To what extent do primary care practice nurses act as case managers lifestyle counselling regarding weight management? A systematic review

A computerized literature search of multiple electronic databases was performed (MEDLINE, PsycINFO) with EBSCO-host as resource for relevant papers published between 1 January 1995 and 1 July 2013, using the following keywords as search strategy in the title or abstract (Table 1). The year 1995 was chosen, because PNs were introduced into primary health care in the nineties. This review is a first approach for carefully examining the role of PN as case manager lifestyle counselling regarding weight management, based on an overview about the description of the actual role of PNs in lifestyle counselling and its cooperation with other health professionals. We also checked Cochrane library for relevant reviews.

Studies had to be peer-reviewed journal articles, which addressed PNs’ involvement in lifestyle counselling in primary care. Only studies published in English language and original papers were included, of which full text was available. The review excluded studies that were based in hospitals, studies among children, and studies about patients’ perceptions.

After the electronic database search by one reviewer (SvD), reference lists of articles and reviews were screened for other potentially relevant papers. Figure 1 shows the flow chart for study selection.

Data extraction of main characteristics was performed, namely:

Two reviewers (SvD and GH) independently assessed study quality of selected studies. The studies were judged on the following quality criteria, which were applied before in a review study among GPs [4]:

A maximum score of ten plusses could be achieved. Studies with eight plusses or more were seen as high quality. Studies with five, six or seven plusses were considered as medium quality studies, and studies with four or less plusses were considered as low quality studies. Although arbitrary, this quality assessment was done by two independent researchers, who compared results and reached consensus.

The results were viewed against conditions for acting as case manager lifestyle counselling regarding weight management in primary care [15]:

An additional file shows the main characteristics in more detail [see Additional file 1]. Thirty-three studies were performed in Europe, specifically in the UK (18 studies) and the Netherlands (10 studies). Six studies were done in Australia and five studies in the USA.

Our review delivered a wealth of studies (45 in total), which all concerned cross-sectional studies. The cross-sectional study of Philips et al. (2009) [16] was also accompanied by a longitudinal study. Both qualitative and quantitative studies were found, with slightly more quantitative studies. Twelve RCTs were found and four national surveys. Next to mail questionnaires, we also found observations, focus groups, and interviews. This order of scientific rigidity will be followed in the evaluation and discussion of the results.

Samples ranged between 1 [17] and 606 PNs [18]. Most studies were published after 2000, especially in the last three years.

All 45 studies found were indeed discussing PNs’ actual role in lifestyle counselling in primary care. Outcomes of these studies were classified into three categories: positive, neutral, and negative. In order to be evaluated as “positive”, the study should show that PNs’ role in lifestyle counselling is warranted. An additional file shows in more detail that the majority of studies were positive about PN’s actual role in lifestyle counselling in primary care [see Additional file 1]. Twenty-six studies demonstrated that PNs’ role in lifestyle counselling is warranted. Furthermore, 10 out of 12 RCTs with an intervention by PNs resulted in positive outcomes. Six intervention studies in the UK and the Netherlands showed that PNs can achieve equally good health outcomes as GPs for different kinds of diseases [19]-[24]. More intensive interventions initiated the most changes [25]. Three other intervention studies revealed that consultations with PNs were significantly longer than those of GPs, and patients were significantly more satisfied with PNs’ care [26]-[28]. Two surveys showed that British PNs reported high levels of physical activity counselling [29],[30] and three other surveys revealed that physical activity counselling increased in recent years in the USA [18],[31],[32]. Two observational studies comparing PNs’ and GPs’ counselling practices showed that Finnish and Dutch PNs more often discussed diet and physical activity than GPs [33],[34]. In the UK, PNs and GPs agreed that PNs have main responsibility to cardiovascular health promotion [35], and weight management was considered as just one aspect of the busy and diverse role of the PN [36]. Australian PNs performed at least six roles, often alternating rapidly between them [16].

However, eight studies were neutral about PNs’ actual role in lifestyle counseling in primary care. According to these studies, parts of the role of PNs in lifestyle counselling in primary care are debatable. A survey among PNs and GPs in Ireland showed that there is some congruence in opinion regarding current role of the PN [37]. Although British PNs were more likely to raise weight issues than GPs, only 9% self-reported to present solutions or discuss health promotion [38], and weight management seems to be based on brief opportunistic intervention undertaken mainly by PNs [39]. Interviews with American PNs identified that realities of PN practice were often different from idealized practice, role identity was considered as ambiguous, and a need to blend medical and nursing models [40].

Moreover, eleven studies were negative about PNs’ actual role in lifestyle counseling in primary care. These studies showed that PNs’ role in lifestyle counselling in primary care seems to be limited. Two RCTs found no outcomes of a intervention by PNs. A RCT showed that adding nurse practitioners (NPs) to Dutch general practice teams did not reduce GPs’ workload, implying that NPs are used as supplements, rather than substitutes [41]. Another RCT showed that follow-up by PNs in the UK does not necessarily translate into better care or clinical outcomes [42]. Results from a national survey in Australia showed that PNs are a clinically experienced workforce whose skills are not optimally harnessed to improve care of growing number of people with chronic conditions [43]. Another national survey among American GPs and PNs indicated that they do not agree about their respective roles in delivery of primary care for complex chronic conditions [12]. The majority of Australian PNs agreed in a survey that PNs’ role could be expanded to include autonomous functioning, while most GPs were amenable to some extension of nursing practice [44]. Regarding weight management, PNs in the UK self-reported that they mainly offer general nutrition and exercise advice [45], and GPs and PNs in another British survey showed diversity with respect to their own relative importance in weight management [46].

Fourteen studies were found to answer the second research question. In all these studies, the relationship with GPs was described. In six studies, it was explicitly mentioned that PNs worked under supervision of a GP [16],[22],[23],[34],[44],[47]. In a Dutch intervention study for example, NPs intensively guided behavioral change process, while GPs oversaw patients’ progress [22]. A national survey showed that for all referrals made to medical specialists, a GP was involved in the nurse-patient encounter [47]. They concluded that greater flexibility in PNs’ role will maximize efficient use of nurses’ skills in primary health care context in Australia. In Ireland, over 85% of PNs and GPs surveyed appear to have an agenda in chronic disease management, and strong primary care teams are under development [37]. Most GPs in the UK seem to refer obese patients to their PN instead of using external sources of support [39]. NPs interviewed in Canada described their expectation in collegial partnerships with GPs, but in reality they work in more traditional hierarchical relationships [48]. Besides GPs, cooperation with dieticians was discovered in eight studies [22],[23],[34],[36],[39],[46],[49],[50]. Collaboration with several disciplines in general practice, like dietician, was perceived as an important facilitator in interviews with Dutch PNs and GPs [49]. Australian PNs were reluctant to cross professional boundaries: they often refer to ‘‘not being a dietician”, when explaining the scope of their own practice [50]. Another collaboration partner appeared to be the practice assistant (two studies). An observational study in Australia showed that PNs spent 45% of their time in contact with patients and 16% in contact with other general practice staff, including bridging the gap between clinical and administrative staff [16]. Interviewed PNs in the UK felt that health care assistants encroached their territory [51].

Studies in this review were assigned six plusses on average. Thirteen studies were perceived as high quality, 20 studies were considered as medium quality studies, and 12 studies were judged as low quality.

All studies had a clear description of study aim, and the majority had a well-developed or appropriate measurement instrument, suitable report of limitations, and an appropriate size of study population. Less than half of the studies had a good response rate, took efforts to optimize response rate, tested the measurement instrument before use, or had a sound selection of study population. Only few studies were representative.

All 45 papers discussed PNs’ actual role in lifestyle counselling in primary care, and addressed the first research question. Of these, 26 were positive, 8 were neutral, and 11 were negative. The 26 studies considered as positive, were of high or medium quality. Not all papers addressed PNs’ cooperation with other health professionals. Fourteen studies were found for answering the second research question. The studies found were of medium quality.

No study explicitly discussed PNs’ role as case manager in primary care. Conditions for acting as case manager in primary care were found in 27 studies.

With respect to the condition time (in relation to task), four studies showed that PNs have more time to provide lifestyle counselling than GPs [23],[33],[34],[39] and that frequency of PNs’ lifestyle counselling has increased in recent years [32]. However, six studies discussed time as a barrier for providing lifestyle counselling, of which five lack of time [40],[50],[52]-[54], but the majority of PNs in the study of Steptoe et al. (1999) [35] disagreed with the statement that they had no time for health promotion.

Regarding money, six studies identified funding as barrier for lifestyle counselling [18],[31],[32],[40],[43],[52]. According to PNs in the study of Donelan et al. (2013) [12], they should be paid equally for the same clinical service. However, PNs did not rank adequate reimbursement as being as important as GPs in influencing their decision to counsel [54].

According to the factor interest, PNs were generally positive towards lifestyle counselling. However, motivation of PNs to continue implementation of a Dutch lifestyle intervention was lower compared with GPs or physiotherapists [55].

Regarding expertise, six studies were found. Grimstvedt et al. (2012) [32] concluded that PNs were knowledgeable. An Australian national survey confirmed the generalist role with PNs seeing patients who have a wide range of chronic conditions [47]. However, there is clearly a tension among PNs and GPs to remain generalists and pressure to become primary care specialists in care of people with diabetes or coronary heart disease (CHD) [56]. Provision of simple lifestyle information and advice was predominant strategy used by PNs [53]. PNs self-reported they would benefit from further training about nutrition knowledge and obesity [36]. In the survey of Hankey et al. (2003) [46] both PNs and GPs felt that dieticians should hold specialist posts in weight management.

Moreover, nine studies dealt with competency issues. PNs were rather ambiguous about their role [43],[51]. Furthermore, both PNs and GPs did not agree on the PNs’ role [12],[16],[44],[46],[49] or showed only some congruence in opinion [37]. Australian PNs felt competent at providing basic nutrition care [50]. However, PNs had better interpersonal skills than GPs [16]. The review of Horrocks et al. (2002) [57] showed that NPs may have superior interpersonal skills than doctors.

With respect to type of intervention activity, the majority of studies reported on lifestyle counselling, while only eight included weight management [20],[22],[23],[36],[38],[39],[45],[46].

Further training is required before case management of chronic diseases in primary care becomes an integral part of the role of PNs in Ireland [37]. The majority of American NPs are interested in receiving additional training to aid in providing physical activity counselling [32]. Competency training in both general communication skills and motivational interviewing skills are recommended.

According to Frank (1998) [66], shifting the major responsibility to non-physician professionals may offer the most promising therapeutic opportunities for obesity management. A review including 11 studies showed that there is potential in primary care nursing to help patients manage obesity [67]. Recently, a study suggested that PNs are well placed to perform two key roles in obesity management, namely counselling patients who have obesity-related co-morbidities and identification of patients who are overweight and healthy [68]. Recently, an observational study identified that PNs’ goal setting could be improved [69]. The quality of PNs' weight loss counselling might be increased by routinely providing assistance in addressing barriers and securing support, and routinely reaching agreement with collaboratively set goals [70]. A multidisciplinary team approach to weight management is preferable, with training of PNs and specialized dieticians to address this issue [46]. Closer liaison with dietetic services could allow dietician expertise regarding weight management to be utilized more fully [36].

It seems to be crucial that members of the primary health care team agree on their respective roles, and feel this teamwork is feasible, attractive, and satisfactory. Monitoring these roles with quantitative studies is recommended.

In conclusion, because of the heterogeneity of the studies, the lack of (national) representative studies and the differences between countries (among other factors), there is no definite answer to the question whether or not the PN can act as case manager lifestyle counselling regarding weight management in primary care. It depends on the context of the situation and the country.