- June 15, 2020
Benefits of Peritoneal Nurse-Led Clinics By,
Benefits of Peritoneal Nurse-Led Clinics 13
Benefits of Peritoneal Nurse-Led Clinics
A dissertation on:
Exploring the benefits of implementing peritoneal nurse ledclinics in the health services to improve peritoneal dialysispatient`s quality of life
The increase in the cases of chronic kidney infections across theglobe necessitated the development of nurse-led clinics. Theadvantages attributed to the outpatient clinics managed by registerednurses coupled with the severity of chronic diseases are consideredto have been the primary factors for the development of a frameworkof treatment that would assist patients undergoing peritonealdialysis. The holistic care provided by the medical professionals wasan indication of the level of attention that was needed in order toimprove the survival of patients in the health facilities. This studywill focus on the evaluation of benefits of implementing peritonealnurse-led clinics in the health services to improve peritonealdialysis patient`s quality of life. An extensive analysis of theliterature review indicated that various advantages could beattributed to the nurse-led clinics in improving the standards ofliving of the patients. The improvements were notable regarding theirphysical appearances and social wellbeing. This paper is thereforeaimed at highlighting the impact of the peritoneal nurse-led clinicsin facilitating the improvement of the quality of life among thepatients undergoing peritoneal dialysis.
I would like to express my special thanks of gratitude toDr. Charles Victor (Specialist Nephrology- Ibra Hospital) andteachers from Cardiff University and OSNI, as well as my academicsupervisor from the UK, who gave me the golden opportunity to do thiswonderful project on the topic “Exploring the benefits ofimplementing peritoneal nurse led clinics in the health services toimprove peritoneal dialysis patient`s quality of life.” They helpedme in doing a lot of research, and I came to know about so many newthings. I am really thankful to them. Finally, I would also like tothank my parents and friends who helped me a lot in finalizing thisproject within the provided time frame.
CHAPTER ONE 7
Aim of the Dissertation 12
Dissertation Question 12
CHAPTER TWO 14
Literature Review 14
Search Strategies 15
Improving quality of Life of Patients 17
Summary of Literature Review 23
Recommendations for service improvement in the locality 24
Cost Effectiveness 24
Patient’s Decision Making Process 25
CHAPTER THREE 26
3.1 Introduction 26
3.2 Service Improvement 27
3.3 Leadership in Healthcare and Service Improvements 29
3.4 Leadership Theories and Styles 30
3.4.1 The Great Man Theory 30
3.4.2 Trait Theories 31
3.4.3 Contingency Theories 31
3.4.4 Situational Theories 31
3.4.5 Behavioral Theories 32
3.4.6 Participative Theories 32
3.4.7 Management Theories 32
3.4.8 Relationship Theories 33
3.5 Introducing peritoneal dialysis nurse-led clinics in the local health organization 34
Before the discovery of dialysis, failure of the kidney was criticaland led to death. However, through extensive investments in research,viable options have been identified. Currently, patients sufferingfrom kidney failure are able to seek treatment alternatives. One suchprocess is known as dialysis. It refers to a medical practice inwhich the blood in the body is cleaned despite the inability of thekidneys to function appropriately. Some of the components that areeliminated through this process include extra salt and water as wellas other wastes. There are two major kinds of dialysis that can beadministered to a patient. Haemodialyis is the process through whichblood is pumped out of the body into an artificial kidney andthereafter returned to the body system using tubes that have beenconnected to the machine. On the other hand, peritoneal dialysis usesthe inside lining of the belly as a natural filter. In order toeliminate wastes from the body, dialysate is passed through the bellyin cycles. For the process to be effective, a catheter is passedthrough the belly through surgery. Thereafter, the tube is used topass the cleansing fluid to the belly. After the process is complete,the fluid is allowed to leave the body.
Despite the common assumptions that the number of patients undergoingperitoneal dialysis across the globe, there are no conclusive resultsto show the variations. The argument has been that the availabilityof such services is extensively limited by the lack of resources inmany locations around the world (Jain et al., 2012:1). Thedevelopment of a framework that promotes the provision of services topatients should take into consideration the patterns of peritonealdialysis (PD) as this would go a long way in assisting in themanagement of ESRD (Jain et al., 2012:1). This process is not onlyimportant to the patients but also the regulatory the medicalregulatory authorities that can use such information to ensurecompare the performance of a country’s PD program with others.
Chaudhary (2012) noted that the substantial increase in the costs ofproviding treatment had led the Center for Medicare and MedicaidServices (CMS) to declare a new payment scheme for dialysistreatments. According to the new policies, it was necessary to makesingle payments for peritoneal dialysis irrespective of whether theservice was provided at home or within a health facility (Chaudhary,2012). He recognized that PD was relatively less expensive comparedto hemodialysis (HD). The variations in the costs incurred wereattributed to a variety of reasons. To begin is considered to lesslabor intensive for the nurses since family and relatives are taskedwith the provision of the most proportion of labor. Moreover, thesupplies utilized in the provision of such services are lessexpensive (Chaudhary, 2012).
There are two major types of peritoneal dialysis. The ContinuousAmbulatory Peritoneal Dialysis (CAPD) happens the entire day as onegoes about their daily lives. In this case, approximately between 1.5liters and 3 liters are run through the body three or four timesdaily. During this time, fluids from the previous exchange arereplaced. The entire process lasts between 30 and 40 minutes(Ballinger et al., 2014). Automated Peritoneal Dialysis (APD) refersto the course of transferring kidney fluids that are accomplished bya machine. In this case, the dialysate solution is transferred by adevice as soon as the patient is asleep. During this period, thedevice is likely to exchange over ten liters of the fluids within agiven period. This might take between eight and ten hours tocomplete. The peritoneal led nurses should be trained on the mostappropriate ways to deal with the patients and limit the occurrencesof accidents that may be experienced as a result of negligence.
A peritoneal dialysis fluid refers to a solution of sugar thatcontains additional salts. The bags are in three major strengthsnamely 1.36%, 2.27% and 3.86% or light, medium and heavy (Chow &Wong, 2010). The heavier the bag, the higher the amount of water thatwill be removed from the body. Therefore, patients with high levelsof fluids in their bodies are encouraged to use heavy bags to reducesuch fluids. For those that are experiencing dehydration, it isrecommended that they should use light bags to ensure that theprocess of dialysis does not eliminate fluid. Therapy is needed forthe diabetic patients since the sugar solution may affect themnegatively in the long run.
However, various problems are associated with peritoneal dialysis(Chow & Wong, 2010). The first major challenge is experienced ininstances where there are fluid leaks in areas around the groin. Suchleaks may also be witnessed around the catheter when the processstarts. However, they are easy to manage and do not pose asignificant threat to the patients. Infections may also arise andcompromise the recovery process of the patient. The infections aremostly based on the patient’s exit site or in the tummy. It mayresult in pain in the belly and the need for immediate medicaltreatment. The nurses have been trained to ensure that they ring thekidney unit as soon as cloudy bags develop. The pain in the stomach,known as peritonitis is treated by antibiotics. The entire processmay require admission to the hospital for a few days (Chow &Wong, 2010). It is only in rare instances whereby the condition mightget serious to the point that the catheter is removed. Thickening ofthe peritoneal membrane may affect the efficiency of the catheter inthe long run. Finally, over time, it might be necessary to change orswitch the dialysis fluid to hemodialysis.
Research indicates that there is an existing difference between thepatients under HD and PD treatment regimes. In the case of thelatter, more than 58% of the patients that have been on theperitoneal dialysis program are from the developing nations with theother 42% in developed countries (Jain et al., 2012:1). It isessential to note that there has been a significant increase in thenumber of patients suffering from chronic diseases. It has the casein both the developed and developing nations and as a result, havenecessitated the development of disease management programs.
Freeman, Lybecker, & Taylor (2011:4) define disease management asa system that involves coordinated healthcare interventions as wellas communications for a particular group of patients. It is commonamong patients that significant health care efforts (Lybecker, &Taylor, 2011:4). Some of the components of disease management includethe process of identification of population, collaborative practices,and evidence-based practices Freeman, (Lybecker, & Taylor,2011:4). Geyman (2007) also contributes to the subject of diseasemanagement by questioning whether the extreme focus on the issue isobjective in the first place. He highlights the growing efforts beingmade by policy makers, legislators, and medical experts to promote adisease management system (Geyman, 2007). Thereafter he proceeds toprovide a snap chat of the existing medical conditions by addressingvarious variables such as rationale and growth, track record withregard to cost and quality of care, and the impacts of primary care(Geyman, 2007). The cost implications of peritoneal dialysis can,therefore, be adequately controlled through the implementation of thedisease management system since the government has failed with theMedicare program (Geyman, 2007). One way of advocating for theimplementation of the proposed systems of operations is throughaggressive marketing to stakeholders as a means of enlightening themon the advantages of the system.
One major component of the disease management system is the nurse ledclinics. In the United Kingdom, the nurse-led clinics have beenutilized as a platform to provide continuity in the health servicewhile also extending the roles of nurses in the provision ofhealthcare services (Hatchett, 2014). In addition, they provideevidence-based care for chronic patients (Hatchett, 2014). Nurse-ledcare promotes equality between various professions in addition toempowerment to patients since it focuses on the needs of thepopulation (Lewis, 2001).
On the other hand, nurse-led clinics are not found in Oman. However,the country’s Ministry of Health has implemented policies that areaimed at improving the provision of healthcare services to Oman.Furthermore, the new strategies have focused on the promotion ofhealth status of the Omani population (MOH, 2014). The Oman Nursingand Midwives Council (OMNC, 2011) are also encouraging the nurses topractice safe care for the patients through the acquisition ofrelevant knowledge and skills (OMNC, 2011). As such, the council isoffering training services to its members with the belief that suchexpertise can be transferred into practice and ensure the improvementof health service delivery in Oman (OMNC, 2011). The country alsointegrates community health nursing with the elder care program(Schober, 2015).
Both Oman and other nations across the globe have developed policiesto combat the spread of chronic diseases. The International Societyfor Peritoneal Dialysis (ISPD) provides guidelines that both thehealthcare providers and patients are required to adhere to. Thepolicies cover a variety of factors such as cardiovascular andmetabolic guidelines, encapsulating peritoneal sclerosis (EPS),peritoneal access and solute and fluid removal. The ISPD has alsoprovided pediatric guidelines such as the Consensus Guidelines forthe Prevention and Treatment of Catheter-related Infections andPeritonitis in Pediatric Patients Receiving Peritoneal Dialysis,Guidelines by an ad hoc European committee for elective ChronicPeritoneal Dialysis in pediatric patients, and Consensus guidelinesfor the treatment of Peritonitis in pediatric patients receivingPeritoneal Dialysis. These guidelines are aimed at streamlining theactivities of the health providers and improving the outcomes of theperitoneal dialysis in patients with chronic kidney infections.
Aim of the Dissertation
The aim of the dissertation is to explore the benefits ofimplementing peritoneal nurse-led clinics in the health services toimprove peritoneal dialysis patient`s quality of life
How will performing peritoneal nurse-led clinics in the healthservices improve peritoneal dialysis patient`s quality of life?
The study will provide an extensive literature on the benefits thatare associated with the implementation of nurse-led clinics in thequality of life among the peritoneal dialysis’ patients. The nextpart of the paper, therefore, focuses on literature review and searchengines used to explore the benefits of implementing peritonealnurse-led clinics in the health services to improve peritonealdialysis patient`s quality of life.
CHAPTER TWOLiterature Review
Cronin, Ryan & Coughlan (2008) define literature review as asummary and critical analysis and research on a particular topic.Through the analysis of past texts of a given topic, individuals canidentify the evolution process that has been necessitated over agiven period of time (Cronin Ryan & Coughlan, 2008). The reviewof existing literature also brings the readers up-to-date with thecurrent information on a topic (Cronin Ryan & Coughlan, 2008).Are also in a position to identify the trend of data and use it tomake future predictions of a particular variable (Cronin Ryan &Coughlan, 2008). A good literature review ensures that informationabout a subject is collected and synthesized to provide conclusiveresearch (Cronin Ryan & Coughlan, 2008). They further state thatidentifying the most appropriate structure of literature review is amajor step in organizing the information in a clear and concisemanner. The literature review section also demands a limited use oftechnical words with references being accurate (Cronin Ryan &Coughlan, 2008).
Randolf (2009) in his article titled “A Guide to Writing theDissertation Literature Review. Practical Assessment, Research &Evaluation” identifies various purposes for writing a literaturereview in a research program (Randolf, 2009). He argues that thissection of the paper provides an overview of the writer’scomprehension of a particular field of study. They identify thenature of variables and methods used in past studies and which applyto the current survey (Randolf, 2009). Besides the earlier-mentionedpurposes for writing a literature review, they can also be used indelimiting research problems, avoiding approaches that may not bearfruits, and seeking the support of the grounded theories. Othersinclude exploring new lines of inquiry, and the identification ofrecommendations that can shape future research on the topics ofdiscussions (Randolf, 2009). Additional reasons include defining thetopics that have been done and those that should attract furtherresearcher in the future (Randolf, 2009). Through literature review,researchers are also in a position to discover the importantvariables that are relevant to the topic and as such can contributeto the subject of study (Randolf, 2009). Ideas can also be related totheories and applied in the research (Randolf, 2009). Finally,literature review assists in rationalizing the importance of a study(Randolf, 2009).
This is considered as the most important step in identifying thesources to be used in a research study. It is usually initiated afterthe identification of the aim of the dissertation. From the title,the researchers are in a position to identify the right word choicesto be used in searching for the sources of information in a researchprocess. In this case, a comprehensive search was conducted onvarious databases in order to identify articles that are related tothe subject of discussion. In some instances, the search for thearticles to be used in the study went beyond the database and othersearch engines such as Google Scholar were utilized. Articlespublished between 2010 and 2016 were selected as the most appropriatefor the literature review section. This was aimed at ensuring thatlatest information was integrated into the study. Some data areredundant and as such using information from such sources would havebeen inappropriate because they could have led to the wrongconclusions being made to the dissertation question. According toPolit and Beck (2004), the time frame was defined as how far back theresearcher can extend their search for the relevant information to beutilized in the literature review section. Current research demandsthat the articles used in the literature review sections to keep atime frame within the last five years. This ensures that only thelatest and relevant information is utilized in the research.
Below are tables indicating the electronic databases that were usedto search for literature as well as the keywords that facilitated theidentification of the relevant articles from several others withinthe databases that were used for the research.
Total Number of Articles
The key words that were used in the search strategy
The main words that were used in the databases included the following: Nurse led clinics, nurse led clinic improving life of peritoneal disease patients, peritoneal disease, disease management program
From the search strategies, 55 hits were found from the five primarydatabases that were utilized in the study. Thereafter, the surveyproceeded to the selection of the sources based on pre-determinedinclusion criteria. The first condition required that all the sourcesto be used in the study are written in English. This is so as tofacilitate future references for other learners. Moreover, English isan international language that is spoken in various countries andacademic institutions. Its inclusion, in this case, would, therefore,ensure that a significant percentage of learners would be able toaccess it if future. Secondly, the source must be a randomizedcontrol trial (RCT). This is a study whereby individuals areallocated by chance to be the recipients of various clinicalinterventions. One primary form of responses under RCT is known asthe standard of comparison which can either standard practice or nointervention whatsoever.
The third condition that must have been met by an article to warrantits inclusion in the research process was that it had to contain bothqualitative and quantitative studies. The latter deals with theunderstanding of existing opinions, reasons, and motivations of theexploratory research. On the other hand, quantitative studies aremore focused on the statistical measurements of outcomes as well asthe numerical analysis of data that has been obtained from primaryand secondary sources. The articles must also be based on adultchronic disease nurse led clinics. Finally, to ensure that theinformation from such sources is current and relevant to the study,the time frame for their publishing is between 2010 and 2016.
The exclusion conditions of sources to be excluded from the researchincluded those that were not written in English as well as those thatdiscussed both adult and pediatric acute disease and surgical nurseled clinics. This resulted in the selection of eight articles to beused in the literature review section of the paper.
Improving quality of Life of Patients
Over the years, the subject of decreasing the mortality of life inpatients did not focus on the health-related quality of life (HRQOL)(Grincenkov et al., 2015). However, research has indicated thatperitoneal dialysis patients are also likely to suffer from bothphysical and emotional distress (Grincenkov et al., 2015). Variousscientists have argued that the change in focus can be attributed tothe outcomes of patients suffering from an end-stage renal disease.Additionally, there has been an increase in the nurse-led diseasemanagement programs with regards to the quality of life of thepatients (Chen et al., 2016). Moreover, the medical practitionershave had to grapple with the debate over the dialysis solution thatis most appropriate for peritoneal dialysis (Jung et al., 2016). Thishas been about instances of acute kidney injury. The decision as towhether to use bicarbonate or lactate in such situations has led toresearch being conducted on the same (Bai et al., 2014).
The choice of the best treatment to manage peritonitis amongindividuals on peritoneal dialysis has led to the development ofvarious theories aimed at ensuring that the best practice isidentified (Ballinger et al., 2014). Peritoneal dialysis isnecessitated by the failure of the kidney. It is a treatment methodbased on the use of Peritoneum to clean blood inside the body ratherthan artificial membrane located outside of the body (Chow &Wong, 2010). It refers to a thin membrane tasked with theresponsibility of surrounding the organs of the body. The peritoneumfunctions by allowing waste products to go through it since it hassmall blood vessels. Therefore, a Tenckhoff Catheter is used to passdialysis into the peritoneal cavity. The process ensures that allwaste materials are eliminated from the blood (Chow & Wong,2010).
To identify the effects of nurse-led management programs on thequality of life in patients undergoing peritoneal dialysis, Chow &Wong (2010) conducted research. The primary objective of their surveywas to examine the role of nurse-led clinics in benefiting patientsundergoing peritoneal dialysis (Ballinger et al., 2014). In thiscase, patients with end-stage renal failure needed integrated care inorder to maintain a desirable quality of life. In the past, studieshad suggested that transitional care based on the disease managementmodel would have the desirable effects on the quality of life for thepatients. However, the results of the analysis had not beenconclusive (Chow & Wong, 2010).
The study commenced in 2005 with eighty-five patients (Chow &Wong, 2010). Since this was a randomized control trial, it was deemedfit to divide them into two groups namely the study group and thecontrol group. The study had a pre-test and post-test (Chow &Wong, 2010). Two regional hospitals in Hong Kong participated in thestudy (Ballinger et al., 2014). The patients from the renal units ofthe two hospitals were recruited into the survey (Chow & Wong,2010). However, exclusion criteria eliminated patients onintermittent PD and HD as well individuals who were planning toadmissions for special procedures (Chow & Wong, 2010).Additionally, patients who were found to have had catheters in situfor less than three months were excluded since the adjustment periodsmay have culminated in bias with regards to the measurement ofquality of life (Chow & Wong, 2010). However, patients withaccess to telephone were incorporated into the study (Chow &Wong, 2010). The study group composed of 43 participants with 42belonging to the control group (Chow & Wong, 2010).
The research involved a comprehensive intervention protocol that hadbeen created by the researchers (Chow & Wong, 2010). Theprocedures were also reviewed by the renal nurses and physicians(Chow & Wong, 2010). For those patients in the control groups,they were given discharge planning protocol (Chow & Wong, 2010).In addition to this, they would be a 6-week telephone follow-upregimen initiated by the nurse (Chow & Wong, 2010). The dischargeframework required the participation of patients and family membersin determining the most appropriate release plan as well as adefinitive analysis of the patient’s physical, social andpsychological wellbeing (Ballinger et al., 2014). The emotional needsof the patients would be based on the Omaha system (Chow & Wong,2010).
In order to ensure that the nurses were conversant with the expectedrequirements for the research, they underwent training (Chow &Wong, 2010). The program was based on a simulated patient so as toensure interventions (Chow & Wong, 2010). The patients were afterthat allowed to proceed to the Community Nursing Service (CNS) forphysical examinations as well as drug monitoring compliancemonitoring (Chow & Wong, 2010). The control group patients wereprovided with routine discharge care as had been recommended by thestudy (Chow & Wong, 2010). The renal unit provided a phonehotline service, standard information, and set of self-help printedbrochures (Chow & Wong, 2010). However, during hospitalization,both the control and study group patients were given a similarroutine care with the other patients in the renal units (Chow &Wong, 2010).
The collection of data was done in three intervals (Chow & Wong,2010). The process began in 2005 with the issuance of a structuredself-support questionnaire. The information was obtained duringdischarge, six weeks after being released, and twelve weekspostdischarge (Chow & Wong, 2010). The study used Egan’s studyof patients to develop the most appropriate platform for determiningthe timeframe within which research data was to be collected (Lee &Son, 2016). Some of the variables whose measurements were taken whendischarging the patients included the duration of peritoneal dialysisregime, existing complications, availability of family, and financialconditions of the patients (Chow & Wong, 2010). The researchprocess adhered to the ethical considerations as it sought approvalfrom the ethics committees of the two hospitals that provided theparticipants for the survey (Chow & Wong, 2010). Ethical approvalwas also obtained from the University that the principal supervisorhad affiliations to.
The data analysis section focused on the comparison between thetwo groups of patients (Chow & Wong, 2010). Descriptive analysiswas used to determine the demographic variables of the patients.These included age, social support, gender, and comorbid conditions(Chow & Wong, 2010). Additionally, general linear model (GLM) theinteractions between the two groups of patients and the significantdifferences between the groups (Chow & Wong, 2010).
The results obtained from the study indicated that 123 patients hadmet the eligibility criteria for the research. As such, theyunderwent assessments at the hospitals with the help of nurses.However, the patients (23) who had failed to meet the criteria wereexcluded (Chow & Wong, 2010). Out of those excluded from thestudy, others were transferred to the hemodialysis before beingreleased (Lee & Son, 2016). Whereas others refused to participateall together in the process, four were dismissed since their physicalconditions posed a major challenge to the researchers. The resultsshowed that the quality of life was relatively higher among thestudents in the study group as compared to those in the controlcategory (Chow & Wong, 2010). Other advantages such as improvedsocial functioning and fewer work problems due to improved physicalconditions were also synonymous with the study group (Lee & Son,2016). The outcomes, therefore, indicated that to ensure the qualityof life for peritoneal dialysis patients, in the long run, it isnecessary to identify the symptoms. The patients should be encouragedto incorporate lifestyles that would curtail the progression of thedisease. The model of this study was also advantageous since itprovided support to the PD patients as well increasing the rapportbetween the patients and the nurses who were involved in the renalunit (Chow & Wong, 2010). This culminated in the behavioralchanges that ultimately led to improved quality of life for thepatients. The collaborative effort between different players in thehealth sector can also improve the quality of life among theperitoneal dialysis patients.
The study experienced numerous challenges that if not addressed mayhave affected the entire process. The main limitation of the surveywas recruitment. This is due to the fact that the study only includedpatients from two hospitals despite the existence of other healthfacilities with better facilities and more experienced staff. Theresult was that the scope of the study was limited to the few medicalfacilities that had been incorporated in the beginning. This meansthat the results obtained from the research may not be an actualpresentation of the state of peritoneal dialysis in Hong Kong.
The most appropriate solution to such a problem would be the use of adouble-blind design in which there is a placebo control group. Thiswould assist in eliminating the possible biases that are synonymouswith clinical trials. Since this study also involved follow-up callsby the nurses, the placebo groups may also be recipients of suchcalls in order to discuss issues that are not included in thestructured telephone interviews.
On the downside however, this form of design contains high levels ofuncertainties, and would pressure the case and unit managers. Theplacebo control group would also be contaminated during the telephoneinterviews conducted by the renal unit nurses as it would impossiblefor them to offer help to the patients based on the problemsidentified during telephone conversations. The research process hadno control for the telephone hotlines since the frequency and thedurations of the calls were not specified in the survey.
In conclusion, the performance of the control group was relativelyhigher than that of the study groups. Patients in the latter teamshowed improved higher quality of life and experienced improvedpsychological reactions. They also indicated that they wereincreasingly feeling energetic. The model that was used in this studyhad incorporated various factors such as offering motivationalinterviewing skills before and after they have been discharged fromthe health facilities. In the future, such techniques can be utilizedin the health sector to humanize technologies in the medicalindustry. This can be achieved by providing the most appropriateresponses to the illness history of the patients as well as the needfor therapeutic regimens. The model can also be employed in varioushealthcare settings before being extended to specific areas such asrenal and chronic disease populations. The research model providesthe foundation for the evaluation of the efficacy of the nurse-ledclinics through the integration of the collaborative approach.Thereafter, the management model will be used to achieve the goal ofimproving the quality of the patients in the control groups.
Summary of Literature Review
The literature review section of the paper identified past researchon the role of nurse-led clinics in improving the quality of life inpatients undergoing peritoneal dialysis. Moreover, it identified theimpacts of various practices within the nurse-led clinics that werelikely to benefit patients and improve their reactions to treatments.Other advantages that were attributed to such health facilitiesincluded disease management in addition to improved psychologicalattributed. The latter were evidenced by the reduced anxiety anddepression through counseling sessions and elevated physicalactivities among the patients. Finally, the research laid emphasis onthe need to promote collaborative approach to the disease managementin the nurse-led clinics.
Recommendations for service improvement in the locality
Due to the number of deaths attributed to the chronic kidneyinfections, the Ministry of Health in Oman have developed strategiesaimed at improving the health of patients with the long termobjective of ensuring that mortality and morbidity rates are reduced(MOH, 2014). This was highlighted by the opening of health facilitiesin order to provide medical services to the patients within theSultanate. The literature argues that the nurse-led clinics providean opportunity to improve the quality of life among patientsundergoing peritoneal dialysis.
The nurse-led clinics are considered to be safe and effective optionsto the formal outpatient clinics. In such instances, extensiveattention is given to the consumers’ views. Ndosi et al. (2013)conducted a study to determine the cost-effectiveness of thenurse-led clinics among patients. The research involved the use of amulticenter design and random sampling method. Prior to beginningthis program, a test had been conducted to establish the effects ofnon-inferiority design. The patients involved in the study were 181.Additionally, Hudorovic and Vicic-Hudorovich (2012) collected a datafrom a similar exercise in 2011. The research was aimed at improvingthe management protocols within the organization (Hudorovic &Vicic-Hudorovich, 2012). The results in this case were divided intovarious sections including participants’ attendances, and level ofsatisfactions. The outcomes indicated that the nurse-led clinics werecost-effective. The cost of outpatient services was determined by aproduct of number of attendances and the relevant hospital unit cost(Ndosi et al., 2013). The results of both researches indicated thatthe nurse-led clinics had relatively lower cost implications on thepatients.
The cost of readmission is usually high in the standard hospitals.Patients are constantly required to go for consultations from theperitoneal dialysis patients whenever they feel any discomfort. Thesevisits culminate in extensive financial implications in the long-run.However, the nurse-led clinics allow the health provider to follow upon the progress of the patients through telephone calls. This notonly lowers the costs of consultations but also improve therelationship between the patients and the nurses. Moreover,admissions at the hospitals increase the medical expenses since thepatient is catered for during their stay. The nurse-led clinics onthe other hand, admit patients in serious cases only. Therefore, thefamilies are involved in taking care of the loved ones. With areduction in labor-intensive practices, the cost of treatment insignificantly reduced.
Patient’s Decision Making Process
The nurse-led clinics have also been considered to be effective ininvolving the patients in the decision making process (Vahdat et al.,2014). The disease management systems ensure that patients areallowed to voice their opinions regarding the treatment techniquesbeing used in the health facilities. The sharing of information aswell expression of feelings is one of the ways through which thenurses develop strategies of ensuring efficient delivery of servicesto the patients (Vahdat et al., 2014). The patients must also bewilling to accept instructions from the health team. Vahdat et al.(2014) provided a review of the involvement of patients in decisionmaking process. In this study, he used various sources to obtaininformation on the role of patients’ involvement. The resultsindicated that the research had been divided into six sectionsnamely defining participation, participation of patients and itsimportance, factors likely to influence participation, methods ofparticipation, evaluation of participation and benefits of theprocess. It was established that some of the factors that influencedpatient involvement in the decision making process includedrelationships with the health providers, physical and cognitiveabilities and beliefs of the patients in relation to health services(Vahdat et al., 2014).
The third part of the paper will focus on the health services andleadership styles as well as the process of establishing nurse-ledclinics to facilitate the improvements in quality of life amongpatients undergoing peritoneal dialysis.
CHAPTER THREE3.1 Introduction
The second chapter of this covered the recent literature on thebenefits that can be associated with improved quality of life ofperitoneal dialysis patients undergoing PD. This was about the use ofcollaborative efforts by the nurse-led clinics. In this case, it isevident that the health care systems across the globe have anobligation of ensuring that the gap between the treatment regimes andthe evidence of outcomes is determined (Apekey et al., 2010).Moreover, there should be an extensive focus on the safety andefficacy of the treatment through efficient management systems(Apekey et al., 2010). However, it should be noted that the relevantmedical authorities have been developing the necessary frameworks ofoperations to ensure that all individuals are provided with theappropriate evidence-based health practices (Gharibi et al., 2014).
Case in point, both the NHS and the Ministry of Health in the UnitedKingdom and Oman respectively have developed futuristic visions thatare aimed at improving the healthcare service delivery to thepatients (NHS, 2015). This is done by encouraging the healthorganizations to adhere to the standards that have been set toinfluence the quality of life among the patients (MOH, 2014). Toimprove the health care system across the two nations, the levels ofskills among the practitioners ought to be given utmost attention(NHS, 2015). In addition to this, there has been a focus on the roleof experienced leadership in steering the new operations towards newlevels of excellence in terms of service delivery. Therefore, theperformance of the healthcare system will massively hinge on thecapabilities and leadership experiences of the medical practitioners(Apekey et al., 2010). The subsequent sections of the paper willhighlight the service improvement framework and the leadershiptheories that are necessary in order to achieve the primary objectiveof improving health services.
3.2 Service Improvement
With the increased focus on the evidence-based practices in theprovision of health services, additional policies have beendevelopment to ensure that the quality of services is elevated(Apekey et al., 2010). Improvement of services is regarded as theimplementation of additional alternative activities with the solepurpose of facilitating the improvement of the quality of life amongpatients (Apekey et al., 2010). Quality, on the other hand, isreferred to as the extent to which health services for individualsand the larger populations are tailored to improve the expectedoutcomes (Apekey et al., 2010). However, these practices must alignwith the current professional knowledge in the medical fields (Apekeyet al., 2010). Some of the primary areas of concern include theprinciples of safety as well as the efficacy and safety of theexperience undergone by the patients (Gharibi et al., 2014).
In the health sector quality is regarded to be one of the primaryindicators of the provision of health services. It is analyzed inthree major aspects, and these include customer, technical, andservice quality (Gharibi et al., 2014). Technical quality in theclinical sense will refer to the aspects of health that are dependenton the ability of the skills of the providers of medical care, thecare outcomes with regard to specific conditions. In this study, thecustomer quality is the area of concern. It analyzes the interventionmechanisms that have been in place to ensure that the clients canreceive services whenever deemed as necessary (Gharibi et al., 2014).It also revolves around the capacity of the medical experts to makecritical decisions that would influence the outcomes of the careprograms as well as actively participating in the service deliveryprocess. Finally, service quality is in most instances not related tothe actual non-health aspects. It majorly defines the relationshipsbetween the customers, medical providers and the care processesinvolved in improving the quality of life among patients (Gharibi etal., 2014). In this case, it refers to the collaborative effortbetween the caregivers and the patients in the nurse-led clinics(Gharibi et al., 2014).
The process of quality improvements comprises of various phases (NHS,nd). According to the NHS, the preparation stage comprises ofeverything that should be done prior to starting the project. It isat this juncture that the aims and objectives of the processes areidentified and the baseline data collected. The next level isreferred to as the launch phase (NHS, nd). Teams to be utilized inachieving the goals of the project are formed and communication plansput in place. The diagnosis phase encourages the determination ofcurrent processes and defining the problem so as to develop the baseassumptions (NHS, nd). The fourth stage is known as implementationand involves phase tests and the determination of the potentialsolutions to the underlying problems. This stage is also responsiblefor mistake proofing in order to ensure sustainability of the qualityimprovement process (NHS, nd). The last phase is evaluation and atthis stage, achievements of the process are acknowledged, andchallenges are determined at an early stage to ensure that the systemfunctions appropriately (NHS, nd).
3.3 Leadership in Healthcare and Service Improvements
To ensure the success of any project, the individuals in charge mustexhibit leadership qualities. This not only plays an integral role inthe planning but also instills discipline among the team members(Giltinane, 2013). The leader must also be in a position to deal withall other front-line managers and ensure that the service improvementprojects are not only sustainable but also efficient once they arecomplete. Leadership refers to the ability of an individual toinfluence others positively (Giltinane, 2013). The leader istherefore charged with the responsibility of ensuring that theemployees undertake in activities that lead to the achievement of theprimary objectives of the organization (Al-Sawai, 2013). They arealso expected to nurture an environment that is not only cohesive butalso coherent.
As is common with most major processes, the leader is likely to facevarious challenges that may impede the achievement of the desirableobjectives (Baker, 2011). They should, therefore, be well conversedwith the different types of leadership theories to enable them toovercome the obstacles that they are likely to face in theiroperations (Giltinane, 2013). These skills and understanding willallow them to overcome the problems that arise within an organization(Wagner, 2008). A leader should also be flexible in order to adapt tochanges that may result over time (Baker, 2011). The same strategycannot be utilized in addressing all issues that affect anorganization. Therefore, it is important to develop a thoroughunderstanding of what is expected of them in ensuring that serviceimprovements are achieved (Wagner, 2008).
3.4 Leadership Theories and Styles
An effective leader should be able to identify the underlyingcircumstances and the most appropriate theories to deal with theissues that might affect the performances of the employees (Wagner,2008). The principles can also be utilized in offering solutions toconflicts that may arise in the process of working together (Kumar,Adhish & Deoki, 2014). Some of the theories that are analyzed inthis section include the Great Man theory, Trait theories,contingency theories, situational theories, participative theories,behavioral theories, management theories, relationship theories(Giltinane, 2013).
3.4.1 The Great Man Theory
This theory assumes that leaders are born rather than made (Kumar,Adhish & Deoki, 2014). In this instance, the leaders areconsidered to be heroic and can provide direction whenever the needarises (Giltinane, 2013). The name arises from the earlier thatleadership positions were a unique preserve of male quality. This wasin reference to leadership within the military ranks (Wagner, 2008).
3.4.2 Trait Theories
These theories assumed that people who are inherent to particularqualities are likely to make better leaders in comparison to others(Kumar, Adhish & Deoki, 2014). It is based on the identificationof specific personality features as well as their behavioralcharacteristics (Wagner, 2008). This theory has however attractedsignificant concerns since, over the years, individuals have beenable to ascend to leadership positions without necessarily having thespecific personality traits that are attributed to leaders(Giltinane, 2013).
3.4.3 Contingency Theories
These are leadership that focuses on specific variables that areregarded as to influence the decision-making the capacity of leaders(Kumar, Adhish & Deoki, 2014). This theory postulates that asingle leadership style cannot apply to all the existing situations(Giltinane, 2013). As such, the success of any leader will depend ona series of characteristics such as quality of the followers,leadership style and the existing situations (Wagner, 2008).
3.4.4 Situational Theories
According to this theory, a leader will select the best course ofaction depending on the situational variable (Kumar, Adhish &Deoki, 2014). As a result, various leadership styles may be utilizedin ensuring that the most appropriate decision is made (Giltinane,2013).
3.4.5 Behavioral Theories
The primary assumption, in this case, points out that leaders aremade rather than born. As such, the actions of the leaders are amajor concern (Giltinane, 2013). People do not focus on the mentalqualities of such individuals. It also allows others to become greatleaders by making observations (Wagner, 2008).
3.4.6 Participative Theories
This is an all-inclusive leadership style. The input of everyone istaken into consideration before the final decision is made by thehead (Kumar, Adhish & Deoki, 2014). It requires a collaborativeeffort among individuals to ensure that the contributions of othermembers of the team are factored in (Wagner, 2008). This form ofleadership makes the group members feel valued and relevant withinthe organizations (Kumar, Adhish & Deoki, 2014). Despite the needto consider the input of everyone, the leader retains the right toexamine the input of others and in cases where there are conflicts,he will be on hand to make the final decision (Giltinane, 2013).
3.4.7 Management Theories
These are also known as transaction methods (Giltinane, 2013). Theirprimary focus is on supervision and the performances of the groups.Additionally, the leadership is based on a reward-punishment system(Kumar, Adhish & Deoki, 2014). Therefore, individuals that areconsidered to have excelled in their duties are rewarded throughpromotions, further training or in monetary terms. However, thosethat do not meet the expected standards are punished (Giltinane,2013). This can be in the form of warnings, demotion or retrenchment(Wagner, 2008). The managerial theories are prevalent within thebusiness environments where employees are either punished or rewardeddepending on their performances (Giltinane, 2013).
3.4.8 Relationship Theories
Otherwise known as transformational theories, these styles ofleadership focus on the relationships between the leaders and thefollowers (Kumar, Adhish & Deoki, 2014). The leaders are seen asa source of motivation since they help others in the completion oftasks as well as improving the performances of the groups (Wagner,2008). In this case, the leaders will create an environment that willenable each of the team members to achieve their potentials(Giltinane, 2013). Transformational theories require the employees tohave high ethical and moral standards in order to lead the groupmembers by example (Kumar, Adhish & Deoki, 2014).
From the above analysis of the leadership theories and styles, it isevident that the change process will hinge on the capacity of theleaders to marshal their followers into achieving service improvement(Kumar, Adhish & Deoki, 2014). The leaders should be able toadapt to the existing situations in order to deal with the challengesthat may affect the change process (Giltinane, 2013). These theoriesare integrated into the nurse-led clinics for peritoneal dialysispatients. The most desirable change theory, in this case, will be thetransformational style of leadership (Wagner, 2008).
3.5 Introducing peritoneal dialysis nurse-led clinics in the localhealth organization
Over the years, the responsibilities of the nurses have shifted fromthe traditional responsibilities of looking after nurses andadministering medication. The evolution of their roles has beennecessitated by changing needs of the health sector (Logan &Hurwitz, 2013). It has therefore become important that the nurses areaware of additional responsibilities that require counseling,educating, and managing the health conditions of the patients.Through training, the nurses are currently able to evaluate andmonitor the progress of the patients (Schadewaldt & Schultz,2011). In this assignment, a nurse-led clinic is being proposed inorder to improve the quality of health among peritoneal dialysispatients (MOH, 2014). Various change management models should betaken into consideration when implementing an efficient serviceimprovement plan. These may include Tuckman’s model, Lewin’stheory, RAPSIES seven-step model and the Empirical Rationale amongseveral other frameworks. In this case, the RAPSIES model will beutilized in facilitating the service improvement plan in thenurse-led clinics.
The model consists of seven stages namely recognizing, analyzing,preparing, strategies, implementing, evaluating and sustaining. Thisstudy aims to use that framework to introduce a peritoneal dialysisnurse-led clinic. The step-by-step analysis is provided below
This is the first process according to the RAPSIES model of change.All leaders are required to identify the existing problems thatcurtail the performance of the teams within organizations. Theseobstacles should be identified in order to facilitate the process ofchange that will rid the organization of such barriers (Gopee &Galloway, 2014). The primary objectives of the proposed changesshould be highlighted in addition to the benefits that the members ofstaff will be able to derive from the changes in standard operations.The leader of officials is tasked with explaining to the employeesthe importance of adhering to such changes. Other factors that shouldbe taken into consideration at this stage include the identificationof the service improvements that will be necessitated by the changesin the organization.
In our case, there has been a substantial increase in the number ofchronic kidney infection. As a result, it is important to identifythe most appropriate interventions to curtail the higher number ofvictims of the illness (Gopee & Galloway, 2014). Theintroduction of the nurse-led clinics is aimed at minimizing thestress on in-patient and out-patient medical facilities in Oman. Additionally, they would ensure improvements in the quality of lifeamong individuals by promoting kidney-infection awareness campaigns.The leader will, therefore, have identified the existing gaps and illtherefore highlight the need for change (Gopee & Galloway, 2014).Moreover, the nurses will be informed of the advantages that areassociated with the proposed changes. Their input will be taken intoconsideration and barriers identified. The leader should be flexibleand appreciate the input of all the stakeholders before making thefinal decision.
This is the second phase of the change model, and it will involve theanalysis of available resources as well as the main players toparticipate in the change process (Barr & Dowding, 2016). A swotanalysis is conducted to identify the strengths, weaknesses,opportunities and threats that are inherent in the change process. Inour case, the clinic had been selected by the leader (Gopee &Galloway, 2014). The privacy of patients will be given importance inthe health facilities. Other resources that will be required willinclude stationery. Diet instruction materials, and other educationalmaterials.
The leader will proceed to form a team that will participate in theproposed change. Each member of the member will be assigned a task(Bonebright, 2010). The individual in charge of the nurse-led clinicswill form a team by using Tuckman’s model since it is the mostappropriate in health organizations (Barr & Dowding, 2016). Theproposed team will comprise of an employee from the National HealthCenter (preferably an executive officer), one of the nurses from theperitoneal dialysis unit, and other practitioners with the standardlevel of expertise. The Tuckman’s model of change consists of fourstages namely forming, storming, norming, performing and adjourning.
At this stage, the leader should have the most appropriate strategyto deal with the proposed changes. In this case, the framework thathas been selected is known as PDSA (Plan, Do, Study and Act) (Gopee &Galloway, 2014). It will assist in addressing the barriers that mayaffect the implementation of peritoneal dialysis nurse-led clinics(Bonebright, 2010).
This stage will be accomplished using the PDSA strategy that wasidentified in the previous step (NHS, 2012). The local chronicinfection center will determine the efficacy of the clinics on theperitoneal dialysis patients and identify barriers that can affectthe process of change. The testing period should last for 24 weeks tominimize mistakes.
The leaders are required to initiate a meeting with the team andidentify the aims of the proposed changes. After determining theobjectives, they have an obligation to prioritize the needs teach theteam the importance of time management (Gopee & Galloway, 2014).The leader should exhibit transformational styles of leadershipwhereby they will offer motivation to the employees and guide themthrough the process (Kerridge 2012b). The roles of each member of theteam towards improving service should also be determined.
This is the actual trial stage for the proposed changes. A qualifiednurse begins leading the health facility and selects patientsaccording to the predetermined requirements (NHS, 2012).
In the Act
At this stage, the nurse-led clinics will be required to use theinformation obtained in the study stage and initiate the necessarychanges so as to improve service delivery. The team should beinformed of all the modifications that have been made (Barr &Dowding, 2016). Additionally, the leader should be able to conduct anevaluation of all the underlying changes and introduce new serviceimprovement within the health facility (Kerridge 2012b).
At this stage, the leader monitors the performance of the new servicedevelopment practices within the local health organization (Gopee &Galloway, 2014). This process is based on evidence that has beenobtained and whether it can support the continuity of the newchanges. The leader determined the impact of the nurse-led clinic onthe quality of life of the peritoneal dialysis patients. Some of thetests that are conducted to establish the wellbeing of the patientwill include physical examination, radiology, and bloodinvestigation. The outcomes will determine whether the proposedchanges were productive or not (Gertler et al., 2011).
This is the last stage of the change model, and it is concerned withensuring that the service improvements are functioning well (Gopee &Galloway, 2014). It also identifies ways through which the currentobstacles can be eliminated. The leader also makes sure that humanresources are available in the health facility. All the members ofthe change program are encouraged to play their roles to fruition(Gopee & Galloway, 2014). The leader should continue to provide afavorable environment for the employees to meet their objectives.
The increase in kidney-related infections across the globe hasnecessitated the development of strategies aimed at curtailing itsimpact. Most health institutions are therefore focusing on theprovision of safe and quality care for the patients. The impacts ofsuch diseases go beyond physical, psychological effects but alsoinfluence the reduction of the population’s life expectancy.Therefore, the creation of the nurse-led clinics is seen as one ofthe most effective ways of controlling the spread of the kidneyinfections in the local Omani setting. The paper therefore focused onthe identification of the advantages of nurse-led clinics for theperitoneal dialysis patients.
The dissertation was divided into various sections. The literaturereview part analyzed existing evidence on peritoneal dialysis. Inthis case, it was divided into three major sections namely improvingthe quality of life, helping the patient to decide a treatment plan,and cost effectiveness. From the available literature, it was evidentthat the nurse-led clinics would provide effective solutions byimproving the quality of life among patients and the costimplications of the treatment regimens. Finally, it provided a seriesof solutions to the patients with regards to the choice of treatmentplan.
Using the RAPSIES change model in conjunction with PDSAimplementation strategy, the study proposed the introduction theperitoneal nurse-led clinics to deal with the increasing incidencesof chronic kidney infections. The location of focus was Oman. Inorder to achieve the desirable outcomes, the role of leadership hadto be integrated into the study. Specifically, transformationalleadership was deemed as the most appropriate for the study due toits ability to nurture creativity and productivity within a team. Theformation of the group to be used in accomplishing the objective ofthe nurse-led clinics was based on Tuckman’s team developmentmodel. An effective style of leadership identifies the barriers at anearly stage and facilitates the development of a framework ofoperation that ensures the completion of tasks within a giventimeline. The efficiency of the leader will be determined based onthe ability to solve conflicts and make changes to the operationalframeworks depending on the needs of the team.
Al-Sawai, A. (2013). Leadership of Healthcare Professionals: Where DoWe Stand? Oman Medical Journal 2013 Jul 28(4): 285–287.
Apekey, T. McSorley, G. Tilling, M. and Siriwardena, A. 2010. Roomfor improvement? Leadership, innovation culture and uptake ofquality improvement methods in general practice. Journal ofEvaluation in Clinical Practice 17, pp. 311-318.
Bai Z, Yang K, Tian J, Ma B, Liu Y, Jiang L, Tan J, Liu T, Chi I.(2014). Two dialysis solutions for acute peritoneal dialysis.Retrieved fromhttp://www.cochrane.org/CD007034/RENAL_two-dialysis-solutions-for-acute-peritoneal-dialysis
Baker, R. (2011). The roles of leaders in high-performing health caresystems. The King’s Fund
Ballinger AE, Palmer SC, Wiggins KJ, Craig JC, Johnson DW, Cross NB,Strippoli GFM. (2014). What is the best treatment to manageperitonitis in people on peritoneal dialysis? Retrieved fromhttp://www.cochrane.org/CD005284/RENAL_what-is-the-best-treatment-to-manage-peritonitis-in-people-on-peritoneal-dialysis
Barr, J. and Dowding, L. 2016. Leadership in Health Care. 3rded. London: SAGE.
Bonebright, D. A. 2010. 40 Years of Storming: A Historical Review ofTuckman’s Model of Small Group Development. In Human ResourceDevelopment International Journal 13 (1), pp. 111–120.
Chaudhary K (2012) Current Trends in Peritoneal Dialysis. JNephrol Therapeut 2:e107. doi:10.4172/2161-0959.1000e107
Chen CC, Chen Y, Liu X, Wen Y, Ma DY, HuangYY, Pu L, Diao YS, Yang K.(2016). The Efficacy ofa Nurse-Led Disease Management Program in Improvingthe Quality of Life for Patients with ChronicKidney Disease: A Meta-Analysis. PLoS One.2016 May 1811(5):e0155890.doi: 10.1371/journal.pone.0155890. eCollection 2016.
Chow, S.K.Y. and Wong, F.K., 2010. Health‐relatedquality of life in patients undergoing peritoneal dialysis: effectsof a nurse‐led casemanagement programme. Journal of advanced nursing, 66(8),pp.1780-1792.
Cronin, P., Ryan, F. & Coughlan, M. (2008). Undertaking aliterature review: a step-by-step approach. British Journal ofNursing, 2008, Vol 17, No 1. Retrieved fromhttp://www.cin.ufpe.br/~in1002/leituras/2008-undertaking-a-literature-review-a-step-by-step-approach.pdf
Freeman, R., Lybecker, K. & Taylor, W. (2011). The Effectivenessof Disease: Management Programs in the Medicaid Population. TheCameron Institute. Retrieved fromhttp://www.fightchronicdisease.org/sites/default/files/docs/Main%20Report%20-%20The%20effectiveness%20of%20DMPs%20in%20the%20Medicaid%20Pop%202011.pdf
Gertler, P. Martinez, S. Premand, P. Rawlings, L. and Vermeersch, C.2011. Impact Evaluation in Practice. Washington: The WorldBank.
Geyman, J. (2007). Disease Management: Panacea, Another False Hope,or Something in Between? Ananals of Family Medicine, vol. 5, (3).Retrieved from http://www.pnhp.org/dm.pdf
Gharibi, F.,  Tabrizi, J., Oskouei, M. &AsghariJafarabadi, M. (2014). Effective Interventions onService Quality Improvement in a Physiotherapy Clinic. Healthpromotion Perspective, 2014 4(1): 61–67. Retrieved fromhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4122040/
Giltinane, C. L. (2013) Leadership styles andtheories. Nursing Standard,27, 41, 35-39.
Gopee, N. and Galloway, J. 2014. Leadership & Management inHealthcare. 2nd ed. Los Angeles: Sage.
Grincenkov FR, Fernandes N, Pereira S, Bastos K, LopesA, Finkelstein FO, Pecoits-Filho R, QureshiAR, Divino-Filho JC, Bastos MG. (2015). Impact of baselinehealth-related quality of life scores on survival ofincident patients on peritoneal dialysis: a cohortstudy. Nephron. 2015129(2):97-103. doi: 10.1159/000369139. Epub2015 Jan 28.
Hatchett, R. (2014). The emergence of the modern nurse-led clinic inthe UK. Retrieved fromhttp://www.ferasi.umontreal.ca/documents/Pr%C3%A9sentation_Richard%20Hatchett.pdf
Hudorvic, N. & Vicic-Hudorovic. (2012). eComment. Nurse-ledclinics and cost-effectiveness. InteractCardiovasc Thorac Surg. 2012 Jun 14(6): 733–734.
Jain, A., Blake, P.,  Cordy, P. & Garg, A.(2012). Global Trends in Rates of Peritoneal Dialysis. JASN 23(3):533–544. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3294313/
Jung HY, Jang HM, Kim YW, Cho S, Kim HY, KimSH, Bang K, Kim HW, Lee SY, Jo SK, LeeJ, Choi JY, Cho JH, Park SH, Kim CD, KimYL & EQLIPS Study Group. (2016). Depressive Symptoms,Patient Satisfaction, and Quality of Life Over Time inAutomated and Continuous Ambulatory PeritonealDialysis Patients: A Prospective Multicenter Propensity-MatchedStudy. Medicine (Baltimore). 2016 May95(21):e3795. doi:10.1097/MD.0000000000003795.
Kerridge, J. 2012b. Leading Change: 2 – Planning. Nursing Times108 (5), pp. 23-25.
Kumar, S., Adhish, V. & Deoki, N. (2014). Making Sense ofTheories of Leadership for Capacity Building. Indian Journal ofCommunity Medicine 2014 Apr-Jun 39(2): 82–86.
Lee SJ, Son H. (2016). Comparison of health-related qualityof life between patients with stage 3 and 4 chronickidney disease and patients undergoing continuousambulatory peritoneal dialysis. Jpn J Nurs Sci. 2016Jan13(1):166-73. doi: 10.1111/jjns.12101. Epub 2015 Nov 5.
Lewis, R. (2001). Nurse-Led Primary Care: Learning from PMS Pilots.King’s Fund. Retrieved fromhttp://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/nurse-led-primary-care-learning-from-pms-pilots-richard-lewis-kings-fund-1-july-2001.pdf
Ministry of Health. 2014. Oman Health Vision 2050. 1st ed.Muscat: Ministry of Health.National Health Service. 2012. First stepstowards quality improvement: a simple guide toimproving services [Online]. Available at:http://www.nhsiq.nhs.uk/resource-search/publications/nhs-imp-service-improvement-guide.aspx.
Ndosi, et al. (2013). The outcome and cost-effectiveness of nurse-ledcare in people with rheumatoid arthritis: a multicentre randomisedcontrolled trial. Ann Rheum Dis doi:10.1136/annrheumdis-2013-203403
NHS. (nd). First steps towards quality improvement: A simple guide toimproving services. NHS Improvement. Retrieved fromhttp://www.nhsiq.nhs.uk/media/2591385/siguide.pdf
Oman Nursing and Midwifery Council. 2011. 2nd ed. Code ofprofessional conduct for nursesand midwives in Oman. Muscat: Ministry ofHealth.
Polit, D. F. and Beck, C. T. 2014. Essentials of Nursing Research:Appraising Evidence for Nursing Practice. 8th ed. New Delhi:Wolters Kluwer.
Randolf, J. (2009). A Guide to Writing the Dissertation LiteratureReview. Practical Assessment, Research & Evaluation. Vol 14, No13. Retrieved from http://pareonline.net/pdf/v14n13.pdf
Schober, M. (2015). Brave and Bold: An International Perspective ofNurse Led Clinics and Services. University of Sheffield. Retrievedfromhttps://www.sheffield.ac.uk/polopoly_fs/1.466636!/file/Madreen_Schober_IND15.pdf
Vahdat et al. (2014). Patient Involvement in Health Care DecisionMaking: A Review. IranRed Crescent Med J. 2014 Jan 16(1): e12454.
Wagner, K. (2008). 8 Major Leadership Theories. Retrieved from http://unpan1.un.org/intradoc/groups/public/documents/APCITY/UNPAN030550.pdf