Impact of community based nurse-led clinics on patient outcomes, patient satisfaction, patient access and cost effectiveness: A systematic review

International Journal of Nursing Studies 73 (2017) 24–33

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Impact of community based nurse-led clinics on patient outcomes, patient satisfaction, patient access and cost effectiveness: A systematic review

MARK

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Sue Randall , Tonia Crawford, Jane Currie, Jo River, Vasiliki Betihavas Sydney Nursing School, Australia

A R T I C L E I N F O

A B S T R A C T

Keywords: Ambulatory care Community Nurse-led clinic Nurse-managed centres Practice Patterns Nurse Primary care Primary health care

Background: The role and scope of nursing practice has evolved in response to the dynamic needs of individuals, communities, and healthcare services. Health services are now focused on maintaining people in their communities, and keeping them out of hospital where possible. Community based nurse-led clinics are ideally placed to work towards this goal. The initial impetus for these services was to increase patient access to care, to provide a cost-effective and high quality streamlined service. Objectives: This systematic review aimed to identify the impact of nurse-led clinics in relation to patient outcomes, patient satisfaction, impact on patient access to services, and cost effectiveness. Methods: A review of community based nurse-led clinic research in Medline, CINAHL and Embase was undertaken using MeSH terms: Nurse-managed centres, Practice, Patterns, Nurse, Ambulatory Care, keywords: nurse-led clinic, nurse led clinic, community and phrases primary health care and primary care. Papers were appraised using the Joanna Briggs Appraisal criteria. Results: The final review comprised 15 studies with 3965 participants. Most studies explored patient satisfaction which was largely positive towards nurse-led clinics. Patient outcomes reported were typically from self-report, although some papers addressed objective clinical measures; again positive. Access was reported as being increased. Cost-effectiveness was the least reported impact measure with mixed results. Conclusions: Nurse-led clinics have largely shown positive impact on patient outcomes, patient satisfaction, access to care and mixed results on cost-effectiveness. Future research evaluating NLCs needs to adopt a standardised structure to provide rigorous evaluations that can rationalise further efforts to set up community based nurse-led clinical services.

What is already known about the topic?

• Nurse-led clinics have been established worldwide in many settings. • In general terms, nurse-led clinics are reported as effective in managing patient assessment and care. What this paper adds

• This review specifically reports evidence of the efficacy of nurse-led clinics in community settings. • This review demonstrates impact of community based nurse-led •

⁎

clinics on patient outcomes, patient satisfaction, patient access and cost effectiveness. The review highlights a lack of standardised structure to rigorously evaluate the impact of community based nurse-led clinics.

1. Introduction The role and scope of nursing practice has evolved in response to the dynamic needs of individuals, communities, and healthcare services. In particular, the ageing population, which has led to higher numbers of people living in the community with a chronic disease, has placed greater demands on health resources and prompted a need for change in service delivery (Australian Institute of Health and Welfare, 2015). Health services are now focused on maintaining people in their communities, and keeping them out of hospital where possible (Standing Council on Health, 2013). Community based nurse-led clinics (NLC) are ideally placed to work towards this goal (Hoare et al., 2011). While it has been argued that community NLCs can provide costeffective, high quality care and can improve patient access (e.g. Handley, 2010; Bentley et al., 2016), to date there has been no systematic evaluation of this new trend in health services. This paper, therefore, provides a systematic review of the literature examining the

Corresponding author at: Sydney Nursing School, The University of Sydney, M02, 88, Mallett St., Camperdown, NSW 2050, Australia. E-mail address: [email protected] (S. Randall).

http://dx.doi.org/10.1016/j.ijnurstu.2017.05.008 Received 4 March 2017; Received in revised form 1 May 2017; Accepted 10 May 2017 0020-7489/ © 2017 Elsevier Ltd. All rights reserved.

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identify the impact of nurse-led clinics in relation to patient outcomes, patient satisfaction, impact on patient access to services, and cost effectiveness.

impact of community based NLCs on patient outcomes, patient satisfaction, patient access and cost effectiveness. 2. Background

3. Defining terms

Nurse-led Clinics have been defined as a clinical practice where nurses have their own patient caseload (Hatchett, 2008). The nursing role in such clinics involves patient assessment, admission, providing health related education, treatment and monitoring, discharge and referral to other health care professionals, as well as, offering psychological support for patients (Hatchett, 2008). Community based NLCs tend to be specialised – commonly focused towards the treatment or management of a specific disease (Schadewaldt and Schultz, 2011). For example, NLCs for upper gastric-intestinal cancers and chemotherapy treatment (Penfold, 2016; Uitdehaag et al., 2014), rheumatoid arthritis (Arvidsson et al., 2006), sexually transmitted diseases (O’Neill, 2009), heart disease (Schadewaldt and Schultz, 2011), diabetes (Hicks et al., 2012) and mental health (Tong and Fong, 2012), as well as specific child focused conditions and disorders such as eczema (Francis, 2010), asthma (Frost and Daly, 2010), and chronic constipation (Ismail et al., 2011). The reported benefits of NLCs are in line with the World Health Organisation's (WHO) (1978) directive, which advocated for Primary Health Care models of service that could provide community based effective, accessible and affordable care. Research indicates that NLCs can reduce patient wait times (Handley, 2010; Moore, 2010); increase consultation times, which have been associated with higher patient engagement (Bentley et al., 2016); increase patient satisfaction (Hegney et al., 2013); improve communication between nurses and patients (Jakimowicz et al., 2015); and provide patients’ with access to tailored advice on self-management of disease and illness (Horrocks et al., 2002; Laurant et al., 2005). NLCs have also reportedly reduced the demand on General Practitioner (GP) services by offering an alternative to traditional providers of healthcare (Mahomed et al., 2012), and nurses working in NLCs report higher levels of job satisfaction related to practice independence and autonomy (Wong and Chung, 2006). While there is conflicting evidence on the cost-effectiveness of NLCs compared to traditional doctor-based clinics (Laurant et al., 2005; Raferty et al., 2005; Mason et al., 2005), individual NLCs have reported significant gains in health outcomes that have economic implications. For example, an NLC for the prevention of coronary heart disease reported an increase in cost for the clinic and pharmacotherapies but fewer deaths in the intervention group, leading to a gain of 0.124 quality adjusted life years (QALY) as well as an improved incremental cost per life year saved (Raferty et al., 2005). Based on this broader view of health costs, Raferty et al. (2005) concluded that NLCs were, indeed, cost-effective. However, a review which explored cost in relation to resource utilisation, tests, investigations and direct costs, found that NLCs were marginally less cost-effective, or there was no cost difference, when compared to standard doctor-led clinics (Laurant et al., 2005). Major factors such as population ageing and subsequent growth in numbers of people living with chronic illness and higher expectations of health services (Bloom et al., 2011) have influenced the location of where patient care takes place. In the context of an ageing population, and an ever-increasing demand for quality care, the emergence of NLCs may represent a considerable advance in health service provision that could assist governments in meeting healthcare demands. Also, under the WHO (1978) directive to provide care within a PHC model, it seems likely that NLCs will to continue to expand (Halcomb et al., 2004) yet, important to the design of any new service, is the evaluation of whether the service is achieving what was intended. In the case of NLCs, the initial impetus for these services was to increase patient access to care, to provide a cost-effective and high quality streamlined service. In order to ensure that the current design of NLCs is effective, evidence about their impact is now required. Therefore, this systematic review aimed to

To aid with clarification, patient outcomes, patient satisfaction, access and cost effectiveness were defined as follows: (i) we defined patient outcomes as health outcomes which were either self-reported or nurse-observed. These included modification in behaviour, as well as physical and psychological clinical outcomes; (ii) while the literature has previously included patient satisfaction within patient outcomes (Jones et al., 2007), we sought to differentiate patient satisfaction from health outcomes. Patient satisfaction with any aspect of receiving care in a NLC was, therefore, taken as a distinct category of evaluation that might also include satisfaction with factors other than clinical outcomes such as the timeliness of services; (iii) we adopted Kringos et al. (2010) definition of access, which includes seven features of accessibility: availability, geographical accessibility, accommodation of accessibility (transport, out of hours appointments), affordability of services, acceptability, utilisation of services and equality in access; (iv) cost effectiveness was defined as an economic value related to system, provider or patient outcomes. 4. Method 4.1. Search strategy and outcome A systematic review of the literature was conducted between September and October 2016 to identify research literature on community based NLCs. As outlined by the Joanna Briggs Institute Reviewers Manual (2014), a search strategy was identified by the research team who have considerable knowledge of the nursing field. For each database a combination of Medical Subject Headings (MeSH), phrases and free text or keywords (KW) were identified. Relevant identified studies prompted follow-up searches using allocated controlled subject headings and relevant references. The search terms used in this review are shown in Table 1. The search was conducted primarily using online bibliographic databases. The services of a research librarian were utilised to undertake the search and the following databases were interrogated: CINAHL, MEDLINE and Embase. A search was undertaken in each database and to support the relevance to clinical practice, literature published between 2006 and 2016 was extracted. A sample of 701 papers were obtained. The titles and abstracts were screened by three authors, duplicates were removed and the inclusion and exclusion criteria were applied as shown in Table 2. Full paper copies (n = 97) were then screened against the inclusion and exclusion criteria. The search process, which used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) (Moher et al., 2009), is outlined in Fig. 1. Table 1 Search terms for systematic review. Database

CINAHL

MEDLINE

Embase

MeSH

Nurse-managed centres Ambulatory carea

Practice Patterns Nurse Ambulatory care

Ambulatory care

KW

Nurse led clinic Nurse-led clinic community

Nurse led clinic Nurse-led clinic community

Nurse led clinic Nurse-led clinic community

Phrase

Primary health care Primary care

Primary health care Primary care

Primary health care Primary care

a

25

Ambulatory care scope note closer to our definition for community setting.

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support for the incorporation of qualitative studies in systematic reviews as this can enhance the quality of findings, and offer valuable insights for clinical practice (Higgins and Green, 2009; Cochrane Qualitative and Implementation Methods Group, 2012; McCutcheon et al., 2014).

Table 2 Inclusion and exclusion criteria for systematic review. Inclusion criteria

Exclusion criteria

Nurse-led clinics Nurse practitioner-led clinic

Literature review Hospital-based setting including outpatients Service setting unclear Telephone-based service Case management

Primary study in peer-reviewed journal English language Published 2006–2016 Outcomes included and/or cost-effectiveness, stream-lined services that improved access and patient satisfaction. Primary health care setting Setting outside of hospital i.e. community

4.3. Data extraction and synthesis Data extraction included author, year, country where the research was conducted, study setting, nurses role, study design, study aim/s, design and outcomes (Table 3). How each study addressed patient outcomes, patient satisfaction, patient access, and cost effectiveness of the intervention is shown in Table 4. The data in Table 3 was subsequently analysed by three authors, in reference to the aims of this systematic review. The conclusions that were drawn from this analysis are presented in Table 4.

4.2. Quality appraisal The Joanna Briggs Appraisal (JBA) criteria (Joanna Briggs Institute, 2016) was used to assess the rigour of the remaining papers (n = 34). A further 19 papers were removed due to a lack of discussion relating to methodology, recruitment processes, or ethical considerations and approval. A final sample of 15 papers included both qualitative, mixed-methods and quantitative studies. Although systematic reviews historically have been limited to quantitative studies, there is broad

5. Results This systematic review focused on the impact of community based NLCs, paying particular attention to cost effectiveness, patient access, patient satisfaction and patient outcomes. The final analysis included 15 studies; four qualitative, three mixed methods and eight quantitative (Table 3). Of these, four were from Sweden, four from United Kingdom,

Subject Headings: Nurse managed centres, ambulatory care, practice patterns nurses Keywords: Nurse led clinic, nurse-led clinic, primary health care settings, community Phrase: Primary health care, primary care

N= 701 Databases: 88 Medline 578 Cinahl 35 Embase

N= 701 Title and abstract screened Title and abstract screened against inclusion and exclusion criteria

N= 604 excluded Duplicates removed and papers removed that were non primary health care setting, hospital based setting, setting not clear, telephone based service or literature review

N= 63 excluded

N = 97 Full text screened Full text screened against inclusion and exclusion and inclusion criteria

N = 34 Eligibility appraisal Screened against Joanna Briggs appraisal tools criteria

Papers removed that were non primary health care settings, hospital based settings, outcomes/ cost-effectiveness/ access or patient satisfaction not evaluated, or non-primary studies

N= 19 excluded Exclusion: No methodology, no obvious recruitment process, or no ethics clearance

N = 15 Final Sample Quantitative (N=8) Qualitative (N=4) Mixed methods (N=3) Fig. 1. PRISMA flow diagram of the study selection process (Moher et al., 2009).

26

27

Sweden

Sweden

Canada

Edwall et al., 2010

Edwall et al., 2008

Harrison et al., 2008

UK

Banks et al., 2012

New Zealand

USA

Bicki et al., 2013

Marshall et al., 2011

UK

McDevitt and Melby, 2014

USA

Australia

Hakanson et al., 2014

Coddington et al., 2011

Primary health care centre, lifestyle clinic

Sweden

Nymberg and Drevenhorn, 2016

Two Diabetes nurse-led clinics at primary care centres Home vs nurse clinic

Community and General Practice Three Hauora, two community and 12 general practice providers comprising a Primary Health organization Primary care Two diabetes primary care clinics

Nurse managed clinics (NMC)

Nurse-led clinic in primary care setting

Walk-in clinic

Urgent care centre in a community setting

Women's Health Centre

Non-hospital setting

Country

Author/year

Table 3 Study characteristics of included studies.

To elucidate the lived experience of regular diabetes nurse specialist check-ups among people with type 2 diabetes Evaluation of home versus clinic care for the management of leg ulcers

Diabetes nurse specialists

Nurses manage leg ulcers either at pt. homes or in clinics using EBP protocols. Registered nurse (with specialist training in leg

To elucidate the essential meaning of a consultation between diabetes nurse specialists and patients to gain a deeper understanding of patient experiences

To evaluate patient experience and opinions and clinical outcomes at a nurseled healthy lifestyle clinic and assess how successfully the clinics engaged the targeted populations

To guage whether the Care of Childhood Obesity Model (COCO) could be effective as a nurse-led clinic in primary care settings To assimilate evidence regarding quality of care received at nurse-managed clinics; Assessment and analysis of care provided to medically underserved children at a local paediatric NMC management

To evaluate the quality of the emergency nurse practitioner service provided to patients presenting to a rural urgent care centre with minor injuries To determine if prospective ED visitors would utilise walk-in non-acute care and if this care would prove cost-effective for both patient and providing facility

To evaluate women's views on whether a nurse-led clinic had improved sexual dysfunction

To explore patients’ experiences of visiting a nurse-led lifestyle clinic

Aim of study

Diabetes nurse specialists

Registered nurses

2 paediatirc NP and 1 registered nurse

Practice nurse

Nurse Practitioners and registered nurses

Emergency Nurse Practitioner (ENP)

Registered Nurse

Public Health Nurse

Nurse role

Home visit (usual care) N = 65 vs community leg ulcer clinics (intervention) N = 61

Quantitative: two armed RCT

Qualitative: narrative interviews (n = 20) Phenomenological-hermeneutic method

Evaluation using demographic clinical outcome data (n = 2850) and patient satisfaction (n = 424) survey 17 health providers, 115 nurses and 2850 individuals who participated in the clinic Qualitative: narrative interviews (n = 20) Phenomenological hermeneutic method

Birth – 21 years of age 500 from 650 chart reviews; Benchmarks: childhood immunisation status; treatment for children with URTI; children's access to primary care providers Mixed methods:

Randomised Controlled Trial Randomised (n = 76) using body mass index standard deviation scores and 4–6 item scales scored 1 = excellent to 6 = very poor Quantitative: Non-experimental design

Patient survey responses and de-identified electronic medical record information

Qualitative-exploratory design Focus groups (n = 14 patients); 4 interviews conducted one month apart using Focus groups duration of 30–60 min Pre test/post-test measurement McCoy Female Sexuality Questionnaire (n = 111) Data collected at baseline, one and six months after last appointment Quantitative: Descriptive study; (n = 111 patients) Retrospective case note review; self-designed patient satisfaction questionnaire Quantitative evaluation and cost effectiveness analysis (n = 256)

Design

Our findings indicate that organisation of care not the setting where care is delivered (continued on next page)

The patients’ experiences of a consultation with the diabetes nurse specialist became the basis for a health maintenance process in dealing with critical health-disease aspects. The DNs influence patient's way of living with the disease which developed their understanding and management of daily life No difference.

Patient's perceived improved health care; the target population was not reached as effectively as planned.

Results suggest that Trinity Nursing Center for Child Health (TNCCH) meets or exceeds national HEDIS benchmark standards of care and targets set by the office of Medicaid policy and planning (OMPP) for quality care

ENPs in rural UCC have the potential to deliver a safe and effective quality service that is reflected in high levels of patient satisfaction Non-physician providers such as nurses can improve access to care for the uninsured with non-urgent health problems Cost effective, an average ROI of over $2 for every $1 invested an estimated $1.28 million in future healthcare costs was saved Most frequent reason for coming was to receive (1) vaccination, (2) TB skin test, (3) chief complaints of pain No evidence that nurse-led primary care clinics were inferior to hospital clinics

A nurse-led clinic in a rural area with health worker shortages demonstrated value in managing female sexual dysfunction

Life style clinics provide an opportunity for patients in the community to modify unhealthy lifestyle behaviours

Study conclusion(s)

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Country

USA

Sweden

England (UK)

Northern Ireland (UK)

USA and New Zealand

Author/year

Savage et al., 2008

Efraimsson et al., 2008

Ingram and Salmon, 2007

Thompson et al., 2007

Krothe and Clendon, 2006

Table 3 (continued)

28 To study perceptions of the effectiveness of two nurse-managed clinics

Smoking cessation support nurses

Nurse

Two nurse-managed clinics (NMCs) one in NZ, one in USA

Community funded nurse-led smoking cessation clinic held on hospital grounds

To evaluate the patterns of use, effectiveness and acceptability of the ‘No Worries’ service for young people under 21 years old To evaluate the effectiveness of a nurse-led smoking cessation clinic

Unclear as referred to as health professional (nurse-led in title)

Three ‘No Worries’ clinics in existing GP surgeries or Health Centres

To examine the effects of a structured educational intervention program on quality of life, and knowledge of COPD and smoking

To compare pre and post-test scores in a group of homeless adults receiving a nurse intervention when utilising a nursemanaged clinic

Aim of study

Nurse

Registered nurse

ulcer management)

Nurse role

Nurse-led primary health care clinic

Nurse-managed clinic for homeless people in a church based facility

Non-hospital setting

Mixed methods: Questionnaire (n = 96) Focus group Pre and post design Self-report and end-carbon monoxide measurement With only n = 36 attending all sessions during the six week course Qualitative methodology (cross cultural evaluation): in depth one on one interviews 20–30 min in duration (n = 21); In NZ = (6 clients, 2 staff members, 4 community board members); in USA (5 clients, 2 staff members and 2 board members)

Quantitative: Pre-post health survey (n = 43) Modified SF12 at baseline and final visit; AUDIT; DAST-10 The intervention tested in this study consisted of four components of care provided to patients by nurses at the clinic: nursing assessment; health education; nursing interventions and referral for treatment. Experimental randomised Intervention group (n = 26) Control group (n = 26) Intervention included 2 visits from COPD specialist nurse focusing on patient self-care and knowledge of COPD St Georges Respiratory Questionnaire and author designed questionnaire Mixed methods: Questionnaire (n = 153) and interview (n = 15)

Design

The environment created in the nursemanaged clinics enhanced perceptions of effectiveness and responsibility for personal health care

The smoking cessation clinic helped 29.2% of those registered at the clinic quit smoking at the end of the six week course

Improved accessibility to sexual health services for young people

Nurse-led clinics for patients with COPD using a structured education program had a positive and statistically significant effect on patient quality of life and stopping smoking

influences healing rates; In comparison to baseline the clinic group improved more on the mental component scores (from 48.4–53.4) than the home care group (50.9–51.8) A nursing intervention can result in improved health outcomes for adult homeless persons.

Study conclusion(s)

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Not measured

Not measured

Not measured

Incorporating quality-adjusted-life- year value of preventive services, an estimated 1.28 million (US $) would be saved. Dividing cost saving by clinic's operational costs meant a return on investment of $34 per $1 invested Patient willingness and ability to pay for care; value of preventative services; return on investment Not measured

Nymberg and Drevenhorn, 2016

Hakanson et al., 2014

McDevitt and Melby, 2014

Bicki et al., 2013

29

Not measured

Not measured

Not measured

Coddington et al., 2011

Marshall et al., 2011

Edwall et al., 2010

Banks et al., 2012

Cost-effectiveness

Author/Year

Not measured

Children's access to primary care The TNCCH scores above the 90th percentile for all age groups when compared to the national benchmark standards for patient access Not measured

Primary care clinic scored slightly higher than traditional hospital based clinic for patient satisfaction

64 respondents could afford less than or equal to $10 for the care they received

Median waiting time 22 min (range 0–120 min) Total length of stay median 45 min (range 5–125 min); 73% patients were seen, treated and discharged within 1 h (n = 91)

Not measured

Not measured

Access

Table 4 How the reviewed papers address, cost effectiveness, patient access, patient satisfaction and patient outcomes.

Gaining insights into own health; increased attention to disease regulation; positive effects from selfmanagement and opportunities to increase selfmanagement skills Being controlled; Feeling exposed; Feeling comfortable;

91% agreed or strongly agreed on questions related to positive aspects of care

Not measured

Primary care clinic scored slightly higher than traditional hospital based clinic for patient satisfaction

Patient safety Effectiveness of ENP service; 83.8% of N = 93 participants indicated that they would be agreeable to seeing the ENP again. High levels of participant satisfaction with the ENP service; 81.3% of patients considered the overall quality of the ENP service to be excellent 96.4% N = 107 would recommend the ENP service to friend Not measured

Patients felt a sense of security, but also expressed unfulfilled expectations Participants perceived positive experiences expressed as a sense of security comprising of: seen as being on an equal level; control of health; the importance of the responsible authority. Participants expressed negative experiences expressed as unfulfilled expectations comprising of disappointment; missing being seen as an individual and physical examinations. Not measured

Patient satisfaction

(continued on next page)

The percentage of adults who reported smoking remained the same between the first and last clinic data, there was a change in the number of cigarettes smoked 0–10 cigarettes a day increased from 14% to 16.7%; whereas 11–19 day decreased from 7.8% to 5.9%; no significant changes in BP, weight, HbA1C. 92% indicated that their health had improved as a result of attending the clinic

Objective clinical outcomes Majority of children (77%) in both arms improved body mass index standard deviation scores during 12 months adjusted for age and sex Immunisation and MX of URTI (without antibiotics) the clinic exceeded the OMPPs target

Not measured

Self-reported outcomes Increased sexual desire, satisfaction and orgasm quality Increased satisfaction with main partner Not measured

Not measured

Patient outcomes

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Not measured

Not measured

Not measured

Ingram and Salmon, 2007

Thompson et al., 2007

Krothe and Clendon, 2006

Patients enjoyed accessing the service and would have paid to access the service “even if the price was more than what it is, it would still be my first choice because of the staff, the atmosphere and just comfort levels”

Clinic chosen as it was nearby or more convenient than anywhere else; easy to attend due to open hours 3–5 pm; drop in clinic Not measured

Not measured

Not measured

Not measured

Efraimsson et al., 2008

There was no statistical difference in resource utilisation and cost by study group

Harrison et al., 2008

Not measured

Not measured

Not measured

Edwall et al., 2008

Access

Savage et al., 2008

Cost-effectiveness

Author/Year

Table 4 (continued)

Patients perceived satisfaction with care secondary to the environment and atmosphere, staff characteristics, provision of holistic care and attention to culture

Participant satisfaction 89% found staff very approachable; 93% very helpful

Not measured

Feeling prepared Being seen as a unique person; continuity of care; trust and respect. Given up-to-date information. Increasing confidence and independence with selfcare. Reduced anxiety and increased feelings of normality 95% were very satisfied with care received in previous 12 months Clinic patients had less waiting time to receiving nursing care compared to patients receiving care at home. High satisfaction with information given within both groups 98% vs 96% respectively. Very satisfied with availability of health care 30.2–65.1 (p = 0.002) Very satisfied with quality of health care 23.3–60.5 (p = 0.001)

Patient satisfaction

The mean score for mental health rose from 35.2 to 42.5 (p = 0.008); The mean score for vitality improved from 52 to 60 (p = 0.042); The mean score for general health rose from 45.8 to 55.3 (p = 0.059); The mean score for physical health rose from 61.1 to 68.6 (p = 0.051); Intervention group showed increase in daily activities (p = 0.00267) Reduction of psycho-social impact of breathlessness in intervention group (p = 0.0161) Smoking reduced in intervention group (p = 0.0185) Overall quality of life improvement reported by intervention participants (p = 0.00030) Participants would be more inclined to practice safer sex, use protection and take fewer risks after visiting the nurse-led clinic At six months half of the participants n = 17 describe themselves as smokers; however n = 17 continue to smoke; Participants had gained motivation from group experience, lowering of their carbon monoxide readings and from positive attitude of smoking cessation nurses Participants described positive experiences with the nurse managed centre. Quality of health education provided improved selfcare

No statistical significance between healing rate of ulcers of patients treated at home or at nurse led clinic

Patient outcomes

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5.3. Patient access

three were from the United States of America (US), one from New Zealand, one from Canada, one from Australia, and one combined New Zealand and US data. All studies met the inclusion criteria and were published between 2006 and 2016. The studies were carried out in a range of community settings including primary care clinics (n = 4), nurse managed clinics (n = 3), clinics within a general practice (GP) service (n = 3), an urgent care centre (n = 1), a women's health centre (n = 1), a walk in clinic (n = 1), a home and nurse clinic (n = 1), and a community clinic on hospital grounds (n = 1). The nurse's role within the NLCs studies were described as: registered nurses (n = 4), nurse (n = 3), a team of nurse practitioners and registered nurses (n = 2), nurse specialists (n = 2), nurse practitioner (n = 1), public health nurse (n = 1) and support nurse (n = 1), practice nurse (1). There was a wide range in patient samples across the studies, from 14 to 2850. In line with the inclusion criteria for this study, all papers examined one or more of the following: patient outcomes, patient satisfaction, patient access, and cost effectiveness. A broad range of research approaches were used including: (i) qualitative: descriptive study, exploratory design, phenomenological hermeneutic method, narrative; (ii) quantitative: descriptive evaluation and cost effectiveness analysis, pre-post survey, non-experimental design, experimental randomised design, two-armed randomised controlled trial and (iii) mixed methods. Of the included studies 10 examined patient outcomes, 10 examined patient satisfaction, six examined patient access and two examined cost effectiveness (Table 4).

One study reported shorter waiting times and shorter total lengths of stay (McDevitt and Melby, 2014). Two studies reported patients’ willingness and ability to pay to access the service (Krothe and Clendon, 2006; Bicki et al., 2013). One study compared patient access to a national benchmark (Coddington et al., 2011). One study reported the convenience and proximity of the service for patients (Ingram and Salmon, 2007). One study compared access in a nurse-led primary care clinic to that of a hospital clinic and access was reported more favourably in the primary care setting (Banks et al., 2012). 5.4. Cost effectiveness Only two of the studies reported cost effectiveness of the nurse-led clinic. Harrison et al. (2008) compared the cost of providing a home clinic service with a nurse-led clinic, and reported no statistical difference in resource utilisation and cost. Bicki et al. (2013) reported the cost effectiveness of a non-urgent walk in clinic in a low-income neighbourhood with the goal of providing uninsured patients access to low cost healthcare. Bicki et al. (2013) identified cost savings for both clinic and patient, a return on investment of $34 per $1 invested. 6. Discussion The studies included in this review focused on NLCs in the community setting and their impact on patient access, satisfaction, outcomes and cost-effectiveness. The majority of studies examined patient satisfaction and outcomes. Overall, the results regarding satisfaction are consistent with other literature, which commonly reports high levels of patient satisfaction with NLCs (Desborough et al., 2011; Wong and Chung, 2006). These results are also consistent with an integrative review of nurse-led case management in community settings (Joo and Huber, 2013). Most reviewed studies also showed general improvements in various aspects of patient health. These results support the findings of Schadewaldt and Schultz (2011) who systematically reviewed studies of nurse-led coronary heart disease clinics (Schadewaldt and Schultz, 2011), and found positive health outcomes among patients attending the clinic. Nevertheless, some caution is required in interpreting findings from this review as the included studies tended to present self-reported outcome data, with only three studies evaluating measurable patient outcomes. While much literature has rationalised the introduction of NLCs in relation to access, few studies have evaluated whether NLC actually improve patient access to care (Desborough et al., 2011; Wong and Chung, 2006). This review provides compelling evidence that NLCs do indeed achieve this aim. This is in line with evidence of improved patient access as a result of community based case management (Joo and Huber, 2013). Although the methodologies used in the reviewed studies were heterogenous, one-third reported improved access to healthcare in terms of access to treatment, reduced waiting times, convenience and cost. Only two studies examined cost effectiveness, a surprise given the fiscal constraints of the health sector. While clinicians and patients might consider NLCs to be preferable, effective and accessible, demonstrating the economic value of a clinic is perhaps challenging. The lack of studies providing an economic analysis would suggest the need for a standardised evaluation framework that would allow researchers to more easily measure the cost effectiveness of NLCs, particularly with the increasing demand for community based care (Halcomb et al., 2004; Schadewaldt and Schultz, 2011). Nevertheless, the results from this review are favourable, with NLCs being equivalent or cheaper than standard doctor-led services. Although focusing on case management, Joo and Huber (2013) also found increased cost effectiveness related to reduced hospital utilisation and readmission.

5.1. Patient outcomes A variety of patient outcomes were measured. Five of the studies reported behaviour change (Marshall et al., 2011; Efraimsson et al., 2008; Ingram and Salmon, 2007; Thompson et al., 2007; Krothe and Clendon, 2006), which included secondary health promotion and preventative practices, for example sex education leading to safer sex practices (Ingram and Salmon, 2007) and ceasing to smoke (Efraimsson et al., 2008). Four studies examined patients’ self-reported improved symptom management or health; for example, feeling of improved general health and wellbeing (Savage et al., 2008; Krothe and Clendon, 2006), increased sexual desire and satisfaction (Hakanson et al., 2014), and specific improvement in chronic obstructive pulmonary disease symptoms (Efraimsson et al., 2008). Three studies measured objective clinical outcomes including healing time of ulcers (Harrison et al., 2008), improved body mass index standard deviation scores in obese children (Banks et al., 2012), and treatment regime for upper respiratory tract infections (Coddington et al., 2011).

5.2. Patient satisfaction The majority of studies reported upon patient satisfaction, with the exception of only three studies (Bicki et al., 2013; Coddington et al., 2011; Thompson et al., 2007). Six studies used Likert scales to examine patients perceived satisfaction with the service (McDevitt and Melby, 2014; Banks et al., 2012; Marshall et al., 2011; Savage et al., 2008; Ingram and Salmon, 2007; Krothe and Clendon, 2006), and each reported high levels of satisfaction. Three studies reported qualitative data from patients’ perceptions of the service, including a sense of security (Nymberg and Drevenhorn, 2016), feeling comfortable and prepared (Edwall et al., 2010), and a feeling of trust and respect (Edwall et al., 2008). One study reported patients’ willingness to recommend a service to a friend (Marshall et al., 2011), with another reporting patients’ willingness to attend the service again (McDevitt and Melby, 2014). Two studies reported negative findings, such as unfulfilled expectations (Nymberg and Drevenhorn, 2016), feeling controlled and exposed (Edwall et al., 2010).

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7. Recommendations for future research

proved. NLCs were reported to be more affordable, convenient and with reduced patient waiting times. Although two studies reported NLCs could be cost-equivalent, or more cost effective than standard doctorled services, there was a general lack of research into the economic value of NLCs. Future research evaluating NLCs needs to adopt a standardised structure to provide rigorous evaluations that can rationalise further efforts to set up community based nurse-led clinical services.

The overall findings of this review favour the NLC model; however, we would suggest that evaluating the impact of NLCs is an important component of growing this service to meet the needs of patients. Besides the lack of cost-effectiveness analysis, we noted a general lack of a standardised structure for rigorously evaluating community based NLCs. Attempts to develop evaluation frameworks have been made in the past. One such example is the Participatory, Evidence-based, Patient-centred Process (PEPPA) framework (Bryant-Lukosius and DiCenso, 2004) that was developed in Canada to address ad hoc approaches to implementing advanced practice nurse roles. The ninestep PEPPA process, which arose from critiques of earlier models, includes a needs analysis, an implementation strategy for nursing roles, and an evaluation strategy that examines process and structure outcomes such as efficacy, satisfaction, costs and professional role transfer (Bryant-Lukosius and DiCenso, 2004). Although the PEPPA framework has been taken up in research, policy and practice (Boyko et al., 2016), it's focus on nurse's roles rather than nursing clinics may make it less rigorous as a standardised evaluation structure for NLCs. Nevertheless, aspects of the framework that focus on efficacy and cost might be a starting point for the development of a standardised evaluation framework. Another validated tool that has been widely used to evaluate quality in healthcare, and found to be effective in evaluating quality in nurse practitioner services (Gardner et al., 2014), is Donabedian's Framework (1966). This framework, which was developed to evaluate structure, process and outcomes, defining structure as the settings in which care takes place, as well as the qualifications of the service providers and administrative processes. Process is defined as the care delivered, and outcomes refer to recovery, restoring function and survival (Ayanian and Markel, 2016). A further ‘seven pillars’ of quality were later described by Donabedian (1990), three of which are particularly relevant to this review: effectiveness – the degree to which health improvements are met; efficiency – the ability to obtain the greatest health improvement at lowest cost; and acceptability – refers to patient preference, including accessibility of services. Donabedian's framework could, therefore, provide a strong platform on which to evaluate NLCs and show impact in relation to patient outcomes (effectiveness), patient satisfaction (acceptability), patient access (acceptability) and costeffectiveness (efficiency) of the NLC model.

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