Nurse management of minor problems in primary care emergencies: a non-randomized controlled trial

Demographic and technological changes, an aging population, and changing health expectations, are common social elements in many countries that determine how citizens experience everything related to health and the processes of getting ill. This in turn affects how primary care (PC) services are used. Other characteristics of society today, such as a prevailing consumerist culture and the medicalization of health, which influence the frequency of consultations [1, 2] must not be forgotten. These challenges, coupled with the increase in chronic diseases and multimorbidity, along with the prevention through the promotion of healthy lifestyles and the substitution of hospital care with community-based care, have led countries around the world to develop new models of primary care delivery [3].

According to the primary health care activity monitoring programme Primary Health Care Activity Monitor for Europe (PHAMEU), funded by the European Commission and operating in 31 countries, PC is currently facing challenges, regardless of the delivery model, derived from a change in demand by the population, a change in the healthcare offer and changes in the financial and technological context [4, 5].

Furthermore, the global economic situation forces governments to reformulate the financing of health services that are under pressure, mainly due to socio-demographic changes. Among the reasons for the increased pressure on health services are the high rates of visits to PC. This is a phenomenon that has been covered by diverse literature from the last two decades [6, 7] and which has been conceptualized as a small subgroup of patients who consume most primary care services [8]. Care of emergencies coming to PC is a challenge in all health systems. In the United States, they amounted to 22% of the 1,090 million outpatient visits per year between 2001 and 2004 [9]. This increasing rate of consultations involves a high cost for public health systems, and a considerable workload and much frustration for general practitioners [10]. In this cross-sectional study conducted in Catalonia, Spain, based on 3,815 interviews with patients from 77 primary care centres, researchers linked frequent visit attendance to factors such as obtaining sick leave, reporting mental health problems, arthritis/rheumatism or bronchitis, among others. Furthermore, and according to a review of 61 articles, mostly from the United Kingdom, the United States and Scandinavia [11], 10% of the patients who attend most frequently represented between 30% and 50% of all consultations.

Health care pressure in primary care has required the reorganization of health professionals and their roles. In this global challenge, the historical evolution of knowledge in the nursing profession based on models and theories of care that support its practice, has abandoned the dependence that characterized it initially as a discipline of support for tasks complementary to medical work [12], in order to build the science of nursing [13]. This science, with a variety of definitions according to each of the theories that the history of nursing has been building, is the substantive knowledge specific to the discipline that focuses on the human health process articulated in nursing and which, according to each theory and its definitions, have as aims helping people to achieve, maintain and recover health (Rey Imogene), facilitate optimal well-being (Betty Neuman), compensate or overcome known or emerging health problems (Dorotea Orem) or promote human improvement in whatever state the person is found to be (Martha Rogers) [14]. It is from this science that nurses currently apply scientific reasoning to their nursing process for patient-centred care, by applying the five sequential steps: assessment, diagnosis, planning, implementation and evaluation [15]. The role of nursing and improvements in training are becoming valid tools for addressing the field of minor health problems. However, international differences in the training of nurses make it difficult to standardize care models due to a disparity in their competencies. In the United States, their advanced training and autonomous roles mean the provision of quality chronic care for patients with pathologies such as diabetes, hypertension, arthritis or asthma can be given, thereby achieving a reduction in the rate of hospital admissions [16]. It must be underlined that there is no data to suggest that nursing professionals in states that impose greater restrictions on their competencies provide safer and better care than those in less restrictive states [17]. These authors state that eighteen US states have liberalized and standardized legislation to expand independent practice and prescribing by nurses. Furthermore, and added to the capacity for nurses to address patients’ health problems, it is necessary to take into account the international evolution of prescribing medicines. Today, nurses can legally prescribe medications in quite a few countries, in some cases under specific circumstances; examples include Australia, Canada, Finland, Ireland, New Zealand, Norway, South Africa, Sweden, the Netherlands, the United Kingdom and the United States of America [18].

Over the last decades, several studies have compared the health care of doctors with that of nurses. A meta-analysis looked at care provided by nurses or midwives in primary care settings in the United States and Canada, with that provided by doctors. The results showed that the care provided by nurses achieved better treatment adherence and satisfaction [19]. Along the same lines, a more recent systematic review [20] indicated that nurses’ care was comparable to that of doctors, but also that nurses obtained better levels of satisfaction and spent more time on seeing patients.

The latest published systematic review by Laurant et al. [3] identified 18 randomized trials that showed that for some persistent physical ailments and chronic diseases, trained nurses provide equal or even better quality care than that offered by primary care practitioners, and they may even achieve better health outcomes.

In Spain, a four-year university degree is required to practise as a nurse, sufficient training to be able to autonomously and safely care for patients with minor acute illnesses [21]. Regional and national legal frameworks have also developed significantly since 2015 with regard to the ability of Spanish nurses to prescribe medications. Royal Decree 1302/2018 reoriented the state legal framework for the indication, use and authorization of dispensing by nurses with respect to certain medications subject to medical prescription through a marked collaborative nature and with the aim of trying to guarantee continuity of care and safety of any patient, and, on the other hand, modifying and expanding the requirements demanded to nursing in order to be able to prescribe.

In Spain, the bulk of health-related competences are transferred to its 17 autonomous communities, a progressive process carried out over 35 years that ended in 2001 [22]. Catalonia was one of the first regions to manage its health services. The Spanish government transferred these competences in 1981 through Royal Decree 1949/1980.

In the early 1990s, the Catalan Institute of Health (ICS), the largest public health services entity in Catalonia, began a process to maximise the professionalization of primary care nurses with the aim of adapting their services to the needs of the population. From that initiative emerged the first manual of standards for nursing diagnoses in PC [23]. This first initiative was updated in 2003 with the aim of facilitating the application of the nursing care process as a systematic method for planning and providing nursing care. Between 2005 and 2006, the ICS implemented the standardization of nursing diagnoses with the NANDA classifications, NIC nursing interventions and NOC (NNN) outcomes [24, 25]. Finally, in 2018, as a result of a broad internal study of the perception and opinion of PC nurses, it was evident that NNN language ​​has an insufficient level of clarity, ease of use and utility. For this reason, care plans are updated based on ATIC terminology [26], a Spanish acronym for Architecture, Terminology, Interface-Nurse-Information and Knowledge, currently in use in PC in Catalonia [27].

In parallel with this period of change, in 2009 the Catalan Department of Health promoted several measures aimed at improving the health system. The Primary Care and Community Health Innovation Plan involved a reorganization of the PC [28]. The objective was to improve economic sustainability and meet the growing demand of patients by referring them to the professional who could best respond within their area of ​​specialization [29]. At this stage, the gradual opening of Primary Care Emergency Centres (PCEC) began in strategically demographic points within Catalonia, intended to address minor and non-serious health problems, open 24 h a day, 365 days a year, and supporting both primary care and hospital emergency services. Within this period of healthcare reorganization in Catalonia, the concept of Nurse Demand Management (NDM) was born [30], a programme led by primary care nurses to address minor health problems. A set of health problems such as minor emergency situations that may be potentially complex, but without life-threatening risk, or non-urgent situations that allow for delayed care and can be scheduled without risk to the patient [31]. This programme is based on agreed protocols and the standardization of diagnoses where the nurse can resolve this demand without the intervention of a doctor and within their area of ​​expertise. In 2016, the ARES-AP (Treatment Standards Harmonization Program) computer tool was deployed in PC [27, 32], an application that collects all the standardized treatment plans. It is designed using ATIC language for nurses to use within their nursing process methodology, in which they make clinical decisions aimed at identifying and resolving or preventing health problems, based on the assessment, diagnosis, planning, execution and evaluation of health problems [25].

In Catalonia, and to the best our knowledge, there has been only one randomized trial comparing the effectiveness of care provided by nurses with the usual care provided by general practitioners. In that study, the nurses demonstrated a capacity for resolution, with success in 86% of the cases while no differences were observed in the resolution of symptoms or satisfaction of patients between groups [33]. This study was carried out before the implementation of the NDM.

Thanks to the results of the implementation of the NDM and the public satisfaction rates, currently 30 paediatric and 36 adult protocols are active in the computerized clinical history software programme (ECAP) of the Catalan Institute of Health.

In the Catalan area, the literature offers results from various transversal studies that agree on the ability of Catalan nurses to solve minor health problems, among which we highlight, on the one hand extensive multi-centre retrospective work by Fernández Molero et al. [34] that included data from medical records between 2019 and 2020 and in which 392 primary care areas of the Catalan Institute of Health participated. In this case, the NDM protocols were fully in force and minor health problems resolved by nurses were 50.9% of adult patients and 55.4% of paediatric patients. However, one of the limitations of this study, which the authors recognized, was not recording the rate of other consultations afterwards for the same reasons. This is a variable that we consider a key element in evaluating the resolution capacity of the NDM. On the other hand, we also highlight the longitudinal study with a 3-year follow-up carried out by Jurado-Campos et al. [35] in which they showed resolved cases increased and the number of other consultations afterwards decreased, concluding that nursing capacity for managing the demand of patients without an appointment improved following an interdisciplinary intervention using a mutually agreed upon and locally adapted approach.

The objective of this study was to determine if the implementation of the NDM in a PCEC improved the efficiency and quality of care.

The Primary Care Emergency Centre (PCEC) serves a population of 270,000 inhabitants of the Maresme region, in the province of Barcelona, in the autonomous community of Catalonia, Spain [36]. The PCEC is located in the municipality of Mataró and started operating in May 2021. Since it opened, it has seen more than 100,000 patients, with it being considered a key piece within the territory’s health system. Its management depends on the Catalan Institute of Health. Potential participants for this study were patients assigned to the demographic area of influence of the health centre.

The protocol for the study was registered retrospectively registered February 29, 2024 in the CinicalTrials.gov (CT) database of the US National Library of Medicine (NIH) with registration number NCT06298240.

The objective of this study was to determine if the implementation of the NDM in a PCEC improved the efficiency and quality of care. The criteria used for the evaluation were waiting times, health care time, patient satisfaction and the consultation rate afterwards for the same reason.

This study focused on the care of patients who were classified as low severity and priority for care after the MAT triage process, which was mandatory and prior to any visit, medical or nursing, at the PCEC. In cases where patients were classified with a triage ≥ 3, they could be treated under the usual medical discipline, or according to the needs of the emergency service, care was provided with the NDM procedure, where nurses apply nursing science within their methodology of the nursing process through standardized treatment plans [32], designed from language used in ATIC [26].

Consultations made by nurses and doctors were of similar severity. Various literature confirms the ability of nurses to care for patients minor health problems, demonstrating a high level of care, similar to that of general practitioners. These are the conclusions of the randomized studies by (Kinnersley et al., 2000; Shun et al.,2000) [43, 44], which are confirmed in the studies carried out in Catalonia by (Iglesias et al., 2013; Fabrellas et al., 2011) [33, 45].

With regards to the reasons for consultation selected for our study, it is worth mentioning that during the recruitment totalled a prevalence of 21.86%. Upper respiratory tract problems were the most prevalent (acute laryngitis, upper respiratory tract infections, pharyngeal pain or acute pharyngitis, cough, acute streptococcal tonsillitis, tonsillitis, rhinopharyngitis, viral infection and COVID), with a rate of 11.93%. In second place, urinary problems (acute cystitis without haematuria or urinary tract infection) with 3.21%; in third place, gastrointestinal disorders (vomiting, diarrhoea or gastroenteritis and infectious or non-infectious colitis) 2.30%; and finally, toothache 0.77%. This prevalence data shows the impact of minor health problems on acute demand in PC and leads to reflection on the importance of reinforcing health education as a measure to reduce demand [46]. Following this line of discussion, addressing hyper-frequency and care pressure in PC is the task of all professionals, and necessarily implies adapting tasks to different professional profiles. In this regard, care for frequent problems with low clinical risk, preventive activity and control of chronic processes can be taken care of by nursing [47].

Regarding the specific results of the four reasons for being seen, upper respiratory tract problems were in the majority for the entire sample with 68.9%. This result is related to the winter months and the flu and COVID peaks of 2022 and 2023 and which, like other years, activated the usual mechanisms contemplated in the Comprehensive Emergency Plan of Catalonia (PIUC) to address these periods of greater demand due to respiratory pathologies. Gastrointestinal disorders accounted for 16.7%, toothache for 8.3%, and urinary problems for 6.1%. As far as wounds are concerned and which were contemplated in the initial project of the study, they were finally not used as it is understood in our emergency centre that they are consultations that nursing cares autonomously (simple sutures or care of non-complex acute wounds) and which are generally only addressed by doctors when there is a complication such as a fracture, functional loss, neuromuscular or venous-arterial issues, cellulitis, etc. Given this, and in order not to interfere with the usual dynamics of the centre, we decided to not use them in this study.

In relation to the time dedicated to the visit, although we detected that nurses spent an average of 65 s more on the visit than their medical colleagues, the results indicate that there is no statistical difference between both professionals. It is true that some studies have found that the time invested by nurses on consultations is greater than that invested by doctors. Furthermore, this extra time is perceived by patients as an increase in the quality of care [3]. At the same time, the review by Karimi-Shahanjarini et al. [48] detected, in the majority of the 69 studies analysed, that patients thought that nursing professionals were more accessible than doctors. For their part, doctors and nurses considered that this substitution, when done with a collaborative attitude, increased the quality and continuity of patient care.

However, the fact that the nursing time invested in solving minor health problems is similar to that used in the usual interventions until now, by doctors, would imply that the care carried out by nurses would not mean an increase in resources due to the fact that it is carried out by different professionals. This leads us to reflect on the potential of implementing a fixed NDM consultation in the future, as a way of improving patient care by better distributing the medical and nursing care burdens.

The results of the study in relation to the efficiency of the NDM, based on the waiting time criterion, show that in the consultations made by nurses the delay in being seen decreased for all reasons for the consultations. Nursing showed a clear difference with their medical colleagues regarding the waiting time for patients before being seen. The experimental group reported shorter wait times for their patients, with 69% who waited less than 15 min to be seen, compared to 34.4% of the control group, treated by doctors. Therefore, an increase of 34.6% was found for the NDM consultation.

In the second evaluation criterion, related to the quality of care based on the frequency of consultations for the same health problem in the subsequent 15 days, we analysed whether the treatments proposed by nurses and doctors were effective. To do this, we reviewed the computerized clinical records of all participants. Some 13% of the total sample visited again for the same reason. In this analysis we see similar quality results in both groups. A proportion of 12.82% of NDM patients visited for the same reason, and of these, only 7.6% required a modification of treatment, prescription or request for new tests. In the control group, the percentage of consultations for the same reason was 13.46%; of these, only 6.41% required changes with respect to the initial visit. In line with these results, we find those of the study carried out by Fabrellas et al. [45] that also detected low rates of return of patients from a nursing management programme for same-day consultation, with 16 reasons for adults and 7 in paediatrics, with a rate of 3% in adult patients seen for back pain, nosebleeds, skin lesions and burns and 2% in paediatrics, seen for skin lesions and burns.

Some 53% of the visits made for the same reason did not imply a change in diagnosis or relevant medicines compared to the first visit in either group. This result invites us to reflect on the social change that citizens are experiencing in their way of facing the process of becoming sick and the use of health services. On the one hand, the consumerist and immediacy culture of today’s society reinforces the over-medicalization of mild acute pathologies or situations of personal or work discomfort, etc. On the other hand, the social-healthcare reality which is characterized by an increase in the prevalence of comorbidity and fragility, linked to aging, with more informed patients, who want to participate in the decisions that affect their health, in an increasingly digitalized society [49]. The care of patients in primary care consultations is a multi-causal phenomenon influenced by the social environment, health organizations and professionals [50]. Healthcare organizations and their professionals must face these new challenges with more cohesive teams and new professional profiles.

Understanding the patient’s experience during the health care they receive, known as the patient journey [51], allows for the optimization of care processes and the detection of points that negatively impact their experience, and understanding their needs, demands and real concerns. To obtain greater knowledge of this experience, the participants were surveyed on the day of the visit, and also a month later. In the survey on the day of the visit, participant satisfaction was higher in the group treated by nurses (9.81) than in the group treated by medicine (9.33). The most plausible explanation for this result is linked to a shorter waiting time between priority care detection phase and being seen, compared to the consultation with a doctor, where the wait was longer. On the other hand, the survey carried out 30 days after the visit shows that there are no differences in satisfaction between the two groups. Two possible explanations for this change, produced by the passage of time, we believe may be, on the one hand, that the patient may have a clearer perspective 30 days after the visit, once the entire global process of the health problem has been completed; but, also, memory of the visit decreases after several weeks. There is little evidence on the effects of memory over long periods, but it can be expected that memory decreases over time and that respondents remember less after several weeks or months, as suggested by the work of Rettig et al., [52]. To reduce possible recall biases, at the time of the survey carried out one month after the visit, the patient was informed of details such as the date and time of the visit, the signing of the consent, the first quality survey answered, the reason for the consultation, the medication prescribed and whether there was any subsequent visit for the same reason in the clinical record. In this way, an attempt was made to refresh the patient’s memory in order to obtain a higher quality response. In this second survey, seven specific aspects of care were evaluated, looking for the strengths and weaknesses of the patient experience. The ratings of 6 of the 7 points were not different in the two groups, as shown in Table 3. However, the last aspect explored shows an unexpected result. To the question about whether the patients considered that the visit would have been more effective if it had been carried out by another health professional, 15.4% of the group seen by nurses responded that they believed that a doctor would have cared for them better; versus 46.34% of the group seen by doctors who considered that a nurse would have treated them as well as a doctor. This makes us think that patients are increasingly accepting nursing’s ability to treat minor health problems with quality. As we have mentioned in the introduction of this study, in Spain, a four-year university degree is required to practice as a nurse. Beyond this education, post-university nursing specialties are active, such as obstetrics and gynecology, mental health, occupational health, geriatrics, pediatrics, and family and community health, which require a two-year residency. In addition to the development of these specialties, Spanish nursing is also advancing in its collaborative role with doctors and other healthcare professionals, training and applying advanced clinical practice in areas such as case management in both hospital and community settings, home care [53, 54], or the management of chronic and acute patients in primary care [55]. All of this has a positive impact on the quality of healthcare patients receive and their satisfaction with nursing care.

Consistent with the results of our study, a multi-centre randomized controlled trial is cited that evaluated the acceptability and safety of a nurse-led minor illness service in the United Kingdom [44] where patients agreed with our study in being more satisfied in terms of quality in consultations with nurses, but where the clinical results did not find differences between nursing and medicine.

The results obtained regarding prescriptions given by nurses indicate that patients maintained a perception of quality during the consultation or had a similar number of subsequent consultations for the same reasons as their medical colleagues, but with a lower number of prescribed medications. In the experimental group, an average of 1.79 medicines were prescribed, compared to the control group, where the average was 2.26. This is a clearly significant difference (p < 0.001). These results lead us to think that the NDM also has potential as an instrument to increase the efficiency and quality of health services in terms of pharmacological prescription. Despite this result, and as we have already commented previously, we believe it is necessary to point out that social changes and polymedication [56, 57] mean that health professionals are often confronted with the erroneous perception of some patients who measure quality of care from doctors or nurses based on the quantity of medicines prescribed, notwithstanding their best efforts to promote reasonable use of medication.

The results of the study suggest that the implementation of Nurse Demand Management (NDM) was a factor in improving the efficiency and quality of care in the Primary Care Emergency Centre (PCEC). The capacity of nurses for resolution has been shown by the results in the low rate of consultations for the same reason afterwards, a decrease in the prescription of medicines and incapacity for work, and a level of satisfaction comparable to the care provided by doctors.

These results should be considered with caution since the project was carried out in a small territory, specifically in the municipality of Mataró, in the autonomous community of Catalonia, Spain. As such, we consider that a second multi-centre experimental project is needed to analyse the potential of the NDM extrapolated to PC emergencies in a wider territory.