Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review
Introduction
In high income countries, the increasing burden of diseases in the aging population and scarcity of health resources sharpen the need for innovative models of health care delivery to meet the growing demand in care and maximise efficiency of care (Laurant et al., 2005, Liu et al., 2014). Extended roles of non-physician clinicians, such as advanced practice nursing roles, have been recognised as one of the proposed solutions to these challenges (Laurant et al., 2009, Safriet, 1992).
According to the International Council of Nurses, the nurse practitioner/advanced practice nurse is a “registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master's degree is recommended for entry level." (International Council of Nurses, 2016). Core advanced practice nursing role domains include direct patient care, research, education, consultation, and leadership activities. Nurse practitioners and clinical nurse specialists are two types of advanced practice nurses. Nurse practitioners are more common in primary care and clinical nurse specialists are more common in acute care settings (Canadian Nurses Association, 2008). Some countries have two additional types of advanced practice nurses: the nurse midwife and the nurse anaesthetist (Heale and Rieck Buckley, 2015).
This paper focuses on nurse practitioners and clinical nurse specialists. Nurse practitioners have advanced competencies to practice autonomously and collaboratively to perform assessments, order laboratory and diagnostic tests, diagnose, prescribe medications and treatments, and perform procedures, as authorised by legislation and their regulatory scope of practice (International Council of Nurses, 2016). Randomised controlled trials and systematic reviews have shown that nurse practitioners deliver high quality care in terms of clinical outcomes and patient and provider satisfaction (Horrocks et al., 2002, Laurant et al., 2009, Newhouse et al., 2011, Tsiachristas et al., 2015). Clinical nurse specialists have a clinical specialty in which they manage the care of complex and vulnerable populations, educate and support interprofessional staff to provide optimal care through use of best evidence, and facilitate change within health care systems (Lewandowski and Adamle, 2009). Randomised controlled trials and systematic reviews have demonstrated that clinical nurse specialist involvement in patient care results in reduced hospital length of stay, readmissions, and emergency visits (Fulton and Baldwin, 2004, Newhouse et al., 2011, Tsiachristas et al., 2015).
While evaluations of advanced practice nursing roles have demonstrated multiple positive outcomes, the question of their cost-effectiveness often surfaces (Donald et al., 2014, Goryakin et al., 2011). Effects of advanced practice nursing interventions on costs have been found to be mixed and dependent on the context of care, model of care (e.g., alternative or complementary), specific nature of advanced practice nursing roles and role domains involved (Laurant et al., 2009). Moreover, economic evaluations of these roles have been criticised for overall low quality and inconsistent reporting (Donald et al., 2014, Goryakin et al., 2011, Marshall et al., 2015). This raises the question as to whether current guidelines for economic evaluation are adequate to evaluate advanced practice nursing roles.
Considering the lack of robust cost-effectiveness analyses of advanced practice nursing roles, we examined whether current guidelines for economic evaluation are appropriate for economic evaluation of nurse practitioner and clinical nurse specialist roles.
Section snippets
Methods
Our methodological review of economic evaluations of nurse practitioner and clinical nurse specialist roles was informed by qualitative synthesis of four key inputs (Fig. 1). First, we conducted a narrative review and synthesis of the published literature reviews and discussion papers on economic evaluations of advanced practice nursing roles to determine challenges in their economic evaluation.
Second, we conducted a detailed quality assessment of the economic evaluation in the 43 randomised
Narrative review
Several challenges in economic evaluations of advanced practice nursing roles were identified in the literature. First, how advanced practice nursing roles are implemented varies across countries due to the unique social, political, economic and geographic contexts of health care systems, policies (e.g., legislation, regulation), funding arrangements, and education that influence role enactment (Delamaire and Lafortune, 2010, Goryakin et al., 2011, Laurant et al., 2005). Second, these roles are
Discussion
To date, the majority of economic evaluations of nurse practitioner and clinical nurse specialist roles are of poor quality and are not comprehensive. Reasons for this are numerous, including the complexity of these roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are often difficult to measure. With increased recognition and employment of nurses in advanced practice roles and the emphasis on cost containment in health care,
Conclusion
Current guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. However, due to the unique nature of these roles, models of care, domains of practice and the roles' effects on patient and provider outcomes, 7 out of 15 guideline sections require role-specific considerations to fully capture the costs and effects associated with nurse practitioner and clinical nurse specialist roles.
Conflicts of interest
Authors state no conflict of interest.
Funding
This work was supported by the Ontario Ministry of Health & Long-Term Care (Grant # 06514, 2010), the Canadian Health Services Research Foundation and Office of Nursing Policy, Health Canada: Co-sponsorship Funds (Grant # 4500244763, 2010), and the Canadian Institutes of Health Research (Grant # 11498, 2011).
Ethical approval
No, this paper is a discussion paper advising on considerations in the economic evaluation of Nurse practitioner and clinical nurse specialist roles and does not require ethics approval.
Acknowledgements
We thank Matthew Lee for his review of discussion papers on the economic evaluation of advanced practice nursing roles. We also thank attendees of the expert meeting: Theresa Agnew, Ivy Bourgeault, Denise Bryant-Lukosius, Nancy Carter, Renée Charbonneau-Smith, Alba DiCenso, Faith Donald, Brian Hutchison, Audrey LaPorte, Matthew Lee, Sandra MacDonald-Rencz, Deborah Marshall, James McKinlay, Ruth Martin Misener, Eddy Nason, Lusine Poghoysan, Kim Reid, Jane Ruseski, Barbara Safriet, and Abigail
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