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Abstract
Introduction The number of young and middle-aged adult patients with multimorbid and/or complex chronic conditions is rising, presenting challenges for healthcare systems. Advanced practice nurses (APNs) are crucial in treating these patients due to their expertise and advanced nursing skills. The article outlines the scope of practice (SOP), competencies and impact of APNs in APN-led models of care for this patient group in hospital settings.
Objectives Description of the SOP, competencies and impact of APNs within APN-led care models for young and middle-aged adult patients in hospital settings.
Design Scoping review based on the methodological framework by Arksey and O’Malley, incorporating the methodological enhancement of Levac and collegues, complying with the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines of Tricco and collegues.
Data sources Systematic research was conducted in the databases MEDLINE (PubMed), CINAHL (EBSCO), EMBASE (Ovid), CENTRAL and PsycINFO (Ovid) using all recognised keywords, item terms and search strings, and OpenGrey was scanned until December 2023. Studies published in English, German or translatable to English using translation tools were included.
Eligibility criteria Studies of APN-led models of care in hospitals were included if they involved adult participants aged 18–64 years with multimorbidity (two or more chronic conditions) and/or complex chronic conditions and provided information on SOP, competencies or impact.
Data extractions and synthesis Data from full-text articles meeting the inclusion criteria were extracted independently by two reviewers, and a narrative summary was developed to present the results related to the objectives and questions of the study.
Results A total of 2119 records were retrieved, with five studies ultimately included. The results included predischarge, postdischarge and bridging transition SOP. The competencies of APNs varied in both form and intensity, due to the heterogeneity of the APN-led models. Direct clinical practice competencies were most frequently described, especially regarding nursing or medical tasks, and shaped and influenced competencies in leadership, collaboration, guidance and coaching, and evidence-based practice. Indirect care activities were often mentioned. These studies indicated that APNs in APN-led care models positively impact clinical and patient outcomes, although high-intensity integrated care did not lead to cost reductions.
Conclusion The review aims to highlight the heterogeneity and current state of knowledge about the potential role of APNs in the integrated care of this increasing patient group in hospitals. The findings emphasise the significance of focusing on the unique needs of this patient population and may serve as a foundation for developing an APN-led model of care for this group in the clinical setting. However, further research is necessary to better elucidate the role of APNs within APN-led care models in relation to the care needs of this patient group.
Trial registration number OSF 4PM38.
- Multimorbidity
- Hospital to Home Transition
- Patient-Centered Care
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information. Not applicable.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
In the scoping review, the following guidelines are used: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.
The search for relevant articles was conducted in English and further languages, if they could be translated into English with translation tools.
According to a scoping review, the risk of bias and the quality of evidence of the included articles was not assessed.
Introduction
Multimorbidity and complex chronic conditions are significant and rising challenges to Europe’s health systems, affecting approximately 50 million people.1 The prevalence of multimorbidity and complex chronic conditions is increasing among young and middle-aged adults.2–4 International studies have shown that up to 50% of these adults are already affected by multimorbidity and complex chronic conditions.2 3 5 Therefore, health services should also prioritise the treatment and care needs of young and middle-aged adults.2 Adults with multimorbidity and/or complex chronic conditions of any age are more likely to suffer from fragmented care,6 inadequacy of existing guidelines, coordination problems and adverse drug reactions, polypharmacy and conflicting treatment recommendations.2 7–9 They generate significantly higher costs for the healthcare systems and are at a significantly higher risk of adverse health outcomes than those with only one or no chronic condition.10 These outcomes include more frequent hospital readmissions and longer average length of hospital stay, high utilisation of healthcare services, greater need for care, increased number of physician contacts, lower life expectancy, decreased health-related quality of life (QoL), impaired functional status combined with poor mental health, premature mortality and lower capacity to manage the types of treatment burden associated with multimorbidity10–15
Multimorbidity and complex chronic conditions are terms that are widely used within multidisciplinary teams and healthcare settings; however, these terms are subject to different definitions16 17 and are defined by the majority as the coexistence of two or more chronic conditions.18 Multimorbidity can be associated with complexity, but the term ‘complex chronic conditions’ not only describes the number of chronic conditions but also includes other dimensions of interrelated components of care, such as psychosocial and socioeconomic factors and the physical environment.19 Thus, patients with complex chronic conditions can be described as having (1) more than one chronic condition, (2) high-risk and high-cost care needs, (3) mental health challenges, (4) biopsychosocial needs and/or (5) socioeconomic or physical anomalies.19 20 The needs and care requirements of multimorbid and/or complexly chronically ill younger and middle-aged adults differ considerably from those of older adults. This is an effect of their more complex life situations, as they bear responsibility not only for their professional activities and career development but also for their families and minor children or their own parents.21 22 Preventive and health-promoting behaviours to influence health behaviours and the ageing process may be better integrated in middle-aged adults than in older adults.22 To meet these complex needs, the implementation of integrated care models is particularly important.23
Integrated care is defined as a model of care that is person-centred and structured to support coordinated and proactive care led by a core interprofessional team, and a principal coordinator communicates and collaborates within and across health sectors.24 Hospitals can play a crucial role in the coordination of chronic care, as they play a principal role in integrating care programmes and leading patients through the healthcare system.25 Care coordination by a defined point of contact as a lead healthcare professional is one of the central elements of integrated care26 27 and requires specific professional competencies, complex knowledge-based actions, skills and attitudes to combine and mobilise existing and available resources to ensure safe and high-quality outcomes for patients and populations.28 In particular, this person must acquire skills in knowledge sharing and collaboration with other professionals from different disciplines, organisations and professions for the care of people with multimorbid and complex chronic conditions to ensure a shared view of complex problems and guarantee continuity and quality of care.29
Consequently, Advanced Practice Nurses (APNs) are particularly suited to take a leading position within integrated care models, as they are well qualified to improve and coordinate care due to their advanced nursing knowledge and skills. In addition, they improve the self-management skills and health literacy of multimorbid and complex chronically ill patients.20 30–32 Studies have shown that advanced healthcare knowledge of APNs and their extended experience in nursing practice lead to optimised and improved patient health outcomes as well as increased knowledge of disease and available services. In addition, APNs in interprofessional healthcare teams offer a cost-effective alternative to time-intensive and complex management.30 33 34 The definition of the APN role is according to the International Council of Nurses (ICN) ‘a generalist or specialised nurse who has acquired, through additional graduate education (minimum of a master’s degree), the expert knowledge base, complex decision-making skills and clinical competencies for advanced nursing practice, the characteristics of which are shaped by the context in which they are credentialed to practice (adapted from ICN, 2008)’ (International Advanced Practice Nursing 35,p.1). The two most commonly identified APNs are clinical nurse specialists (CNS) and nurse practitioners (NP).36 The focus of the CNS is to improve the quality of care provided and patient outcomes through leadership to staff nurses and implementing system-related interventions. Alternatively, the role of the NP focuses more on direct clinical practice and tasks that may be shared with physicians.37 Tracy states that advanced nursing practice is ‘the patient-focused application of an expanded range of competencies to improve health outcomes for patients and populations in a specialised clinical area of the larger discipline of nursing (Tracy MF, 38,p.79). This framework was chosen as a frame of reference for this study.
In the literature, the term ‘nurse-led’ subsumes APNs, CNS and staff nurses, but all have differing scopes of practice. However, heterogeneity in nursing roles and titles affects the generalisability of the results.39 Therefore, to determine how APNs within APN-led models of care contribute to the management of multimorbidity and/or complex chronic conditions among adults, it is essential to understand the various roles and functions of APNs and their impact. A pivotal part of the APN role development process should be a clear definition of the specific characteristics of the role to be performed—the required scope of practice (SOP), the activities performed and required skills, competencies, attributes and areas of action.40 41 Furthermore, it is essential to clearly define the APN role and its objectives in order to reduce role ambiguity and improve the effective implementation and adoption of such APN roles.42 43
Various studies have been conducted to explain and describe the roles of APN, but they comprise only the areas of primary care,44 45 psychiatric and mental healthcare,46 the care of patients following hip fracture,47 geriatric oncology care48 and oncology.49 A recent scoping review published by Gonçalves et al50 describes the characteristics, differences and similarities between various nurse-led models of care for older adults with multimorbidity in hospital environments.50 McParland et al recently published a systematic review to identify which types of nurse-led interventions exist for adults with multimorbidity and which outcomes are positively affected.51 Gordon et al created a scoping review to determine what is known about nurse-led care models for patients with complex chronic conditions.20 No scoping review has been conducted thus far to describe the SOP, competencies and impact of exclusively APNs within APN-led models of care for young and middle-aged adults with multimorbid and/or complex chronic conditions. To address this gap in scientific research, the aim of this scoping review is, first, to describe the SOP, competencies and the overall impact of APNs within APN-led models of care focusing on the treatment and care of young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings, as hospitals can play a crucial role in the coordination of chronic care. Second, to use this evidence to inform the development of a future APN role within an APN-led model of care for young and middle-aged adults in a clinical setting.
Methods and analysis
As a frame of reference for this study, the Hamric and Hanson model of advanced nursing practice was chosen. This framework forms the basis for the considerations of the ICN and many countries regarding the role of APNs. Within this framework, competencies define the standards and SOP consisting of one central competency, direct clinical practice, which serves as a foundation for the five core competencies: guidance and coaching, evidence-based practice (EBP), leadership, collaboration and ethical practice.38
As presented in the published scoping review protocol,52 this scoping review follows the Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR): checklist and explanation.53 The review is conducted according to the five stages described by the Arksey and O’Malley framework54 and the enhancements proposed by Levac et al.55
Stage 1: identifying the research questions
This scoping review was guided by the following questions:
What is the SOP of APNs within APN-led models of care for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings?
What are the competencies of APNs within APN-led models of care for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings?
What overall impact do APN roles have within APN-led models of care for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings?
Stage 2: identifying relevant studies
The search strategy objectives were to find published studies and reviews, opinion articles and other papers that were relevant for answering the research questions. A preliminary search of MEDLINE (PubMed), CINAHL (EBSCO) and JBI Evidence Synthesis was conducted. The result was that there was no published review on the SOP, competencies and impact of APNs within APN-led models of care for adult patients with multimorbid and complex chronic conditions conducted in hospital settings has been conducted. Thus, a threefold search strategy was used, including all identified keywords and index terms, to find both published and unpublished studies. First, systematic research was conducted in the electronic databases MEDLINE (PubMed), CINAHL (EBSCO), EMBASE (Ovid), CENTRAL and PsycINFO (Ovid) using all recognised keywords and search strings. The full search strategy is provided in online supplemental appendix S1. Advice on developing a search strategy was sought from an academic librarian at the University of Basel, Switzerland. Second, a hand search was undertaken by checking the lists of references of the relevant papers and reviews to identify additional studies. Third, grey literature was searched using OpenGrey and ProQuest Dissertations and Theses—Abstract and Index to identify unpublished studies. Grey literature would be examined using the following terms within OpenGrey: nurse-led care, SOP, competencies, nursing management, multimorbidity, complex chronic conditions and outcomes. Studies published in English, German or translatable to English using translation tools will be included. There were no restrictions on geographic setting or date of publication. The search strategies were guided by the Population, Concept, Context framework.56 The advanced search strategy (tailored to all mentioned electronic databases and grey literature) was used to perform a comprehensive search of the literature for this scoping review in November 2023 to December 2023.
Supplemental material
Stage 3: selection of relevant articles
Following the search, all recognised articles in the aforementioned databases and grey literature were organised and uploaded into EndNote V.20 (Clarivate Analytics, Pennsylvania, USA), and all duplicates were erased. One reviewer evaluated all studies against the inclusion and exclusion criteria based on the title and abstract screening. Full-text reports were also obtained for all search results that potentially meet the inclusion criteria. Then, the full texts were screened against all the inclusion criteria by two independent reviewers. Publications that are considered relevant by only one of the two independent reviewers were discussed until consensus was reached. If full-text papers were excluded, as all parties agreed that they did not meet the inclusion criteria, the reasons for exclusion are provided in online supplemental appendix S2. All the results of the research are reported in the final report in full and are presented in a PRISMA-ScR flow diagram53 57 (see figure 1) recommended by the Joanna Briggs Institute as part of methodological guidance for scoping reviews.56 58
Supplemental material
The Preferred Reporting Items for Systematic Reviews and Meta-analysis flow diagram of the study selection process.*Record: The title or abstract (or both) of a report indexed in a database or website. **Report: A document (paper or electronic) supplying information about a particular study. It could be a journal article, preprint, conference abstract, study register entry, clinical study report, dissertation, unpublished manuscript, government report, or any other document providing relevant information. ***Studies: An investigation, such as a clinical trial, that includes a defined group of participants and one or more interventions and outcomes.
Inclusion and exclusion criteria
The following inclusion and exclusion criteria were used to identify relevant studies.
Studies identified via databases, hand search of references and grey literature:
Inclusion and exclusion criteria
Inclusion
Studies that include APN-led models of care in hospital settings, whose participants are adults between 18 and 64 years with multimorbidity (two or more chronic diseases) and/or complex chronic conditions.
Studies that include APNs within APN-led models of care in hospital settings who work in direct patient care and have a master’s degree in accordance with the ICN definition.36
Exclusion
Studies that do not provide outcomes on the impact of APN roles within APN-led models of care, or on the competencies and SOP of APNs within these models of care in hospital settings.
Studies that are only focused on adults aged≥65 years and older and those that do not focus on APNs will also be excluded.
In addition, studies of APN-led models of care in hospital settings, whose participants are younger and middle-aged adults who are being treated primarily for oncologic diseases and those who have major psychiatric conditions like bipolar disorders, major depression and schizophrenia. The exclusion of these APN-led care models was a consequence of the additional qualifications required of APNs in relation to oncological and psychiatric conditions, which would make it difficult/impossible to generalise the findings.
Stage 4: charting the data
Data were extracted from the papers that were included in the review by a reviewer, using a data extraction table designed by the reviewer (Scoping review protocol submitted to BMJ Open). The extracted data contained the following specific details: information about the authors, dates of publication, titles of the article, journals or other sources of publication, study location (country of study), type of study, details about the participants, the competencies and SOP of APNs and impact of APN-led models. The data extraction table is provided in online supplemental appendix S3. Any differences between the reviewers were resolved by discussion until consensus was reached. The selection of the articles was processed in three steps: (1) selection of the articles based on title/abstract by one reviewer, (2) the resulting full texts were screened for eligibility by two independent reviewers and (3) in case of disagreement between the two independent reviewers, the differences that arose were resolved through discussion until consensus was reached.
Supplemental material
Stage 5: collating, summarising and reporting the results
Data analysis was conducted. The tables were accompanied by a narrative summary describing how the results relate to the objectives and questions of the study and were depicted graphically and in tabular form. These findings are discussed in relation to practice and research.
Results
A total of 2023 citations were identified through the scientific database search strategy MEDLINE (PubMed)=406, CINAHL (EBSCO)=1307, EMBASE (Ovid)=219, CENTRAL=11 and PsycINFO (Ovid)=80. After removing duplicates, 1502 articles were screened by title and abstract. A total of 1380 records were excluded. After a full screening of the remaining 122 papers, 120 were excluded, and 2 were included in this review. The 120 articles that were excluded and the reasons for exclusion are listed in online supplemental appendix S1. A total of 65 articles were identified in the grey literature database search, from which all were excluded after title and abstract analysis. A total of 35 articles recognised by checking the lists of references of the relevant reviews and paperswere excluded, and 3 were included in this review. A total of five articles were included in this scoping review.59–63 The number of articles at each stage of the study selection process is displayed in the PRISMA-ScR flow chart (see figure 1).
The studies were published between 2002 and 2017. Four studies originate from the USA59 60 62 63 and one from Canada.61 A total of two randomised controlled trials,59 62 one randomised controlled trial with four groups and an eight-arm design,63 one descriptive case study60 and one preinterventional and postinterventional study61 were found. No study was found that focused exclusively on young and middle-aged adults aged 18–64 years. The reported average age ranged between 59.6 and 62.6 years. The titles of the APN-care models varied among (1) nurse case management, (2) transitional care model, (3) care management, (4) chronic disease management programme and (5) care transition intervention. The duration of integrated care varied between 2 and 12 months. Job titles of APNs within the APN-led models of care were (1) nurse practitioner, (2) APN, (3) diabetes nurse practitioner and (4) advanced practice registered nurse–nurse practitioner. The nurse case management programme focused on individualised lifestyle modification and pharmacological intervention to lower blood lipids in patients with coronary heart disease compared with usual care.59 The main components of the NP model of care focused on chronic disease management, and the use of clinical practice algorithms, patient education on strategies to self-manage their disease and regular monitoring and feedback, in comparison to usual care.62 The case study described the transitional care management process with a patient with diabetes, hypertension, high cholesterol and gastro-oesophageal reflux disease from hospital to home.60 The care management model focused on a short-term diabetes nurse practitioner intervention of patients with diabetes mellitus type 2 admitted to the inpatient cardiology service, where diabetes nurse practitioner were responsible for providing integrated diabetes care and education for patients in the context of their cardiac illness.61 The care transition intervention focused on the cost-effectiveness of four different doses of a home-based care transition intervention compared with usual care to provide care planning and follow-up care, working with a multidisciplinary team.63 The main characteristics of the papers included in this review are described in the following table (see table 1).
Main characteristic of the APN-led models of care included in this review
SOP of APNs
The SOP of APNs in the studies is divided into three phases within the APN-led care models: (1) predischarge SOP, (2) postdischarge SOP and (3) bridging transition SOP.
Predischarge scope of practice
Screening, assessments and comprehensive needs assessments were highlighted as predischarge SOP in two studies60 61: screening on admission, comprehensive needs assessment—including physical and social needs, patient activation for change, health literacy, depression and care goals—to develop an evidence-based care plan.60 Duration of diabetes, previous treatments, diagnoses and blood analysis were gathered through patient interviews and electronic health records. Assessments measured QoL and treatment satisfaction.61 Patient-centred care, individualised care, comprehensive and discharge care planning were identified in three studies60 61 63: comprehensive in-hospital care planning, offering individualised care based on patient goals through daily visits to develop a patient-centred plan.60 Integrated diabetes and discharge care planning was provided for patients with cardiac illness.61 Care planning included strategies to promote patient activation and enhance self-management.63 Education, counselling and coaching were identified in three studies60 61 63: patient education focused on self-managing complex care needs using preferred learning methods. This included a holistic action plan for monitoring, dietary restrictions, medication adherence and behaviour tracking. Education was reinforced through television and tailored sessions with diabetes consultants and nursing staff, covering self-monitoring of blood glucose, eating and exercise behaviours and management of diabetes and hypertension.60 Diabetes education followed guidelines algorithm, covered general information, blood glucose measurements, management of hyperglycaemia and hypoglycaemia and finding additional information and resources.61 Patient education, counselling and coaching for engaging patients in self-management behaviours, enhancement of skills, knowledge and competencies through self-efficacy improvement strategies.63 Collaboration was identified in two studies60 63: collaboration with the multidisciplinary team to implement a transitional care protocol and ensure the patient’s new primary care provider schedules an appointment after discharge.60 Collaboration with the multidisciplinary team to provide care planning.63 Medication management as adjustment, reconciliation and education was identified in three studies as predischarge SOP60 61 63: basic understanding of the newly prescribed medication.60 Reconciliation and adjustment of medications based on recommendations of the Canadian Diabetes Practice Guidelines algorithm.61 Medication reconciliation to ensure correct medication intake.63 Management, monitoring, action planning and red flag identification were identified in one study63: enhancing patient activation to support self-management and encourage ownership of care, including red flag identification for prioritising chronic disease symptom management, action planning and medication management.63 Coordination was identified in one study63: primary coordination of care throughout the episode to ensure provider consistency and streamline the care plan based on patients’ goals.63 Documentation was identified in two studies60 63: development of a written emergency treatment plan, patient health record and tailored education material for specific learning needs60 and a pill card and chart, including all current medications.63
Postdischarge SOP
Assessment of questionnaires was identified in two studies as SOP61 62: assessments to evaluate treatment and management issues 4 months post discharge.61 Measurement of patient perceptions of health-related QoL, care satisfaction and diabetes QoL, treatment adherence, barriers to adherence and family support.62 Patient-centred plan of care, care planning and treatment regimes were reported in four studies59 60 62 63: initiating lipid management plan.59 Creating a patient-centred care plan aligned with patient goals to manage complex needs and collaborating with the primary care provider to transition from intensive transitional care model to self-management.60 Treatment regimens were developed to incorporate patients’ preferences.62 Care planning involved strategies to enhance patient activation and improve.63 Collaboration was reported in four studies59 60 62 63: collaboration with primary providers/cardiologist.59 Collaboration with the primary care provider addressed health screening needs and created a transition plan from intensive care to self-management, while also partnering with the diabetes educator for dietary education.60 Collaborating with the physician team to address problems and decisions not covered by algorithms.62 Collaboration with a multidisciplinary team to enhance patients activation levels.63 Medication management as reconciliation, adjustment, monitoring and prescribing medications was mentioned in four studies59 60 62 63: prescription and adjustment of lipid-lowering medications.59 Monitoring of the patient’s ability to manage and reorder medication.60 Prescribing and monitoring lipid-lowering drug therapy.62 Medication reconciliation to ensure accurate medication intake.63 Management, monitoring, action planning and red flag identification were identified in four studies59 60 62 63: initiating a lipid management plan, managing lipid levels, prescribing or adjusting lipid-lowering medications and counselling on lifestyle modifications, including nutrition, physical activity, home exercise and smoking cessation.59 Monitoring of patients’ self-management behaviours.60 Monitoring patient care by using clinical algorithms and management flow charts, and addressing issues not covered by algorithms.62 Employing strategies to enhance patient activation and support self-management behaviours, including identifying red flags for priority chronic diseases to guide symptom management, action planning and medication management.63 Follow-up home visits were mentioned in three studies59 60 63: offering one outpatient visit to start a lipid management plan, which includes counselling on lifestyle modifications and adjustments or prescriptions for lipid-lowering medications.59 The follow-up visits focused on education for newly diagnosed diabetes.60 Medication management, creation of a personal health record, red flag identification for key chronic diseases, action planning, coaching and teach-back were included in home visits.63 Follow-up telephone calls were identified in all five studies59–63: reinforcing counselling and adjustments of medications.59 Monitoring the patient’s self-management to meet the patient’s goals.60 Administering assessment questionnaires and assessing any issues with current management.61 Creating treatment plans that consider patient preferences, treatment adherence and individual barriers, and family support for treatment.62 Medication management, personal health record development, red flag identification, action planning, coaching and teach-back.63 One study identified follow-up office visits for developing treatment plans.62 One study mentioned follow-up care by mail.61 Education, counselling and coaching were identified in four studies.59 60 62 63 Counselling of lifestyle modifications.59 Providing general diet education through teach-back methods.60 Education on disease self-management strategies.62 Education, counselling and coaching to engage patients in self-management and enhance their skills, knowledge and self-efficacy.63 Documentation was identified in all studies59–63: data collection, developing a written treatment plan, patient health record, follow-up documentation, emergency care plan, lipid management plan and pill cards.59 60 62 63 Regular documentation and digital communication with primary providers/cardiologists, feedback letters to patients and providers, lipid management and medication adjustments.59 Plan for transitioning from intensive transitional care model programme to self-management.60 Data were collected via mail.61 Establishing and implementing treatment plans based on recommendations and flow charts, while incorporating patients’ preferences.62 Creation of pill cards, including all medications.63
Bridging transition SOP
The SOP of APNs includes active involvement both before and after patient discharge, functioning as a bridge across care settings and providing longitudinal support throughout the predischarge and postdischarge periods.64 Two of the five studies used APNs as transitions coaches, engaging with patients before and after hospital discharge.60 63 The APN actively engaged the patient throughout hospitalisation, maintaining contact after discharge through home visits and phone calls. This long-term relationship bridged inpatient and outpatient care. Coleman described this role in improving a patients self-care behaviours as a ‘transition coach’.65 Predischarge visits concentrated on comprehensive needs assessment, care planning and disease-specific education. Postdischarge contacts focused on follow-up, monitoring self-management behaviours, medication adherence and symptom management.60 Before hospital discharge, the APN engaged with patients to promote activation strategies and foster self-management behaviours. Tailored education enhanced patients' knowledge, competencies and skills through self-efficacy improvement strategies, addressing their specific chronic conditions.63 Patient-centred transitional care instructions were used in two of five studies60 63 and involved engaging patients in their care transitions. These individualised records were tailored to each patient’s chronic conditions, health literacy and psychosocial factors. Patient-centred transitional care instructions emphasised collaborative development of a care plan involving patients, family caregivers, physicians and healthcare teams to facilitate the transition from hospital to home,60 starting before discharge home.63 These instructions, including personalised education and training, improved skills and knowledge for managing complex care needs like medication management, chronic disease symptoms, red flag identification and action planning.60 63 The summary of the predischarge, postdischarge and bridging transition SOP is in table 2.
Predischarge, postdischarge and bridging transitions scope of practice (SOP) of APNs within APN-led models of care within clinical settings
Competencies
The competencies of APNs within APN-led models of care for young and middle-aged adults in hospital settings, as outlined by Hamric and Hanson,38 are summarised in figure 2.
Competencies of APNs within APN-led models of care for young and middle-aged adults in clinical settings. APN, advanced practice nurse; SOP, scope of practice; PCPs, Primary Care Providers; TCM, Transitional Care Model.
Direct clinical practice
In direct clinical practice, the following categories have been identified: screening,60 assessment,61 62 comprehensive needs assessment,60 evidence-based care management approach,59–61 63 patient-centred care,60 63 diagnosis and treatment,61 management of medications (prescribing, adjustment, education, reconciliation and monitoring),59–63 management and prescription of blood tests59 61 and monitoring self-management behaviours.60 APNs demonstrated competencies in comprehensive clinical and psychosocial assessments, going beyond standardised screenings. They noted health literacy, readiness for change and past depression, ensuring a holistic understanding of patients’ complex needs. By integrating a holistic, evidence-based approach, APNs effectively served as primary care providers, ensuring consistency across settings. Through patient-centred care, they aligned treatment with individual goals and fostered strong relationships. They autonomously diagnosed, interpreted results and prescribed medications, enhancing patient care while managing medications under primary providers/physician team supervision and administering blood tests. Overall, APNs’ advanced skills addressed patient challenges, positively influencing outcomes and monitoring self-management behaviours to help patients achieve their goals.
Guidance and coaching
In guidance and coaching, the following categories have been identified: empowerment of self-management,60–63 patient participation,59–63 adherence to treatment62 and advanced communication competence.59–63 APNs empowered patients to manage disease-specific symptoms and identify health risks, helping them integrate personal goals into their lifestyles. By considering individual goals and learning preferences, APNs motivated patients to engage in their care and set achievable objectives. They provided counselling and education on dietary restrictions, physical activity, red flag identification and action planning to monitor health and reduce hospital visits. APNs also addressed treatment adherence and barriers while optimising care coordination through advanced communication skills, employing various evidence-based approaches to meet complex healthcare needs.
Collaboration
In collaboration with various stakeholders in the clinical setting and after discharge, the following categories were identified: partnership and exchange with primary care provider/primary provider or physician team,59 60 62 patient and family,59–62 in-hospital health professionals,60 health professionals after discharge63 and disease-specific centres.61 APNs collaborated with primary care providers to manage chronic diseases and medications before and after discharge, maintaining communication to address healthcare needs. They developed treatment plans with primary care providers for transitioning patients from the transitional care model programme and occasionally managed patients independently according to clinical guidelines. APNs engaged patients to enhance self-management and achieve health goals, focusing on chronic disease symptom management, lipid management, medication adherence and lifestyle modifications. Within the hospital, they worked with multidisciplinary teams to implement transitional care protocols, ensuring consistent education and minimising duplication. On discharge, they facilitated referrals to diabetes centres for continued care.
Evidence-based practice
The core competence EBP was identified in the categories in terms of the application of individual clinical decision-making60 61 and as decision-makers within interdisciplinary/multidisciplinary teams.59 62 63 Based on individual clinical decision-making, APNs implemented an evidence-based approach to comprehensive patient care, providing diabetes education and adjusting medications according to guidelines. Working within interdisciplinary teams, they offered tailored lifestyle modifications, pharmacological interventions and self-management strategies to enhance complex needs and optimise chronic disease management. Through evidence-based components of three transitional care models, APNs aimed to increase patient activation, self-management engagement and enhance skills and knowledge.
Leadership
In leadership as APN competency, the following categories were identified: within clinical practice with patients60 61 and interdisciplinary within hospitals/primary care provider practices.59 62 63 In clinical practice, APNs coordinated care to ensure consistency and continuity across settings. They developed evidence-based plans with patients and interprofessional teams to implement transitional care protocols and deliver integrated diabetes care, focusing on high-quality management and improved QoL. APNs prioritised patients’ needs to implement best practices in managing complex care, including initiating lipid treatment plans, counselling on lifestyle modifications, adjusting or prescribing medications and creating tailored regimens. They also provided planning and follow-up care to support self-management for patients and caregivers.
Ethical practice
Although not explicitly mentioned, APNs demonstrated core competency in ethical practice by adhering to ethical standards and using their knowledge and skills to facilitate interprofessional communication and collaboration for the benefit of patients.
Indirect care activities
In indirect care activities, the following categories were identified: coordination,60 patient referral61 and documentation.59–63 APNs served as primary coordinators throughout the care episode, ensuring provider consistency across facilities. They tailored care plans to patient goals during hospitalisation and collaborated with staff for successful discharges. After discharge, APNs facilitated home care continuity and coordinated follow-up appointments with primary care providers, guiding patients from intensive transitional care model to self-management. They developed emergency care plans, health records and educational materials to support self-management. Before discharge, APNs reviewed diabetes education options and referred patients to local diabetes centres, while managing documentation, communicating with primary care providers and cardiologists and adjusting medications based on patient preferences.
Impact
The overall impact of APN roles in APN-led care models is summarised in table 3. These include clinical, patient and system outcomes.
Clinical outcomes, patient outcomes and system outcomes of APN-roles within APN-led models of care in clinical settings
Clinical outcomes
Readmission was not reported after 6 months.60 Emergency department visit was identified once in one study.60 Laboratory findings were identified in four studies59–62: the NP group showed improved blood parameters 1 year after discharge,59 reduction of haemoglobin A1c (HbA1c) was reported after 6 months,60 significant decrease in HbA1c, total cholesterol and low-density lipoprotein levels 3 months post intervention, while high-density lipoprotein levels showed lower trends.61 Nurse practitioner-physician team (NP-MD)-treated patients experienced increased high-density lipoprotein cholesterol (HDL-C) levels and a significant improvement in long-term diabetes control, as shown by decreased HbA1c values.62
Patient outcomes
Preventive care was identified in two studies59 62: increasing risk factor management in coronary heart disease patients could address significant treatment gaps in secondary prevention.59 Preventive care was significantly higher in the NP-MD team-treated group.62 Patient education was identified in one study.62 NP-MD team-treated patients had evidence of more teaching on a wide range of relevant preventive care topics.62 QoL was identified in two studies.61 63 Diabetes significantly affected several QoL domains, but overall QoL remained unchanged.61 After 2 months, QoL improved in groups 2 and 4 compared with usual care, while groups 1 and 3 had lower scores. After 6 months, groups 2, 3 and 4 showed better health status than usual care, but group 1’s QoL did not improve despite the highest intervention intensity.63 General health status was identified in three studies.61–63 No significant changes were observed in Diabetes Treatment Satisfaction Questionnaire scores, and overall patient satisfaction did not improve after diabetes treatments.61 Satisfaction with care from the NP-MD team significantly improved from baseline, with enhanced communication and interpersonal care after 1 year.62 Only group 4 improved general health status after 2 months compared with usual care, while group 1 declined the most. After 6 months, groups 2, 3 and 4 showed improvement, but group 1 continued to decline relative to usual care.63 Nutrition status was stated in one study.59 NP group patients reported a greater reduction in calories from total fat, saturated fat and cholesterol, along with an increased dietary fibre intake, while total calorie intake remained unchanged.59 A significantly higher proportion of patients in the NP group reported exercising at a level of 6 metabolic equivalent hours per week compared with the usual care group, with no significant changes in body mass index in either group.59 Drug compliance and adherence were identified in one study.59 The NP group showed better average blood parameters after 1 year, along with improved medication compliance and adherence to management algorithms.59
System outcomes
The length of APN-led care models varied across the five studies, ranging from 2 months to 1 year.59–63 The length of intervention of the APN-led care models lasted 1 year post discharge.59 62 The transitional care model programme began at admission and lasted 2 months post discharge.60 The diabetes nurse practitioner intervention began in the hospital, with follow-up care and data collection continuing for 4 months post discharge.61 NP-MD-treated patients had a significantly higher median number of outpatient visits for managing diabetes mellitus and hypertension.62 Interventions varied by group: groups 1 and 2 began in the hospital and continued for 8 weeks post discharge, group 3 lasted 4 weeks, while group 4 received a follow-up call after discharge.63 Average time spent and number of contacts with patients was reported in all five studies.59–63 The APN spent an average of 4.5 hours per patient, with 70% on counselling about diet, medications, exercise and smoking cessation. Another 26% was for documentation and communication with insurance and healthcare organisations, while only 4% was spent with primary providers and cardiologists. The nurse practitioner contacted patients an average of seven times over the year.59 Patients received 8 home visits and 10 unscripted phone calls during transitional care.60 The NP-MD spent an average of 180 min with patients over a year, significantly more than the usual care group’s 85 min,62 a single intervention by APN of 30–45 min61 and three APN visits, seven visits and two calls in group 1.63 Cost-effectiveness analysis was evaluated in two studies.62 63 NP-MD-treated patients had significantly higher annual costs for hypertension and diabetes treatment.62 The cost-effectiveness analysis showed no effectiveness for groups 1, 2, and 3 after 2 months. By 6 months, it was effective for all but group 1. Groups 1 and 4 had lower costs at 2 months, while groups 2 and 3 had none. After 6 months, groups 1 and 3 had higher costs than usual care, while groups 2 and 4 had lower costs.63 Clinical, patient and system outcomes are summarised in the online supplemental appendix S4.
Supplemental material
Discussion
Overall, only a few studies were found that represented the SOP, competencies and impact of APNs within APN-led models of care for multimorbid and complex chronic conditions for young and middle-aged adult patients in hospitals. These results are consistent with the findings that the majority of integrated healthcare is currently focused on geriatric patients,66–68 but that integrated healthcare of younger and middle-aged adults is underrepresented. Within the five included studies, there is shown a heterogeneity within these APN-led models. A total of five different models were found: (1) transitional care model, (2) care management model, (3) care transition intervention programme, (4) nurse case management and (5) chronic disease model. In all of these models, APNs play a central role in the care of patients with multimorbidity and complex chronic conditions, whether in coordinating care in the hospital, planning hospital discharge or providing subsequent care at home.
Consequently, the SOP of the APNs within the APN-led models was heterogeneous: in three of these models,60 61 63 the contact of APNs with patients started during the hospital stay. In the remaining two models,59 62 the contact began at home after the hospital stay. The SOP of APNs was designed accordingly: within the transitional care model, APNs provided comprehensive, holistic care in collaboration with the patient and an interprofessional team, including screening, comprehensive needs assessment, patient-centred care planning, education and coaching to enhance self-management, medication education, coordination and documentation before and after discharge with follow-up care including home visits and postdischarge phone calls. This result and approach are in line with the model specification developed by Naylor’s transitional care model with its transitional care core components.69 70 The SOP of the APN within the care transition intervention programme, which was initiated prior to discharge, included individualised care, education and coaching to enhance self-management, medication management, development of a personal health record, red flag identification and action planning. Follow-up care included home visits and telephone calls. This approach is partially consistent with Coleman’s care transition intervention programme, which involves the development of a care plan and a visit to the hospital by the patient, followed by a home visit and three follow-up calls by a transition coach.65 However, this care transition intervention model differs in so far as an APN explicitly took over the management of groups 1 and 2 in cooperation with a certified nursing assistant, and the transition care management components of the Re-Engineered Discharge project71 were added. The integrated care management model provided individualised care, diabetes education, medication adjustment and management and provided referrals to other diabetes centres in the patient’s region to ensure the possibility of diabetes education and conducted various assessments over the phone to assess the patient’s care and QoL. In both the nurse case management and chronic disease models, care for multimorbid and complex chronically ill adults began after hospitalisation. In collaboration with the primary providers/cardiologists or physician team, patients received individualised care planning and a treatment plan, medication management with prescription and adjustment of medications, follow-up visits at home and office visits, and education on diseases self-management strategies and counselling of lifestyle modifications such as nutrition, physical activity, home-based exercise programme and smoking cessation. Only the transitional care management and the care transition intervention model introduced transitional care in the sense of bridging transition between inpatient and outpatient care, in which the APNs remained the same as service providers, but to varying degrees.
Due to the heterogeneity of the APN-led care models, the competencies of the APNs varied in form and intensity. The core competence in direct clinical practice was reported in all studies in this review. This follows the recommendation of Hamric and Hanson that APNs are expected to work predominantly directly with patients and caregivers.38 Direct clinical practice competencies in the transitional care model and care transition model were predominantly related to nursing activities such as a patient-centred, holistic approach that integrated the patient’s individual goals and considered emotional well-being. These results are consistent with Hamric and Hanson, who emphasise the need for a holistic approach that not only concerns the physical health of patients but also takes their emotional well-being into account in order to stabilise or improve a patient’s condition.38 In the care management model and the two chronic care models, the focus was nevertheless on nursing activities. It also mentioned medical skills such as diagnosing, interpreting results and prescribing medication and blood tests. This finding is consistent with the International Council of Nurses Guidelines for advanced nursing practice, which assign APNs some activities previously reserved for primary care providers (eg, diagnostic skills) but emphasise that APNs should focus on nursing principles.40 As direct clinical practice shapes and influences the performance of the other five competencies,38 the core competencies leadership, collaboration, guidance and coaching and EBP within these models of care were different depending on the APN-led model of care. Leadership in the sense of clinical leadership as a foundation that focuses on the needs and goals of patients and caregivers and ensures that quality patient care is achieved42 was reported in all five studies, although the focus of clinical leadership and the intensity of clinical leadership varied. The transitional care model and transitional care intervention models focused more on the self-management of patients’ complex care needs, with the focus of care management being the delivery of evidence-based education. The two chronic care models where APNs were primarily medically active, thus clinical leadership focused on prescribing medications and blood tests and interpreting results. Nevertheless, guidance and coaching as competence differed within the models—guidance in the sense of information and orientation was reported within all APN models, whereas coaching as an exploratory process that helps patients to set and achieve their own goals was also the focus of the transitional care model and care transition intervention models. The competence of collaboration was mentioned in all five studies to varying degrees and intensity. Within the transitional care model, care management and chronic care model models, the APN worked in collaboration with patients, caregivers and other healthcare providers such as primary care providers and cardiologists. The APN within the transitional care model, on the other hand, had the overview of the entire treatment process from patient admission to discharge from the transitional care model, coordinating exchange and communication between disciplines and people that were involved. The results of the transitional care model are consistent with Hamric and Hanson, who define collaboration as a core competence of an APN who has an overview over the entire treatment process, coordinating exchange and communication between disciplines and people involved to achieve best quality of treatment for patients and their caregivers.38 EBP at the individual EBP level, and the application to individual clinical decision-making, was again practised in varying forms and intensities within the included studies of APNs. The transitional care model and care transitional intervention model were based on evidence-based components designed to improve patients’ self-management of their complex needs. In contrast, the care management model provided evidence-based education and the two chronic care models used evidence-based approaches in managing comprehensive care. Explicitly, no information was provided regarding ethical practice within the five studies. This may be due to the fact that the studies did not involve ethically difficult situations. According to Hamric and Hanson, ethical practice involves, as a core competence of APNs, the sensitivity to ethical features of situations and the need for knowledge and skills to lead interprofessional communication and facilitate consensus within interprofessional teams.38
Indirect care activities were mentioned in all of the included studies. These indirect care activities referred to situations of direct clinical practice, promoting coordination and communication between the different sectors and healthcare providers. Within the transitional care model, the APN acted as the primary coordinator throughout the episode of care within and between settings—coordination of ongoing care plans and patients’ discharge. In addition, indirect nursing activities included the development and creation of individual patient health records, emergency and urgent treatment plans and written education materials. In the two chronic care models in particular, the APN coordinated and managed the medication process and regularly documented exchanges to primary care provider/cardiologists, feedback letters to patients and providers, adjustment of medications and lipid management. According to Hamric and Hanson, indirect care activities are closely related to direct patient care. Although indirect care activities are not performed with the patient directly, they do not ‘occur outside the patient-nurse interface’ (Tracy MF, 38,p. 196).
The included studies showed that APN-led care models can have a positive impact on clinical outcomes as the prevention of frequent hospital admissions and emergency department visits. The improvement of the readmission rate and the prevention of emergency department visits are considered a key factor in the APN-led transitional care model, which is achieved by empowering patients and their caregivers to self-manage complex care needs.72–78 APN-led models of care can also have a significant impact on laboratory values as a decrease in HbA1c, total cholesterol and low-density lipoproteins in clinical outcomes. These findings are consistent with results from studies, which stated that a high level of evidence suggests better serum lipid levels in patients cared for by APNs after discharge at home.79 80 A further positive and partly significant impact of the care of APNs in APN-led care models was seen in patient outcomes such as preventive care, patient education, QoL, general health status, nutritional status, physical activity and medication compliance and adherence. These findings are consistent with the results made, which suggest that a high level of evidence also indicates that patient outcomes related to satisfaction with care, health status, functional status, blood glucose and blood pressure are similar between APNs and medical doctors.79 APN-led clinics are related to higher satisfaction with care,81 optimise blood pressure80 and type 2 diabetes treatment with comorbidities82 83 and reduce modifiable cardiovascular risk factors.84 In contrast, the cost-effectiveness analysis of the system outcomes within two studies showed that the average personal costs within the care of diabetes mellitus and hypertension were significantly higher for patients cared for by APNs and that a care transitional intervention model of care showed that cost-effectiveness was only achieved after 6 months in some cases. These results show that high-quality integrated care provided by APNs does not lead to cost reduction. These results are consistent with the findings on cost reduction in older adults cared for by APNs,76 85 86 showing that transitional care management and care transition intervention models are likely to be effective in reducing readmission rates in geriatric patients, without increasing cost. However, the evidence of the cost-effectiveness of APN-led transitional care models is inconclusive, and further research is needed.87 Due to the heterogeneity of the included APN-led models of care, the length of the APN-led models of care and the average time spent and number of contacts with patients differ within these models. These results are consistent with the findings that, depending on the APN-led model, there are already fixed specifications regarding the average time spent and number of contacts with patients.65 70
Limitations
This scoping review has several limitations that must be recognised. First, due to the nature of scoping reviews, we did not evaluate the evidence presented in the included studies. Nevertheless, two reviewers independently assessed all full-text reports based on the inclusion criteria, thereby increasing the reliability. A previously set protocol also enabled a transparent and structured approach in the search process. Second, the focus on incorporating APNs within APN-led care models for patients with multimorbid and/or complex chronic conditions in hospital settings with a Master’s degree was circumscribed. As a result, only a limited number of studies could be included in this scoping. On one hand, it is possible that important aspects of primary care for multimorbid and complex chronically ill adults in younger and middle age were not captured. However, the focus of this scoping review was to outline the SOP, competencies and impact of APNs within APN-led care models in hospital settings, aiming to fill this gap in scientific research. On the other hand, it is also possible that important aspects of the APN role were not captured. One reason for this gap could be that the International Council of Nurses only recommended the Master’s degree as a requirement for the APN role in 2020. It is possible that other qualifications were accepted for the APN role. Nevertheless, focusing on the Master’s degree as the qualification for the APN role aligns with the latest International Council of Nurses recommendations. Third, the included studies were conducted in countries where the role of APNs is already established. However, in Europe, there are significant differences in the definition, regulation, recognition and education of APN roles.88 Another point that can be emphasised is that the focus of this review was on the roles, competencies and impacts of APNs in APN-led care models integrated within hospitals, specifically for young and middle-aged adults with high morbidity and/or complex chronic conditions. This resulted in a limited number of studies included in this scoping review. The aim of this scoping review is to address this research gap, with the inclusion of only five studies being a direct outcome of our search strategy. Another limitation of this scoping review is that studies involving APN-led care models in hospitals, where the participants were young and middle-aged adults primarily treated for oncological conditions or severe psychiatric disorders such as bipolar disorder, major depression and schizophrenia, were excluded. As a result, this led to a more limited number of studies being included. Therefore, the results may have limited generalisability in contexts where the APN role is still emerging.
Conclusion
This is the first review to examine the SOP, competencies and impact of APNs within APN-led models of care for multimorbid and complex chronic conditions in hospitalised young and middle-aged adults. Due to heterogeneity and the small number of studies with limited sample sizes, as well as the fact that no study was found that focused exclusively on multimorbid and complex chronically ill young and middle-aged adults, a narrative summary was useful to show trends rather than results related to outcomes. In addition, some of the findings from these studies involved embedded roles of APNs and other professionals where the SOP was not clearly defined, so conclusions regarding outcomes are limited and cannot be attributed solely to APNs. The results of this research should help to raise the profile of multimorbidity and complex chronic conditions in younger and middle-aged adults in healthcare systems and review the role of APNs in the care of this patient group in hospital and beyond the inpatient setting. As the number of young and adult patients with multimorbidity and complex chronic conditions increases, healthcare systems and services should focus more on the treatment and care needs of young and middle-aged adults.89 This current knowledge of this scoping review can be used as an initial step for the development of a future APN role within an APN-led care model for this patient population in clinical settings. Further investigations are needed to clarify the role of APNs within APN-led models of care, particularly facing the care needs of these patients.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information. Not applicable.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to thank the scientific librarian Dr Thomas Fürst for his contribution to the search strategy, Ellen Ewers for her assistance with screening the full texts and Birgit Schönfelder for her help with revising the article.
References
Footnotes
X @BalesGabriele
Contributors GB was responsible for drafting the manuscript and is the guarantor. GB carried out the literature research. Advice on developing a search strategy was sought from an academic librarian of the University Library of Basel in Switzerland. Inclusion and exclusion of the full-text articles was reached by consensus of GB and an independent reviewer. In case of disagreement on eligibility between the two reviewers, then the article was discussed with the coauthor WH. Data were extracted and analysed by GB. WH, RWK and HM were responsible for the critical revision of the manuscript, advised, edited and made substantial amendments. RWK and HM supervised the scoping review.
Funding Open access funding provided by University of Vienna.
Competing interests None declared.
Patient and public involvement Neither patients nor the public were engaged in the development of this scoping review.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.