse practitioner to be endorsed by the Australian Health Practitioner Regulation Agency (AHPRA) to practise as a nurse practitioner they must have met the competency standards and be endorsed to practise by the Nursing and Midwifery Board of Australia (NMBA) as a nurse practitioner under section 95 of the National Law.¹³ The nurse practitioner's endorsement in Australia is contextualised by their scope of practice, as is the case internationally.

At September 2011, 450 endorsed nurse practitioners were nationally registered with AHPRA¹⁴; 54 of these were endorsed to practise in South Australia.¹⁴ The first orthopaedic nurse practitioner was authorised in South Australia in 2005.¹⁵ To date there are eight endorsed orthopaedic nurse practitioners in Australia authorised to practise in a diverse range of orthopaedic settings that include acute care, community care, outpatient settings, rehabilitation, private practice and rural settings.¹⁵ The current scope of practice for Australian orthopaedic nurse practitioners spans the clinical range of trauma, arthroplasty, fragility fracture and ortho-geriatric care, surgical care: spinal/neurology and paediatric care.¹⁵ Orthopaedic nurse practitioners work within contemporary orthopaedic/musculoskeletal client disease models. These clinical models of care articulate the health care needs of populations living with musculoskeletal conditions, disorders and disease. Osteoarthritis and osteoporosis are ‘highly prevalent long term [musculoskeletal] conditions known to predominantly affect the elderly and comprise the most common cause of disability in Australia’.¹⁶ Musculoskeletal trauma or injury as a result of an ‘external force’ such as vehicle accident, a fall, industrial or home environment accident or assault comprises a leading cause of hospital admission that requires orthopaedic management and care.

There is some evidence to suggest that orthopaedic nursing is a ‘specialty under threat’ as orthopaedic-specific hospital wards are increasingly being absorbed into general surgical units; a trend observed in the United States in the mid 1990's in response to the American experience of ‘downsizing’ orthopaedic nursing services.¹⁷ Despite a limited evidence base¹⁷, early citations with specific reference to orthopaedic nurses in the American context in particular started to populate the literature on or around this time. Several proponents of the specialty began to refer to a core nursing skill set that was ‘highly orthopaedic’ when describing ‘specialist’ orthopaedic nursing practice.^18,19 More recently commentators point to differences in certain variables when patients are ‘outlied’ or managed in a non-orthopaedic ward environment by non-orthopaedic nurses.²⁰

Despite ‘in-principle’ support for expanded scopes of practice for various health practitioner roles, the observation exists from within the specialty of orthopaedic nursing that progress in establishing the orthopaedic nurse practitioner role for this group of specialist clinicians has been slow and their journey has not been without challenge.¹⁵ The majority of orthopaedic nurse practitioners in Australia at least have emerged from extended practice roles similar to the generally well established experience of other nurse practitioners emerging from their own practice interest.^7,9 The orthopaedic nurse practitioner is considered a ‘pioneer’¹⁴ as they fill a ‘gap’ in clinical need and develop an orthopaedic nurse practitioner role. An emerging evidence base suggests that barriers such as a lack of role understanding, lack of ‘team’ support and a lack of resources at a system, organisational and practice level, constrain nurse practitioner practice and integration of the role into practice settings. ^8,9,15

Nurse practitioners function in an advanced clinical role.⁹ Some attempts have been made at quantifying the work of nurse practitioners. For example, Gardner et al² in 2010 divided the work of nurse practitioners into three domains of practice: direct care, indirect care and service-related activities. Within these domains nurse practitioners perform a variety of tasks. Reporting on such activity by way of performance outcome measures is a variable practice amongst nurse practitioners however numbers seen/occasions of service, waiting times, effectiveness of interventions, referral patterns, patient/client satisfaction, clinical quality of care indicators^7,8 are typical of the data maintained and reported by nurse practitioners to either justify their existence, embed their role service wide and/or contribute to workforce planning. Furthermore the orthopaedic nurse practitioner must effectively define and characterise the patient population to which they deliver care within the nurse practitioner's own scope of practice, ultimately to form an ‘indicator’ for the nurse practitioner role.

The international literature pertaining to nurse practitioners or advanced practice nurses²¹ resonates with the many challenges faced by these nurses when it comes to role development and role implementation.^1,2,5,6,7,22 Furthermore there is a body of evidence that validates the effectiveness of these roles.^1,2,5,22 This becomes increasingly important in a context of building the health workforce of the future: a redefined workforce that must ensure adequate numbers of suitably qualified health workers who provide ‘care the first time and every time’.²³

A search of the Joanna Briggs Institute (JBI) Library of Systematic Reviews, Cochrane Library, PubMed and CINAHL has shown there are no existing or systematic reviews underway on this topic. The JBI undertook a systematic review commissioned by the Department of Health South Australia on Advanced Practice in Nursing and Midwifery and recommended a framework for advanced practice in a report released in early 2008.⁴ The framework defined advanced practice, levels of advanced practice, scope of practice, credentialing, education, preparation and regulation of advanced practitioners. The search identified a published systematic review protocol in the JBI Library for a qualitative systematic review by Ramis looking broadly at the experience of advanced practice nurses working in acute settings.²⁴ The JBI Library of Systematic Reviews also contains a systematic review examining the effectiveness of nurse practitioners in residential aged care.²⁵ Whilst these publications provide valuable context to this review neither specifically examines the clinical practice of orthopaedic nurse practitioners.

Similarly a search of the Cochrane Library revealed a review on the topic of substitution of doctors by nurses in primary care.²⁶ The focus of this particular intervention review was neither specific to nurse practitioners nor the acute care setting, but the topic of ‘doctor substitution’ complements the practice of nurse practitioners and may be a consideration in this review. Doctor substitution or care provided by a nurse other than an orthopaedic nurse practitioner is a natural comparator when examining the role and practice of orthopaedic nurse practitioners.

Given the breadth of this topic a comprehensive approach has been chosen to systematically review the evidence as it relates to orthopaedic nurse practitioner role and practice.

Inclusion criteria

Types of participants

Nurse practitioner is an expanded form of advanced practice.¹¹ For the purpose of this systematic review the International Council of Nurses (ICN) definition²⁰ of nurse practitioner will apply whereby a Nurse Practitioner/Advanced Practice Nurse is defined as a Registered Nurse with expert knowledge, complex decision making skills and possessing competency for expanded practice. Importantly the practice of nurse practitioner/advanced practice nurse is characterised further by the “context and/or country” that they practice within.²⁰ Therefore an ‘orthopaedic’ nurse practitioner is defined in accordance with the above definition and with a specific scope of practice (as authorised) within a relevant and specific ‘orthopaedic’ setting.

The quantitative and qualitative components of this review will consider studies that include orthopaedic nurse practitioners in acute care or sub-acute orthopaedic settings.

The textual component of this review will consider publications that pertain to orthopaedic nurse practitioners in acute care or sub-acute orthopaedic settings, where there exists a particular focus on the ‘orthopaedic’ aspect of nurse practitioner practice.

Types of intervention(s)/phenomena of interest

The quantitative component of this review will examine interventions of orthopaedic nurse practitioner specific care.

For this systematic review, orthopaedic nurse practitioner specific care refers to those aspects of care the orthopaedic nurse practitioner is responsible for and/or records as performance outcomes such as: occasions of service/numbers seen; time to and length of nurse practitioner consultation; time to nurse practitioner intervention; referral patterns and other measures of intervention effectiveness.

The qualitative component of the review will examine as phenomena of interest the experience of becoming or being an orthopaedic nurse practitioner in relation to role development, role implementation and (ongoing) role evaluation.

The text and opinion component of the review will examine opinions on the effectiveness and experience of nurse practitioners in orthopaedic settings including role development, implementation and evaluation of nurse practitioners in orthopaedic settings.

Types of outcomes

The quantitative component of this review will consider as primary outcomes the following patient outcomes:

• patients' level of pain
• pressure injury
• urinary tract infection
• patient satisfaction
• in-hospital patient mortality
• hospital readmission
• patients' health-related quality of life
• functional status
• malnutrition score
• constipation
• wound care/complications
• other clinical complications
• morbidity
• other patient encounter data that characterise orthopaedic nurse practitioner practice
• other relevant nurse-sensitive outcome data

The quantitative component of this review will consider as secondary outcomes the following nurse related outcomes or process indicators/outcomes:

• orthopaedic nurse practitioner satisfaction
• key stakeholder (health professional) satisfaction
• specialised knowledge/skill translation
• hospital length of stay
• cost benefit.

Types of studies

The quantitative component of the review will consider both experimental and observational studies, such as randomised controlled trials (RCTs), analytical and descriptive observational studies (including cross sectional studies) for inclusion.

The qualitative component of the review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

The textual component of the review will consider expert opinion, discussion papers, position papers and other text that discuss or describe the contemporary discourse related to nurse practitioner professional practice. The aspects of text with a particular focus on orthopaedic nurse practitioners will be considered for inclusion in the textual component of the review.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Only studies published in English will be considered for inclusion in this review.

Databases will be searched from inception to July 2012, to identify literature for inclusion in this review in order to capture the evolution and journey of the orthopaedic nurse practitioner role in its entirety.

In addition to MEDLINE and CINAHL, the databases to be searched include:

EMBASE, SCOPUS, Informit, PsycINFO, Nursing Consult, Academic Search Premier, Libraries Australia: The National Bibliographic Database, Australia/New Zealand Reference Centre.

Australian Government websites including: Australian Institute for Health and Welfare (AIHW), Department of Health and Ageing, National Health and Medical Research Council (NHMRC).

Other Australian organisational websites such as: Australian Healthcare Reform Alliance

Professional nursing associations for relevant policy and reports, position papers and editorials developed by (Inter)National Nursing Organisations (NNO) such as ICN, ANMC publications, AHPRA, NMBA, RCNA, ANMF, Coalition of National Nursing Organisations; specialist nursing interest groups/organisations with a particular interest in orthopaedic nursing namely ANZONA, NAON, SOTN, CONA and others.

Opinions may be sourced from: public policy documents such as AIHW, other grey literature sources of relevant web based information, theses/systematic review.

The search for unpublished studies will include: ProQuest Dissertations & Theses, Mednar, Conference Proceedings.

Initial keywords/search terms to be used will be:

1. Orthopaedic
2. Orthopedic
3. “orthopedics”[MeSH Term]
4. Musculoskeletal
5. Advanced practice nur*
6. APN
7. Advanced nur* practice
8. Nurse Practitioner
9. NP
10. Expanded practice nur*
11. Extended practice nur*
12. clinical nurse consultant
13. clinical nurse specialist
14. Effectiveness
15. Experience
16. Meaning
17. Barriers
18. Facilitators
19. Length of stay
20. LOS
21. Quality of life
22. QOL

Assessment of methodological quality

Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix III). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data collection

Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix IV). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.

Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix V).

Textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix VI).

Data synthesis

Quantitative papers will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as relative risk for cohort studies and odds ratio for case control studies (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. A random effects model will be used and heterogeneity will be assessed statistically using the standard Chi-square test. Whilst it is common convention to use both meta-analysis methods, a random model based on the assumption that variability in effect measures are present in the primary data, will most likely best suit the data expected to be found in the types of studies under review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Where possible, qualitative research findings will be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorising these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where pooling is not possible, the findings will be presented in narrative form.

Textual papers will be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the conclusions will be presented in narrative form.

Conflicts of interest

The author is endorsed as an orthopaedic nurse practitioner and therefore possesses an ‘abiding interest’ in the practice of orthopaedic nurse practitioners. Given the rigorous process of appraisal, extraction and pooling of data associated with the JBI process of the systematic review of evidence from quantitative, qualitative studies, narrative and text from opinion papers this poses no threat to the review.

Acknowledgements

As this systematic review is submitted in partial fulfilment for the award of Master of Clinical Science, a secondary reviewer will only be used for critical appraisal.

Professor Debbie Kralik, Supervisor

Dr Melanie Attard, Supervisor

Ms Lynda Staruchowicz, Secondary Reviewer