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STEVE FORD, EDITOR

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Nurse-led clinics: 10 essential steps to setting up a service

23 November, 2008 By NT Contributor

This article outlines 10 key steps for practitioners to consider when setting up and running a nurse-led clinic. It lays emphasis on careful planning, professional development and the need to audit and evaluate the service to ensure the clinic is measurably effective.

Richard Hatchett, PhD, MSc, BA, Cert Health Promotion, RNT, RN, is principal lecturer, adult nursing, faculty of health and social care, London South Bank University, and author and co-editor of Nurse-led Clinics: Practice Issues.

Abstract Hatchett, R. (2008) Nurse-led clinics: 10 essential steps to setting up a service. Nursing Times ; 104: 4, 62-64.

There has been a huge growth in nurse-led clinics, improving the patient experience and offering opportunities for role development to nurses. The clinics vary greatly in the way they are set up, both within and between specialties but there are common characteristics. In most cases, nurses have their own caseload and patients consult them in specified time slots. The nurses have a high level of autonomy, with the ability to make often detailed care decisions, admit and discharge from the clinic and refer to other colleagues.

Many clinics demonstrate elements of advanced practice with detailed physiological assessment, subsequent care planning, delivery of treatments, monitoring of the patient’s condition and management of medicines (Hatchett, 2003). A variety of methods are available for medicines management, such as the use of patient group directions (PGDs) and independent or supplementary nurse prescribing.

The literature supporting the role of the nurse-led clinic is growing and demonstrates the variety of issues that nurses encounter in setting up and maintaining a service through this method of delivery. This experience forms the development of 10 key steps outlined here, which aim to enhance the nurse’s ability to run a measurably effective service.

The ten steps

Step 1: the business case In the planning stage, you need to make a business case to present to your employing or funding organisation explaining why the service is needed.

The business case does not refer just to the financial aspect of the service, such as the rationale for using resources but also focuses on what the service can provide. This explains what the service can offer to the organisation and the people needed to run it, and offers a clear overview to all those who may be affected by the project.

For those who have little experience of preparing a business case, the process can be daunting. Using a mentor for support can help to guide you through the process. To find a suitable person, approach staff experienced in this area within your employing trust or healthcare environment or approach your local university. A number of publications detail ideas and principles for building a business case (Cannon, 2005).

Step 2: aims and objectives You need to be clear about the aims of the clinic and its associated objectives. This will help clarify what is being offered to patients and other healthcare professionals who may refer into the service. This process is valuable for subsequent publicity. A clear approach at this stage will also help to demonstrate what needs to be audited and evaluated in the future. It also helps to clarify which patients are appropriate to access the service and which are not. This helps to avoid wasting the time of referrers, patients and those running the clinic.

Step 3: patient criteria Establish the criteria patients need to meet in order to access the nurse-led clinic.

The criteria may be quite broad. For example, a walk-in or drop-in service may offer a variety of services. They may also be quite narrow - for example some clinics investigate a specific symptom and others monitor and treat a particular condition.

Some nurse-led clinics provide leaflets to explain to patients what services they provide. Explicit criteria may come under the objectives of the service and need to be relayed to all those using the service, both patients and other healthcare staff.

Step 4: publicity The clinic will not succeed if patients and referrers do not know of its existence and what service it offers.

Publicity should begin during the planning stage as it may prompt discussion that leads to adjustment of the proposed service. These changes may improve the service for patients and those who refer in. Posters, leaflets, web information, group discussions and visits to those who may use it can all highlight what the service is about and when it starts, as well as explaining when and how it can be accessed.

Patient information about the clinic should be posted on the trust or healthcare provider’s website, and information about what to expect can be sent out with appointment letters.

Step 5: location Decide where the clinic will be run.Questions to consider include: Will it be near to your usual work location or some distance away in the community? Does this raise travel issues for you? Do you have computer access and the necessary facilities to carry out your work effectively in the chosen location? Is there likely to be opposition or problems with using the facilities that you need?

One of the most important issues to consider here is that of administrative support. This should be regarded as a make-or-break issue to running the service as it often causes significant difficulty for nurses setting up a service. Find out whether there is support for typing letters and booking appointments. Nurses need to focus on their specific skills and not be in the office late at night typing letters to patients and to GPs.

Step 6: multidisciplinary support Although the term ‘nurse-led’ implies a strong degree of independence, the clinic is of course part of the patient’s broader healthcare pathway.

A clinic that other healthcare professionals oppose or to which they will not refer patients is doomed to failure. In addition, the sharing of knowledge and experience is a part of all nurses’ professional development.

Prior to starting the clinic you will need to talk to key healthcare professionals who may refer into the service, who may take your referrals and who may suggest who can offer education, advice and support. Consider what they may suggest in terms of adjustments or adaptation or if they do not feel the service is warranted at this stage. The business case is invaluable here in making a clear argument regarding the need and viability of the service.

Step 7: professional development This is one of the most important elements of a nurse-led clinic as it underpins a competent service. It is important to put structures in place that enhance your ability to see deficits in your knowledge base and the ability to rectify these.

One of the main problems with an emphasis on personal reflection on education deficits, within documents such as the Scope of Professional Practice (UKCC, 1992), is that we don’t always know what we don’t know, which may be termed ‘unconscious incompetence’.

Professional development places the emphasis on a continual process, and maintaining a personal education portfolio or file can help focus nurses and managers on where training and education is needed, based on job description and service needs (Hatchett, 2003).

Reviewing cases through clinical supervision offers a formal process through which deficits can be noted and education implemented, much more so if it is tied closely to the education portfolio.

Development does not need to be only through classroom teaching, although this has clear advantages, but considering how competence can be assessed and measured is an important point in closing the gap in personal practice deficits. Building strong links with the local university’s faculty of health care can be helpful in enabling you to discuss education needs and gain advice.

Step 8: managing medicines While this is not an element of all clinics, where medicines are a part of the nurse-led service, it can lead to a hiatus in the smooth delivery of care if it is not managed effectively.

There are various methods of managing medicines, from supplying them through patient group directions (PGDs) to supplementary and independent prescribing. It is an area that nurses need to reflect upon, as undertaking a consultation then handing a pre-printed prescription for signing to a professional who has not seen the patient is not an ideal situation.

Nurses have been successfully educated in prescribing skills and offer an invaluable service as part of their holistic care. Consider what aspect of managing medicines would best suit the service, and indeed the nurses themselves, and how significant advances can be made in this area.

Importantly, if nurse prescribing is the route taken, consider how you will maintain professional development in this area (Bramley, 2006).

Step 9: audit and evaluation Ongoing audit and evaluation is key to meeting patient needs and ensuring that what is offered does make a difference to service users.

There may be areas you are obliged to audit and evaluate but this needs to be considered as part of the planning stage. It will help focus the aims and objectives of the service and allow a consideration of how measurement will be undertaken.

It is important to understand the difference between the two terms - evaluation focuses more on the merit and worth of what is provided, which the audit will make explicit. Are you making a measurably effective difference?

Authors such as Pennery (2003) offer useful advice on the various elements which capture the measured effectiveness of a nurse-led clinic.

Step 10: closing the loop This final step refers to the need to remember that the clinic is an evolving service. Take care to ensure paperwork, such as job descriptions and publicity, have kept pace with any changes in what is being offered.

Keep audit, evaluation and personal development as a clear part of planning, reflecting on where the service will be, perhaps in a year’s time. Audit and evaluation is only useful if it is reflected upon within the healthcare team and adjustments made over time as needed.

Case studies provided by NT.

Bramley, I., (2006) Continuing professional development: what is it and how do I get it? Nurse Prescribing 4: 3, 117-120.

Cannon, J., (2005) Making the Business Case. London: Chartered Institute of Personnel and Development.

Department of Health (1999) Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare . London: DH.

Hatchett, R., (ed) (2003) Nurse-led Clinics: Practice Issues . London: Routledge.

Pennery, E., (2003) Effectiveness and evaluation of the nurse-led clinic. In: Hatchett R (ed) Nurse-led Clinics: Practice Issues . London: Routledge.

UKCC (1992) The Scope of Professional Practice . London: UKCC.

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Reviewed by Geraldine Marrocco, EdD, APRN, CNS, ANP-BC, Associate Professor, Primary Care Division, Yale University School of Nursing, New Haven, Connecticut

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Outcomes of Patient Education in Nurse-led Clinics: A Systematic Review

Zohre pouresmail.

1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

2 Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran

Fatemeh Heshmati Nabavi

3 Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

4 Department of Community Health and Psychiatric Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Najmeh Valizadeh Zare

5 Department of Operating Room, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Introduction:

Patient education is an independent role of nurses performed in nurse-led clinics (NLCs). The measurement of patient education outcomes validates whether nursing educational interventions have a positive effect on patients, which helps determine whether changes in care are needed. Standardized nursing terminologies facilitate the evaluation of educational outcomes. We aimed to explore the outcomes of patient education in NLCs based on the Nursing Outcome Classification (NOC) system.

The review was conducted according to PRISMA guidelines. We searched "Medline", "Embase", "Web of Science", and "Scopus" databases for articles published between 2000 and 2022. Based on the search strategy, 1157 articles were retrieved from PubMed, Scopus, Web of Science, and Embase databases. After excluding the duplicates, 978 articles were appraised. 133 articles remained after reading the titles and abstracts of the articles. In the next step, the articles were evaluated regarding methodology, research population, and exclusion criteria, after which 112 articles were omitted, and finally, 21 articles were included in the full-text review. We assessed all included studies using the Quality Assessment of Controlled Intervention Studies checklist.

A total of 21 randomized controlled trials met the inclusion criteria. "Physiologic health", "functional health", "psychosocial health", "health knowledge and behavior", and "perceived health" were the domains of nursing outcomes investigated as Patient Education Outcomes in NLCs.

Conclusion:

Most of the outcomes were linked to lifestyle-related chronic diseases and, further studies are needed to determine the effects of patient education provided in NLCs in terms of family/society health outcomes.

Introduction

Nurse-led clinics (NLCs) were developed as a dynamic health care innovation 1 to play an advanced practice role for primary chronic disease management during the 1990s. 2 The integrated mind-body care provided by these services is accessible, affordable, high-quality, and patient-centered. 1 The aims behind introducing NLCs include cost reduction and better integration of the pathway of care from the acute to rehabilitative phase, particularly for shortening hospital stays.

Patient education is an independent role of nursing performed in NLCs. The measurement of patient education outcomes vali­dates whether nursing educational interventions have a positive effect on patients, which helps determine whether changes in care are needed. 3 Standardized nursing terminologies facilitate the evaluation of educational outcomes. A standard nursing terminology describes the clinical judgments nurses make based upon the assessment and selection of interventions and the outcome of the patient. 4 A standard nursing terminology allows nurses to diagnose, intervene, and document patient outcomes with specificity, 5 as well as examine the effectiveness of nursing interventions, 6 Ensure nursing accountability and continuity of care. 7 Nursing Outcome Classification (NOC) is one of the standard nursing terminology based on The American Nurses Association. 4 , 5 An NOC was developed in 1991 as a comprehensive, standardized way to classify the outcomes of patients and clients. Specifically, it aims to assess the impact of nursing interventions in health care settings by nursing specialty. 5 It is the most complete and comprehensive standard language currently designed to measure nursing intervention outcomes in patients. 8 Despite growing evidence supporting the value of patient education in NLCs, no comprehensive synthesis of the evidence has been conducted. A previous review of NLCs revealed on health care delivery, 9 care of cancer patients 10 and early discharge, 11 and the overall evidence about outcomes of patient education in NLCs is limited. This review aimed to exploring the outcomes of patient education in NLCs based on NOC.

Materials and Methods

Protocol and registration.

Our systematic literature review was conducted according to the PRISMA guidelines. 12 We get the PROSPERO registration code (CRD42022346293).

Eligibility Criteria

The Population, Intervention, Comparison, Outcome, and Timeframe (PICOT( framework guided our literature search in order to ensure a comprehensive search strategy. 13 In our search, we focused on patient education by nurses in NLCs (P) using patient education interventions (I). The comparison of interest (C) was education performed at the hospital for hospitalized patients. In terms of outcomes (O), it was postulated that reported outcomes could be categorized as the “identification of specific outcomes”. We set a timeframe (T) for research published since 2000, which encompassed the last 22 years.

Information Sources

Two nurse researchers (ZP and FHN) independently searched four electronic databases, including Medline (via PubMed), Embase, Web of Science, and Scopus, to identify eligible publications. A literature search was conducted on January 1, 2022, and a final search was conducted on June 16, 2022.

The search identified original articles. The search keywords were “nurse-led clinic, nursing clinic, public health departments, outpatient clinics, extended care facilities, health maintenance organizations, therapist-owned and -managed centers, wellness center, nurse, education, nursing classification system, and standardized nursing terminology” using AND/OR operators. We searched all combinations of terms from each category to find the target studies. References of the selected articles were also searched. An example of the search strategy was as follows:

(«Nurse-led clinic» OR «nursing clinic» OR «nurse-led outpatient clinics» OR «public health departments» OR «outpatient clinics» OR «extended care facilities» OR «health maintenance organizations» OR «therapist-owned and -managed centers» OR «wellness center») AND (nurse) AND (education) AND («nursing classification system» OR «standardized nursing terminology»).

Study Selection

Two researchers (ZP and FHN) independently reviewed the titles and abstracts of the retrieved articles to find studies that met the inclusion criteria. The inclusion criteria consisted of (a) randomized controlled trials (RCTs), (b) publications in English (c) articles examining one or more nursing outcomes, (d) using a NLC as the research setting, and (e) performing the educational intervention on adults. The exclusion criteria consisted of (a) letters to editors, (b) non-intervention trials, and (c) studies in physicians’ offices and clinics. We then retrieved the full texts of these studies and evaluated their eligibility. A third reviewer (NVZ) helped resolve disagreements regarding eligibility of studies.

Data Collection Process

Our team developed a sheet for data extraction. The data were extracted by two reviewers (ZP and FHN). There was a consensus reached between the reviewers if there were any disagreements, and data was included only if there was an agreement.

To extract and summarize the information from the included studies, the reviewers conducted an in-depth review including the title, author, year, setting, intervention, educational methods, educational materials, outcomes, NOC domain, NOC classes, and how outcomes were measured ( Table 1 ).

Note: HbA1c, glycated hemoglobin; FBG, fasting blood glucose NRT, nicotine replacement therapy; BP, blood pressure; CSES COPD Self efficacy Scale; SGRQ, St. George’s Respiratory Questionnaire; MLHFQ Minnesota Living with Heart Failure Questionnaire; CDS, Cardiac Depression Scale; NLC, Nurse-led clinic; CSE, Cardiac Self-Efficacy; STAI-T, State Trait Anxiety Inventory; HADS, Hospital Anxiety and Depression Scale; MAQ, Medication Self-Assessment Questionnaire; BIPQ, Brief Illness Perception Questionnaire; CMS, clinical management system; PFS, Piper Fatigue Scale; SDS, Self-Rating Depression Scale; PSQI, Pittsburgh Sleep Quality Index; IPAQ-S, International Physical Activity Questionnaire short; FFF, Food FrequencyQuestionnaire; LVEF, left ventricular ejection fraction; DLQI, Dermatology Life Quality Index.

Risk of Bias in Individual Studies

All studies were independently reviewed by two reviewers (ZP and FHN). Quality Assessment of Controlled Intervention Studies (QACIS) was applied to the studies as outlined in the Effective Public Health Practice Project (EPHPP). An agreement was reached by referring to a third reviewer (NVZ) if scores differed.

Synthesis of Results

Two reviewers (ZP and FHN) synthesized and analyzed the data. The discrepancy between them was resolved by consensus, and only data that was agreed upon by both reviewers was included. An evidence synthesis with narrative-descriptive summaries and tables was prepared, which included the main outcomes and consistency of findings across studies. The sixth edition of the NOC system was used as the framework for data synthesis. This system consists of seven domains, 35 classes, and 540 outcomes. The seven domains include «functional health», «physiologic health», «psychosocial health», «health knowledge and behavior», «perceived health», «family health», and «community health». 8 The outcomes were classified based on the domains and classes of NOC. For example, anxiety was assigned to the psychological well-being class and the psychosocial health domain.

Based on the search strategy, 1157 articles were retrieved from Pubmed, Scopus, Web of Science, and Embase databases. After excluding the duplicates, 978 articles were appraised. With the further exclusion of 845 articles, 133 articles remained after reading the titles and abstracts of the articles. In the next step, the articles were evaluated regarding methodology, research population, and exclusion criteria, after which 112 articles were omitted, and finally, 21 articles were included in the full-text review ( Table 1 ). No relevant articles were found in the references of the studies by a manual search. Finally, this review included 21 RCTs that met the inclusion and exclusion criteria after conducting a study-relevant analysis. PRISMA flowchart shows the search strategy and selection process ( Figure 1 ). 35

PRIZMA flow diagram of study selection

Risk of Bias within Studies

Table 2 presents the results of the quality assessment. A study that examined the quality assessment components and ratings of the EPHPP instrument. 36 Quality ratings were generally acceptable for the study reports used.

Characteristics of patient

Finally, 21 articles were reviewed. The target groups included patients with diabetes, 14 - 17 patients with chronic lung diseases including asthma and COPD, 18 - 20 patients with skin diseases, 21 patients with cardiovascular diseases, 17 , 22 - 25 patients with chest pain, 26 patients with arthritis, 27 the elderly with chronic diseases, 28 patients with irritable bowel disease (IBD( (ulcerative colitis, Crohn’s disease), 29 adults with ovarian cancer, 30 Hip fracture risk factors in women over 70, 31 patients with raised blood pressure or raised total cholesterol, 32 patients at risk of breast cancer, 33 and patients with strock. 34

Outcomes Examined in Nurse-led Clinic

The domain of NOC that examined in NLC were “functional health”, “Physiologic health”, “Psychosocial health”, “Health knowledge & behavior” and “Perceived health” ( Figure 2 ).

Outcomes of patient education in nurse-led clinics based on NOC

The functional health domain describes outcomes relating to the performance of basic life activities and the capacity to perform them, functional health has 4 classes (Energy maintenance, growth and development, mobility and self-care). The outcomes investigated in the “energy maintenance” class included fatigue and sleep quality. 30 The frequencies of Breast Self-Examination (BSE) 33 and self-care behavior 22 were the outcomes examined in the “self-care” class.

Physiologic health domain explains outcomes that describe organic functioning and consist of 10 classes (cardiopulmonary, digestion & nutrition, elimination, fluid & electrolyte, immune response, metabolic regulation, neurocognitive, sensory function, therapeutic response and tissue integrity). In the “cardiopulmonary” class, the examined outcomes were cardiac enzymes, 22 left ventricular ejection fraction (LVEF), 22 lipid levels, 14 , 16 hypertension, 14 chest radiographs, 22 urinary nicotine test results, 15 chest pain 26 and blood/urine test results. 16 , 22 The perception of disease 27 was considered the studied outcomes in the “therapeutic response” class. The change achieved in the individual hypertension and cholesterol interventions, the analyses of the continuous measures, and all-cause mortality Hyperlipidemia hypertension 32 was examined outcomes in metabolic regulation classes and clinical fracture 31 was outcome in the tissue integrity.

Psychosocial health domain explains outcomes that describe psychological and social functioning and consist of 4 Classes (psychological well-being, psychological adaptation, self-control and social interaction). The outcomes investigated in the “psychological well-being” class included anxiety 25 , 26 and depression. 25 , 26 , 29 , 30 In the “psychological adaptation” class, the outcome was the coping strategies 29 and fear of falling 31 was the outcome in the fear self-control classes.

Outcomes that describe attitudes, comprehensions, and actions related to health and illness are described by the Health Knowledge & Behavior domain. This domain Consist of 7 classes (Health Behavior, Health Beliefs, Health Management, Knowledge Health Condition, Knowledge Health Promotion, Risk Control and Safety). The outcomes of the “health knowledge and behavior” domain were investigated in four classes of “health behavior”, “health management”, “knowledge health condition” and “risk control”. Besides, the “health behavior” outcomes included drug consumption and pharmaceutical compliance, 23 , 26 , 27 lifestyle behavior change 34 and vaccination rate. 28 The outcome investigated in the “health management” class was self-efficacy, 18 , 25 , 34 cardiac self-efficacy 25 and self-efficacy to manage disease in general. 28 The outcome examined in the “knowledge health condition” class were patients’ knowledge, 14 , 19 , 21 the number of smoking and cessation times, 15 , 19 determinations lipid levels. 14 The outcome examined in the “risk control” class were blood pressure 14 and falls. 31

The Perceived Health domain consists of three classes (Health & Life Quality, Satisfaction with Care, and Symptom Status) describing the health and health care experiences of individuals. Outcome of health and quality of life class consist of the life quality, 19 , 21 , 22 , 24 , 31 generic health status, 29 and heart failure readmission. 24 patients’ satisfaction, 14 , 16 , 20 , 33 in satisfaction with care classes. Glycated hemoglobin (HbA1c) and fasting blood glucose (FBG), 14 anxiety and depression, 26 reduction in systolic & diastolic blood pressure, 17 the proportion of patients who achieve the specified goals for either intervention 32 were outcome in symptom status classes ( Figure 2 ).

The purpose of our systematic review was to determine the nursing outcomes related to patient education in NLCs based on the NOC. The “physiologic health”, “functional health”, “psychosocial health”, “health knowledge and behavior”, and “perceived health” were the domains of nursing outcomes investigated as patient education outcomes in NLCs. Besides, “self-care”, “energy maintenance”, “mobility”, “cardiopulmonary”, “therapeutic responses”, “psychological well-being”, “psychological adaptation”, “health behaviors”, “health management”, “knowledge health condition”, “health and life quality”, “satisfaction with care”, and “symptom status” were the classes of nursing outcomes investigated as patient education outcomes in NLCs.

According to the findings of our review study, most of the outcomes investigated in the studies conducted in NLCs were associated with the outcomes of lifestyle-related chronic diseases. The nursing profession is in direct contact with society; therefore, it provides services for the community and can gain public trust by providing safe, effective, and accessible services. Nursing as a developing profession needs to document the effectiveness of its services. 37

As a result of the present study and access to outcomes such as smoking cessation, self-care, cardiac diseases and diabetes, and patient’s quality of life by the nurses of NLCs demonstrate that the nursing profession contributes to providing effective and accessible services for critical health problems of society. 38 , 39 In this regard, a systematic review revealed that the outcomes relevant to hypertension, quality of life, and patient satisfaction in nurse-led primary care centers were better than the outcomes in centers managed by physicians. 40

According to the findings of our systematic review, in addition to the physical outcomes examined as educational outcomes in NLCs, some outcomes such as anxiety, depression, and coping strategies were investigated in the psychological health domain. However, most patients, especially cancer patients, 41 hemodialysis patients, 42 patients needing surgery, 43 and other groups of patients may experience psychological problems, along with physical illnesses. Accordingly, the examination of and attention to the psychological health domain and development of its variables by the nurses of outpatient centers can contribute to the comprehensiveness and specificity of the nursing outcomes measured in patient education. Therefore, the limitation in outcomes measured in the psychological health domain is considered one of the gaps in investigations conducted on nursing outcomes in NLCs.

According to the findings of our review, less publication about outcomes of the family and society health domain is considered one of the existing gaps in investigations performed on the outcomes of NLCs. The non-evaluated outcomes in the reviewed investigations include caregiver role endurance, caregiver stressors, caregiver emotional health, family coping, parenting performance, community disaster readiness, and community health screening effectiveness. However, nowadays, family and society play a crucial role in home-care due to the population aging and the spread of lifestyle-related chronic diseases 44 , 45 so that the contemporary society requires human resources for health 46 and medical and nursing services to provide home-care services. 47 , 48 Thus, it requires further study to best understand what it is the nurse may be teaching in these domains.

Satisfaction was one of the outcomes evaluated in the reviewed studies, which was expressed as general satisfaction, care satisfaction, and educational satisfaction. General satisfaction is a complex set encompassing various factors and requiring the examination of several aspects of services. As this outcome is affected by a complex set of factors, it produces a bias in answering and interpreting. However, satisfaction is considered an important indicator of healthcare quality. 49 , 50 Therefore, patients’ satisfaction with services is also investigated in relation to the type of service. 51 One of the dimensions of evaluating satisfaction is to determine patients’ satisfaction with the education provided by nurses. Only one of the studies on nursing outcomes in NLCs evaluated the patients’ satisfaction with education. The study reported that patients’ satisfaction with the education provided by nurses was related to BSE. 52 To improve patient satisfaction, healthcare providers need to be responsive to patients’ concerns. 53 , 54 Therefore, patients’ satisfaction with the provided care or education may serve as a specific indicator to determine service efficacy at the initial stages of evaluation.

One of the interesting points among studies on the nursing outcomes of patient education in NLCs was the implementation of patient education as teamwork in most outpatient nursing clinics. A nurse’s care is unique among health professions, and patient education has long been viewed as a priority. In the mid-1800s, nurses were recognized as caregivers who had responsibility for patient education. In early 1993, The Joint Commission (TJC) developed nursing standards for patient education. Later, patient education activities were recommended to other care providers, 55 and as part of TJC’s patient education efforts, an interdisciplinary team approach was taken, meaning that patient education is an interdisciplinary team process. 56 Thus, it is expected that educational services provided by nurses at nursing clinics follow an interdisciplinary approach.

The reviewed investigations indicated that in-person education methods (individually or in groups) were most commonly used at outpatient NLCs, and non-attendance education was only limited to telephone contacts with patients. Due to modern technological developments, educational methods used in clinics change based on the needs of societies so that non-attendance education can employ iBook, 57 computer and tablet-based education at home, 58 software-based education, 55 game-based 59 and simulation based education, 60 which can effectively promote patients’ knowledge. 55 , 56

Despite the exhaustive electronic search, our study had several limitations. First, the limited number of the studies selected by the reviewers did not include grey literature. Second, the retrieved studies were limited to those published in English journals.

Third, lack of specificity of actual material taught and how outcomes of teaching were measured in some of the studies. Fourth, time frame in which outcomes were measured was variable. Fifth, only evaluated teaching/patient education conducted in English.

According to the conducted search, the increasing diversity of recent investigations in the context of patient education and in the areas of educational methods, media, and patient groups is helpful in the development of patient education; thus, it is necessary to consider the evaluation of education, especially concerning patient outcomes. According to our findings, further studies are needed to determine the effects of patient education provided in NLCs in terms of family/society health outcomes.

Acknowledgements

This study is part of a larger study and extracted from a doctoral dissertation. Authors appreciate research vice-chancellery of Mashhad University of Medical Sciences (Number: 980401).

COI-statement

The authors declare no conflict of interest in this study.

Ethical Approval

The Ethics Committee of Mashhad University of Medical Science, Mashhad, Iran, approved this project and assigned it the number “IR.MUMS.NURSE.REC.1398.057.

Research Highlights

What is the current knowledge.

In NLCs, patient education is a distinct role of nursing. Care changes are determined by outcome measurement. NLCs have been found to be effective in the delivery of health care, particularly in the context of cancer patient care and early discharges. There is a scarcity of empirical information about the impact of NLCs on patient outcomes.

What is new here?

Most of the outcomes investigated in NLCs were linked to lifestyle-related chronic diseases.

The psychological health domain also examined as educational outcomes in NLCs.

Further research is needed to determine how NLCs influence family/society health outcomes.

Funding Statement

This research receive grant from Mashhad university of Medical Science with grant number 980401

Nurse Practitioner Clinic Business Plan [Sample Template]

By: Author Tony Martins Ajaero

Home » Business Plans » Medical and Healthcare » Hospital & Clinic

Are you about starting a nurse practitioner clinic? If YES, here’s a complete sample nurse practitioner clinic business plan template & feasibility report you can use for FREE to get started .

Okay, so we have considered all the requirements for starting a nurse practitioner clinic. We have analyzed and drafted a sample nurse practitioner clinic marketing plan backed up by actionable guerrilla marketing ideas for nurse practitioner clinics. So let’s proceed to the business planning section.

Nurse practitioners, also known as advanced practice nurses are registered nurses with advanced clinical training. They provide generalist care including routine physical assessment, treatment of uncomplicated episodic illness, continuing care for persons with stable chronic conditions, and acute care in hospital settings.

In many states in the US, they can act as a primary care provider, managing patients from birth through the aging process (depending on their specialty). One exciting prospect of becoming a nurse practitioner is the idea of opening his/her own practice. Nurse practitioners enjoy autonomy and owning their own practice further enhances their independence.

This is an interesting and lucrative business idea for anyone with the passion for healthcare. They are a lot of things you must consider before deciding to start up your own clinic and one of those things is the legal aspects of physician supervision.

Every state in the united states regulates the practice of nursing, and the rules differ from one state to another.Some states in the United States may require an NP to have a supervising physician to diagnose and treat, to prescribe or both, while some other states allow completely independent practice.

An NP who works in a state where supervision is required will need to set up a consultation contract with a physician to ensure that the business is legal. But as an NP in a state that allows private practice without physician supervision, you could open a private practice in paediatrics, family medicine, adult medicine or women’s healthcare.

There’re also NPs who are interested in less traditional aspects of nursing practice such as holistic care, or want to combine another aspect such as massage therapy into their nursing practice. NPs can also provide direct services to patients in locations other than a hospital, clinic or medical office

A Sample Nurse Practitioners Business Plan Template

1. industry overview.

Generally, nurses work to promote health, prevent disease, and help patients cope with illness. They are advocates and health educators for patients, families, and communities.

When offering direct patient care, they watch, assess, and record symptoms, reactions, and progress in patients; assist physicians during surgeries, treatments, and examinations; administer medications; and assist in convalescence and rehabilitation.

Nurses also develop and manage nursing care plans, advice patients and their families in proper care, and help individuals and groups take steps to improve or maintain their health.

Nurse practitioners (NPs), together with physician assistants (PAs), became necessary in the United States in the 1960s in response to shortages and uneven distribution of physicians. They play important roles in many healthcare fields and especially in primary care.

According to reports, there were approximately 106,000 practicing nurse practitioners and 70,000 practicing physician assistants in 2010.

This estimate represents approximately 10,000 fewer practicing physician assistants than projected by the American Academy of Physician Assistants (AAPA) and approximately 10,000 more nurse practitioners than report having NP in their title in a 2008 national survey.

Robert Graham Centre in recent years used the NPI dataset to examine the practice partners of each nurse practitioner and physician assistant.

By making use of a novel imputation method that assigned field of practice (primary care or a subspecialty care) to each NP and PA based on the specialty of the professionals they work with, they were able to estimate that less than half of physician assistants (approximately 30,000) and slightly more than half of nurse practitioners (approximately 56,000) are practicing primary care in 2010.

2. Executive Summary

Master Touch Family Clinic offers a unique combination of Family medical clinic services and community-based social services to Fort Lauderdale. The type of service we plan to provide is almost non-existent from the private sector in our business location.

Although there are government agencies on the city that provide the same services that we will be providing. But the long delays, lack of personal attention, and quality of service provided by these agencies leave the market wide open for private involvement.

We at Master Touch Family Clinic plan to leverage many strategies to differentiate ourselves from the existing market. One of the major differences we plan to bring to the industry will be the sincere concern for our client’s well being on every level.

Benchmarking customer service is our key approach to corner the market of the industry that is in desperate need of our services. Master Touch Family Clinic will be created as a Florida Limited Liability Company based in Fort Lauderdale, owned by its principal investors and principal operators.

Our initial office will be established in a quality office space in Downtown Fort Lauderdale, which is the heart of Fort Lauderdale. Our family medicine clinic will be supervised by Dr Bernard Will from the prestigious Boward General hospital.

Our clients at Master Touch Family Clinic will be families in Fort Lauderdale in need of healthcare and/or social services. These patients are usually referred by other healthcare professionals such as physicians, attorneys, insurance companies and healthcare facilities.

Master Touch Family Clinic can boost of having an excellent reputation with many of these professionals, through the work of our Clinical Director, who is a known figure in the industry, and through the presentations we have made to the community via marketing tools and personal interactions.

Master Touch Family Clinic will be licensed by the State of Florida and our services reimbursed by Medicare, Medicaid and other private insurance carriers.

We have already initiated the process for licensure and insurance certification and we are well on our way to meeting the regulations and guidelines for providing family medicine and social services to patients in Fort Lauderdale, Florida.

Our marketing strategy at Master Touch Family Clinic involves a combination of print media advertising, website development, networking, and promotional events, all aimed at residents living within 35 miles of the clinic. All pricing will be set according to Medicare, Medicaid and other insurance regulation so pricing is not a major factor of consideration.

Sales estimates project healthy revenues in the first year and modest increases through year three. We at Master Touch Family Clinic plan on taking on debt in the form of a five-year loan, and have no plans for additional debt as growth will be financed mainly through cash flow.

Our plan includes assumptions of 100% sales on credit, and sufficient cash on-hand at start-up to prevent any problems with cash flow.

3. Our Products and Services

Master Touch Family Clinic will provide general care for all ages, as well as providing multiple procedures to create a complete healthcare solution.

We will provide procedures including but not limited to mole removals, biopsies, trigger point injections, and much more. We will also incorporate multiple modalities, such as cryotherapy, hyfrecator, shaving, and excisional removal of lesions.

The costs will depend upon the materials used, the physician’s time and the amount designated for each procedure. Our goal is to ensure that optimal health and performance can be attained through the proper balance of exercise, nutrition, and education.

We at Master Touch Family Clinic will educate our patients as well as treat them by providing group classes and teaching sessions for our patients. Subjects could include nutrition, diabetes and hypertension care, and much more.

Our customer approach to service will be buttressed by our willingness to give our clients the full package. From diagnosis procedure to the point where each patient will be offered education in rehabilitation, nutrition and exercise as it relates to each particular case.

We at Master Touch Family Clinic plan to create the best experience for each patient in order to optimize their health. The services we plan to render to the tourists and families in Fort Lauderdale include:

Gynaecology

• Annual Well Women Exam
• Family Planning
• Acute Gyn Problems

Paediatrics

• New born Care
• Infant Care
• Annual Physicals
• Routine Services
• Possible Immunizations
• Dermatology
• Removal of minor lesions, skin tags, moles and warts
• Biopsies of suspicious dermatological lesions and/or referral
• Allergy Testing and shots
• Immunizations

Minor Surgery

• Laceration Repair
• Lesion Removals
• Hyfrecation for Lesions and Blemishes

Adult Medicine

• Preventive and Routine Services
• Diabetic Teaching
• Nutritional/ Dietician Services
• Exercise and Obesity Counselling
• Possible Stress Testing (Future Service)

4. Our Mission and Vision Statement

• Our mission at Master Touch Family Clinic is to promote the health and well-being of the population of Fort Lauderdale and the State of Florida by providing accessible, high-quality medical care for people of all ages.
• Our vision is to become the recognized leader in the Whole United States for general medical services that are allowed to be rendered by nurse practitioners.

Our Business Structure

We at Master Touch Family Clinic plan to start with six health workers: a nutritionist, three medical assistants and two nurse practitioners. We will also employ the services of other business personnel to help achieve our business goals.

All our health employees will be paid hourly wages and have health and dental benefits. But as the business grows and profits start rolling in, we will employ additional personnel to help with referrals and additional responsibilities that will be needed at that time.

Also during our first year, our supervisory physician will work part-time at the clinic, but will be paid directly by Boward General Hospital. Starting in the second year, the physician will draw his salary directly from Master Touch Family Clinic.

We also plan to establish a policy and procedures manual that will act as a guide and reference to sick pay, leave, vacation, hourly wages, payment, etc. The philosophies and guidelines in this manual will help maintain proper clinical structure. We hope to fulfill all our goals and visions, which is why we have chosen designated portfolios to employ right from the beginning. They are;

• Clinical Director (Owner)

Nurse practitioners

• Medical assistants

Admin and Personnel Manager

Nutritionist

• Accountants / Cashiers

Security Officers

5. Job Roles and Responsibilities

Clinical Director

• Oversees all other employees within the clinic.
• Align with the board of directors and other health workers to determine if the clinic is in accordance with goals and policies.
• Charged with encouraging business investment.
• He also promotes economic development within communities.
• In charge of directing the clinic’s financial goals, objectives, and budgets.
• Implements the clinic’s guidelines on a day-to-day basis.
• In charge of Hiring, training, and terminating employees.
• In charge of developing and implementing strategies and set the overall direction of a certain area of the clinic
• Collaborate with the board of directors to develop the policies and direction of the clinic.
• He makes sure that the members of the Board of Directors have the information necessary to perform their fiduciary duties and other governance responsibilities.
• Direct staff, including clinical structure, professional development, motivation, performance evaluation, discipline, compensation, personnel policies, and procedures.
• Diagnose, treat, and manage acute and chronic illnesses.
• In charge of health promotion, disease prevention, and health education and counselling.
• In charge of conducting, supervising, and interpreting diagnostic and laboratory tests.
• Helps patients make better lifestyle and health choices.
• Serve as researchers and patient advocates for the clinic

Medical Assistants

• Getting treatment and examination rooms ready for patients
• Getting patients ready for examinations, treatments and procedures
• Assisting with examinations and routine procedures, including minor surgery
• In charge of taking blood samples and specimens, dressing wounds and recording vital signs
• Sterilization of equipment
• Administering medications
• In charge of overseeing the running of HR and administrative tasks for Master Touch Family Clinic
• Monitor clinic supplies by checking stocks; placing and expediting orders
• Ensures operation of equipment by completing preventive maintenance requirements; calling for repairs.
• Organise induction for new team members
• In charge of training, evaluation and assessment of employees
• In charge of arranging travel, meetings and appointments
• Oversee the smooth running of the daily office activities.
• In charge of evaluating a client’s nutritional needs
• In charge of providing nutritional counselling and advice to clients
• Tasked with creating a clinical nutrition treatment plan for a client
• Researching the effects of nutrition on health and fitness
• Consulting with a team of healthcare practitioners on nutritional management for a client

Accountants/Cashiers

• In charge of preparing financial reports, budgets, and financial statements for Master Touch Family Clinic
• Provide management with financial analyses, development budgets, and accounting reports
• In charge of financial forecasting and risks analysis.
• Understand cash management, general ledger accounting, and financial reporting
• In charge of developing and managing financial systems and policies
• In charge of administering payrolls
• Ensuring compliance with taxation legislation
• Take care of all financial transactions for Master Touch Family Clinic
• Serves as internal auditor for the clinic
• In charge of cleaning the clinic at all times
• Make sure the toiletries and supplies don’t run out of stock
• Handles any other duty as assigned by the director.
• In charge of protecting the clinic and it’s environs
• Controls traffic and organize parking
• Give security tips when necessary
• Patrols around the building on a 24 hours basis
• Presents security reports weekly

6. SWOT Analysis

We at Master Touch Family Clinic plan to create a medical practice that will exceed patients’ expectations. Our Mission is to provide high-quality healthcare to residents of Fort Lauderdale and to create a medical practice that helps serve the community’s needs.

We understand the importance of these services, that is why we went through the process of conducting a detailed SWOT analysis. This SWOT analysis was able to explain our key strengths and possible pitfalls in the industry. We have also taken time, with help from notable experts, to make sure we utilise our strengths and work our weaknesses. Below is the summary of the SWOT Analysis.

Our strength at Master Touch Family Clinic is fact that we have plenty of health services to render to the people of Fort Lauderdale. We have put plans in place to introduce our clinic to tourists as soon as they land in Fort Lauderdale. Also the experience and expertise of our founding teams makes our clinic attractive. The connections we have set already also make us concrete and strong.

Our detailed SWOT analysis also noted that our location might serve as a weakness to us. It went further to acknowledge that downtown Fort Lauderdale is the business hub of the city and will be filled with businesses trying to offer most of the services we offer. We also have to fight it out with Tenet Healthcare in Fort Lauderdale, but we have put plans in place to outshine and attract more clients.

• Opportunities

The increases in death rate and the prevalence of high priority diseases have taught the citizens of America the need to regularly take care of their health and always seek medical care.

Also patients always want to save time and get a more personalised care, which are rarely afforded in government owned clinics or bigger healthcare institutions. All these are opportunities which our SWOT Analysis noted are available to us.

Our SWOT Analysis also explained that the major threat we will be facing is the fact that we are going to be competing against already existing business in Fort Lauderdale. These businesses include Government and private owned healthcare facilities.

It is believed that these businesses will come after us with all they have got. This won’t be easy for a new entrant in the industry, but the services we offer are unique and new in this area and we plan to make use of that advantage.

7. MARKET ANALYSIS

• Market Trend

As a clinic that wants to provide a healthcare practice that is able to survive off its own cash flow in 10 months or less, we understand the need to keep up with industry trends. We at Master Touch Family Clinic plan to increase the number of patients by 20% per year through superior performance and word-of-mouth referrals.

We want to be and remain an industry leader in family medicine and we hope to do so by staying current. Below are the few trends that are currently riding the industry.

• Demand for family care is increasing

Reports have it that the biggest demand lies in family care physicians, and along with that, the need for additional nurses on staff.

For nurse practitioners new to the profession, or veteran NPs that are looking for a change of pace, family care is one of the best career choices to explore – along with the oncology field – as professionals in these two areas are currently in high demand.

Statistics has it that family care is a branch of medicine that will continue to be in demand despite already having more than half of the NP workforce dedicated to its practice.

• Increased demand for nursing staff in outpatient centres

A lot of patients need continued treatment after a hospital stay, causing an increase in demand for outpatient services. Report has it that over 25% of nurse practitioners worked in an office, 20% worked in an independent clinic, and 15% worked in a hospital clinic.

The study found that only 14% worked in an actual hospital. In addition to these statistics, most of the nurses surveyed worked at several locations under temporary contracts, a common practice as hospitals need the additional staff.

• Growing demand for NPs in rural and underserved communities

With an estimated shortage of about 20,000 physicians, this national issue is especially affecting rural and underserved areas. Since the chance of accident or injury increases in rural communities where licensed physicians aren’t practicing, this has become an even bigger concern.

• Nurses are developing interdisciplinary skills

Just as illnesses evolve and become more complex, an experienced and interdisciplinary skilled nurse practitioner becomes even more valuable. Interdisciplinary skills are quickly becoming a must-have in the nursing industry, and as a result, NPs are learning many valuable skills from areas such as the dental field to social discipline.

• Education is changing due to changes in demographics

Note that diversity within the U.S. population—and increased life-expectancy—is changing what and how NPs are learning. As the international and aging communities in the U.S. increase in number and live longer, nurses must learn and adopt treatments to meet the needs of these communities.

• Advances in nursing and science research are increasing

Naturally, the nursing field needs all the discipline to research, study, and keep up with current research. The best way to do that is by subscribing to a few medical journals. Plenty of advances in nursing research are being developed currently.

In short, an increase in nursing research scholarships has encouraged NPs to study more effective ways to improve patient care.

8. Our Target Market

Our business location in downtown Fort Lauderdale boasts of many new hotels and high-rise condominium developments. Fort Lauderdale downtown area is the largest in Broward County and is a major manufacturing and maintenance centre for yachts.

Due to the Fort Lauderdale many canals, and closeness to the Bahamas and Caribbean, it is also a popular yachting vacation stop, and home port for 42,000 boats, and approximately 100 marinas and boatyards.

Additionally, the annual Fort Lauderdale International Boat Show, the world’s largest boat show, brings over 125,000 people to the city each year. Fort Lauderdale was recently listed as 2017’s third best city out of 150 U.S. cities by WalletHub for summer jobs, and the 24th best city to start a career in.

All these and many more made this city the perfect location for Master Touch Family Clinic. Master Touch Family Clinic will focus all its energy at the entire population (within 35 miles). Below are the reasons why we believe Downtown Fort Lauderdale is the best location for us.

• The people of Fort Lauderdale rarely have the patience, and often cannot wait more than 30 minutes to see a doctor. They would rather “wait it out” on all but urgent matters.
• Fort Lauderdale is always booming with tourists coming in to enjoy the city’s diverse resources or passing through to other big cities around.
• Master Touch Family Clinic is a general family practice, and will treat patients of all ages, incomes, physical abilities, races, and ethnicities. As a family clinic, there is no need to create marketing materials targeted at only one or two of these groups, but we can appeal to all with a similar message.

Our competitive advantage

We can comfortably say that Competition among fellow family practitioners in Fort Lauderdale is small. The growing population base and the limited number of doctors create a great potential for meeting our patient load goals. Most patients when choosing a family health expert go for someone knowledgeable and skilled who will listen carefully to their health concerns.

These same people are more likely to return to a health expert whose location and hours are convenient and accessible, who have short waiting times for getting appointments, whose staff is friendly and helpful, and who work effectively with their insurance provider.

These are the services we plan to render in our business location. We will stop at nothing until we achieve our business goals and visions. Also our well conducted and experienced workforce is another advantage we have in Fort Lauderdale. We have put plans to educate and always remind our employees of the need to remain friendly and calm with any patient.

9. SALES AND MARKETING STRATEGY

• Sources of Income

Our primary source of revenue at Master Touch Family Clinic will be the medical services provided by our well conducted workforce. Master Touch Family Clinic will offer many of the services that are common within this specialty including treatment of medial issues including high blood pressure, cholesterol, and mild medical conditions.

This part of the business will also provide work physicals, and provide cancer screenings, heart disease screenings, and other tests normally associated with the practice of a nurse practitioner. Below are the services we plan to render and make substantial profits at Master Touch Family Clinic:

• Gynaecology related services
• Paediatrics related services
• Minor Surgeries
• Adult Medicine related services

10. Sales Forecast

We at Master Touch Family are very ready to achieve our mission as a clinic. We have put together a sales forecast for our clinic. All pricing will be set according to Medicare, Medicaid and other insurance regulation so pricing is not a major factor of consideration. The projection below is a very conservative sales forecast for our business for the next three years.

• First Year: $420,000
• Second Year: $1,200,000
• Third Year: $3,000,000
• Marketing and Sales strategy

We at Master Touch Family Clinic have put plans in place to achieve all our goals and visions. We intend to use a number of marketing strategies that will allow us to easily target men, women, and families living and coming in Fort Lauderdale. These strategies include traditional print advertisements and ads placed on search engines on the Internet.

This is very crucial to the success of our business, as many people seeking local services, such as medical services, go to the Internet to conduct their preliminary searches. We have plans to register Master Touch Family Clinic with online portals so that people in city and those still coming in can easily reach us. We are currently developing our own standard online website.

We plan to maintain a sizable amount of print and traditional advertising methods within local markets to promote all the medical services we render at Master Touch Family Clinic.

We at Master Touch Family Clinic will also maintain an extensive marketing campaign that will ensure maximum visibility for the clinic to the general public. We will also build relationships with doctors all around Florida and we also plan to implement a local campaign in Fort Lauderdale with flyers, local newspaper advertisements, and word of mouth.

11. Publicity and Advertising Strategy

We at Master Touch Family Clinic believe everybody anywhere in the world is a potential customer and we plan to use a separate Publicity and Advertising plan away from our clinic’s Marketing Plan to reach them.

Master Touch Family Clinic plans to implement a strong publicity and advertising strategy, which is why we have partnered with Ardent and Partners, an advertising firm that specializes in overall business advertisements and many other advertising strategies, to help us with boosting the image of Master Touch Family Clinic.

• Master Touch Family Clinic will pay Ardent and Partners $17,000 to determine the needs of the surrounding population and how best we can meet those needs with promotions, literature and other marketing programs.
• Our Admin and Personnel Manager will work consistent with Ardent and Partners to inform potential clients of our clinic, to encourage an image of community involvement for Master Touch Family Clinic.

12. Our Pricing Strategy

Master Touch Family Clinic will leverage the most advanced computer, server and software systems, as well as Internet connections, in order to optimize the potential EMR and PMS systems software as well as in other software and network system utilized resulting in faster verification, efficient patient information transfer, reduction in administrative costs, computer breakdown or malfunction, as well as allowing outside access for the physician in order to access important patient information for hospital admissions.

We also plan to make use of an outside electronic medical billing company. We at Master Touch Family Clinic believe that this option will allow us to to focus our strength on patient care satisfaction.

This electronic medical billing company, Synthetic Cords, will use electronic claim billing and filing, which in turn will allow us to fully utilize the benefits of electronics claim filing while at the same time letting us maximize valuable clinic time and manpower. Synthetic Cords charges 9% of the total expenses collected.

• Payment Options

In this modern age, we at Master Touch Family Clinic know that good payment options are a powerful business strategy which will attract customers, and we are very much ready to make use of it. We will be bringing payment options that are unique and will make the payment for the service we offer very easy for our customers.

• Payment by via bank transfer
• Payment via online bank transfer
• Payment via check
• Payment via bank draft
• Payment via mobile money

Master Touch Family Clinic have partnered with a renowned bank in the country to enable us provide the above payment options. Our bank account numbers will be made available on our website and promotional materials so that it will be easier for clients to make payments when necessary.

13. Startup Expenditure (Budget)

Starting a good family medicine clinic can be very costly due to the high cost of equipment needed to start the business. We at Master Touch Family understand that this industry is capital intensive but we are also ready to make very good use of the funds we have.

The more reason we have decided to create a business plan that will serve as a commandment or direction for our business. We also acknowledge that prices of equipment can differ across different locations in the country, but the difference we believe can’t be much and can be overlooked. Below is a detailed analysis of how we want to spend our startup capital;

• The Total Fee for Registering the Business in Fort Lauderdale, Florida: $750.
• Legal expenses for obtaining licenses and permits: $1,500.
• Marketing promotion expenses: $150,000
• Cost for hiring Consultant – $5,000.
• Insurance (general liability, workers’ compensation and property casualty) coverage at a total premium – $30,800.
• Cost of accounting software, CRM software and Payroll Software – $3,000
• Cost for leasing facility for the clinic: $100,000
• Cost for facility remodelling – $50,000.
• Other start-up expenses including stationery – $1000
• Phone and utility deposits – $3,500
• Operational cost for the first 3 months (salaries of employees, payments of bills et al) – $80,000
• Storage hardware (bins, utensil rack, shelves, glasses et al) – $1,720
• Cost for medical equipment – $700,000
• The cost of Launching a Website: $600
• Miscellaneous: $5,000

From our detailed analysis above, we will need $1,145,620 to start up Master Touch Family Clinic.

Generating Funding for Master Touch Family Clinic

Master Touch Family Clinic was founded by a great woman, Amanda Liras, a registered nurse practitioner and an astounding entrepreneur. The business will be funded by her until we decide to accept investors or partners. Ways we hope to raise our startup capital include;

• Generate part of the startup capital from personal savings
• Generate part of the startup capital from friends and other extended family members
• Generate part of the capital from the bank (loan facility).

Note: Amanda Libras have been able to raise $500,000 ( $300,000 from personal savings and $200,000 as soft loans from family and friends ) and we are at the final stages of obtaining a loan facility of $1,000,000. We have verified all the necessary procedures to actualize or get our startup cost.

14. Sustainability and Expansion Strategy

Master Touch Family Clinic is a family  clinic founded to fill a gap in Fort Lauderdale. Master Touch Family Clinic, from our research and review has a greater chance of expanding into the nick and crannies of America.

We hope to only purchase medical equipment that has demand within the community, provide fast and friendly service and also ensure strict financial controls to help us manage the expensive capital costs associated with starting a family clinic.

We have plans to make our services the best in the industry. We also plan to establish an excellent customer service culture that will make our clients comfortable and willing to come back.

Master Touch Family Clinic will also make use of the latest equipment in the industry to provide fast, distinctive and reliable services. We hope to establish more business branches as our business gains adequate corporate identity in the industry.

Master Touch Family Clinic marketing strategies will be reviewed every 6 months to enable us understand what our customers want and how best to reach them even in the remote places of our town. We will ensure that all our employees, medical and non-medical, will be the best there is in the industry.

Aside the medical background we hope to leverage, we will be training them to be able to cope with any situation they find themselves in. Master Touch Family Clinic will be run as a family business, where all employees are inculcated into the family stream.

We hope to offer our customers attractive incentives that will move them to give their best and help us move Master Touch Family Clinic to limelight.

Checklist/Milestone

• Business Name Availability Check: Completed
• Business Incorporation: Completed
• Opening of Corporate Bank Accounts in the United States: Completed
• Opening Online Payment Platforms: Completed
• Application and Obtaining Tax Payer’s ID: In Progress
• Application for business license and permit: Completed
• Purchase of Insurance for the Business: Completed
• Conducting feasibility studies: Completed
• Leasing, renovating and equipping our facility: Completed
• Generating part of the startup capital from the founder: Completed
• Applications for Loan from our Bankers: In Progress
• Writing of Business Plan: Completed
• Drafting of Employee’s Handbook: Completed
• Drafting of Contract Documents: In Progress
• Design of The Company’s Logo: Completed
• Printing of Promotional Materials: Completed
• Recruitment of employees: In Progress
• Purchase of the Needed software applications, furniture, office equipment, electronic appliances and facility facelift: In progress
• Creating Official Website for the Company: In Progress
• Creating Awareness for the business (Business PR): In Progress
• Health and Safety and Fire Safety Arrangement: In Progress

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Nurse‐Led Clinics

11 Nurse‐Led Clinics Shelley Mooney and Helen Kerr Abstract Nurse‐led clinics play a significant role in cancer follow‐up reviews and consultations, and support the delivery of effective cancer services. The clinical nurse specialist is one of the advanced practice nurse roles that pioneered the development of nurse‐led clinics. Nurse‐led clinics have reported positive outcomes for patients, the healthcare professional undertaking the clinic and the healthcare organisation. 11.1 Introduction This chapter will focus on the emergence and evolvement of nurse‐led clinics in cancer services. The background to the introduction of nurse‐led clinics within healthcare will be outlined, followed by the pragmatic matters to be considered when introducing a nurse‐led clinic in any service area. There will be a focus on the advanced nursing skills required to successfully implement nurse‐led clinics and the range of approaches used. Various benefits of nurse‐led clinics for patients, the healthcare professional and the healthcare organisation will be outlined, in addition to potential barriers and suggestions to address them. The importance of service evaluation and the future of nurse‐led clinics will also be explored. The chapter will conclude with recommendations on how nurse‐led clinics can be embedded into routine practice. The first author, Shelley Mooney, works as a band 7 uro‐oncology clinical nurse specialist (CNS) in the Northern Ireland (NI) Cancer Centre, Belfast, providing direct patient care to individuals with a diagnosis of prostate or bladder cancer, which includes being responsible for nurse‐led clinics. This author commenced this post in 2017, having previously worked in an inpatient oncology ward for five years as a band 5 registered nurse. The second author, Helen Kerr, is a senior lecturer at the School of Nursing and Midwifery, Queen’s University Belfast, with a clinical background in cancer and palliative care nursing. 11.2 Nurse‐Led Care and the Launch of Nurse‐Led Clinics in Healthcare The evolvement of the broad term nurse‐led care has been in response to the high demand for long‐term holistic support and ongoing follow‐up (Vinall‐Collier et al. 2016 ). Two decades ago, Corner ( 2003 ) suggested that nurse‐led care involved nurses being delegated to accomplish specific tasks previously undertaken by medical staff. This view may be considered contentious, as Hamric and Tracy ( 2019 ) state that advanced nursing roles and responsibilities are not a substitution for medical practice. Lai et al. ( 2017 ) suggest there is no clear and consistent definition of the broad terminology of nurse‐led care but suggest that nurse‐led care involves clinics led by registered nurses who are able to work autonomously delivering person‐centred care within their area of practice and make evidence‐based clinical decisions independently. Nurse‐led care is often provided by an advanced nurse practitioner (NP) in their speciality and uses a holistic approach to patient care that takes account of the individual’s physical, psychological, social and spiritual needs (Ndosi et al. 2014 ). One component of nurse‐led care is the establishment and maintenance of nurse‐led clinics. Due to the diversity of nurse‐led clinics, they are difficult to define; however, Wong and Chung ( 2006 ) state that a nurse‐led clinic is a formalised and structured healthcare delivery mode that encompasses a nurse and a client, in which a client as an individual alongside their family has healthcare needs that can be addressed by a nurse. Nurse‐led clinics first emerged in the United States of America (USA) in the 1990s and the United Kingdom (UK) in the early 2000s (McLachlan et al. 2019 ) in a range of chronic conditions such as cardiology and diabetes. According to Wiles et al. ( 2001 ), nurse‐led clinics were introduced in the UK to provide intermediate care to patients discharged from hospital but still needing support to regain their maximum health. Nurse‐led clinics can also support intermediate care after the acute phase of a disease (Wong and Chung 2006 ). As a result of their introduction, nurse‐led clinics freed up inpatient hospital beds for those requiring acute medical attention and enabled patients to receive ongoing care in an outpatient or community setting. Nurse‐led clinics are now a crucial component of healthcare provision, as they offer an alternative to traditional physician‐led models of care and provide safe, high‐quality care (Connolly and Cotter 2021 ). Nurse‐led clinics are often the responsibility of an advanced practice nurse, such as an NP or a CNS. The development of advanced practice nurses was an important milestone in the professional development of the nursing discipline throughout the twentieth century and has become a global trend in the twenty‐first century. Nurse‐led clinics serviced by advanced practice nurses have become common international practice since the 1990s (Shiu et al. 2011 ). According to Randall et al. ( 2017 ), nurse‐led clinics are now established worldwide in various clinical settings and are reported as an effective method of patient assessment and care. 11.3 Components of a Nurse‐Led Clinic Hatchett ( 2016 ) outlines that nurse‐led clinics involve nurses having their own patient workload, which requires increased autonomy and often using advanced clinical skills such as physical assessment, diagnosis and medication management. For a registered nurse to lead their own clinic, they must demonstrate advanced competence to practice in a specific healthcare area and practice either independently and/or interdependently with other members of a healthcare team in at least 80% of their work (Wong and Chung 2006 ). Nurse‐led clinics are reported to be commonly focused on treating and managing chronic conditions (Randall et al. 2017 ). According to the International Council of Nursing (ICN) ( 2021 ), key to nurse‐led clinics is the central role of the CNS, who has an understanding of the patient and their condition and can develop a trusting relationship with the patient. To effectively lead a clinic, the majority of the caseload should be protocolised, which empowers the nurse to lead the clinic without the need for support from other healthcare professionals; however, there will be situations where unique patient cases present, requiring support from other healthcare professionals and leading to opportunities for further learning and development. In the context of cancer care, the National Cancer Plan in the UK (Department of Health 2000 ) stated that cancer services needed to be re‐designed to make the best use of skills within the cancer workforce and ensure that patients and their families had appropriate and timely access to supportive aftercare. Thus, support and follow‐up after treatment were important in the development of cancer services, and as a result, numerous nurse‐led activities emerged, such as nurse‐led clinics (Cox and Wilson 2003 ). Furthermore, an ambitious strategy launched by the Independent Cancer Taskforce ( 2015 ) aimed to transform cancer care between 2015 and 2020 through alternative models of patient care after cancer treatment, such as follow‐up carried out by a specialist nurse. Nurse‐led follow‐up was identified as a suitable means of follow‐up in cancer care, and its acceptability has been widely demonstrated in lung, breast, prostate and bladder cancer (Smits et al. 2015 ) and continues to be developed in other tumour sites. Nurse‐led clinics are now embedded into routine clinical practice in cancer care for a range of tumour sites. Nurse‐led clinics differ in purpose and functionality. Whilst some nurse‐led clinics are focused on patient assessment and management, others focus on the CNS being in a more supportive role. Nurse‐led clinics may include health assessments to manage a patient’s health condition and symptoms, health education to facilitate compliance and a healthy lifestyle, and co‐ordination of care using a holistic approach (Wong and Chung 2006 ). Within cancer care, a diverse range of nurse‐led clinics may be available throughout the patient pathway, and often the disease site dictates what type of nurse‐led clinic is suitable for which patient group. Depending on the tumour site, a nurse‐led clinic may be available when the individual receives a diagnosis; for other tumour sites, the nurse‐led clinic may be available at treatment review, during radiotherapy or systemic anti‐cancer therapy (SACT), post‐treatment follow‐up, or for a holistic needs assessment (HNA) to be completed. According to Campbell et al. ( 2000 ), whilst the primary aim of a nurse‐led radiotherapy review clinic was to monitor radiation reactions and tolerance to treatment and manage radiotherapy‐related toxicities, it also provided the nurse with an opportunity to assess the patient for physical, psychological and social problems, contributing to a holistic approach to care. The Macmillan Cancer Support Recovery Package and National Health Service (NHS) England highlight the potential benefits of risk‐stratifying follow‐up of individuals with cancer (Macmillan Cancer Support 2015 ; NHS England 2016 ). In terms of post‐treatment follow‐up, certain disease sites, such as prostate and breast cancer, have large cohorts of patients who require long‐term follow‐up over many years (National Institute of Clinical Excellence 2021 ). In response to UK national guidelines, many nurses now provide this routine follow‐up to bridge gaps where medical follow‐up may be ceasing due to high clinical demands for increasing new patient diagnoses and the development of new treatment modalities (Sheppard 2007 ). 11.4 Introducing a Nurse‐Led Clinic Introducing a nurse‐led clinic requires meticulous planning and takes time to ‘pull together’ (Jones et al. 2016 ). Hatchett ( 2008 ) identifies a 10‐step process when establishing a new service. In summary, these 10 key steps include building a business case, defining aims and objectives, establishing patient criteria, planning publicity, determining the clinic location, gaining support from colleagues, planning professional development, considering medicine management if appropriate, planning audit and evaluation and, finally, facilitating ongoing improvement. Following these 10 steps enhances a nurse’s ability to introduce and effectively establish a nurse‐led clinic. Prior to embarking on any new developments within healthcare, Judd ( 2009 ) outlines the importance of establishing whether there is a service need, which involves pre‐determining which patient groups are appropriate. This can be facilitated with discussions with relevant clinical team members to identify current gaps in practice to determine whether a nurse‐led clinic would be a suitable solution to address the service need. In terms of appropriate patient groups, patients with straightforward protocolised follow‐up are often deemed suitable to attend a nurse‐led clinic. These clinics have strict inclusion and exclusion criteria; therefore, only patients who meet these criteria should be referred. Furthermore, clear communication with all multidisciplinary team members is crucial in the initial planning stage, and those influenced by the service change should be included in these discussions in addition to the planning processes. This should include management, relevant healthcare professionals and administrative teams. Setting up a nurse‐led clinic in any speciality may pose challenges due to a potential change in practice. Hatchett ( 2005 ) states that ensuring all staff influenced by the change are kept informed and that their opinions are valued, should lead to a smoother transition to change when introducing a new clinic. A team approach is also required, which includes all stakeholders, such as administrative staff and both medical and nursing healthcare professionals. A team approach will facilitate administrative staff and healthcare professionals to provide their valuable input, contributing to the smooth introduction of a nurse‐led clinic (Hatchett 2005 ). A hierarchy of support is crucial, including the logistics and costs associated with introducing a nurse‐led clinic. Indirect costs may include room allocation, information technology support and clinical supervision for nursing staff provided by medical staff such as oncologists. In addition to these indirect costs, direct costs include CNS staffing for the nurse‐led clinic. A nurse‐led clinic is often embedded into the CNS’s current job plan; therefore, finances to support this component of the role are allocated from this budget with no additional cost (Moore 2018 ). When logistics such as room allocation have been considered and a hierarchy of support is secured, Judd ( 2009 ) suggests the need for a robust protocol to support advanced nursing practice independently. Initial standard operating procedures and protocols must be developed alongside an assessment record. An assessment record acts as a template to guide the nurse when assessing patients to ensure that all required information is included to reduce the risk of omitting vital data. These documents should be developed within the team with refinements provided by oncologists and agreement with written information approval groups (or equivalent) and document control (Jones et al. 2016 ). Robust protocols are essential to deliver independent nurse‐led clinics. Protocols must cover expected patient presentations and potential non‐expected presentations associated with the condition that may arise, alongside an action plan. The importance of these protocols is to assist and direct nurses in their clinical decision‐making. Protocols must be agreed upon by the referring clinicians and validated by the hospital’s Clinical Governance Committee (or equivalent). However, Judd ( 2009 ) advises that nurses must be cautious not to ‘fit the patient to the protocol’, so the nurse in charge of the clinic must draw on their knowledge and expertise when presented with new situations and acknowledge and work within their limitations. Furthermore, Gousy and Green ( 2015 ) highlight that a person‐centred approach is a vital component of nurse‐led clinics to ensure that the clinic is designed to meet the needs of the person and not limited to the clinical diagnosis. Nursing documentation is essential in the nurse‐led clinic, as it provides evidence regarding the patient’s progress and/or any complications that require further interventions (Leahy et al. 2013 ). Individualised assessment records specific to each cancer site may be developed and used for nurse‐led clinics to record symptoms reviewed, blood test results and any follow‐up plans (Robertson et al. 2013 ). In 2016, a Regional Information System for Oncology and Haematology (RISOH) (Northern Ireland Cancer Network 2022 ) was introduced in NI: it is an online system for documenting patient information. Within RISOH, healthcare professionals can type freehand or complete a template questionnaire about their contact with patients. The online information is available for all healthcare professionals within oncology and haematology. This up‐to‐date, real‐time, accurate documentation enhances patient safety and promotes clear communication between teams. In addition, template questionnaires are an excellent resource for recently appointed CNSs responsible for nurse‐led follow‐up clinics, as they ensure that all relevant patient information is available. 11.5 Nursing Skills Required to Introduce and Establish a Nurse‐Led Clinic All registered nurses must demonstrate competencies in a range of skills, such as communication and clinical skills. Nurses who work in advanced practice roles must also demonstrate expertise in the four pillars of advanced practice (Lee et al. 2020 ): clinical, research, education and management/leadership. Furthermore, Wong and Chung ( 2006 ) highlight that CNSs must possess credibility in a relevant speciality area; be capable of contributing to enhancing the quality of service; be competent in project management, research, leadership and people skills; and possess the personal qualities of creativity, flexibility, confidence, assertiveness and perceptiveness.

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Nurse Practitioner-Led Clinics Fill Gap in Patient Care

• The rising number of nurse practitioner-led clinics is supported by evidence of a positive impact on patient satisfaction and outcomes.
• A growing physician shortage has created a gap between demand and supply that was highlighted during the pandemic.
• The American Medical Association is fighting against full-practice authority, despite strong evidence that nurse practitioners provide quality care.

There is mounting scientific evidence that advanced practice registered nurses (APRNs) have a positive impact on patient satisfaction and outcomes. This has led to a rising number of nurse practitioner-led clinics in states where nurse practitioners (NPs) have full-practice authority.

Kevin Lee Smith, DNP, FNP, FAANP, is the chief nurse practitioner officer at The Good Clinic, a chain of nurse practitioner-led healthcare clinics that emphasize patient engagement, wellness, and convenience.

The COVID-19 pandemic highlighted many healthcare disparities and inequities. Among them are gender, age, race, and socioeconomic challenges with access to care. The growth of NP-led clinics helped to answer this need in rural and urban areas.

“There is a growing shortage of primary care physicians in the U.S. due to a preference to practice specialty care,” Smith says. “Primary care providers also experience a high degree of burnout and turnover due in part to a lack of face-to-face time with patients.”

With primary care facing many challenges, the increasing number of clinics has had a positive impact on patient care and an overall influence on the nursing profession.

Nurse Practitioner-Led Care Demonstrates Positive Outcomes

Falling numbers of primary care physicians led to the establishment of the Minneapolis-based Good Clinic, a nurse practitioner-driven model that emphasizes wellness and continuity of care. The Good Clinics are a response to patients needing more than an urgent care physician to manage their chronic illnesses.

Patients can spend more time with a healthcare practitioner, and they are given a safe space to ask uncomfortable questions. The goal in the NP-led practice is to build lasting relationships and support patient’s goals. Smith describes this as a process that is less transactional and more relational.

“We think the growing numbers of NPs in the field of primary care is a wonderful opportunity to increase access to healthcare and provide a more person-centered, holistic experience for the patient,” Smith says.

Data show this care model improves patient outcomes and patient satisfaction, both of which are critical to health and wellness. One systematic review of the literature from 15 studies across several countries, including the U.S., found that clinics led by APRNs can increase access to care, improve patient satisfaction, and have a positive impact on health outcomes.

The data was gathered between 2006 and 2016. Examples of behavioral changes that led to improved health include quitting smoking, improved self-care, and safer sex practices. Two studies measured cost-effectiveness and both showed savings.

The researchers quote Cheryl Fattibene, chief nurse practitioner officer at the National Nurse-Led Care Consortium, which represents nurse-managed health clinics in the U.S. She believes the biggest challenge to the expansion of nurse practitioner-led clinics is the pushback from the American Medical Association (AMA).

She points to the differences in treatment modalities: identifying and treating a disease for physicians versus the APRNs’ focus on wellness and prevention. She believes that continuing in the current way is taking healthcare in the wrong direction.

Physician Groups Fighting Change

Nurse practitioner-led clinics are operational in states where nurse practitioners have full-practice authority. This means they have the right under the law to prescribe, diagnose, and treat patients without physician oversight or supervision.

The American Medical Association has been working for over 30 years to stop full-practice authority in the U.S. Their argument is that “patients deserve care led by physicians” and their “advocacy efforts have safeguarded the practice of medicine by opposing nurse practitioner … attempts to inappropriately expand their scope of practice.”

In June 2022, the AMA claimed a coalition of 108 national, state, and specialty medical societies that have influenced 70 bills introduced in state legislatures. In November 2020, the American Association of Nurse Practitioners published an open letter that criticized the organization’s stance, writing that “NP-delivered care is irrefutable.”

The fight to oppose full-practice authority for nurse practitioners does not appear to be based on data. Instead, the AMA cites their data that show expanding nurse practitioner authority does not equal expanding healthcare access.

They also cite patient preference to have physicians involved in diagnosis and treatment decisions and concern that nonphysician level care is a step in the wrong direction.

Implications of Rising Number of Nurse Practitioner-Led Clinics

The increasing number of nurse practitioner-led clinics and changes to the healthcare system have long-term implications for the nursing profession. These changes to the healthcare system were driven by inequities and disparities made evident during the pandemic.

The need for expanded roles, such as physician shortages and healthcare disparities, is well supported by data. The gap between demand and supply became more evident during the pandemic. Barriers to healthcare include:

In contrast to physician education, nursing programs address health from a holistic perspective and focus on disease prevention and health promotion. Additionally, NPs are educated in population health and the healthcare needs of a larger society.

California passed Assembly Bill 890 , which increases the NP scope of practice without changing the practice authority in the state. NPs will be required to meet specific criteria to practice independently, including 4,600 hours of physician oversight.

The state hopes nurse-led clinics will help close the gap in healthcare and reduce morbidity and mortality in underserved urban areas. Many experts believe the rising number of NPs is good news for the healthcare system as a whole.

However, this growth may also contribute to the registered nursing shortage. In 2017, the increase in the number of NPs and physician assistants was greater than the number of physicians entering practice.

Nurse Practitioner-Led Clinics Guided by Collaboration and Cooperation

According to the Centers for Disease Control and Prevention, six out of every 10 adults in the U.S. have a chronic disease and four out of every 10 have two or more. The rate of chronic disease rises with age. This means that not only is the baby boomer generation retiring by 2030, but they will likely also contribute to an increasing need for healthcare to treat chronic diseases.

To care for these complex patients, nurse practitioners collaborate and cooperate with other healthcare providers, much the same way that a physician-led clinic does. Digital communication also allows near-instant access to more experienced NPs.

Nurse practitioner-led clinics often consult each other internally and may create partnerships with other specialty practices. For example, a partnership with a radiology group could help nurse practitioners quickly consult about the type of imaging that might be most beneficial on a case-by-case basis.

As in other patient care situations, nurse practitioners are quick to refer to a specialist when their patients require a higher level of care. Quality assurance and professional accountability are integral parts of a nurse practitioner-led clinic.

“What is unique about NPs is their patient education focus, experience, and holistic care approach. We want to leverage the nursing perspective that takes the whole person into account — the bio-psycho-social-spiritual being,” Smith says.

Nurse practitioners are patient care providers, but they are also educators and researchers. Their knowledge and skill base can help advance policymaking activities and inform advocacy for legislative change to improve healthcare access.

Meet Our Contributor

Kevin Lee Smith, DNP, FNP, FAANP

Kevin Lee Smith is the chief nurse practitioner officer at The Good Clinic with previous experience helping to create the MinuteClinic model and providing early-stage informatics leadership at Zipnosis. Smith has also been an active primary care nurse practitioner and served in faculty positions at the University of Minnesota throughout his career.

AMA successfully fights scope of practice expansions that threaten patient safety. (1995-2022). https://www.ama-assn.org/practice-management/scope-practice/ama-successfully-fights-scope-practice-expansions-threaten

Assembly bill 890. (2022). https://www.rn.ca.gov/practice/ab890.shtml

Chronic diseases in America. (2022). https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm

Modernization of California nurse practitioner practice is overdue: Implications for nurse-led clinics. (2020).

https://campaignforaction.org/implications-for-nurse-led-clinics/

Open letter to the American Medical Association. (2020).

https://www.aanp.org/news-feed/open-letter-to-the-american-medical-association

Salsberg E. (2018). Changes in the pipeline of new NPs and RNs: Implications for health care delivery and educational capacity. https://www.healthaffairs.org/do/10.1377/forefront.20180524.993081/full/

Sofer D. (2018). Nurse-led health clinics show positive outcomes. https://journals.lww.com/ajnonline/fulltext/2018/02000/nurse_led_health_clinics_show_positive_outcomes.6.aspx

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Impact of community based nurse-led clinics on patient outcomes, patient satisfaction, patient access and cost effectiveness: A systematic review

Affiliations.

• 1 Sydney Nursing School, Australia. Electronic address: [email protected].
• 2 Sydney Nursing School, Australia.
• PMID: 28531549
• DOI: 10.1016/j.ijnurstu.2017.05.008

Background: The role and scope of nursing practice has evolved in response to the dynamic needs of individuals, communities, and healthcare services. Health services are now focused on maintaining people in their communities, and keeping them out of hospital where possible. Community based nurse-led clinics are ideally placed to work towards this goal. The initial impetus for these services was to increase patient access to care, to provide a cost-effective and high quality streamlined service.

Objectives: This systematic review aimed to identify the impact of nurse-led clinics in relation to patient outcomes, patient satisfaction, impact on patient access to services, and cost effectiveness.

Methods: A review of community based nurse-led clinic research in Medline, CINAHL and Embase was undertaken using MeSH terms: Nurse-managed centres, Practice, Patterns, Nurse, Ambulatory Care, keywords: nurse-led clinic, nurse led clinic, community and phrases primary health care and primary care. Papers were appraised using the Joanna Briggs Appraisal criteria.

Results: The final review comprised 15 studies with 3965 participants. Most studies explored patient satisfaction which was largely positive towards nurse-led clinics. Patient outcomes reported were typically from self-report, although some papers addressed objective clinical measures; again positive. Access was reported as being increased. Cost-effectiveness was the least reported impact measure with mixed results.

Conclusions: Nurse-led clinics have largely shown positive impact on patient outcomes, patient satisfaction, access to care and mixed results on cost-effectiveness. Future research evaluating NLCs needs to adopt a standardised structure to provide rigorous evaluations that can rationalise further efforts to set up community based nurse-led clinical services.

Keywords: Ambulatory care; Community; Nurse-led clinic; Nurse-managed centres; Practice Patterns Nurse; Primary care; Primary health care.

Copyright © 2017 Elsevier Ltd. All rights reserved.

Publication types

• Systematic Review
• Cost-Benefit Analysis*
• Health Services Accessibility*
• Patient Satisfaction*
• Practice Patterns, Nurses'*

25 Most-Profitable Small Business Ideas For Nurses

New profitable nurse businesses are developing and evolving quickly throughout our nation. Unique niche ideas are popping up in cities and online. Nurses are beginning to realize their exceptional potential in the business world. You, too, may be wondering about a nurse-owned business. Questions such as “What options are there for nurse-owned ventures?” and “Can I be successful as a business owner?” may be going through your mind. Even more important, you may not realize that owning a business can be profitable. Are you seeking a career as an independent small business nurse owner that can pay well? You may wonder, “What are the most profitable small business ideas for nurses?” You have come to the right place if you have these internal conversations. Here, I illuminate the most profitable small business ideas for nurses, where you can easily top the $100K mark. These ventures range from simple home business companies that require little time or cash for a start-up to more elaborate ideas that you can expand to reap top-dollar. Let’s jump right into this exciting topic!

What Are The Most Profitable Small Business Ideas For Nurses?

Small business #1: legal nurse consultant, about the small business:, how to start this small business:, potential earnings:, small business #2: staffing agency, small business #3: home health agency, small business #4: senior care assistance, small business #5: night shift new baby nurse, small business #6: private duty nurse.

• Stethoscope, BP cuff, thermometer, glucometer (and supplies) • A means to advertise your business, such as a web page, Facebook, local social media pages, and LinkedIn account • Malpractice insurance

Small Business #7: Home Medical Equipment Sales

Small business #8: online nurse education specialist/writer.

• Writing CEs for nurse education sites • Developing nursing checklists, flow sheets, and protocols • Writing nursing workbooks and textbooks • Educational podcasts • Educational Facebook support • Study guides and flashcards for nursing students • Medical care plan development

Small Business #9: Medical Writer

Small business #10: cannabis nurse, small business #11: intravenous infusion.

• Nausea/vomiting • Dehydration • Morning sickness • Hangover • Weakness • Athletic post-workouts • Vitamin infusions • Immunity boost • Anti-Aging • Skin health • Jet lag

Small Business #12: Senior Consultant/Advocate

• Educating families and seniors about available resources • Assist in placement in assisted living or other care arrangements • Offer nursing support post-hospitalization • Help decipher medical bills and payment arrangements • Champion for fair and quality medical treatment and billing • Serve as a go-between for the client and insurance company

Small Business #13: Online Supplement Company

Small business #14: health and wellness and beauty.

• Wellness retreats (a growing trend!) • Health product sales such as essential oils, dietary supplements • Work-out clothing and gear sales • Healthy food sales • Organic beauty products • Anti-aging products • Wellness center • Clinics on wellness • Juice bars • Wellness spa (to include skin and Botox treatments)

Small Business #15: Nursing Gear Retailer

Small business #16: healthy meal delivery service, small business #17: sick child care, small business #18: nurse career coach, small business #19: speaker, small business #20: hospice nurse, small business #21: nursing education consultant.

• Teaching online or in-person nursing classes • Guest speaking on educational nursing topics or specialty medical topics • Blogs and podcasts to assist student and new grad nurses • Nurse class and test review courses and workbooks and flashcards • Support and guidance social media outlets for nurses • Developing CEU’s • Writing nursing and other medical staff text and workbooks • Developing flow sheets and “cheat” sheets for nurses and aides

Small Business #22: Specialty Sales

Small business #23: healthcare app developer.

• Tracker for fitness • Weight loss app • Support apps for physical and mental wellness • Software to support nurses and nursepreneuer • Specialized nursing apps such as study apps, flow sheets, reminders/organizers, and skill instruction

Small Business #24: Diabetic Care

• Contract with local physicians to do diabetic teaching sessions • Hold diabetes seminars and clinics in local community and senior centers • Write a diabetes care and support blog • Podcast to showcase your diabetes expertise • Contract with home health agencies, hospice, and skilled nursing facilities for diabetic care and education

Small Business #25: Foot and Wound Care

Bonus 5 important factors to consider while deciding which small business is right for you as a nurse, factor #1: what am i an expert in, factor #2: do i want to spend a lot of money, factor #3: do i want to hire employees, factor #4: do i want my business to be virtual, factor #5: am i tech and social networking savy, my final thoughts.

Nurse-led service transformation: A pathway to professional advancement – and better patient care

• 5th August 2020

Stuart O'Brien

• no comments

By Milica Zina Bojin (pictured), Nurse Consultant Urology at United Lincolnshire Hospitals NHS Trust

According to  reports , the upcoming NHS People Plan will include ‘radical’ proposals to allow nurses to perform surgical procedures to ease the burden on under-pressure consultants. Under the new plan, aspirational nurses will be trained to become Surgical Care Practitioners, qualifying them to carry out a range of surgical tasks.

It’s a positive step forward for our profession. But it’s by no means the only way that nurses can play a role in transforming acute services. In fact, nurse-led transformation is already happening without the need for two-year training. My experiences in helping redesign the prostate cancer pathway at United Lincolnshire Hospitals (ULH) NHS Trust demonstrate just how nurses can lead change and make a difference to patient care. All that’s required is a clear need, a good business case and plenty of determination.

I’ve been a nurse consultant (urology) at UHL since 2015 and have always believed that service development and improvement is a fundamental part of the role. Good examples include the development of both our emergency urology and local cancer guidelines – projects in which I was heavily involved. I also oversee the professional development of our urology team, especially nurses. My overarching objective is to ensure we provide a high quality service offering for patients. A key aspect of this is making sure that any initiatives that might improve our pathways are considered, developed and, where viable, applied. In that sense, those two main components of my role – professional development and service improvement – go hand-in-hand; pathway redesign can not only improve the patient experience, it presents great development opportunities for staff. Two recent UHL projects in urology perfectly illustrate the point.

Nurse-led telephone triage

In February 2018, UHL began exploring the possibility of introducing a nurse-led telephone triage system to the prostate cancer service. The exercise was prompted by a Cancer Alliance call for ideas to improve the pathway. The rationale for telephone triage appeared obvious; our existing pathway was protracted, often requiring two-week-wait (TWW) patients to go back and forth to the hospital for investigations while we determined the right course of action. At times, the patient experience could be poor. We needed to improve it.

Having suggested the concept of nurse-led triage, I worked closely with our business unit, the cancer department and Cancer Alliance to map the project and build a business case to show it could transform the pathway. That business case was subsequently approved by the trust. Today, the system – which sees our triage nurse proactively arrange all required investigations for TWW patients – is part of standard practice. We were grateful to receive financial support from the Cancer Alliance who funded a long-term triage nurse.

The triage system ensures patients have completed all of their investigations – whether that’s an additional PSA, MRI, bone scan, CT or prostate biopsy – prior to their first appointment with a consultant. As a consequence, the consultant has all the results (s)he needs to make timely and appropriate clinical decisions. The approach has made a huge difference, accelerating the referral pathway, removing avoidable delays and ultimately expediting diagnosis. In most cases, the pathway has been shortened by a good two weeks. In the immediate aftermath of the system’s introduction, we saw improvements in our 62-day cancer pathway for three consecutive months. It’s a great example of how nursing innovation can transform patient care.

Redesigning the biopsy pathway

But the journey to service improvement is never-ending. Having made good gains with telephone triage, we shifted our focus onto improving the pathway for patients requiring transperineal biopsy. Our approach was again driven by a pain point I’d identified when auditing the pathway: since transperineal biopsies were being conducted in theatre, there was often a six week wait for the procedure. Additionally, the hospital was doing many TRUS biopsies that were coming back negative – and the majority of these patients would then go to theatre for a template biopsy to give clinicians the reassurance to discharge or step them down from the pathway. The whole process was slow, inefficient and distressing for patients.

Having presented my findings at one of our audit meetings, a Trust partner told me about a new technique that was helping hospitals conduct transperineal biopsies under local anaesthetic in outpatient settings – thereby facilitating pathway change. In many of these trusts, the procedure – LATP – is carried out by trained nurses, relieving the burden from urological consultants and freeing them to focus on diagnosed patients.

The benefits of LATP were self-evident: efficiencies in the pathway would save us time and money, whilst moving the procedure into an outpatient setting would help the urology team maximise precious theatre time. Evidence indicates that LATP is a good alternative to traditional TRUS biopsies, which can increase the risk of infection and yield inaccuracies in identifying cancer cells. LATP isn’t a practical option for everyone – but shifting to it, where possible, seemed like a good idea.

Having recognised the opportunity, I again worked with key stakeholders in the trust to build the business case. They immediately saw the transformative potential and supported me in driving it through.

In November 2018 I began learning how to use PrecisionPoint™, the pioneering freehand technology that’s opening the door to LATP. The training, supported by SE London Accountable Cancer Network, saw me journey to Guy’s and St. Thomas Hospital every week for three months to observe, learn and practice under the tutelage of Jonah Rusere, the Network’s Advanced Nurse Practitioner.  Subsequently, one of our urology consultants gave me his patient list, enabling me to carry out the procedure in theatre, under supervision. I then graduated to the outpatient setting, performing the procedure under local anaesthetic,  with the supervision of expert practitioners. I’m now fully authorised to conduct LATP on my own. We run 4 lists a week in outpatients.

The outcomes to date have been encouraging. Beyond the practical benefits of redesigning the pathway, the clinical gains have been good. An audit of patients undergoing prostate biopsy between May and August 2019, showed that targeted and systematic LATP biopsies picked up more clinical significant disease than TRUS – and also allowed us to discharge almost 60% of patients with negative biopsies. The approach has enhanced the patient experience too, with patients no longer stuck in a repeat cycle of invasive biopsies before they’re diagnosed or discharged. It’s a win-win for everyone.

Nurse-led transformation

The triage and LATP projects at UHL are good examples of nurse-led service transformation – and, while specific to the NHS, they’re a vindication of any approach internationally that advocates nurses playing a greater role in optimising patient pathways.

With the World Health Organisation estimating that the world will be short of approximately 18 million health workers by 2030 – a fifth of the workforce needed to keep healthcare systems going – it is important that healthcare ecosystems make the most of the valuable resources that we have.

Changing existing processes and engrained ways of thinking isn’t easy. Neither is achieving success. It requires perseverance to overcome potential resistance, and hard work to develop the evidence-base to persuade others of the need for change. However, with a good business case, a good understanding of your service and patient needs, and good support from core stakeholders, it’s possible to make a huge difference for patients. Ultimately, as nurses, that’s all we’re here to do.

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Anti-abortion activist who led a clinic blockade is sentenced to nearly 5 years in prison

FILE - Anti-abortion activists Lauren Handy, front, with Terrisa Bukovinac, from left, Jonathan Darnell, and Randall Terry, speak during a news conference in Washington, April 5, 2022. An anti-abortion activist has been sentenced to nearly five years in prison for leading others on an invasion and blockade of a reproductive health clinic in the nation’s capital. Lauren Handy declined to address the court before U.S. District Judge Colleen Kollar-Kotelly sentenced her on Tuesday to four years and nine months in prison. (AP Photo/Manuel Balce Ceneta, File)

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WASHINGTON (AP) — An anti-abortion activist who led others on an invasion and blockade of a reproductive health clinic in the nation’s capital was sentenced on Tuesday to nearly five years in prison.

Lauren Handy, 30, was among several people convicted of federal civil rights offenses for blockading access to the Washington Surgi-Clinic on Oct. 22, 2020. Police found five fetuses at Handy’s home in Washington after she was indicted.

A clinic nurse sprained her ankle when one of Handy’s co-defendants forced his way into the clinic and pushed her. Another co-defendant accosted a woman who was having labor pains, preventing her from getting off a floor and entering the clinic, prosecutors said.

Inside the clinic’s waiting room, Handy directed blockaders to link themselves together with locks and chains and block the doors. A co-defendant used social media to livestream the blockade, which lasted several hours before police arrested the participants.

Handy declined to address the court before U.S. District Judge Colleen Kollar-Kotelly sentenced her to four years and nine months in prison.

Handy’s supporters applauded as she was led out of the courtroom. “You’re a hero, Lauren!” one of them shouted.

The judge told Handy that she was being punished for her actions, not her beliefs.

“The law does not protect violent nor obstructive conduct, nor should it,” Kollar-Kotelly said.

Prosecutors recommended a prison sentence of roughly six years for Handy. They described her as an anti-abortion extremist who was a “criminal mastermind” behind the Washington invasion and similar attacks on other clinics.

“Her strongly held anti-abortion beliefs led her to devise a plan to block access to the Surgi-clinic,” prosecutors wrote . “The blockade, which was broadcast to Handy’s legion of followers, encouraged others to commit similar crimes, publicized her own offense, and traumatized the victims.”

A jury convicted Handy of two charges: conspiracy against rights and violating the Freedom of Access to Clinic Entrances Act, more commonly known as the FACE Act.

Defense lawyers asked for a prison sentence of one year for Handy, who has been jailed since her August 2023 conviction. Her attorneys described her as a compassionate activist who “cares deeply for the vulnerable communities she serves.”

“Her goal in life is to protect those who cannot protect themselves, and to empower those who do not feel that they have any power,” the defense attorneys wrote .

Handy’s nine co-defendants were Jonathan Darnel, of Virginia; Jay Smith, John Hinshaw and William Goodman, all of New York; Joan Bell, of New Jersey; Paulette Harlow and Jean Marshall, both of Massachusetts; Heather Idoni, of Michigan; and Herb Geraghty, of Pennsylvania.

Goodman and Hinshaw were sentenced on Tuesday to prison terms of 27 months and 21 months, respectively, according to prosecutors.

Smith was sentenced last year to 10 months behind bars. Darnel, Geraghty, Marshall and Bell are scheduled to be sentenced on Wednesday. Idoni is scheduled to be sentenced next Tuesday. Harlow’s sentencing is set for May 31.

“These are good people who wouldn’t hurt anybody on purpose,” said Martin Cannon, one of Handy’s attorneys. “Lauren has done enough time. Send Lauren home. Send them all home.”

Darnel joined Handy in planning and leading the Washington clinic invasion, using social media to recruit participants and discuss their plans, prosecutors said.

Handy used a false name to book a fake appointment at the clinic on the morning of the invasion. When a clinic employee unlocked a door to admit patients, the defendants pushed and shoved their way in while Darnel livestreamed the blockade.

“As the codefendants executed the blockade, Handy used a rope stretched across the entrance threshold to obstruct entry into the clinic’s waiting room,” prosecutors wrote. “After the blockade was successfully executed, Handy briefly left the building to act as the group’s police liaison.”

The judge said Handy and her fellow activists didn’t show any compassion or empathy to the patients who were prevented from getting care that day.

“No caring or sympathetic gestures at all,” Kollar-Kotelly said.

Handy and some of her co-defendants also blockaded reproductive health clinics in Silver Spring, Maryland, and Alexandria, Virginia, after the Washington invasion, prosecutors said.

Handy’s attorneys said she founded and operated a nonprofit organization, Mercy Missions, that “helps families and mothers in crisis pregnancies.” She also joined a group called Progressive Anti-Abortion Uprising before her March 2022 arrest.

An old worry returns for Steward’s nurses and retirees: Can they count on their pensions?

The health of the retirement funds for thousands of people is tied to the fate of steward’s hospitals.

For thousands of nurses and other employees of Caritas Christi Health Care, the hospital system’s 2010 sale to for-profit Steward Health Care seemed to answer a pressing question: Would their pensions, frozen by financially struggling Caritas, be there in their retirement?

Fourteen years later, the retirement plan is fully funded and pensions are paid regularly to about 11,000 beneficiaries in the state. But with Steward now mired in bankruptcy and its eight Eastern Massachusetts hospitals on the auction block, the old worries have returned.

“Bankruptcy could jeopardize all the work to shore up the [pension] plan,” said Julie Pinkham, executive director of the Massachusetts Nurses Association and a trustee of the nurses’ retirement plan. “Until we see how things fall out for the hospitals, we just don’t know.”

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The future of the pensions — whether workers can count on them for the long haul — is bound up with the fate of hospitals that serve mostly low-income neighborhoods and communities from Dorchester and Haverhill to Brockton, Taunton, and Fall River.

Much is on the line for those who spent decades caring for patients. Retirees like Karen Kravitz, 72, who worked for 46 years as a nurse at St. Elizabeth’s Hospital in Brighton under Caritas and Steward, depend on pension income to get by in high-cost Massachusetts.

“If I didn’t get my pension,” said Kravitz, who is still paying off a mortgage on her home in Stoughton, “I don’t know how I could live.”

The new pension jitters differ from those that prompted the Boston Archdiocese to sell its Catholic hospitals to Steward more than a decade ago. The pension plan was underfunded then and Steward, backed by a private equity firm, was the only potential buyer willing to assume the liability and put cash into the retirement plan. Today, the plan is independently managed, federally insured, and financially sound.

Steward, by contrast, owes about $9 billion to its landlords, lenders, contractors, and service providers, according to a tally of debts the company presented at a May 7 bankruptcy hearing. The pension plan will need new hospital operators to assure its long-term viability.

For now, pension payments continue as before. At the hearing, Judge Christopher Lopez issued an order allowing Steward, which filed for bankruptcy May 6, to keep paying wages and benefits. That includes the company’s contributions to the pensions of about 2,500 active nurses covered by labor contracts at the Steward hospitals.

Contracts between Dallas-based Steward and the nurses union contain so-called successorship clauses requiring any operators acquiring the hospitals to honor the contract terms, including pension obligations. But those protections won’t hold if Steward can’t find buyers.

Steward has agreed to sell its Massachusetts hospitals by the end of June. The company said it has received letters of interest, but no bidders have been disclosed. If new owners can’t be found and some hospitals close, that would reduce revenue flowing into the pension fund, making it more vulnerable to the volatility of market investments.

“Without new owners, there’s no new contributions to the fund,” Pinkham said. “And that would be potentially devastating.”

A spokesperson for Steward declined to discuss the pensions’ future but said that Steward is leaving the plan in good shape. “The current plan is fully funded and backed by the PBGC,” she said, referring to the federal agency that insures and protects retirement plans.

Pensions aren’t a top concern of the US Bankruptcy Court in Houston, where Steward’s lenders and creditors are haggling over who will get paid, and how much. But nurses who dedicated their careers to serving patients at Steward hospitals see the pensions as a matter of fairness, something earned on the job and in tough contract negotiations.

“We fought for the pensions, for all of us,” said Joan Ballantyne, 67, a long-time Norwood Hospital and St. Elizabeth’s nurse who is pondering retirement.

The history of the pension plan mirrors that of the state’s Catholic health care system. The original plan, called the Caritas Christi Retirement Plan, dates back decades, covering not only nurses but secretaries, kitchen staffers, maintenance workers, and even some doctors. Many worked in the Caritas hospitals, others at church-run nursing schools, nursing homes, and other facilities, some of which have closed.

By the time Caritas put its hospitals up for sale, the pension plan had been frozen, meaning Caritas had stopped making contributions. The plan was underfunded and uninsured; because of a religious exemption, the Catholic system didn’t have to pay into the federal Pension Benefit Guaranty Corporation, which thus couldn’t guarantee payments to beneficiaries if there wasn’t enough money in the plan.

The solution was to convert to a so-called Taft-Hartley pension plan, an insured multi-employer plan covering workers from different companies. Under an agreement struck with the nurses union just before the sale to Steward, the hospitals agreed to put pension contributions for active nurses in an escrow account until the new plan was formed.

Steward and the union ultimately opted to join an existing fund for workers represented by the Teamsters at funeral parlors and other industries in New York. On Dec. 15, 2015, they deposited pension and escrowed assets into what was renamed the Nurses and Local 813 IBT Retirement Plan. It pools funds from the legacy Caritas Christi plan with money set aside for active nurses and about 1,800 Teamsters.

By merging with established Taft-Hartley plans, unions seeking to pool their resources “have the advantage of not having to start from scratch and deal with all the administrative expenses,” said Gene Kalwarski, chief executive of Cheiron in McLean, Va., which provides actuarial services to private- and public-sector pension funds.

At the same time, Kalwarski said, multi-employer plans are prone to the same long-term trends as other pension plans. Many employers have stopped contributing to pensions, older industries that offered pensions are shrinking, and baby boomers are retiring. There are often more retirees collecting benefits than workers paying into the system.

Because Steward doesn’t disclose its finances to regulators, there’s no public record of when the company injected cash into the pension plan. At the end of 2014, four years after it promised to fund the Caritas plan, the pension liability was $368 million, according to a 2015 state attorney general’s report. But at the end of 2015, records provided by the nurses union show that Steward had transferred $605.3 million into the new plan to fund the legacy Caritas Christi employee pensions.

The following year, Steward sold the land and buildings on which its Massachusetts hospitals sit to Medical Properties Trust, an Alabama-based real estate company, leaving the hospitals with multimillion-dollar lease payments. In March, it agreed to sell its national doctors network, Stewardship Health, to the Optum unit of UnitedHealth.

Steward has said it plans to exit the Massachusetts market, but its workers — and their hopes for a secure retirement — will remain.

With the asset sales clouding the future of Steward hospitals and complicating their sales, the nurses say buyers can still count on them and other employees to come to work and treat patients every day.

“We are the most valuable asset,” said Pinkham.

Robert Weisman can be reached at [email protected] .

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Whales Have an Alphabet

Until the 1960s, it was uncertain whether whales made any sounds at all..

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email [email protected] with any questions.

[MUSIC PLAYING]

From “The New York Times,” I’m Michael Barbaro. This is “The Daily.”

Today, ever since the discovery that whales produce songs, scientists have been trying to find a way to decipher their lyrics. After 60 years, they may have finally done it. My colleague, Carl Zimmer, explains.

It’s Friday, May 24.

I have to say, after many years of working with you on everything from the pandemic to —

— CRISPR DNA technology, that it turns out your interests are even more varied than I had thought, and they include whales.

They do indeed.

And why? What is it about the whale that captures your imagination?

I don’t think I’ve ever met anybody who is not fascinated by whales. I mean, these are mammals like us, and they’re swimming around in the water. They have brains that are much bigger than ours. They can live maybe 200 years. These are incredible animals, and animals that we still don’t really understand.

Right. Well, it is this majestic creature that brings us together today, Carl, because you have been reporting on a big breakthrough in our understanding of how it is that whales communicate. But I think in order for that breakthrough to make sense, I think we’re going to have to start with what we have known up until now about how whales interact. So tell us about that.

Well, people knew that whales and dolphins traveled together in groups, but up until the 1960s, we didn’t really know that whales actually made any sounds at all. It was actually sort of an accident that we came across it. The American military was developing sophisticated microphones to put underwater. They wanted to listen for Russian submarines.

As one does. But there was an engineer in Bermuda, and he started hearing some weird stuff.

[WHALE SOUNDS]

And he wondered maybe if he was actually listening to whales.

What made him wonder if it was whales, of all things?

Well, this sound did not sound like something geological.

It didn’t sound like some underwater landslide or something like that. This sounded like a living animal making some kind of call. It has these incredible deep tones that rise up into these strange, almost falsetto type notes.

It was incredibly loud. And so it would have to be some really big animal. And so with humpback whales swimming around Bermuda, this engineer thought, well, maybe these are humpback whales.

And so he gets in touch with a husband and wife team of whale biologists, Roger and Katy Payne, and plays these recordings to them. And they’re pretty convinced that they’re hearing whales, too. And then they go on to go out and confirm that by putting microphones in the water, chasing after groups of whales and confirming, yes, indeed, that these sounds are coming from these humpback whales.

So once these scientists confirm in their minds that these are the sounds of a whale, what happens with this discovery?

Well, Roger and Katy Payne and their colleagues are astonished that this species of whale is swimming around singing all the time for hours on end. And it’s so inspirational to them that they actually help to produce a record that they release “The Song of the Humpback Whale” in 1970.

And so this is being sold in record stores, you know, along with Jimi Hendrix and Rolling Stones. And it is a huge hit.

Yeah, it sells like two million copies.

Well, at the time, it was a huge cultural event. This record, this became almost like an anthem of the environmental movement. And it led, for whales in particular, to a lot of protections for them because now people could appreciate that whales were a lot more marvelous and mysterious than they maybe had appreciated before.

And so you have legislation, like the Marine Mammal Act. The United States just agrees just to stop killing whales. It stops its whaling industry. And so you could argue that the discovery of these whale songs in Bermuda led to at least some species of whales escaping extinction.

Well, beyond the cultural impact of this discovery, which is quite meaningful, I wonder whether scientists and marine biologists are figuring out what these whale songs are actually communicating.

So the Paynes create a whole branch of science, the study of whale songs. It turns out that pretty much every species of whale that we know of sings in some way or another. And it turns out that within a species, different groups of whales in different parts of the world may sing with a different dialect. But the big question of what these whales are singing, what do these songs mean, that remains elusive into the 21st century. And things don’t really change until scientists decide to take a new look at the problem in a new way.

And what is that new way?

So in 2020, a group of whale biologists, including Roger Payne, come together with computer scientists from MIT. Instead of humpback whales, which were the whales where whale songs are first discovered, these scientists decide to study sperm whales in the Caribbean. And humpback whales and sperm whales have very, very different songs. So if you’re used to humpback whales with their crazy high and low singing voices —

Right, those best-selling sounds.

— those are rockin’ tunes of the humpback whales, that’s not what sperm whales do. Sperm whales have a totally different way of communicating with each other. And I actually have some recordings that were provided by the scientists who have been doing this research. And so we can take a listen to some of them.

Wow, It’s like a rhythmic clicking.

These are a group of sperm whales swimming together, communicating.

So whale biologists knew already that there was some structure to this sound. Those clicks that you hear, they come in little pulses. And each of those pulses is known as a coda. And whale biologists had given names to these different codas. So, for example, they call one coda, one plus one plus three —

— which is basically click, click, click, click, click, or four plus three, where you have four clicks in a row and a pause and then three clicks in a row.

Right. And the question would seem to be, is this decipherable communication, or is this just whale gibberish?

Well, this is where the computer scientists were able to come in and to help out. The whale biologists who were listening to the codas from the sperm whales in the Caribbean, they had identified about 21 types. And then that would seem to be about it.

But then, an MIT computer science graduate student named Prajusha Sharma was given the job of listening to them again.

And what does she hear?

In a way, it’s not so much what she heard, but what she saw.

Because when scientists record whale songs, you can look at it kind of like if you’re looking at an audio of a recording of your podcast, you will see the little squiggles of your voice.

And so whale biologists would just look at that ticker of whale songs going across the screen and try to compare them. And Sharma said, I don’t like this. I just — this is not how I look at data. And so what she decided to do is she decided to kind of just visualize the data differently. And essentially, she just kind of flipped these images on their side and saw something totally new.

And what she saw was that sperm whales were singing a whole bunch of things that nobody had actually been hearing.

One thing that she discovered was that you could have a whale that was producing a coda over and over and over again, but it was actually playing with it. It was actually stretching out the coda,

[CLICKING] So to get a little bit longer and a little bit longer, a little bit longer.

And then get shorter and shorter and shorter again. They could play with their codas in a way that nobody knew before. And she also started to see that a whale might throw in an extra click at the end of a coda. So it would be repeating a coda over and over again and then boom, add an extra one right at the end. What they would call an ornamentation. So now, you have yet another signal that these whales are using.

And if we just look at what the sperm whales are capable of producing in terms of different codas, we go from just 21 types that they had found in the Caribbean before to 156. So what the scientists are saying is that what we might be looking at is what they call a sperm whale phonetic alphabet.

Yeah, that’s a pretty big deal because the only species that we know of for sure that has a phonetic alphabet —

— is us, exactly. So the reason that we can use language is because we can make a huge range of sounds by just doing little things with our mouths. A little change in our lips can change a bah to a dah. And so we are able to produce a set of phonetic sounds. And we put those sounds together to make words.

So now, we have sperm whales, which have at least 150 of these different versions of sounds that they make just by making little adjustments to the existing way that they make sounds. And so you can make a chart of their phonetic alphabet, just like you make a chart of the human phonetic alphabet.

So then, that raises the question, do they combine their phonetic alphabet into words? Do they combine their words into sentences? In other words, do sperm whales have a language of their own?

Right. Are they talking to each other, really talking to each other?

If we could really show that whales had language on par with humans, that would be like finding intelligent life on another planet.

We’ll be right back.

So, Carl, how should we think about this phonetic alphabet and whether sperm whales are actually using it to talk to each other?

The scientists on this project are really careful to say that these results do not definitively prove what these sperm whale sounds are. There are a handful of possibilities here in terms of what this study could mean. And one of them is that the whales really are using full-blown language.

What they might be talking about, we don’t know. I mean, perhaps they like to talk about their travels over hundreds and thousands of miles. Maybe they’re talking about, you know, the giant squid that they caught last night. Maybe they’re gossiping about each other.

And you have to remember, sperm whales are incredibly social animals. They have relationships that last for decades. And they live in groups that are in clans of thousands of whales. I mean, imagine the opportunities for gossip.

These are all at least imaginable now. But it’s also possible that they are communicating with each other, but in a way that isn’t language as we know it. You know, maybe these sounds that they’re producing don’t add up to sentences. There’s no verb there. There’s no noun. There’s no structure to it in terms of how we think of language.

But maybe they’re still conveying information to each other. Maybe they’re somehow giving out who they are and what group they belong to. But it’s not in the form of language that we think of.

Right. Maybe it’s more kind of caveman like as in whale to whale, look, there, food.

It’s possible. But, you know, other species have evolved in other directions. And so you have to put yourself in the place of a sperm whale. You know, so think about this. They are communicating in the water. And actually, like sending sounds through water is a completely different experience than through the air like we do.

So a sperm whale might be communicating to the whale right next to it a few yards away, but it might be communicating with whales miles away, hundreds of miles away. They’re in the dark a lot of the time, so they don’t even see the whales right next to them. So it’s just this constant sound that they’re making because they’re in this dark water.

So we might want to imagine that such a species would talk the way we do, but there are just so many reasons to expect that whatever they’re communicating might be just profoundly different, so different that it’s actually hard for us to imagine. And so we need to really, you know, let ourselves be open to lots of possibilities.

And one possibility that some scientists have raised is that maybe language is just the wrong model to think about. Maybe we need to think about music. You know, maybe this strange typewriter, clickety clack is actually not like a Morse code message, but is actually a real song. It’s a kind of music that doesn’t necessarily convey information the way conversation does, but it brings the whales together.

In humans, like, when we humans sing together in choruses, it can be a very emotional experience. It’s a socially bonding experience, but it’s not really like the specific words that we’re singing that bring us together when we’re singing. It’s sharing the music together.

But at a certain point, we stop singing in the chorus, and we start asking each other questions like, hey, what are you doing for dinner? How are you going to get home? There’s a lot of traffic on the BQE. So we are really drawn to the possibility that whales are communicating in that same kind of a mode.

We’re exchanging information. We’re seeking out each other’s well-being and emotional state. And we’re building something together.

And I think that happens because, I mean, language is so fundamental to us as human beings. I mean, it’s like every moment of our waking life depends on language. We are talking to ourselves if we’re not talking to other people.

In our sleep, we dream, and there are words in our dreams. And we’re just stewing in language. And so it’s really, really hard for us to understand how other species might have a really complex communication system with hundreds of different little units of sound that they can use and they can deploy. And to think anything other than, well, they must be talking about traffic on the BQE. Like —

— we’re very human-centric. And we have to resist that.

So what we end up having here is a genuine breakthrough in our understanding of how whales interact. And that seems worth celebrating in and of itself. But it really kind of doubles as a lesson in humility for us humans when it comes to appreciating the idea that there are lots of non-human ways in which language can exist.

That’s right. Humility is always a good idea when we’re thinking about other animals.

So what now happens in this realm of research? And how is it that these scientists, these marine biologists and these computer scientists are going to try to figure out what exactly this alphabet amounts to and how it’s being used?

So what’s going to happen now is a real sea change in gathering data from whales.

So to speak.

So these scientists are now deploying a new generation of undersea microphones. They’re using drones to follow these whales. And what they want to do is they want to be recording sounds from the ocean where these whales live 24 hours a day, seven days a week. And so the hope is that instead of getting, say, a few 100 codas each year on recording, these scientists want to get several hundred million every year, maybe billions of codas every year.

And once you get that much data from whales, then you can start to do some really amazing stuff with artificial intelligence. So these scientists hope that they can use the same kind of artificial intelligence that is behind things like ChatGPT or these artificial intelligence systems that are able to take recordings of people talking and transcribing them into text. They want to use that on the whale communication.

They want to just grind through vast amounts of data, and maybe they will discover more phonetic letters in this alphabet. Who knows? Maybe they will actually find bigger structures, structures that could correspond to language.

If you go really far down this route of possibilities, the hope is that you would understand what sperm whales are saying to each other so well that you could actually create artificial sperm whale communication, and you could play it underwater. You could talk to the sperm whales. And they would talk back. They would react somehow in a way that you had predicted. If that happens, then maybe, indeed, sperm whales have something like language as we understand it.

And the only way we’re going to figure that out is if we figure out not just how they talk to themselves, but how we can perhaps talk to them, which, given everything we’ve been talking about here, Carl, is a little bit ironic because it’s pretty human-centric.

That’s right. This experiment could fail. It’s possible that sperm whales don’t do anything like language as we know it. Maybe they’re doing something that we can’t even imagine yet. But if sperm whales really are using codas in something like language, we are going to have to enter the conversation to really understand it.

Well, Carl, thank you very much. We appreciate it.

Thank you. Sorry. Can I say that again? My voice got really high all of a sudden.

A little bit like a whale’s. Ooh.

Yeah, exactly. Woot. Woot.

Thank yoooo. No. Thank you.

Here’s what else you need to know today.

We allege that Live Nation has illegally monopolized markets across the live concert industry in the United States for far too long. It is time to break it up.

On Thursday, the Justice Department sued the concert giant Live Nation Entertainment, which owns Ticketmaster, for violating federal antitrust laws and sought to break up the $23 billion conglomerate. During a news conference, Attorney General Merrick Garland said that Live Nation’s monopolistic tactics had hurt the entire industry of live events.

The result is that fans pay more in fees, artists have fewer opportunities to play concerts, smaller promoters get squeezed out, and venues have fewer real choices.

In a statement, Live Nation called the lawsuit baseless and vowed to fight it in court.

A reminder — tomorrow, we’ll be sharing the latest episode of our colleagues’ new show, “The Interview.” This week on “The Interview,” Lulu Garcia-Navarro talks with Ted Sarandos, the CEO of Netflix, about his plans to make the world’s largest streaming service even bigger.

I don’t agree with the premise that quantity and quality are somehow in conflict with each other. I think our content and our movie programming has been great, but it’s just not all for you.

Today’s episode was produced by Alex Stern, Stella Tan, Sydney Harper, and Nina Feldman. It was edited by MJ Davis, contains original music by Pat McCusker, Dan Powell, Elisheba Ittoop, Marion Lozano, and Sophia Lanman, and was engineered by Alyssa Moxley. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly.

Special thanks to Project SETI for sharing their whale recordings.

That’s it for “The Daily.” I’m Michael Barbaro. See you on Tuesday after the holiday.

• May 29, 2024   •   29:46 The Closing Arguments in the Trump Trial
• May 28, 2024   •   25:56 The Alitos and Their Flags
• May 24, 2024   •   25:18 Whales Have an Alphabet
• May 23, 2024   •   34:24 I.C.C. Prosecutor Requests Warrants for Israeli and Hamas Leaders
• May 22, 2024   •   23:20 Biden’s Open War on Hidden Fees
• May 21, 2024   •   24:14 The Crypto Comeback
• May 20, 2024   •   31:51 Was the 401(k) a Mistake?
• May 19, 2024   •   33:23 The Sunday Read: ‘Why Did This Guy Put a Song About Me on Spotify?’
• May 17, 2024   •   51:10 The Campus Protesters Explain Themselves
• May 16, 2024   •   30:47 The Make-or-Break Testimony of Michael Cohen
• May 15, 2024   •   27:03 The Possible Collapse of the U.S. Home Insurance System
• May 14, 2024   •   35:20 Voters Want Change. In Our Poll, They See It in Trump.

Hosted by Michael Barbaro

Featuring Carl Zimmer

Produced by Alex Stern ,  Stella Tan ,  Sydney Harper and Nina Feldman

Edited by MJ Davis Lin

Original music by Elisheba Ittoop ,  Dan Powell ,  Marion Lozano ,  Sophia Lanman and Pat McCusker

Engineered by Alyssa Moxley

Listen and follow The Daily Apple Podcasts | Spotify | Amazon Music | YouTube

Ever since the discovery of whale songs almost 60 years ago, scientists have been trying to decipher the lyrics.

But sperm whales don’t produce the eerie melodies sung by humpback whales, sounds that became a sensation in the 1960s. Instead, sperm whales rattle off clicks that sound like a cross between Morse code and a creaking door. Carl Zimmer, a science reporter, explains why it’s possible that the whales are communicating in a complex language.

On today’s episode

Carl Zimmer , a science reporter for The New York Times who also writes the Origins column .

Background reading

Scientists find an “alphabet” in whale songs.

These whales still use their vocal cords. But how?

There are a lot of ways to listen to The Daily. Here’s how.

We aim to make transcripts available the next workday after an episode’s publication. You can find them at the top of the page.

The Daily is made by Rachel Quester, Lynsea Garrison, Clare Toeniskoetter, Paige Cowett, Michael Simon Johnson, Brad Fisher, Chris Wood, Jessica Cheung, Stella Tan, Alexandra Leigh Young, Lisa Chow, Eric Krupke, Marc Georges, Luke Vander Ploeg, M.J. Davis Lin, Dan Powell, Sydney Harper, Mike Benoist, Liz O. Baylen, Asthaa Chaturvedi, Rachelle Bonja, Diana Nguyen, Marion Lozano, Corey Schreppel, Rob Szypko, Elisheba Ittoop, Mooj Zadie, Patricia Willens, Rowan Niemisto, Jody Becker, Rikki Novetsky, John Ketchum, Nina Feldman, Will Reid, Carlos Prieto, Ben Calhoun, Susan Lee, Lexie Diao, Mary Wilson, Alex Stern, Dan Farrell, Sophia Lanman, Shannon Lin, Diane Wong, Devon Taylor, Alyssa Moxley, Summer Thomad, Olivia Natt, Daniel Ramirez and Brendan Klinkenberg.

Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Sam Dolnick, Paula Szuchman, Lisa Tobin, Larissa Anderson, Julia Simon, Sofia Milan, Mahima Chablani, Elizabeth Davis-Moorer, Jeffrey Miranda, Renan Borelli, Maddy Masiello, Isabella Anderson and Nina Lassam.

Carl Zimmer covers news about science for The Times and writes the Origins column . More about Carl Zimmer

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