Citation for this paper:
Donald, F., Kilpatrick, K., Reid, K., Carter, N., Martin-Misener, R., Bryant-Lukosius,
D., …, & DiCenso, A. (2014). A Systematic Review of the Cost-Effectiveness of
Nurse Practitioners and Clinical Nurse Specialists: What Is the Quality of the
Evidence? Nursing Research and Practice, Vol. 2014, Article ID 896587.
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A Systematic Review of the Cost-Effectiveness of Nurse Practitioners and Clinical
Nurse Specialists: What Is the Quality of the Evidence?
Faith Donald, Kelley Kilpatrick, Kim Reid, Nancy Carter, Ruth Martin-Misener, Denise
Bryant-Lukosius, Patricia Harbman, Sharon Kaasalainen, Deborah A. Marshall, Renee
Charbonneau-Smith, Erin E. Donald, Monique Lloyd, Abigail Wickson-Griffiths,
Jennifer Yost, Pamela Baxter, Esther Sangster-Gormley, Pamela Hubley, Célyne
Laflamme, Marsha Campbell–Yeo, Sheri Price, Jennifer Boyko, & Alba DiCenso
2014
© 2014 Faith Donald et al. This is an open access article distributed under the terms of the Creative Commons Attribution License. http://creativecommons.org/licenses/by/3.0
This article was originally published at:
http://dx.doi.org/10.1155/2014/896587
Review Article
A Systematic Review of the Cost-Effectiveness of
Nurse Practitioners and Clinical Nurse Specialists:
What Is the Quality of the Evidence?
Faith Donald,
1Kelley Kilpatrick,
2Kim Reid,
3Nancy Carter,
4Ruth Martin-Misener,
5Denise Bryant-Lukosius,
4,6Patricia Harbman,
4,7Sharon Kaasalainen,
4Deborah A. Marshall,
8Renee Charbonneau-Smith,
4Erin E. Donald,
9Monique Lloyd,
10Abigail Wickson-Griffiths,
4Jennifer Yost,
4Pamela Baxter,
4Esther Sangster-Gormley,
11Pamela Hubley,
12Célyne Laflamme,
13Marsha Campbell–Yeo,
5,14Sheri Price,
5Jennifer Boyko,
15and Alba DiCenso
4,161Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
2Faculty of Nursing, Universit´e de Montreal and Research Centre of Hˆopital Maisonneuve-Rosemont, CSA-RC-Aile Bleue-Room F121,
5415 boulevard l’Assomption, Montr´eal, QC, Canada H1T 2M4
3KJ Research, Rosemere, QC, Canada J7A 4N8
4School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
5School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
6Department of Oncology, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON, Canada L8S 4L8 7Health Interventions Research Centre, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
8Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Health Research Innovation Centre,
Room 3C56, 3280 Hospital Drive NW, Calgary, AB, Canada T2N 4Z6
9Fraser Health Authority, Suite 400-13450 102nd Avenue, Surrey, BC, Canada V3T 0H1
10International Affairs and Best Practice Guidelines Centre, Registered Nurses’ Association of Ontario, 158 Pearl Street,
Toronto, ON, Canada M5H 1L3
11School of Nursing, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC, Canada V8W 2Y2
12The Hospital for Sick Children, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 555 University Avenue,
Toronto, ON, Canada M5G 1X8
13Primary Health Care Nurse Practitioner Program, School of Nursing, University of Ottawa, 600 Peter Morand Crescent,
Suite 101, Ottawa, ON, Canada K1G 5Z3
14Departments of Pediatrics and Psychology and Neurosciences, Dalhousie University, P.O. Box 15000, 5869 University Avenue,
Halifax, NS, Canada B3H 4R2
15School of Health Studies, Western University, Health Sciences Building, Room 403, London, ON, Canada N6A 5B9
16Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8 Correspondence should be addressed to Faith Donald; fdonald@ryerson.ca
Received 2 March 2014; Revised 26 June 2014; Accepted 27 June 2014; Published 1 September 2014 Academic Editor: Patrick Callaghan
Copyright © 2014 Faith Donald et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement
nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization).
Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique
records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2),
Volume 2014, Article ID 896587, 28 pages http://dx.doi.org/10.1155/2014/896587
CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.
1. Introduction
Nurse practitioners (NPs) and clinical nurse specialists (CNSs) have practiced for over 50 years in the United States, followed closely by Canada and the United Kingdom, and the roles are increasingly being implemented in other countries [1]. The quest for improved quality of care and control of healthcare costs are important drivers in the decision to implement these roles. We conducted a systematic review to assess the evidence of cost-effectiveness of NP and CNS roles.
2. Background
Both NPs and CNSs are considered advanced practice nurses [2]. NPs are defined as RNs who have additional educa-tion in recognized programs, preferably at the graduate level. They demonstrate advanced competencies to practice autonomously and collaboratively to perform assessments, order laboratory and diagnostic tests, diagnose, prescribe medications and treatments, and perform procedures, as authorized by legislation and their regulatory scope of prac-tice [2], as well as performing an advanced nursing role that includes consultation, collaboration, education, research, and leadership. CNSs are registered nurses (RNs) with a graduate degree in nursing who have expertise in a clinical specialty and perform an advanced nursing role that includes practice, consultation, collaboration, education, research, and leadership [3].
NPs and CNSs function in alternative or complementary provider roles. Those working in alternative roles provide similar services to those for whom they are substituting, usu-ally physicians [4]. Those working in complementary roles provide additional services that are intended to complement or extend existing services. The intention of the alternative role is typically to reduce cost or workload or to address work-force shortages while maintaining or improving the quality of care; in contrast, the intention of the complementary role is to improve the quality of care [5].
During the 1970s, the first randomized controlled trials (RCTs) of NPs demonstrated their safety and effectiveness, as well as patient satisfaction with the NP role [6–17]. NPs improved resource utilization and access to care [14, 18– 20], increased primary care services in the community [7], and reduced costs [15]. Over the past 30 years, a number of literature reviews and systematic reviews have summarized the findings of studies evaluating NPs [21–25]. The reviews have consistently shown no difference in the health outcomes of patients receiving NP care when compared to patients receiving physician care, but often both quality of care and patient satisfaction are higher with NP care.
Most RCTs of CNS roles have been published since 1980 except one. In 1977, Pozen and colleagues [26] found that the CNS increased the knowledge of heart disease in patients with myocardial infarction resulting in an increased rate of return to work and a reduction in smoking. Literature reviews and systematic reviews of CNSs [25, 27] reveal that CNSs are associated with reductions in hospital length of stay, readmissions, emergency room visits, and costs, as well as improvements in staff nurse knowledge, func-tional performance, mood state, quality of life, and patient satisfaction.
Study findings are consistent that NPs and CNSs, either in alternative or complementary provider roles, deliver high quality patient care that results in high patient satisfaction. To address a question that often surfaces, “are NPs and CNSs cost-effective?,” we conducted a systematic review of RCTs of NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization) entitled “A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: 1980 to July 2012.” The purpose of this paper is to report on the methodological strengths and threats to internal and external validity of these RCTs.
3. Methods
3.1. Eligibility Criteria. We sought RCTs of NP and CNS cost-effectiveness between January 1980 and July 2012. Due to inconsistencies in the use of titles and lack of role clarity for these two roles [28], we developed specific criteria to decide if the role was an NP, a CNS, or an RN in an expanded role. To be deemed an NP, the nurse had to have completed a formal postbaccalaureate or graduate NP education program or be licensed as an NP. To be deemed a CNS, the nurse had to have completed a graduate degree and the role had to be reflective of the CNS role definition. If necessary, we contacted the lead author and/or experts in advanced practice nursing from the country where the study was conducted to determine eligibility.
The principal outcomes of interest in this review were objective measures of health system utilization. These included length of stay, rehospitalization, costs of healthcare (e.g., hospital, professional, and family costs), and health resource use (e.g., diagnostic tests and prescriptions). Because it is important to examine health system utilization in the context of patient and provider outcomes, we also extracted data on all patient (e.g., mortality, morbidity, quality of life, and satisfaction with care) and provider (e.g., quality of care and job satisfaction) outcomes.
Participants were patients of any age receiving care in all types (e.g., teaching and nonteaching, public and private), sizes (e.g., small, medium, and large), and locations (e.g., rural and urban) of hospitals or community settings (e.g., long-term care, primary care, and home care).
Substantive developments since 1980 (e.g., training, pay-ment models, and scope of practice of NPs) have reduced the relevance of pre-1980 studies to modern-day policy. In consultation with a policy advisor, we chose to exclude pre-1980 studies from this review. Studies were also excluded if (1) the NP or CNS education failed to meet our criteria or if we could not contact the author for clarification despite repeated attempts; (2) the NP or CNS was part of a multicomponent or multidisciplinary intervention in which the impact of their contribution could not be isolated from other healthcare providers on the team; (3) the study evaluated a very specific intervention (e.g., cognitive behavioural therapy) that was delivered by an NP or CNS but could be delivered by other clinicians, such as an RN; (4) the control group was also exposed to an NP or CNS during the study; (5) a measure of health system utilization was not included; (6) true randomization was not used (randomization was predictable, for example, assignment by day of hospital admission and alternating assignment).
3.2. Search Strategy. A search was conducted to identify all relevant published and unpublished RCTs reported from January 1980 to July 2012. No restrictions were imposed on jurisdiction or language. Medical librarians conducted a comprehensive search of the literature using CINAHL, EMBASE, Global Health, HealthStar, Medline, Allied and Complementary Medicine Database (AMED), Cochrane Library Database of Systematic Reviews and Controlled Trials Register, Database of Abstracts of Reviews of Effects (DARE), Health Economics Evaluation Database (HEED), and Web of Science. Relevant Medical Subject Headings (MeSH) key-words, inclusive suffixes, and search strings formed the search strategy (appendix). In addition, the following methods were used to identify primary studies: handsearching of 16 high-yield journals, checking reference lists of all relevant papers and reviews, contacting authors of an early list of relevant studies, searching personal files, reviewing bibliographies, and searching websites of nursing research and professional organizations and national, provincial/state, and territorial governments.
3.3. Study Selection. We uploaded all identified citations to a web-based reference management program (Ref Works) and removed duplicate entries. Two-member teams inde-pendently screened titles and abstracts of these citations for relevance using prespecified criteria. Translators assisted with the review of all citations in languages other than French or English. The full-text of a published paper and/or study report was obtained if it appeared to meet the inclusion criteria, if an abstract was unavailable, or if it was not possible to determine relevance from the title and abstract review. In instances where a study was reported in more than one paper, we grouped the study’s papers in a constellation and
collectively reviewed them. Two-member teams indepen-dently screened these full-text papers for eligibility based on the inclusion criteria. Discrepancies were discussed and resolved by consensus. We catalogued all excluded studies and the reason for exclusion. Studies that met eligibility criteria advanced to the quality assessment phase of the review.
3.4. Quality Assessment. Two team members (AD and KR) independently assessed the methodological quality of the studies for internal validity and disagreements were resolved through discussion and consensus. The internal validity of each study was assessed using a slightly modified version of the Cochrane risk of bias criteria [29]; modifications to the criteria were three-fold. First, we did not assess for blinding of participants and personnel because the nature of NP and CNS interventions precludes this possibility. Second, outcome assessment and completeness of outcome data were evaluated separately for objective and subjective outcomes within a study. We looked for evidence of key outcomes that would typically be measured for each study’s research question [29]. Third, if outcomes had more than 20% missing data, we judged the study to be at high risk of bias for “incomplete outcome data.”
We assessed studies, assigning a high, low, or unclear risk of bias for each of the following eight questions: (1) To avoid selection bias, was the strategy used for random sequence generation likely to produce comparable groups (e.g., random number table, computer random number generator)? (2) To avoid selection bias, was a method used to conceal the allocation sequence so that group allocation could not be foreseen in advance (e.g., sequentially numbered, opaque, sealed envelopes; central allocation office)? (3) To avoid detection bias, was an appropriate method/source used to col-lect objective (e.g., mortality) measures (e.g., death records, blinding of outcome assessor, trained chart abstracter)? (4) To avoid detection bias, was an appropriate method used to collect subjective (e.g., quality of life) measures (e.g., blinding of outcome assessor; use of reliable, valid, established self-administered questionnaires)? (5) To avoid attrition bias, was outcome data complete for the objective measures (i.e., complete for≥80% of sample; missing data balanced between groups; missing data imputed using appropriate methods)? (6) To avoid attrition bias, was outcome data complete for the subjective measures (i.e., complete for≥80% of sample; missing data balanced between groups; missing data imputed using appropriate methods)? (7) To avoid reporting bias, were all outcomes described in the methods section of the study reported in the results and were all key outcomes reported? (8) Were “other” biases detected in the study (e.g., contamination bias in which the control group had exposure to the intervention)?
We sought clarification from 40 of the 43 study authors when there were insufficient details in the paper to determine the risk of bias and we received 28 (70%) responses. An overall risk of bias was assigned to each study as follows:
low risk of bias (at risk in 0-1 category), moderate risk of bias (at risk in 2-3 categories), high risk of bias (at risk in 4–6 categories), and very high risk of bias (at risk in 7-8 categories).
External validity refers to the generalization or applica-bility of the study to other circumstances [30]. To assess external validity, two team members independently assessed the generalizability of the study population, intervention, control, and outcomes (PICO). Disagreements were resolved through discussion and consensus. Historically, RCTs of NPs and CNSs have been criticized because the number evaluated in any study has been small (e.g., one or two NPs) causing concern that those willing to be evaluated may be atypical in training, experience, knowledge, skills, or practice characteristics. We consulted with our policy advisor and together decided that 10 NPs or CNSs either within a single study or across studies combined in meta-analyses would be a reasonable minimum sample necessary to generalize results to similar NP or CNS roles.
As reported in a separate paper, we applied the Quality of Health Economic Studies (QHES) instrument [31–33] to eval-uate the economic analyses in each study. The quality of the body of evidence for individual outcomes was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system [34, 35] and GRADEpro software. The results of the GRADE assessments are reported elsewhere [36].
3.5. Data Extraction. A trained research assistant (KR) extracted data from each study into a summary table regard-ing general information (i.e., author, country, settregard-ing, lan-guage of publication, and publication status), characteristics of the study (design and group allocation), characteristics of the participants (number per group, sex, ages, and health conditions), characteristics of the intervention (number and type of NPs or CNSs, education and training, specific role, and comparison intervention), outcomes (health system, patient, and provider), length of follow-up, proportion fol-lowed to study completion, and study findings. If the findings of a single study were reported in two or more papers, they were extracted as one study. Team members checked the accuracy of extractions and discrepancies were resolved through discussion and consensus.
3.6. Analysis. Studies were categorized into the following six groupings: NP-outpatient, NP-transition, NP-inpatient, CNS-outpatient, CNS-transition, and CNS-inpatient. In a transition role, the NP or CNS could provide “time-limited services designed to ensure healthcare continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another” [37, page 747]. Within these groupings, studies were further categorized into alternative or complementary NP or CNS role function.
The strengths and threats to internal and external validity of the included RCTs are summarized narratively, organized by the six groupings identified above.
4. Results
4.1. Results of the Search. The searches yielded 4,397 unique records of which 3,981 were excluded during title and abstract review. Based on full-text review of the remaining 416 papers, 351 were excluded based on reasons listed in Figure1. The remaining 65 papers described 43 relevant RCTs (28 studies reported in single papers and 15 studies reported in 37 papers). All studies were published in English. In general, the control intervention was “usual care.”
The distribution of the 43 RCTs across groupings was NP-outpatient (𝑛 = 11), NP-transition (𝑛 = 5), NP-inpatient (𝑛 = 2), CNS-outpatient (𝑛 = 11), CNS-transition (𝑛 = 13), and CNS-inpatient (𝑛 = 1). We summarize the results by grouping beginning first with a brief overview of the study characteristics (Tables 1 and 2) followed by a description of threats to internal validity (Figures 2 and 3). Finally, threats to internal and external validity across studies will be described.
4.2. Study Characteristics and Internal Threats to Validity 4.2.1. NP-Outpatient Care. Eleven RCTs of NPs in outpatient care [38–48] met our inclusion criteria (Table 1). All but one were published in the year 2000 or later. They were conducted in the United States (𝑛 = 7), United Kingdom (𝑛 = 2), or the Netherlands (𝑛 = 2). Six studies evaluated NPs in alternative provider roles and five in complementary provider roles. The number of NPs ranged from one to 20 in NP alternative provider studies and from one to four in NP complementary provider studies. Some of the trials were quite large with over 1000 patients, while most of the trials examining specific patient populations tended to be much smaller. The studies were conducted at between one and 20 sites.
Threats to Internal Validity. Overall, six of the 11 RCTs were judged to be at low risk of bias (in other words, the methods were of high quality), four at moderate, and one at high risk of bias (Figure2). With regard to selection bias, nine studies used a random sequence generation process that was likely to produce comparable groups; for two studies, we had insuffi-cient information about the sequence generation process to permit judgement, despite contact with one of the authors. Seven trials used an adequate process to conceal allocation so that participants and those enrolling participants could not foresee the group to which the next patient would be assigned. We judged one study as unclear because there was insufficient information and three at high risk of selection bias.
All the RCTs were judged to be at low risk of detection bias with respect to objective outcome measures (e.g., blood levels and medical records abstraction) and all but two trials were assessed at low risk of detection bias for subjective
Records identified through database searching after duplicates removed
S cr eenin g El ig ib il it y In cl ude d Iden tifica tio
n Additional records identified through
other sources (key journals, author contacts, websites, personal files,
reference lists)
Initial record review (title and abstract)
Records excluded Did not meet design criteria: 2,468 Did not meet intervention criteria: 902
Did not meet design and intervention criteria: 611
Full-text articles excluded Did not meet design criteria: 35 Did not meet intervention criteria: 210
Did not meet design and intervention criteria: 21
Did not meet outcomes criteria: 44 Could not isolate impact of NP/CNS: 38
Study submitted for publication/in press (author requested that study be included in future update): 3 Full paper or report reviewed for eligibility
Studies included
Constellations of studies = 15 (37 papers) Single studies = 28
NP studies included NP-outpatient: 11 studies in 18 papers NP-transition: 5 studies in 7 papers NP-inpatient: 2 studies in 2 papers
CNS studies included CNS-outpatient: 11 studies in 18 papers CNS-transition: 13 studies in 19 papers CNS-inpatient: 1 study in 1 paper
(n = 4,241)
(n = 3,981) (n = 4,397)
(n = 156)
(n = 416) (n = 351)
Figure 1: Identification and screening of relevant studies. Flow diagram adapted from Moher et al. [109].
measures because most used established validated self-report instruments (e.g., SF-12 and SF-36). Three trials used blinded assessors for some data collection. Two studies were judged as unclear, one because they used self-reported dietary intake and physical activity which can be subject to recall and social desirability bias and the other because clinicians self-recorded the length of time they spent with each patient.
Seven RCTs were judged to be at low risk of attrition bias for the objective measures; one study reported a follow-up rate less than 80% for a blood cholesterol measure, and two did not report all follow-up rates. The risk of attrition bias for subjective measures was high or unclear for six studies due to failure to report follow-up rates or poor response rates for at least one self- or interviewer-administered questionnaire by last follow-up.
One study was judged at high risk of reporting bias because they did not report any patient outcomes such as child’s health status, quality of life, or parent satisfaction in a study of the appropriateness of follow-up care after
attendance at an emergency department. We rated one study at high risk of “other” bias because there was substantial baseline imbalance which was not adjusted for in the analyses. 4.2.2. NP-Transition Care. Five RCTs evaluated NPs in a tran-sition role [49–53] (Table 1). Three studies were conducted in the US, one in Canada, and one in the UK. Four of the studies were published in the year 2000 or later. One study evaluated NPs in an alternative provider role and four in complementary provider roles. One or two NPs were evaluated in each study. The number of patients included in the trials ranged from 54 to 750 and they were conducted at between one and 10 sites.
Threats to Internal Validity. Overall, two studies were judged to be at low risk of bias and three at high risk of bias (Figure2). The trials assessed to be at low risk of selection bias used a random number generator that revealed the intervention assignment when a patient was ready for allocation and
T a ble 1: Summa ry o f N P st u d y ch ar ac te ri st ics. Au th o r, ye ar ,a n d co un tr y (addi ti o n al p u b lica tio n s) Stu d y o bj ec ti ve (n um b er anal yzed) Pa rt ic ip an ts Int er ve n ti on (NP ro le) Nu m b er o f si te s Nu m b er o f N P s exp er ience an d tra inin g NP in o u tp at ien t se tt in g (𝑛=1 1) Allen, 20 02 ,U S [ 38 ] (P aez and Allen, 20 0 6 ) [ 87 ] Co m p ar e N P p lu s u su al ca re (𝑛 = 115 )t ou su al ca re (𝑛 = 113 ) in the ma nag emen t of bl o o d li pi d s in p at ie n ts w it h CHD 22 8 adu lt s w it h h yp er cho lest er o lemia an d CHD w ho wer e hosp it al ize d fo rC A B Go rP C I NP co un se led o n li p id ma na ge men t an d li fe st yl e ch ange s an d h ad p er m is si on to pre sc ri b e (co m p lemen ta ry ro le) 1 1N P E d uca tio n and exp er ience we re not re p or te d Dier ic k-va n D aele ,2 0 0 9, NL [ 39 ] (Dier ic k -va n D aele et al ., 20 10 ) [ 88 ] Co m p ar e N P (𝑛 = 817 )a n d GP (𝑛 = 684 ) in the p ro visio n of pr im ar y care 15 01 pa ti en ts at te ndin g a pr im ar y care app oi n tm en t for co mmo n co m p la in ts N P sa w p at ie nt s at fi rs t p o int o f co n tac t; a G P w as re q uir ed to sig n o ff all p re sc ri p tio n s (al ter na ti ve ro le) 15 12 NP s All co m p let ed a 2-y ea r A NP MS c in p re vio u s 2 mo n th s K inner sle y, 20 0 0 ,U K [ 40 ] Co m p ar e N P (𝑛 = 652 )a n d GP (𝑛 = 716 ) in the p ro visio n of pr im ar y care 14 65 (13 68 an al yzed) p at ien ts see k in g a sa m e-d ay ap p o in tm en t N P sa w p at ie nt s at fi rs t p o int o f co n tac t; a G P w as re q uir ed to sig n o ff all p re sc ri p tio n s (al ter na ti ve ro le) 10 10 NP s A ll co m pl et ed an N P d ipl oma at le as t 1 ye ar p re vi o u sl y K rein, 20 0 4 ,U S [ 41 ] Co m p ar e N P p lu s u su al ca re (𝑛 = 123 )a n d u su alc ar e (𝑛 = 123 ) in the ma nag emen t of ty p e 2 d ia b et es 24 6 adu lt s w it h ty p e 2 d iab et es an d p o o r gl ycemic co n tr o l NP fo llo w ed th e C hr o nic C ar e M o del in hel p in g pa ti en ts to ma na ge gl ucos e lev el s; P CP s w er e req uir ed to ap p ro ve medica tio n cha n ges (co m p lemen ta ry ro le) 2 2N P s 2-da y tra inin g sessio n ;o th er ed uca tio n and exp er ience we re not re p or te d L imog es-G o nzalez, 2011, US [ 42 ] C o mp ar e ga st ro ent er o lo gy N P (𝑛=5 0) to gast ro en ter o logists (𝑛 = 100 ) in scr eenin g co lo nos co p ies 15 0 ave ra ge ri sk p at ie n ts ≥ 50 yr s w h o we re re fe rr ed for a scr eenin g co lo n os co p y NP p er fo rme d the colo nos co p y u nder th e sa m e co n di ti o n s as m edical do ct o rs and p o ly p ec to mies w er e p er fo rme d by the NP indep enden tl y (al ter na ti ve ro le) 1 1N P In te n si ve tra inin g fo llo w ed by 2 ye ar s o f p rac ti ce L it ake r, 20 03 ,U S [ 43 ] Co m p ar e N P p lu s u su al ca re (𝑛=7 9)a n d u su alP C P ca re (𝑛=7 8) in the ma nag emen t o f p at ien ts wi th h yp er ten sio n an d d ia b ete s 15 7 adu lt p at ie n ts w it h mild-mo d era te h yp er te n sio n an d N ID D M w it h out end-o rga n co m p lica tio n s N P sa w p at ie nt s at fi rs t p o int o f co n tac t and p ro vided telep ho nic an d in-o ffi ce ma na ge men t; p er missio n to p res cr ib e w as no t rep o rt ed (co m p lemen ta ry ro le) 1 1N P ∗ Sp ecific tr ainin g fo r th e ma nag emen t o f di ab etes an d hy p er te n si o n M u ndin ge r, 20 0 0 ,U S [ 44 ] (L enz et al ., 20 02; L enz et al ., 200 4 ) [ 89 , 90 ] Co m p ar e N P (𝑛 = 1181 )a n d ph ys ic ia n (𝑛 = 800 ) o ngoi ng pr im ar y care 19 81 ED o r ur ge n t ca re ad ul t pa tie n ts wi th n o re gu la r so u rc e o f ca re N P sa w p at ie nt s at fi rs t p o int o f co n tac t and had au tho ri ty to p res cr ib e (al ter na ti ve ro le) 5 7P T E N P s Sc h o o lo f n u rs in g fa cu lt y mem b er s w it h sp ecial ti es in ad u lt p ri ma ry ca re Ne ls o n ,1 9 91 ,U S [ 45 ] Co m p ar e p ed ia tr ic N P te le ph on e supp o rt plu s u su al ca re (𝑛=9 1)t ou su al ca re (𝑛=9 3) o f p are n ts afte r an E D visi t fo r th eir chi ld ’s ac u te ill n es s 19 0( 18 4a n al yz ed ) o u tp at ie n t ch ildr en (< 8y rs ) w h o at te n d ed th e E D for an ac ut e inf ec ti o u s o r aller gic co n di ti o n N P m ad e te le ph on e con ta ct w it h p are n t( s) aft er d is ch ar ge ,p rov id ed ed uca tio n and tr ea tm en t re vie w , an sw er ed q u est io n s, an d faci li ta te d co mm unica tio n b etw een fa mil y an d P C P; p er m iss io n to p re sc rib e w as no t re p o rt ed (co m p lemen ta ry ro le) 2 2N P s E d uca tio n and exp er ience we re not re p or te d
Ta b le 1: C o n ti n u ed . Au th o r, ye ar ,a n d co un tr y (addi ti o n al p u b lica tio n s) Stu d y o bj ec ti ve (n um b er anal yzed) Pa rt ic ip an ts Int er ve n ti on (NP ro le) Nu m b er o f si te s Nu m b er o f N P s exp er ience an d tra inin g Sc h u tt el aa r, 20 10 ,N L [ 46 ] (S ch u tt elaa r et al ., 2011) [ 91 ] Co m p ar e N P (𝑛=8 1)a n d der m at o logist (𝑛=7 9)c ar eo f ch il dr en wi th eczema 16 0 ch il d re n w it h at o pi c der m at it is w h o w er e n ew ly re fe rr ed by th ei r G P o r paedia tricia n NP p ro vided the sa me se rv ices as th e der m at o logist and was ab le to p res cr ib e indep enden tl y (al ter na ti ve ro le) 1 1N P ANP m ast er s p rep ar ed wi th 3-y ea r exp er ience in der m at o log y Sm it h ,2 0 0 6 ,U S [ 47 ] (L yl es et al ., 20 03 ;L uo et al ., 20 07) [ 92 , 93 ] Co m p ar e N P p lu s u su al ca re (𝑛 = 101 )a n d u su alc ar e (𝑛 = 105 ) in the ma nag emen t o f pa ti en ts wi th medicall y unexp la ined sym p to m s 20 6 p at ien ts (18–6 5 ye ar s) wi th medicall y unexp la ined sym p to m s an d hig h u ti liza ti o n o f p rima ry ca re ser vices N P co ord in at ed an d m an age d ca re o ver a minim um o f 12 sc hed u led visi ts ove r a ye ar an d te le ph on e con ta ct be tw ee n vi si ts (co m p lemen ta ry ro le) 3 4N P s C er ti fi edw it h8 4h o u rs o f sp ecial tra inin g ,no p rio r exp er ience in men tal he al th V ennin g ,20 0 0 ,U K [ 48 ] Co m p ar e N P (𝑛 = 651 )a n d GP (𝑛 = 665 )p ri m ar y ca re o f pa tie n ts see k in g sa m e d ay co n su lt at io n s 13 16 pa tien ts o f all ag es N P sa w p at ie nt s at fi rs t p o int o f co n tac t; a G P w as re q uir ed to sig n o ff all p re sc ri p tio n s (al ter na ti ve ro le) 20 20 NP s Di p lo m a, BS c, o r MS c pre p are d w it h 1– 5 ye ars as an NP NP in tr an si ti o n ro le (𝑛=5 ) Co le m an ,2 0 0 6 ,U S [ 49 ] (P ar ry et al ., 200 3) [ 94 ] Co m p ar e ge ri at ri c N P p lu s usu al ca re (𝑛 = 379 )a n d u su al ca re (𝑛 = 371 )o fo ld er p at ien ts wi th co m p lex ca re n eed s 75 0 chr o nicall y ill , co mm uni ty-d w ellin g ,lo cal , ol d er adu lt s (≥ 65 yr s) ad m itt ed to h o spit al for 1 of 11 no n p sychi at ric co ndi tio ns N P m et w it h p at ie n t in h o spit al an d made a h o m e visi t an d telepho ne ca ll s aft er dis cha rg e; p at ien ts tr an sf er re d to a skill ed n u rs in g fa ci li ty w er e te le ph on ed or vi si te d at le as t we ek ly (co m p lemen ta ry ro le) 10 2N P s ∗ E xp er ienced ger ia tr ic NP s wh o w er e skill ed in pa tie n t ed uca tio n and ad vo cac y H o ll in gs w o rth 2000 ,U S [ 50 ] C o m p are N P -f ac il it ate d ear ly dis cha rg e, fo llo w -u p ca re p lu s usu al ca re (𝑛=5 4)a n d u su al ca re (𝑛=5 9)o fw o m en w h o ha ve had an ab d o mina l hy st er ec to my 113 w o men (≥ 21 yr s) under go in g ab do minal hy st er ec to my fo r no no nco logic indica tio n s NP s h ad co n tac t w it h p at ien t in hosp it al ,e nco u rage d ea rly dis cha rge, made ho me vi si ts an d telepho ne ca ll s, an dw er ea va il ab le fo rp at ie n tsa n d fa mi lies by te lep h o n e (co m p lemen ta ry ro le) 1 2 N P s (1 FTE and 1 P TE) Ma st er s p re p are d
Ta b le 1: C o n ti n u ed . Au th o r, ye ar ,a n d co un tr y (addi ti o n al p u b lica tio n s) Stu d y o bj ec ti ve (n um b er anal yzed) Pa rt ic ip an ts Int er ve n ti on (NP ro le) Nu m b er o f si te s Nu m b er o f N P s exp er ience an d tra inin g K o to w ycz, 20 10, C AN [ 51 ] C o m p are N P -f ac il it ate d ear ly dis cha rg e, fo llo w -u p ca re p lu s usu al ca re (𝑛=2 7)a n d u su al ca re (𝑛=2 7) o f p at ien ts w it h lo w-r isk ST EMI 54 lo w -ri sk (Z w o ll e P ri m ar y PCI Index ≤ 3) ST EMI p at ien ts tr ea te d w it h p ri m ar y or re sc u e PCI. N P sa wp at ie n tsb ef o rea n d aft er d is ch arge an d prov id ed edu ca ti on an d ap p o in tm en t reminder s; p er missio n to p res cr ib e w as no t rep o rt ed (co m p lemen ta ry ro le) 1 1N P ∗ E d uca tio n and exp er ience we re not re p or te d Na th an ,2 0 0 6 ,U K [ 52 ] C o m p ar e resp ir ato ry sp ec ia list NP (𝑛=7 8) and re sp ira to ry do ct o r (𝑛=7 6)i nt h e p ro vi si o no ff o ll o w -u p ca re to ac u te ast hma p at ien ts 15 4 ac u te ast h ma pa tien ts (> 16 yr s) dis charge d fr o m h o spit al .Th o se w it h C OP D w er e ex cl uded . NP sa w o u tp at ien ts aft er dis cha rg e and fo r fo llo w-u p ap p o in tm en ts; N P p res cr ib ed indep enden tl y acco rdin g to a p at ien t gr o u p dir ec ti ve (al ter na ti ve ro le) 1 1N P Ma st er s p re p are d w it h sp ecialist tr ainin g in ac u te ast h ma ma nag emen t R aw l, 19 98, US [ 53 ] (E ast o n et al ., 19 95) [ 95 ] C o m p are N P p o std is ch arge fol lo w -u p p lu s u su al ca re (𝑛=4 9)a n d u su alc ar e (𝑛=5 1) o f reha b ili ta tio n p at ien ts wi th lo n g-t er m dis ab ili ti es 10 0 reha b ili ta tio n p at ien ts (≥ 18 yr s), w ho wer e no t co nfined to th eir h o m e NP co n tac te d p at ien ts b ef o re d is ch ar ge an d in the re ha b ili ta ti o n cl inic, in their ho me, and by telepho n e after d is cha rge (co m p lemen ta ry ro le) 1 1N P C er tified in reha b ili ta tio n, 10-y ea r exp er ience NP in in pa ti en t set ti n g (𝑛=2 ) Mi tchel l-D iC en so ,1 9 9 6 , CAN [ 54 ] Co m p ar e N P (𝑛 = 414 )a n d p edia tr ic residen t te am s (𝑛 = 407 )i nn eo n at al in te n si ve ca re 82 1 n eo n at es admi tt ed to th e neo n at al in te n si ve ca re uni t. NP te am assume d p ri mar y re sp ons ibi li ty for n eo n at es (al ter na ti ve ro le) 1 4.5 FTE N P s A ll gr adu at es of a 16 -m o n th Ma st er s p ro gr am Pi oro ,2 0 01 ,U S [ 55 ] Co m p ar e N P (𝑛 = 193 )a n d ho us e st aff (𝑛 = 188 )i nc ar eo f ge neral m edical pa ti en ts 38 1 adu lt ge n er al m ed ic al pa tie n ts NP s p ro vide d m an y o f the sa me se rv ices deli ve re d by tradi ti o n al ho us e st aff (al ter na ti ve ro le) 1 2.5 F TE NP s E xp er ience an d tra inin g w er e no t d es cr ib ed ANP : ad va n ced n u rs e p rac ti tio n er ; BS c: B ac h elo r o f Sc ien ce; CAB G: co ro na ry ar te ry by pass sur ger y; CAN : C an ada; CHD: co ro na ry he ar t d is ea se ; C O P D: chr o n ic obstr u ct iv e p ulmo na ry dis eas e; GP: genera l p rac ti tio n er ; E D: emer ge nc y d epa rtmen t; FTE: fu ll-time eq u iv al en t; MS c: M ast er o f Sc ience; NID D M : n o n -in sulin dep enden t d ia b et es m elli tu s; NL: Th e N et herla n ds; N P: n u rs e p rac ti tio ner ; PCI: p er cu ta n eo us co ro na ry in te rv en tio n ;P CP :p ri ma ry ca re p ro vider ;P TE: p ar t time eq u iv alen t; ST EMI: ST -ele va tio n m yo ca rdial infa rc tio n ;U K: U n it ed K in gd o m ;US: Un it ed St at es . ∗Da ta p ro vi d ed by au th o r.
T a ble 2: Summa ry o f C NS st ud y cha rac ter ist ics. Au th o r, ye ar ,a n d co un tr y (addi ti o n al p u b lica tio n s) Stu d y o bj ec ti ve (n um b er anal yzed) Pa rt ic ip an ts Int er ve n ti on (CNS ro le) Nu m b er o f si te s Nu m b er o f C N Ss exp er ience an d tra inin g CNS in o u tp at ien t set ti n g (𝑛=1 1) Alexa n der ,1 988, US Co m p ar e C N S (𝑛=1 1)a n d usu al p ri ma ry co n tin ui ty ca re (𝑛=1 0)o fp o o rl yc o n tr o ll ed no nco m pli an t ast h ma ti c ch il d re n 21 ast h ma tic childr en (15 mo n ths to 13 ye ar s) fr o m lo w-inco me fa milies w h o u se d th e E D as their p rima ry ca re so u rc e C N S p rom o te d se lf -c are b as ed o n th e Or em Se lf-C ar e N ur sin g M o del; p er m is si on to pre sc ri b e w as n o t des cr ib ed (al ter na ti ve ro le) 1 1C N S E d uca tio n and exp er ience we re not re p or te d Ar ts, 201 2, NL Co m p ar e C N S (𝑛 = 169 )a n d ph ys ic ia n (𝑛 = 168 )c ar ea n d cost-eff ec ti veness in the tr ea tm en t o f p at ie n ts w it h dia b et es 33 7 p at ien ts w it h d ia b et es tr ea te d in a h o spit al -b as ed se tt in g. All req uir ed in sulin tr ea tm en t o r o ral b lo o d -g lu cos e medica tio n and had inadeq u at e regula tio n o f b lood gl u co se ,b lood p re ss u re , or li pi d s CNS m an ag ed dia b et es p at ien ts in sa me wa y as the p h ysicia n s, inc ludin g dia b et es-r ela ted cl inical admissio n s; re fe rral s to spec iali st ca re req uir ed a p h ysicia n (al ter na ti ve ro le) 1 4 C NSs D o ct or al or Ma st er s p re p are d wi th ext en si ve exp er ience in dia b et es ca re B ra n do n, 20 0 9, U S Co m p ar e C N S (𝑛=1 0)a n d usu al ca re (𝑛=1 0) o f p at ien ts wi th HF 20 ad ul t p at ien ts li vin g w it h HF fo r > 6m o n th sw h o w er e ca pa b le o f se lf-ca re C N S p rov id ed edu ca ti on ,c are ma na ge men t an d m edica tio n ad her ence adv ice, an d p at ien t su p p o rt; p er m is si on to pre sc ri b e w as n o t re p o rt ed (co m p lemen ta ry ro le) 1 1C N S Ma st er s p re p are d ∗ St uden t p rac ti cu m u nder ca rd io lo gi st sup er vi si on plu s 10-y ea r exp er ience in in ten si ve an d coron ar y care B ro o te n, 20 01, U S Co m p ar e C N S (𝑛=8 5 mo th er ;9 4 infa n ts) and usu al ca re (𝑛=8 8 mo th ers; 10 0 infa n ts) o f hig h-r isk p regna n t wome n 17 3 p re gna n t w o m en at hig h ri sk du e to ge st at ion al or p reg est at io n al dia b et es melli tus, chr o nic hy p er te n si o n ,o r p re te rm la b o ur wi th 19 4 infa n ts CNS p ro vided p re na ta lm o n it o rin g , as se ss m en t, edu ca ti on ,c ou ns el in g ,an d co mm uni ty re fe rr als; medica tio n re gi m ens we re ad ju st ed aft er p h ys ic ia n co n su lt at io n (co m p lemen ta ry ro le) 1 3C N S M ast er s p re pa re d sp ecializin g in hig h-r isk p regna ncies and infa n ts (exp er ience n o t re p o rt ed) C hien, 2012, C hina C o m p ar e p sy ch ia tr ic CNS (𝑛=3 9)a n d u su alc ar e (𝑛=4 0) o f p at ien ts w it h psy chia tr ic sym p to m s 79 re fer re d ad u lt (18– 49 yrs) pa ti en ts wi th fir st-ep is o de , mo dera te ly se ve re psy chia tr ic sym p to m s w h o w er e at lo w ri sk o f se lf-ha rm o r vio lence CNS p ro vided 6 se ssio n s o f ass ess men t, su p p o rt sy stem des ig n , co o rdina tio n o f ca re ,a n d ed u ca ti o n in sym p to m m an ag emen t; p er m issio n to p res cr ib e w as no t rep o rt ed (co m p lemen ta ry ro le) 1 1C N S Ma st er s p re p are d ∗ wi th tr ainin g in p sy ch os o cial in te rv en ti ons for p at ie n ts w it h men ta lhe al th p roblems (exp er ience n o t re p o rt ed) Ev an s, 19 97 ,U S (S tr um p f et al ., 19 92 ; Pat te rs o n et al ., 19 95 ; Si eg le r et al. ,1 9 97 ; C ap ezu ti et al ., 19 98) [ 96 – 99 ] C o m p ar e ger o n to logic CNS ed uca tio n (𝑛 = 152 ), CNS ed uca tio n p lu s co n sul ta tio n (𝑛 = 127 ) and nei ther ed uca tio n n o r co n sul ta ti o n (𝑛 = 184 )i nt h e u seo f p h ysical re st ra in ts in n u rs in g ho mes 6 43 (4 63 anal yzed) re siden ts (> 6 0 yr s) fr o m 3 n ur sin g ho mes C N S edu ca ti on in volve d te n 30 -m in ut e se ssio n s addr essin g issues sur ro u ndin g re st ra in t u se ;C N S co ns u lt at ion in vo lv ed 12 ho ur s/w eek o f uni t-bas ed co n su lt at io n fo r residen ts w it h cl inicall y ch allen gin g b eha vio ur (co m p lemen ta ry ro le) 3 1C N S Ma st er s p re p are d (exp er ience n o t re p o rt ed)
Ta b le 2: C o n ti n u ed . Au th o r, ye ar ,a n d co un tr y (addi ti o n al p u b lica tio n s) Stu d y o bj ec ti ve (n um b er anal yzed) Pa rt ic ip an ts Int er ve n ti on (CNS ro le) Nu m b er o f si te s Nu m b er o f C N Ss exp er ience an d tra inin g F ai thfull ,2 00 1, U K Co m p ar e C N S (𝑛=5 8)a n d usu al ca re (𝑛=5 7)o fm en tr ea te d w it h radical ra d io th er ap y for pro st at e an d b ladder ca n cer 115 men u nder go in g radical (> 6 0 G y) radio th era p y fo r pro st at e or bl ad d er can ce r CNS m ade ini ti al ass essmen ts, had o p en access clinics d ur in g thera p y, and made p o st th era p y telep ho ne co n tac ts; p er m is si on to pre sc ri b e w as n o t re p o rt ed (al ter na ti ve ro le) 1 1C N S Ma st er s p re p are d w it h exp er tis e in radio th era p y to xici ty ma nag emen t ∗ (exp er ience n o t re p o rt ed) R it z,2 0 0 0 ,U S Co m p ar e C N S (𝑛 = 106 )a n d usu al ca re (𝑛 = 104 )o fb re as t ca ncer p at ien ts 21 0 w o m en wi th n ewl y diag nos ed b re ast ca n cer (3 0–8 5 ye ar s) w h o w er e re fe rr ed by th eir p h ysicia n an d we re ca re d for w it h in th e sys tem CNS p ro vided ass essmen ts, in for m at ion ,s upp o rt ,a n d co o rdina tio n o f ca re; p er m issio n to p res cr ib e w as no t d es cr ib ed (co m p lemen ta ry ro le) 1 2 C NSs Ma st er s p re p are d ∗ (exp er ience n o t re p o rt ed) Ry an ,2 0 0 6 ,U K C o m p ar e rheuma to logic CNS pl us usu al ca re (𝑛=3 6)a n d usu al ca re (𝑛=3 5) o f p at ien ts wi th rh eu m at o id ar th ri ti s 71 pa ti en ts wi th dia gnos ed rheuma to id ar th ri ti s w ho wer e b eginnin g n ew dis eas e m o d if yi n g an ti rh eu m ati c dr ugs CNS p ro vide d the sa me se rv ice as the o u tp at ien t cl inic n u rs e w it h addi ti o n o f ass essmen t an d ref er ra l re sp o n sib ili ti es; p er missio n to p res cr ib e w as no t rep o rt ed (co m p lemen ta ry ro le) 1 1C N S D o ct or al pre p ar at io n w it h 16-y ea r exp er ience in rheuma to log y ∗ Sw indle ,20 03 ,U S C o m p ar em en ta lh ea lt hC N S (𝑛 = 134 ) and p h ysicia n ca re (𝑛 = 134 ) o f vet era n s w it h d epre ss ion 26 8 n ew p at ien ts wi th P RIME-MD dep ressio n dia gnosis C N S con ta ct ed p at ie n ts by te le ph on e o r visi ts, w hile th e C NS re co mmended an tidep ress an t medica tio n and ch an ge s to typ e and dos e; p er missio n to p res cr ib e w as no t rep o rt ed (co m p lemen ta ry ro le) 2 9C N Ss 5 h ad cog n it iv e b eha vio ral tr ea tm en t tra inin g; 9–2 3-y ea r exp er ience tr ea ti n g dep ressio n T ijh uis, 20 02 ,N L (T ij h u is et al ., 20 03 ; T ijh uis et al ., 20 03; va n De n H o u t et al ., 200 3)[ 10 0 – 10 2 ] C o mp ar e C N S o u tp at ie nt ca re (𝑛=7 1), in pa ti en t ca re (𝑛=7 1), an d d ay -pa tien t ca re (𝑛=6 8) o f p at ien ts w it h rheuma to id ar th ri ti s 210 rheuma to id ar thr it is p at ien ts wi th incr ea sin g fu n cti o n al li m ita ti o n s CNS p ro vided inf o rma ti o n ,r ef er rals, an d h ardw are p re sc ri pt io ns ;C N S d id no t h av e p er missio n to p re sc ri b e o r ch an ge dr ugs (al ter na ti ve ro le) 6 6 C NSs E d uca tio n and exp er ience we re not re p or te d C N Si nt ra n si ti o nr o le( 𝑛=1 3) B ro o te n, 19 86, U S C o m p ar e p er ina tal CNS-ca re (𝑛=3 6 mo th er s; 39 infa n ts) an d u su al ca re (𝑛=3 6 mo th er s; 4 0 infa n ts) o f ve ry -lo w -b ir th w eig h t infa n ts 72 mo th ers and 79 ve ry -lo w -b ir th w eig h t infa n ts (≤ 15 0 0 g) CNS co n ta ct ed pa re n t(s) d ur in g infa n t hosp it al iza tio n and made ho me vi si ts an d telep ho ne co n tac t; p er m issio n to p res cr ib e w as no t rep o rt ed (co m p lemen ta ry ro le) 1 3 C NSs (1 F TE; 2 PTE) Ma st er s p re p are d in p er in at al an d n eo n at al n u rs ing B ro o te n, 19 94, U S C o m p ar e C NS pl us usu al ca re (𝑛=6 1)a n d u su alc ar e (𝑛=6 1) o f hig h risk p o st pa rt um w o men 12 2 p o stp ar tu m w om en w h o had recei ve d an u n p la nned caes ar ea n d eli ver y CNS p ro vided co m p rehen si ve in h o sp it al an d fo llo w-u p ca re wi th p o st d is ch ar geh o m ev is it sa n d tel epho n e ca lls (co m p lemen ta ry ro le) 1 3C N Ss ∗ E d uca tio n and exp er ience we re not re p or te d
Ta b le 2: C o n ti n u ed . Au th o r, ye ar ,a n d co un tr y (addi ti o n al p u b lica tio n s) Stu d y o bj ec ti ve (n um b er anal yzed) Pa rt ic ip an ts Int er ve n ti on (CNS ro le) Nu m b er o f si te s Nu m b er o f C N Ss exp er ience an d tra inin g D el las ega, 20 0 0 ,U S (D ellas ega an d Z erb e, 200 2) [ 103 ] C o m p ar e C NS pl us usu al ca re (𝑛=6 9 pa tie n ts; 34 ca re gi ve rs ) an d u sual ca re (𝑛=7 1 p at ien ts; 31 ca reg iv er s) o f elderl y fra il dis cha rg ed pa tie n ts 14 0 elderl y p at ien ts w h o w er e sc h ed u le d to b e d is ch ar ge d ho me, w er e cog ni ti vely fr ai l an d/o r fu nc ti o n all y im pa ir ed , or we re a com pl ex ca se (p lu s 65 ca re gi ve rs ) CNS o r N P visi ted p at ien t b ef o re dis cha rg e and aft er dis cha rg e; ad d it ion al te le ph on e ca ll s or vi si ts w er e ini tia ted as n eeded (co m p lemen ta ry ro le) 3 ∗ 2 C NSs an d 2 NP s E d uca tio n and exp er ience we re not re p or te d K enned y, 19 87 ,U S (N eidlin ge r et al ., 1987) [ 10 4 ] C o m p ar e ger o n to logic CNS pl us usu al ca re (𝑛=3 9)a n d usu al ca re (𝑛=4 1)o fe ld er ly p at ien ts admi tt ed to no nin te n si ve ca re uni ts 80 co n sec u ti ve elderl y p at ien ts (≥ 75 yr s) admi tt ed to no nin te n si ve ca re uni ts w h o we re ex p ec te d to st ay ≥ 72 ho ur s C N S m et p at ie n ts ,f am il y, an d care p ro vider s in hosp it al an d aga in ju st p rio r to d is ch ar ge ;p er missio n to p res cr ib e w as no t rep o rt ed (co m p lemen ta ry ro le) 1 1C N S Ma st er s p re p are d w it h ad d iti o n al ge ria tri c k n o wl ed ge an d skill s La ra m ee ,2 0 03 ,U S Co m p ar e C H F C N S p lu s u su al ca re (𝑛 = 141 )a n d u su alc ar e (𝑛 = 146 ) in the ma nag emen t o f HF p at ien ts admi tt ed to hosp it al 28 7 p at ie n ts at ri sk o f ea rl y re admissio n w ho had b een admi tt ed to hosp it al fo r pr im ar y o r se con d ar y C H F, left ven tr ic ula r d ysf unc tio n < 4 0%, o r radio logic ev idence of pu lm on ar y o ed em a C N S vi sit ed p at ie n ts d ai ly in h o spit al an d m ad e p o std is ch arge tel eph on e co n tac ts (co m p lemen ta ry ro le) 1 1C N S Ma st er s p re p are d w it h 18 -ye ar exp er ience in cr it ical ca re an d ca rdio log y M cC o rk le ,2 0 0 0 ,U S (J ep so n et al ., 1999 ) [ 105 ] C o m p ar e C NS pl us usu al ca re (𝑛 = 190 )a n d u su alc ar e (𝑛 = 185 ) o f o lder p o stsurg ic al ca ncer p at ien ts 375 o ld er (6 0 – 92 yr s) n ew ly dia gnos ed so lid-t u mo r ca n cer p at ien ts dis cha rg ed aft er surger y to their ho me CNS co n ta ct ed p at ien ts aft er dis cha rg e an d m ad e h om e vi sit s an d te le ph on e co n tac ts (co m p lemen ta ry ro le) 1 7 C NSs ∗ Co m p le te d 2-ye ar p ro gr am in o n co log y Mc C o rk le ,2 0 0 9, U S (M cC o rk le et al ., 2011) [ 10 6 ] C o m p ar e o nco log y C NS p lus usu al ca re (𝑛=6 3)a n d u su al ca re (𝑛=6 0)o fw o m en re co ve ri n g fr o m gy neco log ical ca ncer sur ger y 14 9 (12 3 anal yzed) w o men (≥ 21 yr s) wi th su sp ect ed o va ria n ca n cer re co ve ri n g fr o m gy naeco logical ca ncer sur ger y and under go in g che m ot he ra p y C N S p rov id ed tai lo re d sp ec ia li ze d ca re th ro ug h 18 p ost d is ch ar ge pa ti en t co n tac ts (co m p lemen ta ry ro le) 2 1 C NS an d 4 NP s ∗ E d uca tio n and exp er ience we re not re p or te d N ayl o r, 1990 ,U S C o m p ar e C NS pl us usu al ca re (𝑛=2 0)a n d u su alc ar e (𝑛=2 0) o f elderl y p at ien ts admi tt ed to hosp it al 4 0 En gl ish sp eakin g in p at ien ts (≥ 70 ye ar s) w h o h ad b een ad m itt ed to h o spit al fr om ho me. C N S con ta ct ed p at ie n ts in h o spit al , im p lemen te d the dis cha rg e p la n, an d co n tac te d p at ien ts aft er d is ch ar ge w h ile co o rdina tin g w it h P CP an d p ro vidin g telep ho ne o u tr ea ch (co m p lemen ta ry ro le) 1 2 P TE CNSs Ma st er s p re p are d
Ta b le 2: C o n ti n u ed . Au th o r, ye ar ,a n d co un tr y (addi ti o n al p u b lica tio n s) Stu d y o bj ec ti ve (n um b er anal yzed) Pa rt ic ip an ts Int er ve n ti on (CNS ro le) Nu m b er o f si te s Nu m b er o f C N Ss exp er ience an d tra inin g Na yl o r, 19 94 ,U S C o m p ar e ger o n to logic CNS pl us usu al ca re (𝑛 = 140 )a n d usu al ca re (𝑛 = 136 )o fe ld er ly p at ien ts admi tt ed to hosp it al 27 6 E ng li sh sp ea k ing in pa ti en ts (≥ 70 ye ars ) admi tt ed fr o m th eir h o m es: medical (CHF an d an gina/MI) an d su rg ic al (C A B G an d CVR) pa tien ts C N S con ta ct ed p at ie n t in h o spit al , made p o stdis cha rg e visi ts, an d w as av ai la b le 7 da ys/w eek d ur in g hosp it aliza tio n and aft er dis cha rg e (co m p lemen ta ry ro le) 1 2 P TE CNSs Ma st er s p re p are d w it h at le as t on e ye ar ex p er ie n ce as a sp ec ia list N ayl o r, 1999 ,U S (N ay lo r and M cC aule y, 1999 ) [ 107 ] C o m p ar e ger o n to logic CNS pl us usu al ca re (𝑛 = 177 )a n d usu al ca re (𝑛 = 186 )o fe ld er ly p at ien ts admi tt ed to hosp it al 36 3 h osp it alized elderl y pa tie n ts (≥ 65 yr s) admi tt ed to hosp it al fr o m ho me w h o w er e at ri sk o f re admissio n C N S con ta ct ed p at ie n t in h o spit al , made ho me vi si ts an d w ee k ly te le ph on e con ta ct s, an d in d iv id u al iz ed p at ien t m an ag emen t; p er m issio n to p res cr ib e w as no t rep o rt ed (co m p lemen ta ry ro le) 2 5 P TE CNSs Ma st er s p re p are d w it h a m ean of 6 .5 ye ar s p o st d eg re e exp er ience Na yl o r, 20 0 4 ,U S (M cC au le y et al ., 20 0 6) [ 10 8 ] C o m p ar e C NS pl us usu al ca re (𝑛 = 118 )a n d u su alc ar e (𝑛 = 121 ) o f elderl y p at ien ts hosp it al ize d w it h HF 23 9 H F p at ie n ts (≥ 65 ye ars ) admi tt ed to st ud y h osp it als fr om th ei r h om es C N S con ta ct ed p at ie n ts in h o spit al an d aft er dis cha rg e and p ro vided d is ch ar ge p la nnin g ,ass essmen ts, ed uca tio n, an d de ve lo p m en t and im p lemen ta ti o n o f ca re go al s (co m p lemen ta ry ro le) 6 3C N Ss Ma st er s p re p are d w it h sp ecialized tra inin g in ma na gin g elderl y H F p at ien ts Tho m p so n, 20 05, U K C o m p ar e C NS pl us usu al ca re (𝑛=5 8)a n d u su alc ar e (𝑛=4 8) o f p at ien ts admi tt ed to ho sp it al fo r H F 10 6 p at ien ts w it h ac u te admissio n s to hosp it al fo r CHF and left ven tr ic ula r ej ec ti o n fr ac ti o n ≤ 45%, w h o wer e dis cha rge d ho me CNS p ro vided clinic an d h o m e-bas ed ca re wi thin 10 da ys o f dis cha rg e; p er m is si on to pre sc ri b e w as n o t re p o rt ed (co m p lemen ta ry ro le) 2 2 C NSs P o stgrad ua te ed uca tio n w it h HF ma nag emen t exp er ience Yo rk ,1 9 97 ,U S Co m p ar e p er in at al CNS-faci li ta te d ea rl y dis cha rg e p lu s u sual ca re (𝑛=4 4 mo th er s; 4 2 infa n ts) an d u su al ca re (𝑛=5 2 mo th er s; 51 infa n ts) o f hig h-r isk p regna n t w o men 9 6 hig h-r isk p regna n t w o men wi th ei th er dia b et es o r h yp er te n si on du ri ng pre gn an cy CNS p ro vided in h osp it al and p o st dis cha rg e fo llo w-u p ca re ; p er m is si on to pre sc ri b e w as n o t re p o rt ed (co m p lemen ta ry ro le) 1 1C N S Ma st er s p re p are d C N S in inp at ie nt se tt in g (𝑛=1 ) T all ey ,1 990 ,U S C o m p are p sy ch ia tr ic li ai so n C N S cons u lt at io n (𝑛=4 7) an d n o cons u lt at io n (𝑛=6 0) fo r n ur sin g ca re an d the us e o f si tt er s 10 7 acu te ca re pa ti en ts wh o had b een assigned la y si tt er s pr im ar il y b ec au se of a d ange r of “h ar m to se lf ” or “g en er al ly un p redic ta b le ” b eha vio u r CNS p ro vided indi vid ualized co n su lt at io n s to p at ie nt s, nu rs in g st aff , an d si tters so met imes o n m u lt iple o ccasio n s; p er m is sio n to p res cr ib e w as no t rep o rte d (co m p lemen ta ry ro le) 1 2 C NSs E d uca tio n and exp er ience we re not re p or te d ANP: ad va nced n u rs e p rac ti tio ner ; CAB G: co ro na ry ar te ry by pass gra ft ; C HF : co n ge sti ve h ea rt fa il ur e; CNS: clinica l n u rs e sp ecia list; CVR: ca rd io va sc ula r re co ve ry ; G P : ge n eral p rac ti tio n er ; ED: em er gen cy depa rt men t; H F :he ar t fa il u re ;FTE: full-time eq ui va len t; G y: gra y (uni t o f abs o rb ed radia tio n); MI: m yo ca rdia linfa rc tio n ;M Sc :M ast er o f Science ;N L: The N et h erl ands; NP: n urs e p ra ct it io n er ;P C P :p ri mar y ca re p ro vider ;P RIME-MD: p ri ma ry ca re ev al ua tio n o f men tal dis o rd er s; PTE: pa rt time eq ui valen t; U K: U n it ed K in gd o m ;US: U n it ed St at es. ∗Da ta p ro vi d ed by au th o r.
Rando m se quence g enera tion Allo catio n co nce almen t Outc ome ass essmen t: ob jectiv e me asur es Outc ome ass essmen t: sub jectiv e me asur es Com plet e out com e da ta: ob jectiv e me asur es Com plet e out com e da ta: sub jectiv e me asur es No s elec tive r epor ting Other b ias Overall r isk o f bias NP-outpatient
Allen et al., 2002 [38] Low Dierick-van Daele et al., 2009 [39] Moderate
Kinnersley et al., 2000 [40] Moderate Krein et al., 2004 [41] Moderate Limoges-Gonzalez et al., 2011 [42] Low
Litaker et al., 2003 [43] High Mundinger et al., 2000 [44] Low
Nelson et al., 1991 [45] NA NA Low Schuttelaar et al., 2010 [46] Low Smith et al., 2006 [47] Low Venning et al., 2000 [48] Moderate
NP-transition
Coleman et al., 2006 [49] NA NA Low Hollingsworth and Cohen, 2000 [50] High
Kotowycz et al., 2010 [51] High Nathan et al., 2006 [52] Low
Rawl et al., 1998 [53] High NP-inpatient
Mitchell-DiCenso et al., 1996 [54] Low Pioro et al., 2001 [55] Low
Low risk of bias
Unclear risk of bias Moderate: at risk in 2-3 categories High risk of bias High: at risk in 4–6 categories
Very high: at risk in 7-8 categories
+ + + + + + + + + + + + + + ? + ? + + + + + + ? ? + ? ? + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ? + + + + + + + + + ? ? + ? ? + ? ? + + + + + + + + + + + ? ? + + + + ? + + ? + + + + + + + + + + + + + + + + + + + + + + + − − − − − − − − − − − − − − − − − − − − −
Low: at risk in≤1 category
Figure 2: Risk of bias assessment of NP studies (𝑛 = 18).
a computer generated sequence concealed in sequentially numbered, opaque, sealed envelopes. The other three studies provided insufficient information to fully judge random sequence generation and allocation concealment.
All five RCTs were judged to be at low risk of detection bias for objective measures as they used abstraction of hos-pital administrative records or blinded outcome assessment. With respect to subjective measures, two trials were at high risk of detection bias because patients self-reported their
smoking cessation success and the NP, who delivered the intervention, also collected baseline and outcome data from the comparison groups during a guided interview.
All but one trial were at low risk of attrition bias for objective measures as they followed over 80% of participants and this was balanced across comparison groups within each study. With respect to subjective data, three trials scored high for risk of attrition bias due to poor response rates to self- or interviewer-administered questionnaires.
Rando m se quence g enera tion Allo catio n co nce almen t Outc om e ass essmen t: ob jectiv e me asur es Outc om e ass essmen t: sub jectiv e me asur es Com plet e out com e da ta: ob jectiv e me asur es Com plet e out com e da ta: sub jectiv e me asur es No s elec tive r epor ting Other b ias Overall r isk o f bias CNS-outpatient
Alexander et al., 1988 [56] NA NA High Arts et al., 2012 [57] Moderate Brandon et al., 2009 [58] Moderate Brooten et al., 2001 [59] Moderate Chien et al., 2012 [60] Low Evans et al., 1997 [61] NA NA NA Moderate Faithfull et al., 2001 [62] Low
Ritz et al., 2000 [63] High Ryan et al., 2006 [64] Low Swindle et al., 2003 [65] NA Low Tijhuis et al., 2002 [66] Low Brooten et al., 1986 [67] Moderate Brooten et al., 1994 [68] Moderate Moderate Kennedy et al., 1987 [70] Moderate Laramee et al., 2003 [71] Moderate McCorkle et al., 2000 [72] Low McCorkle et al., 2009 [73] Low Naylor et al., 1990 [74] High Naylor et al., 1994 [75] High Naylor et al., 1999 [76] Moderate Naylor et al., 2004 [77] Moderate Thompson et al., 2005 [78] Low
York et al., 1997 [79] Moderate CNS-inpatient
Talley et al., 1990 [80] + + + NA NA ? Moderate
? ? + ? + ? + + + + + + ? ? + + + + + + + + + + + + + + ? + + + + + ? + + + ? ? + + + + + + + + + + + + + + + + + + + + + + + + + + ? + + + + + + + + + + ? + + + + + + + ? + + + ? + + + + + + + + + + + ? + + + + ? + + + + + + + + + ? ? ? + + + ? ? + + + + ? ? + + + + + + + + + + + + + ? + ? + + + ? ? + + + + + + + ? +
Low risk of bias
Unclear risk of bias Moderate: at risk in 2-3 categories High risk of bias High: at risk in 4–6 categories
Very high: at risk in 7-8 categories +
?
Low: at risk in≤1 category
− − − − − − − − − − − − − − − − − − − − − − − − − − − − − CNS-transition
Dellasega and Zerbe,2000 [69]
Two studies identified outcomes that they planned to measure but did not report, placing them at risk of reporting bias.
4.2.3. NP-Inpatient Care. Two RCTs of NPs in inpatient settings met our inclusion criteria, both of which evaluated the NP in an alternative provider role [54,55] (Table1). One study was conducted in the US and one in Canada. One study was conducted before and one after the year 2000. The number of NPs in the trials ranged from 2.5 to 4.5 full-time equivalent NPs. The number of patients included in the trials ranged from 381 to 821 and each study was conducted at one site.
Threats to Internal Validity. Overall, the two studies were judged to be at low risk of bias (Figure2). Both studies were at low risk of selection bias having used acceptable random sequence generation processes (table of random numbers; computer random number generator) and having concealed allocation through the use of sequentially numbered, sealed, opaque envelopes.
Both were at low risk of detection bias as they relied on medical record and hospital database extraction of objective data such as mortality, medical complications, and length of hospital stay. In cases where study participants completed questionnaires, there were reliable, valid measures such as the SF-36 and the Minnesota Infant Development Inventory (MIDI).
Both studies were judged to be at low risk of attrition bias for the objective measures but at high risk of attrition bias for the subjective measures. While many of the primary objective outcome data were available for all study participants (e.g., mortality, complications, and length of stay), subjective self-report measures often had response rates less than 80%. We judged both studies to be at low risk of reporting bias and other biases.
4.2.4. CNS-Outpatient Care. Eleven RCTs [56–66] addressed
the CNS role in delivering outpatient care (Table 2). Six studies were conducted in the US, two in the UK, two in the Netherlands, and one in China. Nine studies were published in the year 2000 or later. Four trials evaluated one to six CNSs in the alternative provider role, while seven trials evaluated one to nine CNSs in the complementary provider role. The number of patients included in the trials ranged from 20 to 643 and the studies were conducted at between one and six sites.
Threats to Internal Validity. Overall, five of the eleven studies were assessed at low risk, four at moderate risk, and two at high risk of bias (Figure3). While seven studies used valid methods to generate the random sequence and were at low risk of selection bias, we judged the remaining four to be at unclear risk of bias because the authors did not include this information in their papers and we did not receive responses to our request for further details. With respect to allocation concealment, five trials were assessed at low risk of selection bias (e.g., central allocation and sealed envelopes) and three
at unclear risk of bias because methods were not described. We judged one at high risk of bias because the patients were randomly assigned by the CNS to one of the study groups by drawing the next allocation from an envelope; using this method, it is possible that the drawn assignment could be returned to the envelope and redrawn if allocation was deemed unsuitable. Two studies used cluster randomization and allocation concealment was not applicable as the clusters were all randomized at one time.
All the studies were rated as low in risk of detection bias for objective outcome measures (e.g., mortality and rehospitalization). Of the nine studies that included subjec-tive outcomes, eight were judged at low risk of bias as they used established, validated instruments, or blinded outcome assessment and one was at high risk of bias because the CNS who delivered the intervention also collected data from both groups before and after the intervention via telephone interviews.
With respect to attrition bias, all but three studies were assessed at low risk of bias for objective measures. Two of the studies judged at unclear risk of bias provided insufficient information to assess the completeness of all objective out-come measures and one, judged at high risk of bias, did not have cost data for at least 80% of the study participants.
While seven trials were judged to be at low risk of reporting bias, four were judged at high risk because they did not fully report all the outcomes they collected or did not collect all patient-important outcomes that would have been expected (e.g., patient/parent satisfaction with care and quality of life). Finally, one trial was judged at high risk of “other” bias because they did not adjust for cluster randomization.
4.2.5. CNS-Transition Care. Thirteen RCTs [67–79] evaluated
the CNS in the delivery of transition care in the US (𝑛 = 12) and in the UK (𝑛 = 1) (Table2). Seven studies were conducted before the year 2000. All trials evaluated the CNS in a complementary provider role. The studies included between one and seven CNSs. The number of patients included in the trials ranged from 40 to 375 and the studies were conducted at between one and six sites.
Threats to Internal Validity. Overall, three of the thirteen trials were at low risk, eight at moderate risk, and two at a high risk of bias (Figure3). Most trials were not at risk of selection bias. All but one trial used valid methods to generate the random sequence and all but one trial concealed allocation.
All trials were rated at low risk of detection bias for objective measures, except one. In this study, the risk of bias was unclear because healthcare utilization outcomes were based on self-report rather than medical record review data. For subjective measures, two trials were judged to be at unclear risk of detection bias because the validity of their scales was not described, and, in one trial, treatment adherence was based on self-report rather than objective measures, such as pill counts and was assessed at high risk of bias.
Other bias
(%) No selective reporting
Complete outcome data: subjective measures Complete outcome data: objective measures Outcome assessment: subjective measures Outcome assessment: objective measures Allocation concealment Random sequence generation
Low risk of bias Unclear risk of bias High risk of bias
0 10 20 30 40 50 60 70 80 90 100 n = 13 n = 5 n = 3 n = 4 n = 11 n = 17 n = 13 n = 13 n = 5 n = 2 n = 10 n = 3 n = 15 n = 2 n = 2 n = 1 n = 1 n = 17 n = 3
Figure 4: Risk of bias horizontal graph of NP studies (𝑛 = 18).
For objective measures, six trials had a low risk of attrition bias but, for five trials, the risk was unclear and, for two, it was high. For subjective measures, four trials had a low risk of attrition bias but, for six trials, the risk was unclear and, for three, it was high. For those studies in which it was unclear, the response rates were not specified or data were imputed; for those at high risk of bias, the follow-up rate was less than 80%.
Of the 13 trials, four were at high risk of reporting bias, three of which did not report on all outcomes measured and one of which did not include a measure of health status. One study was at unclear risk of bias because it was unclear if measures reported at baseline should have been reported as outcomes. Finally, seven trials were assessed at high risk of “other” bias because there were baseline differences between the groups for which adjustments were not made.
4.2.6. CNS-Inpatient Care. Only one study, conducted in the US in 1990, evaluated the CNS delivering inpatient care [80] (Table 2). The study examined CNSs in a complementary role. Two CNSs participated in the study, which included 107 patients and was conducted at one site.
Summary of Threats to Internal Validity. Overall, the risk of bias for this study was judged as moderate (Figure 3). We judged the study at low risk of selection bias and detection bias. The study, however, was judged to be at high risk of attrition bias because over 20% of patients were dropped from the study after randomization as the intervention they received was changed (e.g., sitters discontinued and control
group receiving CNS consultation) resulting in unequal distribution of patients in the two groups.
The study was also at high risk of reporting bias because they did not report whether the CNS and staff nurse inter-vention influenced patient risk behaviours as intended. Con-tamination bias was possible because the same staff nurses who received coaching from the CNS for intervention group patient management and for charting nursing observations cared for the control group and might have provided the same patient management and charting strategies for them. Because the associated risk of bias was unknown, we judged this as unclear “other” bias.
4.2.7. Summary. Overall, we assessed that 18 of the 43 trials (42%) were at low risk, 17 (39%) at moderate risk, and 8 (19%) at high risk of overall bias (Figures2and3). No study was judged to be at very high risk of overall bias. Figures4and5 summarize the studies by type of bias. With respect to the NP trials, many studies were at high risk of detection bias with incomplete (<80%) follow-up for subjective outcomes (e.g., self-administered scales). In CNS trials, a number of studies were at high risk of reporting bias because they either did not report on all outcomes measured or did not include a key outcome that we would have expected. A number of studies (especially smaller studies) had baseline differences with no mention of adjusting the analyses to account for these differences.
Some of the potential threats to validity may not in reality be threats, but rather it may be an issue of lack of reporting. There were many instances that we rated categories
n = 20 n = 24 n = 5 n = 4 n = 1 n = 1 n = 1 n = 1 n = 18 n = 18 n = 14 n = 10 n = 15 n = 16 n = 8 n = 9 n = 4 n = 4 n = 2 n = 2 n = 7 n = 8 Other bias (%) No selective reporting
Complete outcome data: subjective measures Complete outcome data: objective measures Outcome assessment: subjective measures Outcome assessment: objective measures Allocation concealment Random sequence generation
Low risk of bias Unclear risk of bias High risk of bias
0 10 20 30 40 50 60 70 80 90 100
Figure 5: Risk of bias horizontal graph of CNS studies (𝑛 = 25).
as “unclear risk of bias” because there was insufficient infor-mation in the paper or from the author to permit judgment of low or high risk of bias.
4.3. Summary of Threats to External Validity. Of the 43 RCTs, 70% of the studies were conducted in the United States (𝑛 = 30) and the remainder in four other countries: the United Kingdom (𝑛 = 6; 14%), The Netherlands (𝑛 = 4; 9%), Canada (𝑛 = 2; 5%), and China (𝑛 = 1; 2%). Given that healthcare systems and NP and CNS education, role implementation, and scope of practice vary internationally, applicability of study findings from one country to another may be compromised.
Some RCTs evaluating NP and CNS roles were conducted across many sites which may enhance generalizability. How-ever, many trials were conducted in single sites, which likely limits the generalizability of study findings.
Of the 43 RCTs, 13 (30%) studies were published prior to the year 2000. Given the substantive progress that has occurred in the development of NP and CNS roles and dynamic changes in healthcare systems internationally, the results of these studies may be less relevant to current-day policy. Although we found a substantial number of eligible RCTs, when broken down by grouping, we identified only one dated RCT of CNSs in the nontransitional care role for inpatient settings. This RCT evaluated two CNSs providing consultation for a small very particular population of medical-surgical patients requiring sitters due to the risk of self-harm or unpredictable behaviour. Similarly, we identified only two RCTs of NPs in the nontransitional care role in inpatient settings, both of which were published over 10 years ago. One study evaluated NPs caring for a homogeneous pop-ulation of critically ill infants in a Canadian hospital and the other evaluated NPs caring for a heterogeneous population
of adults admitted to general medical wards in a US-based hospital. Given the existence of only three fairly dated RCTs of NPs or CNSs in inpatient settings and somewhat specific populations, caution is needed in generalizing these results to NPs and CNSs in other inpatient settings.
Nine (21%) trials were conducted with small numbers of patients (𝑛 < 100) with specific health conditions. Four trials of NPs in outpatient settings were large with over 1,000 patients. The larger studies with patients experiencing com-mon conditions are more readily generalizable to the general population than smaller trials with patients experiencing a specific condition. However, one of the larger trials [44] limited study entry to poor, non-English speaking Hispanic people which may limit the generalizability of the findings to other patients seeking primary healthcare.
Twenty-seven (63%) of the RCTs evaluated one or two NPs or CNSs, 9 (21%) evaluated three to five, four (9%) evaluated six to nine, and three (7%) evaluated 10 or more all of which were NP-outpatient studies. The small number of NPs and CNSs evaluated in any study raises concern that the results may not be generalizable to colleagues in similar roles. In some cases when study outcomes were similar we were able to combine study findings which increased the number of NPs or CNSs evaluated for that outcome.
About two-thirds of the studies (𝑛 = 29; 67%) specified that they evaluated experienced NPs or CNSs (i.e., NPs or CNSs who had completed their training at least one year before the evaluation and/or had graduate degrees). Many of the studies did not include information about training and experience. One study posed concern, as it compared novice NPs who had completed a two-year advanced nursing practice graduate degree in the previous two months with general practitioners who had an average of 16 years work experience [39].
