The second, called favorable and unfavorable aspects of the expansion of nurses' functions, reports and discusses the expansion of the functions of nurses and their impact on primary care and professional practice. The interviewees signed an Informed Consent Form. To maintain the anonymity of the subjects, identifying acronyms were used for testimonials with abbreviation of the main functions - Nurse Practitioner NP , Practice Nurse PN , an association representative nurse RCN and professor PROF - followed by the number of order of interviews e.
NP1, NP2 and so on. Regarding the characterization of study subjects, there was predominance of graduate nurses because as this is new at the graduation level, some professionals working for longer were nursing technicians and attended other graduations after the change in legislation, such as psychology, anthropology or obstetrics, whose formation is separated from nursing.
Their duties included practice as general nurses, clinical nurses, advanced nurse, teacher and consultant in primary care. The time after the training was, on average, 30 years. It was evident also long stay in the same unit of primary care, ranging from 5 to 15 years. In England, nursing education occurs at graduation, lasting at least three years or hours in four main areas: Adult, Children, Mental Health and Learning Disabilities. In this article, the focus is on nursing careers and activities in primary care.
These, nurses graduated in the adult area, differing by additional training in short courses on clinical management of several chronic diseases and for prescription of medications. It is noteworthy that the performance in clinical and therapeutic functions occurs only after specific training for each case and registration in the NMC and the NHS. Specifically in primary health care, nurses with different functions are called nurse practitioner, practice nurse, health visitor and district nurse.
They exert various clinical and non-clinical activities, with extended professional skills and emphasis on management of clinical cases, especially of chronic conditions and prescription of drugs. Their functions are summarized in Box 1. The practice of nurses in case management in English PHC is guided by the use of care protocols based on diagnostic evidence, procedures, drug treatment, guidelines for changes in lifestyle and individual monitoring.
Case management clinical case management is defined as the effective and efficient approach to adults with chronic diseases or complex health care needs Case management, in addition to clinics, extends care to the social demands of the patient. Keeping the person with chronic disease outside the hospital, safe and in their home requires partnership with social service and other staff members, constant evaluation of health, hygiene, nutrition and capacity for self-care.
So, to try to keep the patient out of the hospital, so theyd be working close to the social services, social worker, and be looking at other needs that somebody might have in their own home, and keep them safe and keep them well at home if they can't come to the clinic. Case management is not a specific skill of the profession, but a response to the complex individual health needs, perceived from the nursing consultation.
Such clinical leadership is usually not formalized, however, finds fertile ground from the fragmentation of the care process and from a most often contact of the nurse with the community in relation to other members of the health team:. So, case management is not taught as a specific skill but when you have a relationship with the patient and that patient has complex needs and you are the one who sees him more often and has the best knowledge of his condition and needs, you by default will become the case manager.
And it's not always very formal. The care of people with prevalent chronic conditions like asthma, diabetes, chronic obstructive pulmonary disease, hypertension and heart problems is guided by clinical protocols, developed by the National Institute for Health and Care Excellence NICE and by goals set in Quality Outcomes Framework QOF. In the UK, since , nurses with special training have prescribed medications. In , this responsibility was legally expanded, seeking to increase the efficiency of services provided from the flexibility of the division of labor between doctors and nurses Box 3 summarizes the law progression of nurse's role in prescribing medicines in the UK.
Source: translated 13 and adapted by the author. So I prescribe Someone wants to stop smoking, I'll prescribe nicotine replacement therapy or tablets to help them to stop smoking. Contraception, any of the contraceptives. Blood pressure tablets and cholesterol tablets.
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Legally, the nurse is registered in the category board as prescriber and also in the NHS and, as well as medical professionals, they have their practice supported by insurance. So, once you've done your university course, your exams, your portfolio past, you have to wait a while until you are on the NMC registered and you sign in there as a prescriber, so it's like a supplementary extended role and most practices would wait until that is all in place before asking you to prescribe. I waited until it's all done, so it's not that you need that once you pass your exam than you have to be accepted for the NHS as a prescriber.
And then you have to have your insurance and your things in place.
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In the following statement, it becomes clear that the nurse acts clinically by prescribing drugs for patient care just like the general practitioner would do. Nurses interviewed demonstrated a positive outlook towards expansion of functions in the PHC, which is convergent with the results of the literature review on the nurses' working reality.
With larger clinical functions, these professionals perform consultations for diagnosis and drug therapy of patients with chronic conditions. The follow-up of these cases in the unit makes the nurse assume functions that were exclusively medical, such as prescription of medicines, requesting and interpretation of tests and case management, in a practice guided by care protocols and supported by staff. So, the introduction of that really led to the biggest expansion of practice nursing, because it made it economically viable, so let's say appealing for practices to employ more nurses.
And then over time [some practices] having introduced this networking, and what we call the care packages, so that was to produce enhanced care packages with pa-tients, who have long term conditions. So, was very much based around nurses working with patients, probably increasing in nurses locally. No, I mean it's totally good model, clearly there's a nurse, and you could see that it's up to the person to extend role to the advance practice.
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So here, I'm a clinical leader, so I've got to some leading practice, for the CPs to work and manager so, it was the role reversal, but it's given me the opportunity to work in an advanced standard role, which, so yeah it's good. I think it makes it more interesting jobs for nurse, because you can, as well as nurse, assessment and realistic assessment, in your medication review, you can look up at, you have the time to look up at how's someone been taking the medication, whether they understand it, you have more time and can bring them back.
The regulatedpay is now starting to break up into, so the practice nurses don't have the same terms and regulations as the NHS nurses. Nurses in England have suffered pressure from both government policies formulated for primary care and from their employers, in primary care settings, to increase their area of expertise, expanding their functions, in order to contribute more effectively in care of patients, especially those with chronic conditions. Studies analyzed 12 - 27 refers to the expansion of the nurses' functions in prescribing medications, replacing medical consultations to patients with chronic conditions.
In these cases, they are responsible for case management in chronic conditions, as reported in the statements of study subjects. The reality of the health professionals here focused was not always as depicted in the previous paragraph, for the academic nursing education in England is quite recent, dating back to the s.
Before that time, nursing training occurred in practice spaces, usually hospitals, in the form of direct learning with a more experienced supervisor and they received a certification provided by the hospital. The first graduate degree in nursing began in September , with a curriculum that blended theoretical and practical activities, with emphasis on health promotion and disease prevention, leaving aside the focus of the hospital There has been a new conception of the profession with a status of a graduation in the last twenty years.
However, it has been said that a profession that was eminently practical, now has a predominantly theoretical training; the graduation does not correspond to the needs of health services 14 , Furthermore, when analyzing the work of nurses in the English primary care from the reformulation of health system occurred in , it is worth mentioning that, with the changes in the organization of services, there was a change in the form of hiring these professionals, which initially hindered their inclusion in health facilities.
On the other hand, with the consideration of health determinants in care, the demand for these professionals, who usually have the preparation to deal with the comprehensive patient care, has increased, converging with the social reality of the country From the expansion of functions demanded by the social and health environment, nurses have become reference for the management of chronic diseases in the PHC team in England, with the help of protocols for clinical trial, leading to specific decisions for each case according to that reported by the nurses interviewed in this study Study results 16 on the work of nurses as case manager in three most common chronic conditions in England have shown strong evidence of effectiveness of care by nurses as managers of clinical cases, since responsiveness to treatment and the patient's understanding of his condition were improved.
Furthermore, nurses perceive themselves with more professional autonomy because they examine, evaluate and decide which the best patient care is Literature review showed that when the practice nurse became responsible for prevention of coronary artery disease in patients with clinically stable ischemic heart disease, this was well accepted by patients and nurses, leading to self-reported improvement on lifestyle and health conditions In secondary clinic prevention, there was decrease in the total number of deaths and probable coronary events, and care was more cost-effective.
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The same occurred in relation to diabetes, whose patients monitored by nurses reduced their HbA1c glycosylated hemoglobin and cholesterol and increased their adherence to therapy, compared to the results of medical care The percentage of prescriptions made by nurses in the PHC in England is small compared to doctors.
Nurses' prescription happens when there appears to be relative advantage for all concerned, especially in areas with fewer medical professionals, in rural or low income areas. Another aspect that contributes to this not very significant number is that this practice has not yet been firmly established in PHC as routine Some professionals do not feel fully prepared for this function, report little time to study, need for continuing education on the subject, staff limitations, concern with the knowledge base required for practice There is need of professional competence with close clinical training to safeguard patient safety, together with the support of a professional to guide the practice clinical mentorship Nurses evaluate that their practice as prescribers offers significant benefits for the care of patients.
They understand that prescribing within their scope of responsibilities has become an intrinsic part of the profession, and the practical experience brought increased confidence. They understand that to prescribe, one must have previous clinical experience, and the prescription by the nurse is important to improve access to health services It is noted, however, ambiguity regarding support to the activity of NP as prescribers. On the one hand, the NHS encourages this practice, on the other, in health services, the need for mentoring keeps the control of this practice with the medical profession, coupled with the attitude of some doctors who, exercising their position of power, restrict and control the time and opportunities for joint discussions With the expansion of the functions of nurses, there has been improvements in care and continuity of care to patients.
A study evaluating 35 scientific publications on the results of the consultant nurse practice in England observed positive impact in cases where nurses take care of patients, with improvement of physical and psychological symptoms such as reduction of anxiety, waiting time and rate mortality, better care, better understanding of their health problem and increased confidence In addition, the greater autonomy of the practice nurse in primary care staff increased the feeling of satisfaction of nurses at work The literature review 17 analyzed 25 articles related to 16 research and focused on the period, to assess the impact of the replacement of doctors by nurses in caring for patients in the PHC in relation to the results, care process, resource and use, including costs.
The nurse has replaced the medical professional in health care in two modalities, as supplementary and as substitute of physician's work. In seven studies, the nurse assumed responsibility for the first contact and continuity of care for patients seen.
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