King's College London, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London, United Kingdom.
King's College London, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London, United Kingdom.
Int J Nurs Stud. 2018 Feb;78:76-83. doi: 10.1016/j.ijnurstu.2017.10.009. Epub 2017 Oct 19.
Nursing is an integral part of all healthcare services, and has the potential of having a wide and enduring impact on health outcomes for a global ageing population. Over time nurses have developed new roles and assumed greater responsibilities. It is increasingly important to demonstrate the safety and overall impact of nurses' practice through research, to support the case for greater investment and development of nursing services around the world.
To provide an overview of existing research evidence on the impact of nursing on patient outcomes, identify gaps in evidence, and point to future priorities for global research. Specifically to address two questions: what is the evidence that nursing contributes to improving the health and well-being of populations?; and where should research activity be focused to strengthen the evidence base for the impact of nursing?
A search of the literature from 1996 using CINAHL, MEDLINE, the Cochrane Library, Google Scholar and the NICE evidence databases using the key words: nursing, nurse led, nursing interventions and patient outcomes. Initial analysis of the retrieved citations to reveal clusters of evidence of nursing impact in clinical areas which had been subject to systematic/integrative reviews or meta-analyses. Further analysis of these reviews to provide an overview of the research evidence for nurses' contributions to healthcare to inform discussion on future research agendas. We use the terms low, moderate and high quality evidence to reflect the assessments made by the review authors whose work is presented throughout.
Analysis of 61 reviews, including ten Cochrane reviews and two scoping/selective reviews to provide a summary of the research evidence for nurses' contributions to healthcare in the following areas of practice: nursing in acute care settings; nurses' involvement in public health; the contribution of specialist nurse and nurse-led services to the management of chronic disease; comparison of care provided by nurses and doctors; and task shifting to invasive procedures.
There is evidence that adequate numbers of well-educated nurses working in acute care areas can reduce the risk of patient mortality, although the evidence for this is confined to studies in high income countries and the evidence is not sufficiently robust to draw up definitive nurse: patient ratios. There is also moderate evidence that well trained nurses can produce health outcomes that are equivalent to those of doctors for patients with a range of chronic health problems, particularly for those patients managed in primary care, and that nurse-led care may be more effective than medical care in promoting patient adherence to treatment and patient satisfaction. There is low to moderate evidence for the benefits of parenting support programmes delivered by nurses on a range of health outcomes; and for the impact of home visiting on improving function and other health service outcomes for older people. The wider societal benefits of home visiting by nurses and the impact of this on long term outcomes and related cost-effectiveness of home visiting has not been established. There is limited available information regarding the wider global impact of increasing the numbers of nurses and their contribution to healthcare through improved education. Moreover there is very little evidence for the cost-effectiveness of changing care providers from doctors to nurses and as the majority of cost data available has tended to come from studies based in higher income countries, their external validity in terms of applicability to settings in low and middle income countries is questionable. In addition to effectiveness, cost and safety, future research needs to address how implementing expanded nursing roles and task shifting impacts on the morale, retention, and professional development of nurses and the other workforces, and the longer term implications of these developments both locally and internationally.
护理是所有医疗保健服务的一个组成部分，对于全球老龄化人口的健康结果，具有广泛而持久的影响的潜力。随着时间的推移，护士已经发展出了新的角色，并承担了更大的责任。越来越重要的是通过研究来证明护士实践的安全性和总体影响，以支持在全球范围内对护理服务进行更多投资和发展的理由。
提供有关护理对患者结局影响的现有研究证据概述，确定证据中的差距，并为全球研究确定未来重点。具体来说，要解决两个问题：有什么证据表明护理有助于改善人口的健康和福祉？；护理活动应集中在哪些领域，以加强护理影响的证据基础？
使用 CINAHL、MEDLINE、Cochrane 图书馆、Google Scholar 和 NICE 证据数据库，从 1996 年开始搜索文献，使用的关键词是：护理、护士主导、护理干预和患者结局。对检索到的引文进行初步分析，以揭示在已进行系统/综合评价或荟萃分析的临床领域中具有护理影响证据的集群。对这些综述进行进一步分析，提供护士对医疗保健贡献的研究证据概述，为讨论未来的研究议程提供信息。我们使用低、中、高质量证据的术语来反映评审作者的评估，他们的工作贯穿全文。
分析了 61 篇综述，包括 10 篇 Cochrane 综述和 2 篇范围/选择性综述，总结了护士在以下实践领域对医疗保健的贡献的研究证据：急性护理环境中的护理；护士参与公共卫生；专科护士和护士主导服务对慢性病管理的贡献；护士与医生提供的护理比较；以及将任务转移到侵入性手术。
有证据表明，在急性护理领域工作的受过良好教育的护士人数充足，可以降低患者死亡的风险，尽管这方面的证据仅限于高收入国家的研究，而且证据不够稳健，无法确定明确的护士与患者比例。还有中等质量的证据表明，经过良好培训的护士可以为患有各种慢性健康问题的患者提供与医生相当的健康结果，特别是在初级保健中管理的患者，并且护士主导的护理可能比医疗护理更有效地促进患者对治疗的依从性和患者满意度。有低至中等质量的证据表明，护士提供的育儿支持计划对一系列健康结果有好处；以及家访对改善老年人功能和其他卫生服务结果的影响。护士家访的更广泛的社会效益及其对长期结果和相关成本效益的影响尚未确定。关于通过改善教育来增加护士人数和提高其对医疗保健的贡献的更广泛的全球影响的信息有限。此外，关于将护理提供者从医生更改为护士的成本效益的证据很少，并且由于大多数可用的成本数据来自高收入国家的研究，因此其在低和中等收入国家的适用性（即适用于这些国家的情况）存在疑问。除了有效性、成本和安全性之外，未来的研究还需要解决扩大护士角色和任务转移对护士和其他劳动力的士气、保留和职业发展的影响，以及这些发展在当地和国际上的长期影响。
