Value of intensified nursing.

The concept "intensified nursing" is mentioned in differentiation to concepts of "nursing care" or "nursing" which intensifies resources or patient contact. Especially psychic and social needs of patients are very appreciated in nursing. A similar type of nursing is known under the concept "advanced nursing practice" (ANP) which means, that a specialised, academically trained nurse offers an extended nursing care in which a focus on the published knowledge of evidence based research is made.From the thin literature to this topic a selection of predetermined topics was analysed where at least two articles with a sufficient high methodical quality were available. The selected topic groups were: "Infant and paediatric nursing", "gerontology" and "oncology". Generally the five publications concerning infant and paediatric nursing could conclusive show a benefit of intensified nursing. Further research is still needed to prove intensified nursing care. Two publications could be found to the gerontological intensified nursing; both used an extended nursing model and an enlarged use of resources. Both studies demonstrated a measurable success in the applied parameters. Two studies also could be analysed in the oncological field in which successes were also provable by the applied parameters. The success was given especially in a higher patient satisfaction, one study showed an improved scheduling (time planning) of nurses.There was not one article concerning economic questions of intensified nursing care. It has to be taken into account that the financial resources have to be used effectively also in nursing nowadays. It has to be assumed that the costs are driven by increased use of resources. Savings can be achieved, however, in the form of avoided therapies and days in hospital by intensified nursing. The intensified nursing can be considered as similar cost-effective as conventional models of nursing.Ethically it is necessary to consider that the possibilities of the intensified nursing should be exhausted as much as possible for the patients. The daily work is limited, due to restrictions of resource. This means a conflict for nurses between knowledge and the predefined resource requirements which often leaded to overtaxing and dissatisfaction. It is desirable that decision makers of the health policy appreciate the evidence and promote intensified nursing care models.Nursing science has to do special research to prove the meaning and effectiveness of intensified nursing and establish this in the health care delivery system.

Executive Summary

1. Introduction

Nursing is based on its own scientific research in the practice of the profession and uses the knowledge and methods of the nature-, and social sciences. It is important to use the possibilities of optimal nursing care for patients within organisations of the public health service to improve satisfaction of nurses and patients.

Unlike the numerous definitions of the "normal nursing care", at present, the "intensified nursing care" is not defined. Intensified nursing care means that nursing care takes place with more intensive patient contact or with extended means. The social and psychic needs with intensified nursing care are much appreciated.

This report defines first nursing and intensified nursing and describes later the publications to three selected topics in detail and discusses this with respect to effectiveness.

2. Scientific background

2.1 Definitions of nursing

Nursing is often defined with the background of the concepts health and disease where conditions, abilities, life events and the condition of human beings are described. These two concepts are not defined obviously and uniformly, though.

A famous definition is from Virginia Henderson which passed through numerous variations and new definitions and finally became the base of the WHO definition of nursing:

"The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible".

(Henderson 1991)

2.2 Definition of the intensified nursing care

Unlike the definitions of the "normal nursing", at present, the "intensified nursing" is not defined correspond-ingly. The most extensive manual "Pflegewissenschaft" mentions this concept neither in the subject index nor in the content.

Intensified nursing care could be understood as use of additional resources (according to of the time and mate-rial), which goes beyond the conventional nursing.

The social and psychic needs have basically a high importance in intensified nursing. The main emphasis is put on the holistic analysis of body, soul and social environment as a unit under the holistic conception of man. Nursing is emphasising, what man needs for being man.

The following differentiations are important with respect to "intensified nursing": It is not the same like "intensive care"; it can be used also in an intensive care unit in addition to the normal "intensive care".

If "intensified care" is mentioned then this idea is the concept of the "advanced nursing practice" (ANP). At first ANP was introduced in the 60's, 70's in the USA in the psychiatry, then the concept developed to practitioners with different specialisations for all sorts of fields of nursing. Firstly ANP established itself in Belgium, the Netherlands and Scandinavia.

ANP specialists concentrate on a school of the care, on a special health problem or on a certain patient group. They permanently are informed about the current state of knowledge in their field in which they do not only win this knowledge from the literature but also from the practice. There activity does not consist of the traditional shift-work activity, but is applied in there where it seems necessary.

There is an increasing need for further development of this discipline. This is important in the health service and relevant to economy.

3. Question

Which role do special methods of intensified nursing achieve for the outcome of patients in opposite to other forms of therapies? Is there an effectiveness of use of an intensification of the nursing supply for patients with select diseases?

The following areas were selected:

intensified infant and paediatric nursing,

intensified nursing in gerontology,

intensified nursing in oncology.

4. Medical assessment

4.1 Methodology

A systematic literature search was carried out in the 24 databases of the DIMDI superbase retrieval and in the Cochrane Library:

ME90; ME0A; EM90; EA08; CB85; BA90; IS90; CA66; HT83; DAHTA; CCTR93; CDSR93; HB00; HA85; LT01; GA03; CC00; SM78; GE79; KR03; KL97; SPPP; SP97; TV01.

Search strings were: Nursing and technology assessment or HTA, and effectiveness, and cost, and ethic, and outcome and review as well as combinations from these search strings. In addition, details of the retrieval were done in the nursing scientific special database CINAHL sought according to the concepts "advanced nursing practice".

Literature selection

The arrived literature quotations were judged by two independent, familiar with the methods of evidence based medicine reviewers with regard to relevance. The delimitation of the topic choice was carried out due to the contents of the scientific literature. Topics were included, where there were at least two studies with respect to intensified nursing.

Nine studies remained for the selected topics (infant and paediatric care, gerontology and oncology) in this HTA report. Further eight publications were selected for the description of the scientific bases, the economy and the ethics of intensified nursing.

Excluded studies

The following studies were excluded: demographic and ethnological studies, studies with pharmacological focus, studies with focus on nursing supply, case reports as well as technological methods, prevention measures, intensive care treatments.

4.2 Results

4.2.1 Intensified nursing in the field of infant and paediatric nursing

A randomised clinical study dealt with the early discharge and another care following on this at home by a so-called advanced practice nurse (APN) to an unplanned caesarean section.

This study consists of a case and a control group. The women of the comparison group fulfilled the same criteria as those of the case group. The difference was that the women in the control group did not get any care at home according to standard models of practice.

After the discharge the APN made at least one home visit in the first one and another one in the second week. In the course of the visit the nursing care power carried out a physical examination at the mother and the newborn. There was an evaluation of the health status, the emotional status of the mother and the adaptation of the family to the newborn. In addition to the visits the family was contacted via phone by the APN two times a week within the first two weeks after the discharge and once a week the following six weeks.

The results were measured in terms of time for direct nursing as well as the number of telephone calls and home visits. At the time, it can be said home primarily that home visits are necessary and important by an APN for women with an unplanned caesarean section birth summarising after the early discharge.

The success of the intensified nursing care is calculated indirectly about the factor "care time" in this study - this is a parameter which does not have to be in direct connection with the quality of outcome.

- The McGill nursing care model at families with chronically ill children

A randomised controlled trial for one year [1] tried to examine the effectiveness of nursing interventions according the McGill model. Families which had at least a chronically sick child in the age of four to 16 years were included.

The McGill model of nursing was used as an intensified nursing measure. This model serves as a framework condition for practice, research and education.

The results were classified (concerning the patient, the nursing care and the results) according the McGill classification by describing qualitatively the patients perspective on the one hand, on the other hand assessing the perspective of the nurses.

Although it was mentioned that an estimate of the effectiveness of the one-year intervention took place by means of two groups in a direct test of comparison, this was not indicated in the study in detail. Obviously the study was designed and carried out correctly along high-quality criterions. The results are missing; the interpretation of the effectiveness of the nursing care model compared with the usual standard (without use of the McGill model) is questionable. So the main conclusion is not derivable from the study.

- Study for the parent's experience regarding technology in neonatologic intensive care units

A study dealt with the neonatologic intensive care unit and the parent's reaction to the technological oriented nursing. Parents of seven newborns who were treated in an intensive care unit for neonatology, the "neonatal intensive Care Unit" (NICU), took part in this study.

In was a qualitative investigation to describe experiences of parents regarding the nursing care of their child in the intensive care unit. All parents claimed to have made negative experiences concerning the technology and the ambiance on the NICU. They experienced the intensive care unit as a shocking and anxiety inducing setting. Blinking lights, alarms of the monitors and the presence of the technical instrumentation caused anxiety. The whole technical equipment was considered as very depressing for the parents and induced a feeling that the parents cannot cope with their role. The authors conclude that discomfort and anxiety disturbs the relation between the parents and the child. Therefore it is very important to inform extensively and to offer support for the parents by the nursing staff. The stress of the parents can possibly be reduced if a pleasant, domiciliary atmosphere can be created on the NICU.

- Study for a comparison between the midwife team nursing and standard nursing

1000 pregnant women participated in a randomised controlled trial for the comparison between standard nursing care and a team nursing care model. The purpose of this study was to make a comparison of the effectiveness of the team nursing care in comparison with the standard nursing care with respect to operations and the length of the stay in hospital. The satisfaction of the women concerned with the model also was examined. The nursing of the team nursing consists of visits of a midwife in the 12th, 16th, 28th und 36th week in case of woman with low risk.

The team nursing caused less need in comparison to standard nursing; there were also less general anaesthetics and epidural anaesthetics necessary and the newborn had to be monitored less often. No significant difference could be found in respect to the frequency of caesarean section births. The women of the team nursing care group were discharged seven days earlier as the standard nursing control group.

- Review concerning intervention studies of the paediatric nursing

A review from Beal and Betz [2] covers publications from 1980 to 1989. 53 (16.6% were) of the 319 articles publications are intervention studies which tested nursing care results. It could be noticed that only few of these articles include result parameters of nursing care. Evaluations of existing procedures are primarily the main issue. Articles concerning nursing were found primarily in paediatric journals. The authors conclude that many more research has to be carried out in the field of paediatric nursing to guarantee an improved practice. More data as well are needed about the effectiveness of nursing to be able to show that nursing methods are effective and cost-effective.

- The effect of body exercises on the skin health of incontinent nursing care patients

144 incontinent residents of four different geriatric care centres took part in a randomised controlled trial where skin health the skin parts affected by the incontinence were investigated.

As a nursing intervention the research staff motivated to incontinence training and physical exercises between 8.00 and 16.30 every two hours for five days for the duration of 32 weeks. Between the four medical treatment processes the participants were motivated to go to the toilet and the nappy was changed always immediately if it was wet. All changes in the incontinence nursing care and the physical ability to act permanently were supervised and documented in the two groups. The control group, however, got the usual standard nursing care from the nursing staff for the complete studies course of 32 weeks.

The outcome parameters in this study were the moisture of the skin which was analysed statistically. A significant difference of the physical activity between the control and the treatment group could be achieved (p<0.001). The urine and rectal incontinence also improved significantly in the medical treatment group (p=0.036 urinary incontinence, p=0.001 for rectal incontinence respectively). No improvement could be observed in the control group.

The medical treatment group in any case improved fundamentally in comparison to the control group which even deteriorated in the course of the study. It could be shown in this study, that those participants with the best improvement in urine and rectal incontinence could show the highest improvement in the skin condition, too.

- The use of a nursing care protocol in the medical treatment of nursing care patients with chronic obstructive pulmonary disease (COPD)

A randomised, controlled clinical trial tried to demonstrate whether the use of a nursing care protocol can lead to improvements for patients and nurses.

A special nursing care protocol was designed in which the exact nursing care of the patients, the duration of the nursing care interventions and the kind of support were described exactly. These nursing care protocols were developed in cooperation with the district nurse, the regional nursing care and a lung specialist. The designed nursing care protocol was used by the district nurse and the nursing staff of the geriatric care centres for the duration of six months in the medical treatment group after the discharge from hospital and the admission to the geriatric care centre.

The functional, the psychological and the respiratory status of the patients were used as parameter for this study. In addition, the patient satisfaction and the satisfaction of the nursing staff were investigated. The length of stay, the resumptions into the hospital and the discharges from the hospital also were documented.

A significant difference was seen in anxiety and insomnia (p=0.002) in the functional, respiratory and psychological parameters for the subgroups. At the end, the treatment group reported significantly few anxiety and insomnia (p=0.001) whereas no significant difference could be found in the control group (p=0.108).

Additionally, a significant difference could be found in the general Health Questionnaire GHQ for the complete assessment the (psychological status, p=0.008). The well-being in the treatment group increased significantly (p<0.001) whereas no significant difference could be found in the control group (p=0.841).

The psychic well-being is an important factor in the rehabilitation and in the treatment of chronically ill persons. Exactly this important point is very often neglected and could be derived (opinion of the authors) confirmed in this study.

- Development of a nursing management in a haematological oncology day clinic

The patient's satisfaction could be increased in a haematological oncology department of a day clinic by specific interventions of the nursing staff which was demonstrated in a study in Queensland, Australia.

The waiting time of the patients, the patient satisfaction and the symptom management were improved in the first two phases. With these changes the nursing staff also had more time to deal with the psychosocial situation of the patients and support them. The first two phases were action studies; the third one should evaluate the results. In the third phase interventions were set primarily to intensify the contact between nurse and patient. The patients were assigned at any required treatment to a nurse. If possible, the nursing, was assigned to one and the same patient as often as possible and the patients was informed about his responsible nurse.

The satisfaction of the patients was determined by questionnaires. The results of the statistical analysis could not prove any statistically significant differences between the pre-interventions, and post intervention study group. The results concerning patient satisfaction showed that before and after the interventions there was a high degree of satisfaction with the quality of nursing.

In case of the questions about the symptom management an improvement from 54.33 (mean) increasing to 63.44 could be established after the interventions.

The results of this study showed that an appropriate patient order system and a thought-out staff allocation can bring staff resources, absolutely advantages for the individual treatment of every single visit of the patients.

- Nursing care intervention with breathlessness of lung cancer patients

A multi-centric randomised controlled clinical trial tested an intervention method with 119 lung cancer patients.

The medical treatment group was supported by the nursing staff in addition to the standard care by a standardised intervention program. The interventions consisted of breath control, controlled dealing with dyspnoea attacks, relaxation techniques and psychosocial support for the patients and their families. The best possible support was offered for the dyspnoea in the treatment group. The control group got the usual medicinal and nursing standard care.

At the beginning the burden of the disease and the functional restrictions were comparable in both groups. After eight weeks the values of dyspnoea, the WHO performance status, the scales for depression and anxiety and the data of the Rotterdam check list (physical symptoms) improved significantly in the intervention group. No significant difference was seen between the two groups with respect to the general psychological level of suffering and in the assessment of the quality of life, though.

4.3 Discussion

All studies which included statistical comparisons of the effectiveness of intensified nursing care measures with the standard nursing care models could establish successes or improvements in the test groups of the intensified nursing care. This concerned primarily psychic factors, like timidity, depression, general well-being and patient satisfaction.

The introduction of selected intensified nursing care measures only can be recommended due to these studies. The sometimes necessary initial additional expenses "amortise" rapidly and lead to higher satisfaction of patients and nurses. In addition, positive effects have to be expected on many psychic and physical parameters.

With the selected examples it turns out that the methods of nursing can be assessed in principle just the same way as it is known from medical research. The fact that the nursing science is younger and there are not so many publications demonstrates the need for further research. The increasing acceptance and implementation of results of nursing research leads to an increased number of active researchers, the increased competence of knowledge of methods, a detailed concept of outcome measurement, and a development of appropriate research designs and so on.

5. Economic assessment

As in the whole filed of public health it is nowadays necessary to look at the restriction of financial resources also in the area of nursing. Therefore a cost-effective use is important.

The nursing is not only influenced by the arising costs nowadays but also by increased technology and the progresses of interventions. An adaptation of the nursing interventions to the available technical equipment is required. This has primarily to be taken into account for the future with respect to nursing since the influence will get bigger and bigger by the rapid growth of economy and science. Since the nursing care persons take the main responsibility for the operation of many devices and machines, more and more knowledge is needed in this area of the nursing. The increasing complexity of the used technology has an enormous influence on the nursing staff and the supply of nursing for patients.

Nursing science is apparently in a rapid development to integrate economic aspects which is not yet very developed. Therefore not one single publication dealt with questions of economic considerations. Methodical challenges have to be solved in this field.

6. Ethical assessment

Nursing ethics can be considered as a part of the general ethic in public health or health ethics and covers the ethical questions of health professions in interdisciplinary cooperation.

Under an ethical behaviour you respect the autonomy and the self-determination of every individual to avoid damages to do good practice and to perform fairness. In nursing ethics especially you have to add broader ethical principles as truthfulness, be discrete and with a high level of credibility.

The ethics in connection with intensified nursing care appears mostly relevant to the professional ethics or the ethics of rationing. Professionally the problem of nurses can be mentioned that nursing staff itself knows the important contribution to the convalescence very well but cannot realise this in full context due to real limitations. If the state of the art can't be done due to a lack of time or other resources, ethical problems and a psychologically discouraging work climate can arise. The same is valid, if real restrictions have to be applied e.g. required nursing care places are not available or in a insufficient quantity. Topics of this type would be rather suitable in principle as health ethics, responsibility ethics as well as further aspects of the ethics. Despite this thematic openness and a comprehensive systematic search the scientific output was extremely low concerning sound studies.

7. Summarising discussion of all results

The studies included into the presenting HTA report cover the topics paediatric care, geriatrics and oncology. Both home nursing care models (midwife care, McGill model) and clinical management models (team nursing care, reference nursing care, nursing care protocol) were included.

All studies which included statistical comparisons of effectiveness of intensified nursing care measures with the standard nursing care models could establish successes or improvements in the test groups of the intensified nursing care. It concerned primarily psychic factors like timidity, depression, general well-being and patient satisfaction.

The introduction of intensified nursing care measures can only be approved due to these studies. The occasional necessary initial expenditure amortises usually very quickly and leads to higher satisfaction of patients and nurses as well. Additionally, further positive effects can be expected on several psychological and physical parameters.

8. Conclusion

The intensified nursing care leads in principle to higher satisfaction and improvements in some scores; the selected examples show an improvement concerning timidity, uncertainty and other psychic and social areas and are also able to improve functional symptoms.

In the last few years due to an increased discussion about humanity in hospitals, particularly in intensive and geriatric care the efforts for intensifying nursing got important.

The studies with results of intensified nursing demonstrate successes primarily in the psychic needs of the patients which were not so important in the past. The research and development of intensified nursing models should therefore be supported by decision makers in the public health service.

According to the select examples of intensified nursing in the broadest sense the increasing importance of scientific questions in nursing can be demonstrated. The huge variety of investigations allows only showing the individual results and does not allow any synthesis of the results due to methodological problems of lacking validity. A parameter which is able to measure the nursing interventions qualitatively or quantitatively can not be seen as well as a required definition for intensified nursing. Furthermore nursing science tends in its approach to qualitative methods strongly and the further development of the methodical orientation can not be assessed at present.

With the achieved results it became evident that there is an enormous need for scientific research, scientific studies are realisable and enough sensible for the assessment of nursing procedures and there are numerous encouraging examples.

The concept "intensified nursing" is mentioned in differentiation to concepts of "nursing care" or "nursing" which intensifies resources or patient contact. Especially psychic and social needs of patients are very appreciated in nursing. A similar type of nursing is known under the concept "advanced nursing practice" (ANP) which means, that a specialised, academically trained nurse offers an extended nursing care in which a focus on the published knowledge of evidence based research is made.

From the thin literature to this topic a selection of predetermined topics was analysed where at least two articles with a sufficient high methodical quality were available. The selected topic groups were: "Infant and paediatric nursing", "gerontology" and "oncology". Generally the five publications concerning infant and paediatric nursing could conclusive show a benefit of intensified nursing. Further research is still needed to prove intensified nursing care. Two publications could be found to the gerontological intensified nursing; both used an extended nursing model and an enlarged use of resources. Both studies demonstrated a measurable success in the applied parameters. Two studies also could be analysed in the oncological field in which successes were also provable by the applied parameters. The success was given especially in a higher patient satisfaction, one study showed an improved scheduling (time planning) of nurses.

There was not one article concerning economic questions of intensified nursing care. It has to be taken into account that the financial resources have to be used effectively also in nursing nowadays. It has to be assumed that the costs are driven by increased use of resources. Savings can be achieved, however, in the form of avoided therapies and days in hospital by intensified nursing. The intensified nursing can be considered as similar cost-effective as conventional models of nursing.

Ethically it is necessary to consider that the possibilities of the intensified nursing should be exhausted as much as possible for the patients. The daily work is limited, due to restrictions of resource. This means a conflict for nurses between knowledge and the predefined resource requirements which often leaded to overtaxing and dissatisfaction. It is desirable that decision makers of the health policy appreciate the evidence and promote intensified nursing care models.

Nursing science has to do special research to prove the meaning and effectiveness of intensified nursing and establish this in the health care delivery system.