The Patient

1. Start with the patient -- a clinical problem or question arises out of the care of the patient.

The Hospital Board wants to provide more services in outpatient settings and has determined through a community needs assessment that a Rheumatology clinic is needed. However there is concern among the Board members that they will not be able to recruit a physician Rheumatologist to staff the clinic.  The Nurse Administrator has proposed that the clinic be staffed with a Nurse Practitioner instead of a physician. Several Board members raise objections to this idea and are concerned about whether Nurse Practitioners can provide the same quality of care and whether patients will be satisfied with seeing a nurse rather than a doctor. They want to know if this has ever been done in other clinics and is there any evidence that shows the effectiveness of using nurse practitioners. The Board asks the Nurse Administrator to gather some information and make a presentation at the next meeting.

The Question

2. Construct a well-built clinical question derived from the case.

Based on this scenario, choose the best, well-built clinical question:

A. What are good strategies for recruiting rheumatologists to work in community-based outpatient clinic?

B. How effective are nurse practitioners in outpatient clinics?

C. In an outpatient, clinical setting, how effective are nurse practitioners in providing quality care and achieving patient satisfaction?

The Resource

3. Select the appropriate resource(s) and conduct a search

The Evaluation

4. Appraise the evidence for its validity (closeness to the truth) and its applicability (usefulness in clinical practice).

Read the following article, then determine if the article properly addresses the issues of validity. As we stated previously, evaluating the medical literature is a complex undertaking. You will find that the answers to the questions of validity may not always be clearly stated in the article and that you may have to use your own judgment about the importance and significance of each question.

J. Hill, H.A. Bird, R. Harmer, V. Wright and C. Lawton. An evaluation of the effectiveness, safety and acceptability of a nurse practitioner in a Rheumatology Outpatient Clinic. British Journal of Rheumatology. 33:283-88, 1994.

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Permission to use parts of this article was generously given by the authors and The British Society for Rheumatology.

1. Randomization:: Was the assignment of patients to treatment randomized?

2. Patient follow-up:  Were all patients who entered the trial properly accounted and attributed for at its conclusion?

3. Analysis of patients:  Were patients analyzed in the groups to which they were randomized?

4. Blinding:  Were patients, health workers, and study personnel "blind" to treatment?

5. Baseline characteristics of patients:  Were groups similar at the start of the trial?

6. Treatments:  Aside from the experimental intervention, were the groups treated equally?

Are the results of this study valid?

This covers the first aspect of evaluating the evidence. There are two additional questions that you, as clinicians, need to consider:

1. What are the Results of the study?

   By study end (week 48), both groups of patients had a similar reduction in mean PV and duration of morning stiffness as well as similar improvements in AI, physical function scores, and psychological assessment scores. Compared with the CR group, the RNP group had a better mean pain score (2.2 vs. 2.7; P for the 0.5 difference = 0.05), increased knowledge of their disease (P less than 0.001), and higher overall satisfaction with their care (P less than 0.001). The groups did not differ for safety outcomes.

   Conclusion: Patients with rheumatoid arthritis who were monitored by a rheumatology nurse practitioner had greater improvement in measures of pain, knowledge, and satisfaction than patients receiving conventional care from a consultant rheumatologist.

   Reprinted with permission from the American College of Physicians. (ACP Journal Club, 121:45, Sept.-Oct. 1994)

2. Are the Results applicable to your patients?

   In this case, the patients are those people who would be attending the Rheumatology clinic. Given the concerns of the Board for staffing this clinic and the results of this study, which showed a high degree of satisfaction with the Nurse Practitioners, it would seem that using Nurse Practitioners is a reasonable alternative to consider.

The Patient

5. Return to the patient -- integrate the evidence and clinical expertise, patient preferences and apply it to practice.