Ryan J. Shaw, PhD, RN; Jennifer R. McDuffie, PhD; Cristina C. Hendrix, DNS, NP; Alison Edie, DNP, FNP; Linda Lindsey-Davis, PhD, RN; Avishek Nagi, MS; Andrzej S. Kosinski, PhD; John W. Williams Jr., MD, MHSc
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of U.S. Department of Veterans Affairs or Duke University. All work herein is original. All authors meet the criteria for authorship, including acceptance of responsibility for the scientific content of the manuscript.
Acknowledgment: The authors thank Connie Schardt, MLS, for help with the literature search and retrieval and Liz Wing, MA, for editorial assistance.
Financial Support: This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at the Durham Veterans Affairs Medical Center, Durham, North Carolina, which is funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development (VA-ESP Project 09-010; 2013). The first author, Dr. Ryan Shaw, was supported by a Department of Veterans Affairs Health Services Research and Development Office of Academic Affiliations nursing postdoctoral research award (TPP-21-021).
Disclosures: Dr. Williams reports grants from Veterans Affairs Health Services Research and Development during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2567.
Requests for Single Reprints: Ryan J. Shaw, PhD, RN, Health Services Research and Development (152), 411 West Chapel Hill Street, Suite 600, Durham, NC 27701; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Shaw and McDuffie: Durham Veterans Affairs Medical Center, 411 West Chapel Hill Street, Suite 600, Durham, NC 27701.
Drs. Hendrix, Edie, and Lindsey-Davis: Duke University School of Nursing, 307 Trent Drive, DUMC 3322, Durham, NC 27701.
Mr. Nagi and Dr. Williams: Durham Veterans Affairs Medical Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701.
Dr. Kosinski: Duke Clinical Research Institute, 2400 Pratt Street, Room 7058, Durham, NC 27705.
Author Contributions: Conception and design: R.J. Shaw, J.R. McDuffie, C.C. Hendrix, A. Edie, L. Lindsey-Davis, J.W. Williams.
Analysis and interpretation of the data: R.J. Shaw, J.R. McDuffie, C.C. Hendrix, J.W. Williams.
Drafting of the article: R.J. Shaw, J.R. McDuffie, J.W. Williams.
Critical revision of the article for important intellectual content: R.J. Shaw, J.R. McDuffie, C.C. Hendrix, A.S. Kosinski, J.W. Williams.
Final approval of the article: R.J. Shaw, J.W. Williams.
Provision of study materials or patients: J.R. McDuffie, J.W. Williams.
Statistical expertise: A.S. Kosinski, J.W. Williams.
Obtaining of funding: J.W. Williams.
Administrative, technical, or logistic support: J.R. McDuffie, A. Nagi, J.W. Williams.
Collection and assembly of data: R.J. Shaw, J.R. McDuffie, C.C. Hendrix, A. Edie, L. Lindsey-Davis, A. Nagi, J.W. Williams.
Changes in federal health policy are providing more access to medical care for persons with chronic disease. Providing quality care may require a team approach, which the American College of Physicians calls the “medical home.” One new model may involve nurse-managed protocols.
To determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia.
MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL from January 1980 through January 2014.
Two reviewers used eligibility criteria to assess all titles, abstracts, and full texts and resolved disagreements by discussion or by consulting a third reviewer.
One reviewer did data abstractions and quality assessments, which were confirmed by a second reviewer.
From 2954 studies, 18 were included. All studies used a registered nurse or equivalent who titrated medications by following a protocol. In a meta-analysis, hemoglobin A1c level decreased by 0.4% (95% CI, 0.1% to 0.7%) (n = 8); systolic and diastolic blood pressure decreased by 3.68 mm Hg (CI, 1.05 to 6.31 mm Hg) and 1.56 mm Hg (CI, 0.36 to 2.76 mm Hg), respectively (n = 12); total cholesterol level decreased by 0.24 mmol/L (9.37 mg/dL) (CI, 0.54-mmol/L decrease to 0.05-mmol/L increase [20.77-mg/dL decrease to 2.02-mg/dL increase]) (n = 9); and low-density-lipoprotein cholesterol level decreased by 0.31 mmol/L (12.07 mg/dL) (CI, 0.73-mmol/L decrease to 0.11-mmol/L increase [28.27-mg/dL decrease to 4.13-mg/dL increase]) (n = 6).
Studies had limited descriptions of the interventions and protocols used.
A team approach that uses nurse-managed protocols may have positive effects on the outpatient management of adults with chronic conditions, such as diabetes, hypertension, and hyperlipidemia.
U.S. Department of Veterans Affairs.
Summary of evidence search and selection.
* Methods or follow-up articles.
Table. Study and Patient Characteristics of Included Diabetes, Hypertension, and Hyperlipidemia Studies
Effects of nurse-managed protocols on hemoglobin A1c level.
Effects of nurse-managed protocols on systolic (top) and diastolic (bottom) blood pressure.
Effects of nurse-managed protocols on total cholesterol (top) and low-density lipoprotein cholesterol (bottom) levels.
To convert mg/dL to mmol/L, multiply by 0.0259.
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Michelle A. Lucatorto APRN, DNP, FNP-BC; Storm Morgan MSN, RN, MBA
Veterans Health Administration
July 22, 2014
Conflict of Interest:
The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government
Nurses - An Untapped Resource in Primary Care
Shaw et al. does a nice job of quantifying clinical outcomes for patients who receive care by nurses using protocols. Jauhar and Battinelli follow with commentary asking if nurses are the answer to the national problem of primary care physician shortages at a time when demand for services continues to rise. We suggest that nurses are not the sole answer to the challenges in primary care; the solution is the implementation of high performing team-based care. However, nursing is a vital and untapped component of this high performing team. It literally takes a village to manage health care needs, including chronic conditions, care coordination, and promotion of self-care and self-management in a manner consistent with patient’s desires and values. This village includes nurses (RN, LPN), providers (MD, DO, APRN, and PAs), pharmacists, nutritionists, physical therapists, social workers and others – the list is too large to complete here. But in addition to having a full team, it is also essential that everyone functions to their full potential. As cited in the IOM report on team-based care, turf issues and verbalizing concerns about “independent practices” and who leads a team are barriers that emerge at a political level or at the top of organizations where the players are very much removed from the reality of care1. At the point of care, the most effective teams share leadership, recognize that professional practice can overlap, mentor each other, and develop deep mutual respect and appreciation.
In our roles working directly in and with both primary and specialty care teams, we regularly interact with the “front lines”. What is frequently and clearly heard is the desire for nurses to deliver patient care using protocols that include the initiation and titration of medications as part of team-based care. In sites where we have seen this piloted, teams reported an improved bond between pharmacy, nurses and providers, often with bidirectional mentoring occurring at all levels. In addition, the nurses reported that the pilot training they received for the protocol medication titration responsibilities enhanced their ability to coach and mentor patients, and ultimately improved their job satisfaction. In the UK, all primary care teams may engage in the use of protocols. The UK practice of nurse prescribing emerged sequentially beginning in 1989 with an advisory group, followed by pilots, development and funding of training programs, and legislation sanctioning the role of nurse prescribers. The UK has two levels of nurse prescribers – an independent level requiring significant academic training and a supplementary level. The supplementary role is one requiring the use of defined protocols for prescribing. In the United States, the independent nurse role is included with diagnostic and health care treatment in a full practice authority model for APRN practice. There is a great opportunity for the United States to define a supplementary protocol- based model of implementing treatment plans that include medications. We strongly support and endorse funding for piloting new programs, analysis of new and existing programs, and legislation to support a United States model for supplemental registered nurse practice. When will the United States catch up?
1. Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, and I. Von Kohorn. 2012. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC. www.iom.edu/tbc.
Roy C. Gumpel, MD, FACP
June 4, 2015
I am not sure whether nurses are the answer to the problem of primary care physician shortages, but for me a nurse at my side made my team look like a “performing team”, that patient was producer, actor and director.
I heard a 21 year old was brought for evaluation. I noticed he was going in and out of seizures. He seemed to be unresponsive to painful stimuli and pupils reflected opiate use.
The experienced nurse at my side felt certain he was faking. She would lift his head above his face and when it fell it missed his face. When the family entered the room his seizures increased.
Not wanting to miss anything in a 21 year old, I had him evaluated at a nearby referral center. He was discharged a day lager with a diagnosis of malingering, but only after a spinal tap and a PET scan.
An Oscar for that patient and roses for the nurse.
Shaw RJ, McDuffie JR, Hendrix CC, et al. Effects of Nurse-Managed Protocols in the Outpatient Management of Adults With Chronic Conditions: A Systematic Review and Meta-analysis. Ann Intern Med. 2014;161:113–121. doi: https://doi.org/10.7326/M13-2567
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Published: Ann Intern Med. 2014;161(2):113-121.
Cardiology, Coronary Risk Factors, Diabetes, Dyslipidemia, Endocrine and Metabolism.
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