A substantial part of cardiovascular disease prevention is delivered in primary care. Special attention should be paid to the assessment of cardiovascular risk factors. According to the Dutch guideline for cardiovascular risk management, the heavy workload of cardiovascular risk management for GPs could be shared with advanced practice nurses. AimTo investigate the clinical effectiveness of practice nurses acting as substitutes for GPs in cardiovascular risk management after 1 year of follow-up. Design of studyProspective pragmatic randomised trial. SettingPrimary care in the south of the Netherlands. Six centres (25 GPs, six nurses) participated. MethodA total of 1626 potentially eligible patients at high risk for cardiovascular disease were randomised to a practice nurse group (n = 808) or a GP group (n = 818) in 2006. In total, 701 patients were included in the trial. The Dutch guideline for cardiovascular risk management was used as the protocol, with standardised techniques for risk assessment. Changes in the following risk factors after 1 year were measured: lipids, systolic blood pressure, and body mass index. In addition, patients in the GP group received a brief questionnaire. ResultsA larger decrease in the mean level of risk factors was observed in the practice nurse group compared with the GP group. After controlling for confounders, only the larger decrease in total cholesterol in the practice nurse group was statistically significant (P = 0.01, twosided). ConclusionAdvanced practice nurses are achieving results, equal to or better than GPs for the management of risk factors. The findings of this study support the involvement of practice nurses in cardiovascular risk management in Dutch primary care.

Background Women with newly diagnosed breast cancer face multiple treatment options. Involving them in a shared decision-making (SDM) process is essential. The aim of this study was to evaluate whether a multilevel implementation programme enhanced the level of SDM behaviour of clinicians observed in consultations. Methods This before–after study was conducted in six Dutch hospitals. Patients with breast cancer who were facing a decision on surgery or neoadjuvant systemic treatment between April 2016 and September 2017 were included, and provided informed consent. Audio recordings of consultations made before and after implementation were analysed using the five-item Observing Patient Involvement in Decision-Making (OPTION-5) instrument to assess whether clinicians adopted new behaviour needed for applying SDM. Patients scored their perceived level of SDM, using the nine-item Shared Decision-Making Questionnaire (SDM-Q-9). Hospital, duration of the consultation(s), age, and number of consultations per patient that might influence OPTION-5 scores were investigated using linear regression analysis. Results Consultations of 139 patients were audiotaped, including 80 before and 59 after implementation. Mean (s.d.) OPTION-5 scores, expressed on a 0–100 scale, increased from 38.3 (15.0) at baseline to 53.2 (14.8) 1 year after implementation (mean difference (MD) 14.9, 95 per cent c.i. 9.9 to 19.9). SDM-Q-9 scores of 105 patients (75.5 per cent) (72 before and 33 after implementation) were high and showed no significant changes (91.3 versus 87.6; MD −3.7, −9.3 to 1.9). The implementation programme had an association with OPTION-5 scores (β = 14.2, P < 0.001), hospital (β = 2.2, P = 0.002), and consultation time (β = 0.2, P < 0.001). Conclusion A multilevel implementation programme supporting SDM in breast cancer care increased the adoption of SDM behaviour of clinicians in consultations.

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voogdt‐pruis h.r., beusmans g.h.m.i., gorgels a.p.m. & van ree j.w. (2011) Experiences of doctors and nurses implementing nurse‐delivered cardiovascular prevention in primary care: a qualitative study. Journal of Advanced Nursing 67(8), 1758–1766. Abstract Aim.  This paper reports on a study of the experiences of general practitioners and practice nurses implementing nurse‐delivered cardiovascular prevention to high risk patients in primary care. Background.  Difficulties may arise when innovations are introduced into routine daily practice. Whether or not implementation is successful is determined by different factors related to caregivers, patients, type of innovation and context. Methods.  A qualitative study nested in a randomized trial (2006–2008) to evaluate the effectiveness of nurse‐delivered cardiovascular prevention. Six primary health care centres in the Netherlands (25 general practitioners, 6 practice nurses) participated in the trial. Interviews were held on two occasions: at 3 and at 18 months after commencement of consultation. The first occasion was a group interview with six practice nurses. The second consisted of semi‐structured interviews with one general practitioner and one practice nurse from each centre. Findings.  Main barriers to the implementation included: lack of knowledge about the guideline, attitudes towards treatment targets, lack of communication, insufficient coaching by doctors, content of life style advice. At the start of the consultation project, practice nurses expressed concern of losing nursing tasks. Other barriers were related to patients (lack of motivation), the guideline (target population) and organizational issues (insufficient patient recording and computer systems). Conclusions.  Both general practitioners and practice nurses were positive about nurse‐delivered cardiovascular prevention in primary care. Nurses could play an important role in successive removal of barriers to implementation of cardiovascular prevention. Mutual confidence between care providers in the healthcare team is necessary.

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