OUTCOMES OF ADVANCED PRACTICE NURSES IN MATERNAL

AND CHILD HEALTH CARE IN THAILAND

KOCHAPORN SINGHALA

A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE DOCTOR DEGREE OF PHILOSOPHY

IN NURSING SCIENCE (INTERNATIONAL PROGRAM)

THE FACULTY OF NURSING

BURAPHA UNIVERSITY

NOVEMBER 2011

COPYRIGHT OF BURAPHA UNIVERSITY

ACKNOWLEDGEMENTS

I would like to express my sincere gratitude and deep appreciation to my

major advisor, Associate Professor Dr. Wannee Deoisres, and my Co-advisor,

Assistant Professor Dr. Julaluk Baramee, Professor Dr. Dorothy Brooten, and

Professor Dr. JoAnne M. Youngblut, also to Professor Dr. Somchit Hanucharurnkul

as an external examiner, for all of their guidance throughout this study. Great

appreciation is offered to all committee members and all experts involved in

validating the instruments. Special thanks go to the Faculty of Nursing,

Mahasarakham University, which gave me opportunity to continue my studies and

also to the Thailand Nursing and Midwifery Council and the Graduate School,

Burapha University, which provided partial scholarship during my study in the Doctor

of Philosophy in Nursing Science.

Great appreciations are also offered to all the hospital’s directors who gave

me permission to conduct my research. I am gratefully indebted for all maternal and

child advanced practice nurses and their patients who participated in this study.

My deepest gratitude goes to my doctoral classmates for assistance and

experience sharing.

Finally, I offer my great respect to my parents and my younger brother for

their loving, understanding, supporting, motivation and encouragement throughout

my study process.

Kochaporn Singhala

v

48810335: MAJOR: NURSING; Ph.D. (NURSING SCIENCE)

KEYWORDS: ADVANCED PRACTICE NURSES/ PATIENT OUTCOMES/

HEALTH SERVICE USE/ PATIENT SATISFACTION

KOCHAPORN SINGHALA: OUTCOMES OF ADVANCED PRACTICE

NURSES IN MATERNAL AND CHILD HEALTH CARE IN THAILAND.

ADVISORY COMMITTEE: WANNEE DEOISRES, Ph.D., JULALUK BARAMEE,

Ph.D., DOROTHY BROOTEN, Ph.D., JOANNE M. YOUNGBLUT, Ph.D. 126 P.

2011.

The purpose of this comparative research was to compare the outcomes of

maternal and child advanced practice nurses (APNs) care during four years with

outcomes of care at one year before implementation of the maternal and child APNs.

A sample of 143 patient’s charts before implementation of APNs and 362 patient’s

charts after implementation of APNs were examined in order to compare outcome

differences. Additionally, 321 patients who seek maternal and child APN services

during data collection period was recruited during October 2009 and March 2010 to

assess their satisfaction with maternal and child APN services. To compare outcomes

differences, one-way ANOVA, independent t-test were used. For skewed data,

Kruskal-Wallis, Chi-square test, and Mann-Whitney test were used.

The results of this study revealed that in preterm labor patient group after

APN implementation, their gestational ages were higher. The proportion of neonatal

complications and neonatal admission to special care nursery or neonatal intensive

care unit were lower in comparison to before initiation of APN. For childbirth

preparation group, time use in first stage of labor and amount of blood loss were

lower compared to before introduction of APNs. Additionally, for gestational diabetes

mellitus group, fasting blood sugar level at 6 weeks postpartum and the proportion of

neonatal complications were lower than before initiation of APNs. For patient

satisfaction with maternal and child APN care, it was found that the average patient

satisfaction score was 50.14 which skewed toward high satisfaction.

These findings indicated effectiveness of maternal and child care by APNs

in Thailand. It supported the need to promote more implementation of APNs practice

in the Thai healthcare system in order to improve maternal and child health outcomes.

vi

CONTENTS

Page

ABSTRACT ............................................................................................................... v

CONTENTS ............................................................................................................... vi

LIST OF TABLES ..................................................................................................... viii

LIST OF FIGURE...................................................................................................... x

CHAPTER

1 INTRODUCTION ............................................................................................ 1

Background ............................................................................................... 1

Purposes of the Study ................................................................................ 5

Research questions .................................................................................... 5

Hypotheses of the study ............................................................................ 5

Conceptual framework .............................................................................. 5

Scope of the study ..................................................................................... 7

Contribution to knowledge ........................................................................ 7

Definition of terms .................................................................................... 8

2 LITERTURE REVIEWS .................................................................................. 10

Definition of the advance practice nurse ................................................... 10

Historical development of advanced nurse practitioner roles

Internationally ........................................................................................... 11

Development of advanced practice nurse role in Thailand ....................... 13

Development of maternal and child nursing in Thailand .......................... 15

Donabedian’s structure-process-outcome framework ............................... 18

Literature review of outcomes of advanced practice nurses (APNs)

Care ........................................................................................................... 21

Literature review of APNs practice in Thailand ....................................... 28

3 RESEARCH METHODOLOGY ..................................................................... 31

Research design ......................................................................................... 31

Settings ...................................................................................................... 31

Sample ....................................................................................................... 34

vii

CONTENT (CONTINUED)

CHAPTER Page

Instruments ................................................................................................ 38

Protection of human subjects .................................................................... 40

Data collection ........................................................................................... 40

Data analysis.............................................................................................. 42

4 RESULTS ......................................................................................................... 46

Description of maternal and child APNs demographic ............................. 46

Description of sample demographic .......................................................... 48

Results related to research questions ......................................................... 57

5 CONCLUSIONS AND DISCUSSION ............................................................ 78

Conclusions ............................................................................................... 78

Discussion ................................................................................................. 79

Limitations................................................................................................. 84

Implications ............................................................................................... 85

REFERENCES .......................................................................................................... 87

APPENDICES ........................................................................................................... 96

APPENDIX A .................................................................................................. 97

APPENDIX B ...................................................................................................104

APPENDIX C ...................................................................................................118

APPENDIX D ..................................................................................................124

BIOGRAPHY ............................................................................................................126

viii

LIST OF TABLES

Table Page

1 Overview of maternal and child APNs practice settings, year of APN

certification and specific area of practice ......................................................... 32

2 Sample size of each patient group before and after the introduction of

certified ............................................................................................................. 38

3 Maternal and child APN specific area of practice, outcome variables,

data collection plan, and instrumentations ....................................................... 43

4 Maternal and child APNs demographic............................................................ 46

5 Demographic data of the samples cared for by APN with specific area of

practice in preterm labor ................................................................................... 48

6 Demographic data of the samples cared for by APN with specific area of

practice in teenage pregnancy........................................................................... 50

7 Demographic data of the samples cared for by APN, with specific area of

practice in childbirth preparation at a community hospital .............................. 52

8 Demographic data of the samples cared for by APN with specific area of

practice in childbirth preparation at regional hospital ...................................... 54

9 Demographic data of the samples cared for by maternal and child APN

with specific area of practice in GDM ............................................................. 55

10 Comparison of outcomes before and after the introduction of APN in the

preterm labor patient group .............................................................................. 57

11 Comparison of proportion of outcomes in preterm labor patient group

before and after the introduction of APN ......................................................... 59

12 Comparison of the proportion of neonatal complications in preterm labor

patient group before and after the introduction of APN ................................... 61

13 Comparison of outcomes before and after the introduction of APN in

the teenage pregnancy patient group ................................................................ 63

14 Comparison of the proportion of outcomes before and after the

introduction of APN in the teenage pregnancy patient group .......................... 66

15 Comparison of outcomes before and after the introduction of APN in the

childbirth preparation patient group at a community hospital .......................... 68

ix

LIST OF TABLES (CONTINUED)

Table Page

16 Comparison of the proportion of outcomes before and after the

introduction of APN in the childbirth preparation patient group at a

community hospital .......................................................................................... 69

17 Comparison of outcomes before and after the introduction of APN in the

childbirth preparation patient group at the regional hospital ............................ 69

18 Comparison of the proportion of outcomes before and after the

introduction of APN in the childbirth preparation patient group at the

regional hospital ............................................................................................... 70

19 Comparison of outcomes before and after the introduction of APN in the

gestational diabetes mellitus (GDM) patient group .......................................... 71

20 Comparison of the proportion of outcomes before and after the

introduction of APN in the gestational diabetes mellitus (GDM) patient

group ................................................................................................................. 73

21 Descriptive statistics of patient satisfaction by items ....................................... 74

x

LIST OF FIGURE

Figure Page

1 Sampling frame and chart sample of maternal and child APN ........................ 37

CHAPTER 1

INTRODUCTION

Background

Maternal and child health has been important and has continually been

declared as being a top priority for the Thailand National Health Development Plan

because it serves as a good indicator of the overall health status (World Health

Organization, 2004). Maternal mortality ratio (MMR) in Thailand has been lowered

but does not meet the national target. The MMR in Thailand has decreased from 36.5

per 100,000 live births in 1998 to 20.9 per 100,000 live births in 2001(Bureau of

Health Promotion, 2006). In 2003, the MMR was 20.63 per 100,000 live births

(Bureau of Health Promotion, 2004). In 2005, the national MMR was 19.6 per

100,000 live births, while the MMR target was set at 18 per 100,000 live births

(Department of Health, 2006). The highest MMR was found in northern region,

measuring at 32.76 per 100,000 live births (Bureau of Health Promotion, 2004).

The three major national targets in maternal and child health in Thailand including 1)

maternal mortality 2) percent of low birth weight infants (weight less than 2500

grams) 3) percent of pregnant women with hemoglobin levels of less than 11g/ dl

have not been met (Bureau of Health Promotion, 2004).

In other countries, especially in the United States, Advanced Practice Nurses

(APNs) have been able to improve maternal and child health and lower costs of health

care (Brooten et al., 2001; Mvula & Miller, 1998; Ruiz, Brown, Peters, & Johnston,

2001). In Thailand, maternal and child APNs have been certified and have delivered

care for women and their families since 2003. However, it is not known if APNs have

been able to improve maternal and child health in Thailand because no studies have

been conducted to evaluate the effects of maternal and child APN practice on patient

outcomes and health care costs.

Major maternal and child health problems

In Thailand, major maternal and child health problems are: maternal

mortality (Bureau of Health Promotion, 2006), low birth weight infants (Ministry of

Public Health revealed, 2007), and anemia during pregnancy (Department of Health,

2

2006). Contributing problems are lack of patient knowledge regarding health care

issues, including prenatal care, childhood immunization, nutrition, and self care

(Wongeak, Inprom, Riewpitak, & Jindarat, 2006). From 2003 to 2006, the leading

causes of maternal deaths were hemorrhage during pregnancy and delivery and

preeclampsia. The Bureau of Health Promotion reported that such deaths can be

prevented through better and earlier care (Bureau of Health Promotion, 2006).

In 2003-2005, low-birth-weight (LBW) infants (weighting less than 2500

grams) have been one of the main maternal and child health problems in Thailand that

have not reaching the national target of less than 8 percent of all live births.

In addition, LBW is closely associated with fetal and neonatal mortality and

morbidity (United Nations Children’s Fund and World Health Organization, 2004).

Several studies have also found that subsequent school performance and IQ

development are usually less optimal in LBW infants, if compared with normal birth

weight (NBW) infants (ACC/ SCN, 2000; Kramer, 2003) Additionally, recent

epidemiological data has shown an increase risk of development of late adulthood

diseases such as type-2 diabetes, hypertension, and coronary artery disease for LBW

(Eriksson, Forsén, Tuomilehto, Osmond, & Barker, 2001; Kramer, 2003).

In 2003, the percentage of pregnant women with a hemoglobin level of less

than 11g/ dl was 12.35 percent (Bureau of Health Promotion, 2004), while the target

was set at 10 percent or less (Department of Health, 2006). The Bureau of Health

Promotion (2004) reported differences by region with the southern region having the

highest percent (16.03 percent), followed by the central region (11.31 percent), and

the northern region (10.96 percent). In 2005 the national percentage of women with

anemia during pregnancy was 10.6 percent and still had not reached the national

health target of 10 percent (Ministry of Public Health, 2008). Current knowledge

indicates that iron deficiency anemia in pregnancy is a risk factor for preterm delivery

and subsequent infant born LBW (Allen, 2000). Inferior neonatal health is a likely

outcome and the mother may experience serious health problems, should she bleed

during delivery. Thus, reducing the low birth weight rate and anemia during

pregnancy as well as the overall maternal mortality is essential to enhancing the

health status of the Thai population.

3

Advanced practice nurse practices can improve maternal and child

healthcare services, improve patient outcomes, and reduce healthcare costs. Ruiz,

Brown, Peters, and Johnston (2001) compared newborn outcomes and costs of

hospital stays for twins born to mothers receiving specialized care from an advanced

practice nurse (APN) during prenatal care versus twins whose mothers received

standard prenatal care. The results showed that no newborns of less than 30 weeks of

gestation were born to women in the APN specialized care group. The mean birth

weight was higher, days in the NICU were reduced from a mean of 17 to 7, and

hospital charges were $30,000 less per infant. Brooten et al. (2001) examined

prenatal, maternal, and infant outcomes and cost for 1 year after delivery, using a

model of prenatal care for women at high risk of delivering low-birth-weight infants

in which half of the prenatal care was provided in women’s homes by advanced

practice nurses. The results of the study showed that fetal and infant mortality in the

intervention group was lower than in the control group (2 vs. 9), 11 fewer preterm

infants, more multiple pregnancies carried to term (77 % vs. 33 %), fewer prenatal

hospitalizations (41 vs. 49), fewer infant re-hospitalizations (18 vs. 24), and savings

of 750 hospital days.

Jackson et al. (2003) examined outcomes, safety, and resource utilization in

a collaborative care (APN and physician) birth center program compared with

traditional physician-based perinatal care in low risk and low in-come pregnant

women. The results demonstrated that collaborative care had a greater number of

normal spontaneous vaginal deliveries, and required less use of epidural anesthesia.

Furthermore, a home care follow-up program using an APN was initiated to deliver

care for mothers and newborns discharged early (Dana & Wambach, 2003). The

study results demonstrated a very high satisfaction with the home visit care. The

major correlates of satisfaction were nurse friendliness, technical skills, infant care

teaching, and individualized care.

The advanced nursing practice concept has been initiated in the nursing

profession in Thailand for more than two decades (Ketefian, Redman, Hanucharurnkul,

Masterson, & Neves, 2001); however, there has been no evaluation of the effect of

APNs practice on patient outcomes and health care service use. In 1977, the first post-

basic advanced practice nurse program was established (Hanucharurnkul, 2007).

4

In 1994, according to the Nursing and Midwifery Acts, the Thailand Nursing and

Midwifery Council (TNMC) set up a policy to certify an advanced practice nurse

(APN) certificate to nurses who meet the eligibility requirement for work as advanced

practice nurses. The requirement for an individual who will be certified to be an APN

is a master’s degree in nursing in specialty area, or a degree attained through a post-

basic nurse practitioner program that was accredited by the TNMC (Hanucharurnkul,

2003). Accordingly, the first certification was awarded to 49 APNs in 2003

(Hanucharurnkul, 2003). In 2007, the TNMC set 10 specialty areas for a master’s

degree preparing for APN practice: maternal and child nursing, community health

nursing, midwifery, mental health and psychiatric nursing, pediatric nursing, medical

and surgical nursing, gerontological nursing, infectious control nursing, anesthetic

nursing, and community health nurse practitioner (Hanucharurnkul, 2007). In

addition, the TNMC set the scope of practice and competency standard for 10 APN

specialty areas (Thailand Nursing and Midwifery Council, 2008). During 2003-2007,

20 maternal and child APNs have been certified and have provided care for patients in

tertiary, secondary and primary care levels.

Although there have been APNs’ role performance and outcome of APNs’

service studies in Thailand, no research examining the effect of maternal and child

APNs on outcomes of practice. Three studies of 4-month training NPs’ practice were

found. Those studies were focused on characteristics and working situation, process

of care, and treatments of NPs’ services (Boontong, Athaseri, & Sirikul, 2007;

Hanucharurnkul, Suwisith, Piasue, & Terathongkum, 2007). One study was reported

outcomes of NP’s service; nevertheless, the results came from NPs’ perception

(Boontong et al, 2007). One study was described patients’ satisfaction with NPs’

service (Sindhu, Arjsalee, Phutthaphitakphol, & Kongkumneard, 2004). There is,

however, no published study that using a comparative design or other strong designs

to evaluate the effect of master’s degree preparing APN specialty in maternal and

child care on patient outcomes, health service use, and satisfaction with APN care.

This study is necessary for several reasons. First, outcome studies are

necessary to see the effects maternal and child APNs have on health care in Thailand.

Second, outcomes studies can show the potential of maternal and child APNs practice

in regards to quality of care. The literature in developed countries demonstrated that

5

the use of APNs can minimize the cost of care, provided a good quality of service and

high client satisfaction.

Purposes of the study

There were two purposes of this study included:

1. To compare the outcomes of maternal and child APN care at the same

health care settings before and after the introduction of the certified maternal and

child APNs,

2. To describe patient satisfaction with maternal and child APN care.

Research questions

This study is designed to answer the following research questions.

1. Before and after the introduction of maternal and child advanced practice

nurses in hospital settings, are there differences in patient outcomes and health service

use?

2. How satisfied are patient with the service of maternal and child APNs?

Hypotheses of the study

As research questions above, this study was hypothesized that there are

differences in patient outcomes and health service use after the introduction of

maternal and child APNs compare to before the introduction of maternal and child

APNs.

Conceptual framework

The framework for the study is based on Donabedian’s conceptual

framework (structure-process-outcome model) (Donabedian, 2003). Donabedian’s

conceptual framework was employed to evaluate quality of care and guide quality

assurance programs that originally were directed at evaluating the quality of medical

care. However, it has since been applied more generally to the evaluation of health

care systems, as well as to evaluations of nursing practice and nurse practitioner

practice.

6

Donabedian (2003) briefly defined the concepts of structure, process, and

outcome as follows. Structure is the conditions under which care is provided. These

include the attributes of material resources (such as facilities and equipment), human

resources (such as the number, variety, and qualifications of professional and support

personnel), organizational characteristics (such as the organization of the medical and

nursing staffs, the presence of teaching and research functions, kinds of supervision

and performance review, methods of paying for care, and so on). Process refer to the

activities that constitute health care including diagnosis, treatment, rehabilitation,

prevention, and patient education that usually is carried out by professional personnel,

but also includes other contributions to care, particularly by patients and their

families. Outcomes are changes (desirable or undesirable) in individuals and

populations that can be attributed to health care. Outcomes include changes in health

status, changes in knowledge acquired by patients and family members that may

influence future care, changes in the behavior of patients or family members that may

influence future health, satisfaction of patients and their family members with the care

received and its outcomes.

Donabedian (2003) emphasized that structure influences process and process

influences outcome as shown in the following simple diagram:

p p

Structure Process Outcome

However, the relations existing between adjacent pairs in the structure-

process-outcome model are not certainties. Rather, they are probabilities, hence the

lower-case “p” that is placed over each of the arrows in the diagram shown above.

The higher the probabilities are, the more credible our judgments of quality can be

(Donabedian, 2003).

The structure-process-outcome model provides a theoretical foundation for

linking outcome with process and structure. In this study, structure is the

characteristics of APNs’ practice settings such as type of hospital, number of

specialist physician, and nurses’ educational background. Process in this study is

divided into two types of care: 1) care that is carried out by maternal and child APNs

7

and 2) care that is carried out by health care providers before the initiation of the

maternal and child APNs role. Outcomes are patient outcomes (a. maternal outcomes

prenatally [hemoglobin level, maternal complications, b. maternal outcomes during

delivery [intrapartum hemorrhage, amount of analgesics used, duration of labor, type

of delivery], c. maternal outcomes during postpartum [postpartum hemorrhages], d.

fetal/ infant outcomes [neonatal complications, gestational age, birth weight]); health

service use (e. health service use prenatally [acute care visits, length of hospital stay,

rehospitalization, antenatal transfer] , e. health service use during delivery

[intrapartum transfer, neonatal admission to special care nursery or ICU] and f. health

service use during postpartum [neonatal admission to special care nursery or ICU]);

and patient satisfaction.

Scope of the study

The purposes of this research were 1) to compare the outcomes of maternal

and child care during two periods of APN practice, i.e., one year before maternal and

child APNs were in practice and four years after maternal and child APNs were in

practice, and 2) to describe patient satisfaction with maternal and child APN practice.

The study settings were four hospitals where APNs agreed to participate in work and

patients’ data available to be studied. Studied outcomes were patient outcomes, health

service use, and patient satisfaction.

Contribution to knowledge

The results of this study will contribute to healthcare policy, nursing

practice, nursing research, nursing education and nursing administration as following

described.

Although there is some research about 4-month training NPs’ service in

Thailand, little is known in the effect of master’s degree preparing maternal and child

APNs care on patient outcomes, use of health service, and satisfaction with maternal

and child APN care. Outcomes of maternal and child APN practice can result in

making the role of maternal and child APNs more visible. The quality and the

effectiveness of maternal and child APN practice that policy makers or healthcare

8

administrators can use for healthcare cost comparison and healthcare workforce

planning. This data will allow policy makers or healthcare administrators to allocate

maternal and child APNs in health care settings in order to decrease the maternal and

child health problems. Outcomes of APN practice can provide guidance for nursing

educators in evaluating educational outcomes of APNs and whether the APN

curriculum needs revision. Furthermore, the results of this study can useful for nurse

researcher in providing of guidance for further research in improving maternal and

child APNs practices, and for outcomes research. Study methods can be used to

evaluate the outcomes of APNs practice in other clinical specialty areas.

Definition of terms

For the purpose of this study, the operational definitions of terms are

explained as follow:

Maternal and child advanced practice nurse (APN) refer to a licensed

registered nurse with a Bachelor of Science degree and a Master’s of Science degree

in Nursing or related field, who possesses evidence of maternal and child advanced

practice nurse certification according to the requirements of the TNC. Maternal and

child APN practices within the TNC’s scope of practice and the advanced practice

nurse competency standard as declared by the TNC. Certification is conferred upon

an individual who has met eligibility requirements for and successfully passed the

certification examination of the TNC (Hanucharurnkul, 2003; TNC, 1998).

Patient outcomes refer to effect of care provided for women and their

babies during prenatal, delivery, and postpartum period. Patient outcomes encompass

information that demonstrate maternal and newborn health status and also include

safety or freedom from infection, or complication during pregnancy, delivery, and

postpartum period.

Health service use refer to information regarding the number of times and

places that patient visit or admitted to the health care setting in order to receive care,

treatment, or advice regarding maternal and child health during the prenatal, delivery,

or postpartum period, as recorded in the client chart. Information regarding health

service use includes the number of hospitalizations.

9

Patient satisfaction is a maternal perception of the quality of the maternity

services received from the maternal and child APN. Perceptions of care are

influenced by the expectations of the woman who uses that care as well as the actual

of the care that she receives (Bear & Bowers, 1998).

CHAPTER 2

LITERATURE REVIEWS

This chapter presents the literature review that is comprised of seven parts.

First is the definition of advanced practice nurse. Second is the historical development

of advanced nurse practitioner roles internationally. Third is the development of the

advanced practice nurse role in Thailand. Fourth is the development of maternal and

child nursing in Thailand. Fifth is the Donabedian’s structure-process-outcome

framework. Sixth is the studies review of advanced practice nurses (APNs) practice

effects on patient outcomes, health service use, and satisfaction of APNs practice.

Last is the literature review of APNs practice in Thailand

Definition of the advanced practice nurse

An advanced practice nurse (APN) or advanced practice registered nurse

(APRN) is defined by the American Nurses Association as ‘a registered nurse (RN)

who has attained advanced education and expertise and specialize in such medical

fields as pediatrics, anesthesiology, gerontology, neonatology and mental health.

APRNs include nurse practitioners, clinical nurse specialists, certified nurse-midwives

and certified registered nurse anesthetists (ANA, 2003 cited in Hamric, 2005).

Hamric (2005) conceptualized definition of APNs as “advanced practice nursing is

the application of an expanded range of practical, theoretical, and research-based

competencies to phenomena experienced by patients within a specialized clinical area

of the larger discipline of nursing”. The International Council of Nurses (ICN)’s

Board of Directors approved a definition of APNs in order to facilitate a common

international understanding and foster unity around this emerging role. The ICN’s

position is that the nurse practitioner/advanced practice nurse is:

11

a registered nurse who has acquired the expert knowledge base, complex

decision-making skills and clinical competencies for expanded practice, the

characteristics of which are shaped by the context and/ or country in which she/he is

credentialed to practice. A masters level degree is recommended for entry level.

(Schober & Affara, 2006; p. 12)

Historical development of advanced nurse practitioner roles

internationally

1. United States of America

In the United States, the term advanced practice nurse (APN) is an umbrella

term that includes nurse practitioners (NP), clinical nurse specialists (CNS), certified

nurse-midwives (CNM), and nurse anesthetists (CRNA). The expansion of nurse-

midwifery practice and education has been influenced by factors such as the shortage

of physicians, the availability of federal funding, and changes in nurse practice acts

(Hamric, 2005). Nurse anesthetists, who are pioneers in advanced practice nursing,

have provided quality anesthesia for more than 100 years (Macdonald, Herbert, &

Thibeault, 2006). The growth of hospitals in the 1940s and the development of

medical specialties and technologies stimulated the evolution of the CNS. In the

1960s, nurse practitioners (NPs) were created in the US to provide primary health care

services to populations with unmet needs, and to promote community-based

continuity of care (Schober & Affara, 2006).

The first CNS program was initiated in 1954. The first NP program was

established almost 10 years later (Macdonald et al., 2006). Regardless of the

population served, or the care setting, advanced practice nursing in the United States

is characterized by complex decision-making, independent functioning, and advanced

knowledge and skills obtained through graduate nursing education, ether at a master’s

or the doctoral level (Stanley, 2005). Some APNs in the US practice in urgent care or

long-term care settings exclusively, whereas others move across settings from

outpatient to inpatient settings, or to wherever the patient is located (Stanley, 2005).

By 2004, the number of RNs prepared to practice in advanced practice roles was

estimated to be 240,461 (US Department of Health and Human Service, 2004).

12

2. Canada

The CNS was introduced into the Canadian health care system in the 1960s

as a result of increasing complexity in health care. Health care reform combined with

physician shortages resulted in a national conference that was to discuss the need for

the role of physician assistance, which took place in 1971. Participants instead

recommended that there be immediate development of nurse practitioner programs in

Canada. In 1973, directors of the Canadian Nurses Association (CNA) and the

Canadian Medical Association approved a policy statement on the expanded role of

nurses (Macdonald et al., 2006). Nevertheless, several factors resulted in the demise

of NP programs by the mid-1980s including issues regarding reimbursement, a

surplus of physicians instead of the predicted shortage, confusion among the nursing

community regarding the meaning of nurse practitioners, lack of support from the

national nursing organization, and lack of government funding for the expansion of its

role (Macdonald et al., 2006).

In the late 1990s, because of declining health care budgets and an increasing

emphasis on community and primary health care, there was renewed interest in NPs

as cost-effective health care providers (Schober & Affara, 2006). The NP role has also

moved into tertiary care settings, where nurses with titles such as advanced nurse

practitioner and extended role nurse offer direct clinical care to patients (Macdonald

et al., 2006). In 2002, the CNA developed a national framework for advanced nursing.

Currently, the government is funding a multiple stakeholder NP initiative to create a

pan-Canada framework for facilitating the introduction and permanent integration of

NPs into the Canadian health system (Schober & Affara, 2006).

3. Australia

The Australian nurse practitioner debate started in 1990 in New South

Wales. With the support of the Minister for Health, a working party was established to

pursue issues associated with the development of NP roles (Offredy, 2000). A series

of pilot projects were conducted to explore the role and function of NPs, prescribing

rights, initiation of diagnostic tests, client outcomes and cost effectiveness of NP

services (Offredy, 2000). This development was underpinned by efforts on the part of

regulators and professional organizations in order to reach a national consensus on

definition, scope, education and regulation, and in order to deal with inconsistencies

13

and confusion. In 1999, 40 nurse practitioner positions were created in rural and

remote New South Wales (NSW). In 2000, the Minister of Health gave full support to

the concept (Stanley, 2005). The Minister for Health announced the support and

expansion of NPs into metropolitan areas of New South Wales in 2002 (“Nurse

practitioner,” 2008). Victoria endorsed the first four nurse practitioners in 2004

(Wortansw, Happell, & Johnstone, 2006). To date, 105 NPs have been authorized by

the Nurses and Midwives Board (NMB) of NSW (Nurse practitioner, 2008).

4. United Kingdom

The role of the NP was developed in the United Kingdom (UK) as an

acknowledgement of the inadequacy of past medically dominated approaches to

health care, and a reaction to the physician shortage in primary care. However, the

confusion over scope, titles and education for the role became evident (Schober &

Affara, 2006). A framework for differentiating between elementary, specialist and

advancing nursing practice was proposed in 2003 (Daly & Carnwell, 2003); however,

researchers use the terms nurse practitioner, advanced nurse practitioner and nurse

consultant interchangeably (Woodward, Webb, & Prowse, 2006).

The Royal College of Nursing (RCN) has published standards describing the

roles, competencies, and accreditation standards for the NP program. NPs are

required to complete an advanced education program beyond the basic nursing

training. In 1992, the first cohort of 15 NPs graduated from the RCN NP program.

NPs in the UK work as part of a professional team in both primary and secondary

care. More than 60 different advanced practice nursing roles identified in the UK are

situated within hospital settings rather than in community settings (Stanley, 2005).

Development of advanced practice nurse role in Thailand

The advanced nursing practice concept has been initiated in the nursing

profession in Thailand for more than two decades (Ketefian et al., 2001); however, the

initial nurse practitioners (NPs) were not masters-level certified nurse practitioners.

The first post-basic nurse practitioner program was established in 1977. It was a one-

year program, titled ‘Public Health Nurse Practitioner Program’. However, this

program was closed in the late 1980s because it was deemed unacceptable by the

physicians (Hanucharurnkul, 2007). During 1979-1984, three nurse practitioner

14

programs were established to serve the physician shortage. One program, a 6-month

eye nurse practitioner program, was established by a physician in collaboration with

school of nursing, and in collaboration with the Ministry of Public Health (MOPH).

Two programs, 6-months general nurse practitioner program and 4-month neonatal

nurse practitioner program, were established by a physician in collaboration with

school of nursing.

In 1994, according to the Nursing and Midwifery Acts, the Thailand Nursing

and Midwifery Council (TNMC) set a policy to certify an Advanced Practice Nurse

(APN) certificate to nurses who meet the eligibility requirement allowing them to

work as APN in five specialty areas: community nursing; mental health and

psychiatric nursing; maternal and child nursing as well as medical and surgical

nursing. The requirement for an individual certified as an APN is graduation at a

master level in nursing in a specialty area, or as is, completing a post-basic NP

program accredited by the TNMC (Hanucharurnkul, 2003). Accordingly, the TNMC

offered the first certification examination and awarded the APN certification to 49

APNs in 2003 (Hanucharurnkul, 2003).

The need for advanced practice nurse role, especially the urgent need for

nurse practitioners (NPs) to work at 10,000 primary care units, has become evident in

Thailand since the health care reform was initiated and a universal health care

coverage system was started in 2002 (Hanucharurnkul, 2007). The nurse leaders in the

TNMC paid more attention in order to improve the quality of nursing care

(Boonthong, 2005) and envisioned that besides providing care for patients who

struggle with complex problems in the hospital settings, nurses should be at the

frontier in providing primary care (Hanucharurnkul, 2007). The TNMC presented the

primary care APN idea to the policy makers. In addition, several APN

legislations/regulations were set up by the TNMC pushing (Boonthong, 2005) to serve

that idea. Additionally, the schools of nursing in Thailand, with TNMC

encouragement, have produced four-month post-basic APNs and maters-level APNs

to work in the community as primary care providers (Hanucharurnkul, 2007).

Currently, the TNMC has certified 2,717 four-month post-basic NPs and more are

coming (Hanucharurnkul, 2007).

15

For the master’s degree preparing APN, the TNMC set 10 specialty areas for

APN practice: maternal and child nursing, community health nursing, midwifery,

mental health and psychiatric nursing, pediatric nursing, medical and surgical nursing,

gerontological nursing, infectious control nursing, anesthetic nursing, and community

health nurse practitioner (Hanucharurnkul, 2007).

During 2003-2007, 474 APNs have been certified by the TNMC; including

20 APNs in maternal and child nursing, 66 APNs in community health nursing, 48

APNs in mental health and psychiatric nursing, 48 APNs in pediatric nursing, 258

APNs in medical and surgical nursing, 34 APNs in gerontological nursing.

Development of maternal and child nursing in Thailand

The development of maternal and child nursing in Thailand has been guided

by the need to decrease maternal and infant mortality. This development was inspired

and supported by the investments of two wealthy and influential groups, the

monarchy and privately-based foundations located primarily in the United States

(York, Bhuttarowas, & Brown, 1999). Maternal and child nursing was first introduced

in Thailand in 1860 by a Thai woman named Esther or Mrs. Prateepasen. Esther was

sponsored by her Presbyterian missionary to study in the United States. and returned

to Siam to provided midwifery care. However, maternal and child nursing at that time

was not a formal career field. Nursing as a career was initiated by Queen

Sripatcharintra 36 years later (Taweeboon, 2001).

The first nursing school focusing on midwifery and the care of newborn

(Ekintumas, 1999), called the School of Medicine-Midwifery and Female Nurses, was

established in 1896 (Taweeboon, 2001). The initial nursing curriculum was in line

with the Queen Sripatcharintra’s wish to decrease infant mortality and maternal

deaths and was greatly influenced by the tragedy of losing her infant son to cholera.

Thus, the initial nursing curriculum emphasized obstetrical nursing, in particular

midwifery but included a 1 year practicum in meal preparation, massage, vaccination,

and sewing (York et al., 1999). The teachers were primarily foreign physicians.

Royal recognition of the potential contributions of nurses to health care

helped transform the social standing of women between 1925 and 1935. The

Monarchy arranged for government scholarships supported by the Rockefeller

16

Foundation to be awarded to send potential nursing students to study abroad (to

China, the Philippines, and the United States). The Monarchy also arranged for two

professional nurses from the United States to develop and teach a new nursing

curriculum. These American nurses were influential in strengthening the profession

by raising the educational admission requirements from the third to the tenth grade;

extending the length of the curriculum from 2 to 3 years, plus an additional 6 months

of midwifery clinical experience; and creating licensure with the receipt of the nursing

diploma (York et al., 1999).

The first baccalaureate degree program for nursing was established in 1956

at Siriraj Hospital in Bangkok. In 1971, the first dedicated nursing faculty was

created at Khon Kaen University in northern of Thailand (Anders & Kunaviktikul,

1999). Nursing became a professional discipline independent of medicine for the first

time in Thailand. The completion of the 12th grade has been the standard educational

admission requirement for diploma nursing programs since 1959. The midwifery

curriculum continues to be an important aspect of the nursing profession. Every

registered nurse is also a certified nurse-midwife, whether she earned a diploma or a

baccalaureate degree (York et al., 1999).

In 1977, the first master’s program in maternal and child health nursing was

established at the Faculty of Nursing, at Mahidol University (Taweelap, 2007). In the

master’s programs, the emphasis is primarily on educating both nurse administrators

and nurse specialists in a variety of fields. Upon graduation, these nurses are most

often employed as educators and staff nurses. They do not, however, have expertise

to the level of advanced practice nurses (Anders & Kunaviktikul, 1999).

Scope of practice of nursing, midwifery, and maternal and child

advanced practice nursing

According to the Professional Nursing and Midwifery Act B.E. 2528, scopes

of practice for nursing and midwifery have been given as follow.

“Nursing” means the actions related to helping and caring for the sick for the

purpose of alleviating the symptoms of illness and preventing it from deterioration,

assessment of their health condition, promotion, and rehabilitation of health, diseases

prevention, including providing assistance to physicians and execution of a physician

instructions in a treatment, based on scientific principles and the art of nursing

17

“Midwifery” means the action related to examination, giving advice,

promotion of health and care given to a pregnant woman in order to prevent

complications during her pregnancy and childbirth, conduct of labor and delivery.

This includes post-natal care for both the mother and child, providing assistance to a

physician and execution of a physician’s instructions in a treatment based on scientific

principles and the art of midwifery (TNMC, 1998, p.2).

Maternal and child advanced practice nursing was introduced in 1998 with

the TNMC as the regulatory body. At that time, the scope of maternal and child APN

practice was declared by the TNMC as:

The actions related to helping and caring for women and their family in

premarital, pregnancy, delivery, and postnatal period, with normal or at risk status,

included newborn baby until 1 month of age. The actions related to helping and caring

for women and their family can take place both at clinical setting and community

setting. The actions will be guided by applying nursing science, related science and

research results in holistic way including practicing, teaching, managing, and

counseling in order to enhancing self care for women, their baby, and family to

maintain healthy status and family relationship (TNMC, 1998, p.2).

In 2008, the new scopes of practice for APN in Thailand were declared by

the TNMC in 10 specialty area of practice i.e., maternal and child nursing, community

health nursing, midwifery, pediatric nursing, medical - surgical nursing, mental health

and psychiatric nursing, gerontological nursing, community health nurse practitioner,

infectious control nursing, anesthetic nursing. The new scope of practice for maternal

and child APN was declared as follow:

The actions related to helping and caring for women and their family in

premarital, pregnancy, delivery, and postnatal period, with normal, at risk, and

abnormal status, included newborn baby until 1 month of age. The actions related to

helping and caring for women and their family can take place both at clinical setting

and community setting. The actions will be guided by applying nursing science,

related science, research results, and evidence base in holistic way including

practicing, ethical decision making, teaching, managing, and counseling in order to

enhancing self care for women, their baby, and family to maintain healthy status and

family relationship (TNMC, 2008, p.2).

18

The core competencies for advanced practice nursing in Thailand

In 2003, Hanucharurnkul (2003) was summarized the core competencies for

APNs practice in Thailand as follow: 1) clinical expert 2) teaching skill 3)counseling

skills 4) skill in collaboration with intra and interprofession, health care team and

other staff in work organization and health care systems 5) change agent skills 6)

leadership inside and outside profession 7) skill in conducting research and utilizing

research results to improve quality of nursing and health services 8) ethical decision

making skill 9) skill in evaluating nursing outcomes 10) skill in quality assurance.

In 2008, however, there is the resolution of the nursing specialty training and

examining committee that summarized the core competencies for APNs practice as

follow: 1) care management skill 2) direct care skill 3) collaboration skill

4) empowering, educating, coaching, and mentoring skills 5) consultation skill

6) change agent skill 7) ethical reasoning and ethical decision making skills

8) evidence-based practice skill 9) outcome management and evaluation skills

(TNMC, 2008).

Donabedian’s structure-process-outcome framework

Donabedian’s conceptual framework was employed to evaluate the quality

of care and to guide quality assurance programs (Donabedian, 2003). However, it has

since been applied more generally to the evaluation of health care systems, as well as

to evaluations of nursing practice and nurse practitioner practice. Donabedian (2003)

briefly defined the concepts of structure, process, and outcome as follows:

Structure refers to the conditions under which care is provided. These

include: 1) Material resources, such as facilities and equipment, 2) Human resources,

such as the number, variety, and qualifications of professional and support personnel,

organizational characteristics, such as the organization of the medical and nursing

staffs, the presence of teaching and research functions, kinds of supervision and

performance review, methods of paying for care, and so on.

Process means the activities that constitute health care – including

diagnosis, treatment, rehabilitation, prevention, and patient education – usually

carried out by professional personnel, but also including other contributions to care,

particularly by patients and their families.

19

Outcome refers to changes (desirable or undesirable) in individuals and

populations that can be attributed to health care. Outcomes include: 1) Changes in

health status, 2) Changes in knowledge acquired by patients and family members that

may influence future care, 3) Changes in the behavior of patients or family members

that may influence future health, 4) Satisfaction of patients and their family members

with the care received and its outcomes.

Donabedian (2003) also provided a more complete and detailed

classification of outcomes as follows:

1. Clinical outcome

1.1 Reported symptoms that have clinical significance

1.2 Diagnostic categorization as an indication of morbidity

1.3 Disease staging relevant to functional encroachment and

prognosis

1.4 Diagnostic performance - the frequency of false positives and false

negatives as indicators of diagnostic or case finding performance

2. Physiological-biochemical outcome

2.1 Abnormalities

2.2 Functions

2.2.1 Loss of function

2.2.2 Functional reserve-includes performance in test situations under

various degrees of stress

3. Physical outcome

3.1 Loss or impairment of structural form or integrity- including

abnormalities, defects, and disfigurement

3.2 Functional performance of physical activities and tasks

3.2.1 Under the circumstances of daily living

3.2.2 Under test conditions that involve various of stress

4. Psychological, mental outcome

4.1 Feelings-discomfort, pain, fear, anxiety (or their opposites,

including satisfaction)

4.2 Beliefs that are relevant to health and health care

4.3 Knowledge that is relevant to healthful living, health care, and

20

coping with illness

4.4 Impairments of discrete psychological or mental functions

4.4.1 Under the circumstances of daily living

4.4.2 Under test conditions that involve various of stress

5. Social and psychological outcome

5.1 Behaviors relevant to coping with current illness or affecting

future health, including adherence to health-care regimens and changes in health-

related habits.

5.2 Role performance

5.2.1 Marital

5.2.2 Familial

5.2.3 Occupational

5.2.4 Other interpersonal

5.3 Performance under test conditions involving varying degrees of stress

6. Integrative outcomes

6.1 Mortality

6.2 Longevity

6.3 Longevity, with adjustments made to take into account impairments

of physical, psychological or psychological function: “full-function equivalents”

6.4 Monetary value of the above

7. Evaluative outcomes

Evaluative outcome refer to client opinions about, and satisfaction with,

various aspects of care, including accessibility, continuity, thoroughness, humaneness,

informativeness, effectiveness, and cost.

Donabedian (2003) emphasized that structure influences process and process

influences outcome as shown in the following simple diagram:

p p

Structure Process Outcome

However, the relations existing between adjacent pairs in the structure-

process-outcome model are not certainties. Rather, they are probabilities, hence the

21

lower-case “p” that is placed over each of the arrows in the diagram shown above.

The higher the probabilities are, the more credible our judgments of quality can be

(Donabedian, 2003).

Examples of structure measures are size of hospital, ownership, number of

board-certified physicians, and number of registered nurses (Donabedian, 1988).

Process measures emphasize the actual performance of care such as what physicians

and nurses do for patients (Keeler et al., 1992). Examples of process measures include

evaluation of patient teaching, drug administration, and nurses’ communication

pattern. Outcomes measures include rate of mortality and morbidity, length of stay,

rates of readmission and complication, number of visits, number of patient

hospitalizations, number of consultations, diagnoses made, low birth weight rates,

rates of cesarean section, Apgar scores, cost, and patient satisfaction (Kleinpell &

Weiner, 1999).

Literature review of outcomes of advanced practice nurses (APNs)

care

1. Patient outcomes

Numerous studies have reported the effectiveness of APNs practice on

patient outcomes. Several randomized control trials on the role of the NP in primary

care compared NPs to general practitioners (physicians) in the US and UK study

results have revealed similar outcomes for patients in terms of health status, efficacy

or resolution of symptoms (Kinnersley et al., 2000; Mundinger et al., 2000; Vending,

Durie, Roland, Roberts, & Leese, 2000). Kinnersley et al. (2000) conducted a

randomized control trial to ascertain any differences between care from nurse

practitioners and from general practitioners in south Wales and south west England.

The results show that resolution of symptoms and concerns did not differ between the

two groups. The number of prescriptions issued, investigations ordered, and referrals

to secondary care were similar between the two groups. Vending et al. (2000)

reported their finding of a randomized control trial of comparing cost effectiveness of

general practitioners and nurse practitioners in primary care in England and Wales.

They found no significant difference in patterns of prescription or health status

22

outcome for the two groups. There was no significant difference in health service

costs. Mundinger et al. (2000) reported their findings of a randomized control trial to

compare primary care outcomes in patients treated by nurse practitioners or

physicians in New York. They found no significant differences in patients’ health

status between the two groups at 6 months after initial appointment. Physiological test

results for patients with diabetes or asthma were not different. For patients with

hypertension, the diastolic value was statistically significantly lower for nurse

practitioner patients.

Sakr, et al. (1999) using randomized control trial to compared outcomes of

NPs and junior doctors in an acute & emergency department. They found that NPs

provided care for patients equal to or better than that provided by junior doctors.

Naylor et al. (1999) examined the effects of a discharge planning and home follow-up

intervention on elders hospitalized with common medical and surgical cardiac

conditions. The intervention protocols were: initial APN visit within 48 hours of

hospital admission, APN visits at least every 48 hours during the index hospitalization, at

least 2 home visits by APN (1 within 48 hours after discharge, a second 7-10 days

after discharge) additional APN visits based on patients' needs with no limit on

number, APN telephone availability 7 days per week (8 AM to 10 PM on weekdays

and 8 AM to noon on weekends), and at least weekly APN-initiated telephone contact

with patients or caregivers. They found no significant group differences in regards to

functional status and depression.

Sharples et al. (2002) conducted a randomized control trial to compare

outcomes of care and resource use between nurse practitioner led care and doctor led

care in a bronchiectasis outpatient clinic in the UK. They found that there were no

significant differences in forced expiratory volume (FEV) in 1 second (FEV1), 12

minute walk test, health-related quality of life measures. Nurse practitioner led care

resulted in significantly increased resource use compared with doctor led care.

Ritz et al. (2000) examined the effects of advanced nursing care on quality

of life and cost outcomes of women diagnosed with breast cancer. The intervention

group received standard care plus APN follow-up care that was provided at the clinic,

by telephone, or via home visits. The APN interventions included provision of

continuous care and offering ongoing support. They found that uncertainty decreased

23

significantly more from the baseline in the intervention versus control group at one,

three, and six months after diagnosis. They also found that unmarried women and

women with no family history of breast cancer benefited from APN interventions in

regards to states of mood and well-being. Lambing, Adams, Fox and Divine (2004)

explored the effectiveness of NPs managing the care of inpatient geriatric patients.

Results from this study indicated that NPs delivered effective care to hospitalized

geriatric patients particularly to those who were older and more sick. While NPs met

expectations, sometimes they exceeded their medical counterparts in particular areas

such as identifying the need for and initiating physical and occupational therapy and

nutrition consultation.

Another positive outcome associated with APNs practice is the ability to

effectively combine both education and management into the delivery of care.

A large, representative, national survey was carried out from 1997-2000. National

Hospital Ambulatory Medical Care examines rates of health counseling provided

during outpatient visits involving NPs across the US (Lin, Gebbie, Fullilove, & Arons,

2004). The results of the survey indicated that health counseling for diet, exercise,

human immunodeficiency virus, and sexually transmitted disease prevention, tobacco

use and injury prevention were more likely to be provided during non-illness care

visits involving a NP. Furthermore, Allen and Fabri (2005), using qualitative

methods, examined potential outcomes of a community aged-care nurse practitioner

(ACNP) service on clients and the health care team. Findings suggested that an ACNP

could provide a high quality of holistic nursing care and positively affect clients’

physical and psychological symptom management, enhance clients’ quality of life,

assist with supplies, provide health education and assist with advocacy.

Positive outcomes of APN practice were also found in maternal and child

studies. Gebauer, Kwo, Haynes and Wewers (1998) conducted a nurse-managed

smoking cessation intervention during pregnancy using a fifteen-minute

individualized intervention delivered by an advanced-practice nurse, combined with

contact via telephone by an APN 7-10 days after the clinic visit. Study results

demonstrated that the intervention may be an effective strategy for intervening with

pregnant smokers, especially in African-Americans. Mvula and Miller (1998)

evaluated the effectiveness of an advanced practice nurse-obstetrician collaborative

24

prenatal practice in New Orleans. They compared the low-risk obstetric patients who

registered for prenatal care at the collaborative-practice site with the low-risk obstetric

patients who registered for prenatal care the university obstetric clinic. They found

that collaborative-care patients had more prenatal visits and birth weight and

gestational age at delivery were greater. Furthermore, they found a significantly lower

occurrence of low birth weight infant at the collaborative-practice site.

Clark, Rapkin, Busen and Vasquez (2001) using an innovative parent

education classes’ curriculum for substance-abusing women, showed that the

education program was successful in increasing the knowledge of the mothers about

common skin disorders, care of infants, toddlers, and preschoolers, as well as basic

first aid. Lieu et al. (2000) compared the effectiveness of nurse practitioner visitation

with pediatric clinic follow-up in a randomized control trial in California. They found

that no significant differences occurred in clinical outcome as measured by

breastfeeding discontinuation or maternal depressive symptoms at the 2-week

interview. Ruiz et al. (2001) compared newborn outcomes and costs of hospital stays

for women with twin pregnancies who received specialized prenatal care by an

advanced practice nurse versus women with twin pregnancies who received standard

prenatal care. Study results showed that no newborns of less than 30 weeks gestation

were born to women in the specialized care group. The mean infant birth weight was

also higher.

Jackson et al. (2003) examined outcomes, safety, and resource utilization in

a collaborative care birth center program and compared these with traditional

physician-based perinatal care in low risk and low-income pregnant women. The

results showed that collaborative care resulted in a greater number of normal

spontaneous vaginal deliveries and less use of epidural anesthesia. Garcia-Patterson et

al. (2003) compared the rate of insulin treatment and perinatal outcome in women

with gestational diabetes mellitus (GDM) under endocrinologist-based versus diabetes

nurse-based metabolic management in Spain. The diabetes nurse’s role in Spain was

similar to that of an advanced practice nurse in the U.S. They found that rates of

insulin treatment and perinatal outcome (hypertension, preterm delivery, cesarean

section, low Apgar score, macrosomia, newborns of small and large sizes of given

their gestational age, obstetric trauma, major malformations, hypoglycemia,

25

hypocalcaemia, polycythemia, jaundice, respiratory distress, and mortality) were

similar in both the endocrinologist-based management group and the diabetes nurse-

based management group.

Brooten et al. (2001) examined prenatal, maternal, and infant outcomes and

costs through 1 year after delivery using a model of prenatal care for women at high

risk of delivering low-birth-weight infants in which half of the prenatal care was

provided in women’s homes by advanced practice nurses. A randomized control trial

was conducted, in which APN home visits and telephone follow-up were substituted

for half of the routine antenatal care provided by physicians in the clinic or

physicians’ office. They found that fetal and infant mortality in the intervention group

was lower than in the control group (2 vs. 9), 11 fewer preterm infants in the

intervention group than in the control group, more multiple pregnancies in the

intervention group carried to term (77 % vs. 33 %) (Brooten et al., 2001).

2. Health Service Use

The impact of APNs practice on health service use and health care costs

were shown by several studies. Naylor et al. (1999) examined the effects of a

discharge planning and home follow-up intervention on elders hospitalized with

common medical and surgical cardiac conditions. They found that, by week 24 after

the index hospital discharge, control group patients were more likely than intervention

group patients to be readmitted at least once (37.1 % vs 20.3 %). Intervention group

patients had fever multiple readmissions (6.2 % vs 14.5 %) and fewer hospital days

per patient (1.53 vs 4.09 days). At 24 weeks after discharge, total medicare

reimbursements for health services were about $1.2 million in the control group

versus about $0.6 million in the intervention group. Mundinger et al. (2000) reported

their findings of a randomized control trial to compare primary care outcomes in

patients treated by nurse practitioners or physicians in New York. They found no

significant differences in health services utilization after initial appointment either 6

months or 1 year.

Lieu et al. (2000) compared the effectiveness of nurse practitioner visitation

with pediatric clinic follow-up in a randomized control trial in California. They

reported their findings that no significant differences occurred in maternal or newborn

rehospitalization within 10 days postpartum, maternal or newborn urgent clinic visits

26

within 10 days postpartum. Ruiz et al. (2001) compared newborn outcomes and costs

of hospital stays for twins born to mothers receiving care in a specialized care, which

an advanced practice nurse provided prenatal care versus twins whose mothers

received standard prenatal care. The results showed that days in the NICU were

reduced from a mean of 17 to 7, and hospital charges per infant were $30,000 less

compared to standard prenatal care.

Brooten et al. (2001) conducted a randomized control trial to examine

prenatal, maternal, and infant outcomes and cost through 1 year after delivery using a

model of prenatal care for women at high risk of delivering low-birth-weight infants

in which half of the prenatal care was provided in women’s homes by advanced

practice nurses. They found fewer prenatal hospitalizations (41 vs. 49), fewer infant

rehospitalizations (18 vs. 24) in the APN home care group than in the standard

prenatal and postpartum care group. For postpartum rehospitalization, they also

found the intervention women had significantly shorter lengths of stay than did the

control women. This resulted in a saving of 42 hospital days for the intervention

group. Furthermore, in the intervention group, mean prenatal hospital charges were

significantly less than those for controls ($6213 vs $10,196).

3. Patient Satisfaction

Patient satisfaction with APNs practice as reported in the international

literature has been positive. Garvican, Grimsey, Littlejohns, Lowndes and Sacks

(1998) examined satisfaction with clinical nurse specialists (CNS) in a breast care

clinic in London. They reported on an overall evaluation of clinical care and hospital

services showed that patients were significantly more satisfied with the CNS than

with other aspects of hospital care. In a randomized controlled trial by Kinnersley et

al. (2000), comparing nurse practitioners with physicians delivered care in primary

care in the UK. They found that clients reported significantly greater levels of

satisfaction with nurse practitioner consultations. They reported receiving more

education regarding their health condition from nurse practitioner consultations. In

another randomized trial comparing nurse practitioners with junior doctors in an

accident and emergency unit in the UK, patients seen by nurse practitioners were

found to be better informed about their injury (Sakr et al., 1999). A randomized trial

comparing nurse practitioners with medical practitioners in a major rural emergency

27

department in Australia, found that patients were equally satisfied with care provided

by nurse practitioners and medical practitioners (Chang et al., 1999).

When NPs were compared to physicians, two studies showed that patients

believed the quality of health care to be equivalent. Mundinger et al. (2000) found in a

randomized control trial of care between nurse practitioners and physicians in New

York that no differences in satisfaction ratings were registered following the initial

appointment. Pinkerton and Bush (2000) examined perceived health and patient

satisfaction of 160 patients in a managed care setting. Results indicated no statistically

significant difference in perceived health and satisfaction with care was existent,

independent of whether the care was given by a nurse practitioner or a primary care

physician.

MacMullen, Alexander, Bourgeois and Goodman (2001) compared patients’

satisfaction with care provided by the acute care nurse practitioner (ACNP) or a

doctor in emergency care facility. The patient satisfaction level was found to be

higher among patients treated by the ACNP. Martin (1999) conducted a

nonexperimental, descriptive study to evaluate the role and impact of two pediatric

critical care nurse practitioners (PCCNPs) in the pediatric intensive care unit at a

tertiary care children’s hospital. Study findings showed that parents were very highly

satisfied with PCCNP care. Overall, parents reported that the care their children

received from the PCCNP was adequate.

Bryant and Graham (2002) measured client satisfaction with care delivered

by 36 APNs at 26 different practice sites across Ohio. The results showed that clients

were very satisfied with APNs care. Hayes (2007) explored patient satisfaction,

intention to adhere to NP plan of care, and the impact of managed care on NPs’

patients. She found that patients were very satisfied with NP communication and with

their healthcare visit. They mostly intended to adhere to the NP-recommended plan of

care but less so to recommended lifestyle changes. Patients trusted their NPs, valued

their expertise, were confident in the NPs’ care, and believed that the NPs considered

their best interests. They appreciated that the NPs took time to listen to their concerns

and helped them obtain healthcare resources.

Patient satisfaction with APN practice was also found in maternal and child

studies. Lieu et al. (2000) compared the effectiveness of nurse practitioner visitation

28

with pediatric clinic follow-up in a randomized control trial in California. They found

that there were significant differences between groups, with markedly higher maternal

satisfaction with care among the nurse practitioner-visited clients in the areas of

preventive advice, providers’ skills and abilities, new born and maternal posthospital

care, and overall perinatal care received by mothers and newborns. A home-care

follow-up program using an advanced practice nurse was initiated to deliver care for

mothers and newborns that were discharged early (Dana & Wambach, 2003).

The study results demonstrated very high satisfaction with their home visit care.

The major correlates of satisfaction were nurse friendliness, technical skills, infant

care teaching, and individualized care.

Brooten et al. (2001) conducted a randomized control trial to examine

prenatal, maternal, and infant outcomes and cost through 1 year after delivery using a

model of prenatal care for women at high risk of delivering low-birth-weight infants

in which half of the prenatal care was provided in women’s homes by advanced

practice nurses. They found that women in the intervention group were significantly

more satisfied with care than the controls.

Literature review of APNs practice in Thailand

Three studies of APNs practice in Thailand were found. Sindhu et al. (2004)

study satisfaction of 426 clients who received primary medical care from 4-months

training nurse practitioners (NP). They reported that all clients received 5 steps of

service from the NPs, included establishing relationship, health history and physical

examination, providing information, and providing time. The overall scores of clients’

satisfactions were at a high level. Women had a higher satisfaction score level than

men. There was statistically significant difference in satisfaction score levels among

different age groups. Clients with age over 60 indicated higher satisfaction than those

aged 20 to 60 and ages under 20. The clients from different groups of education levels

had significant difference in satisfaction levels. The clients with no formal education

or only primary level of school education had significantly higher score levels of

satisfaction.

Hanucharurnkul et al. (2007) explored characteristics and working situations

of 1,928 nurse practitioners (NPs) who were certified by TNMC. They found that

29

most of the NPs were female with the average age of 39.03 years. Their average years

of working experience were 16.43 years. Most of their educational backgrounds were

baccalaureate degree (91.5 %) most with a four-month short course as general nurse

practitioners (92.5 %). These NPs work mostly in the central region of Thailand the

most (32.5 %), the others work in the south region (29.1 %), the northeast region

(17.7 %), the north region (14.8 %), and the east region (6.2 %). The health

institutions where they mostly work were community hospitals (57.5 %) and the

health post/primary care unit where there was no physician (34 %).

Health care services which these NPs were frequently provided included the

diagnosis and treatment of common health problems (88.2 %), taking care for the

elderly (87.9 %), and giving continuity of care for the chronically ill persons (85.4 %).

The most common health problems which these NPs managed were upper respiratory

tract infection (95.1 %) such as common cold, tonsillitis and pharyngitis. For chronic

illness patients, the NPs were frequently managed hypertension and heart disease

(66.6 %) and diabetes mellitus (59.9 %). The average number of patients they

provided care for per day was 26 (SD = 19.94). Furthermore, many NPs who worked

at the community hospitals reported that they were asked to provide care in the OPD

clinic in place of the physicians. They also reported that they have many nurses’

responsibilities to do in addition to the role of NPs.

Boontong et al. (2007) explored the role of 400 nurse practitioners (NPs)

who work at the primary care units (PCUs) throughout Thailand. The NPs participants

completed a post-basic NP program accredited by the TNMC and were certified by

the TNMC. They found that the majority of the NPs performed physical examination

before providing treatment. The NPs’ frequent treatments were prescribing oral

medication (97 %), wound dressing (78.50 %), and muscle injection (78.30 %).

Ninety-two percentages of NPs gave advices to patient regarding their treatment and

health practices. These NPs also performed roles in health promotion, disease

prevention, care for chronically ill patients and the elderly in the community as well

as client empowerment.

The NPs perceived that more than 57 percent of patients who received care

recovered from illness and 43 percent improved. The NPs also perceived that most of

patients (97.30 %) expressed their willingness to come back to received care from the

30

NPs. The NPs perceived that patients expresses that receiving care from NPs saved

them traveling time. The NPs also reported that the obstacles of primary care service

were: 1) that the number of NPs were not comparable with the amount of the patients,

2) the NPs did not work full time as NPs and that could lead to ineffective care for

patients, 3) a lack of proper medications and medical instruments, and 4) a lack of

network coordination in the PCU system.

Conclusion

APN roles have implemented in the US and other countries including the

UK, Canada, Australia, Taiwan, and Hong Kong. APNs also delivered care in a

variety of settings including traditional inpatient, outpatient, and primary care

settings. In addition, APNs managed care in a variety of patient populations,

including elders and pregnant women, and specialized in management of specific

diseases, e.g., breast cancer, diabetes mellitus, and bronchiectasis. The structure of

APN practice affects both the process and the outcomes of APN practice. For process

of practice, APN used their competencies to bring about positive care outcomes in

terms of patient outcomes and satisfaction with APN practice.

APNs use advanced clinical knowledge, critical thinking, and

communication skills to address complex problems. Several studies measuring

differences in provision of patient care outcomes have determined that care delivered

by physicians and advanced practice nurses are equivalent. The effective APN model

of care can lower cost of care or hospital charges. Patients are very satisfied with APN

care. Some reported that they were more satisfied with APNs care than they were with

care provided by physicians.

Although researchers have studied the effectiveness of APN practice in a

variety of specialized hospital settings and in a variety of outcomes of care

internationally, there is limited research about the effectiveness of maternal and child

APNs practice in Thailand. This study examined the outcomes of maternal and child

APNs practice in terms of patient outcomes, health service use, and patient

satisfaction with APNs care.

CHAPTER 3

RESEARCH METHODOLOGY

This chapter presents the research methodology including research design,

setting, sample, instrumentation, protection of human subjects, data collection, and

data analysis.

Research design

A comparative design was used to compare the outcomes of maternal and

child care at the same settings before and after initiation of the maternal and child

APNs. The outcomes of care in this study were patient outcomes and health service

use.

Settings

During data collecting period, there were 20 maternal and child APNs who

had been certified more than one year, however, only five APNs were currently active

in providing maternal and child care services. Thus the study settings were those that

APNs were working.

Data for patient outcomes, health service use, and patient satisfaction were

obtained from the hospital settings where maternal and child APNs working and

patient outcomes and health service use data were available. There were 4 hospital

settings that data were regarding patient outcomes and health service use available

during data collection period (shown in table 1).

32

Table 1 Overview of maternal and child APNs specific area of practice, year of APN

certification, and practice settings

Specific area of

practice

Number

of APN

Year of

certification

Practice site Hospital

Preterm labor

Teenage pregnancy

1

1

2004

2004

Labor unit

Antenatal clinic

Provincial

hospital

at southern region

Childbirth preparation

1

2006

Labor unit

Community

Hospital

at southern region

Childbirth preparation 1 2006 Labor unit Regional Hospital

at southern region

GDM*

1 2007 Postpartum ward

University

hospital

at central region

*GDM = Gestational Diabetes Mellitus

The characteristics of four APNs’ practice site hospitals were described as

follows: the 480-bed provincial hospital had 8 obstetricians and 11 pediatricians on

services. Approximately 4,300 women gave birth annually. Two APNs whose specific

groups of patients were women with preterm labor and teenage pregnancy patients

were employed to provide services in two practice areas, the labor and delivery unit

and the antenatal care unit. There were 17 registered nurses that held bachelor’s

degrees in nursing working in the labor and delivery unit. The APN who cared for the

preterm labor patients had a master’s degree in Nursing, and had been certified as an

APN for five years. There were 14 registered nurses who held bachelor’s degrees in

nursing working in the antenatal care unit. The APN that cared for teenage pregnancy

patients held a master’s degree in Nursing, and had been certified as an APN for five

years.

The labor unit in a 120-bed community hospital was used as a study setting.

Approximately 1,200 women gave birth annually at this site. There was no

obstetrician on service. The APN at this site had specialized in childbirth preparation,

33

cared for the childbirth preparation patient group, held a master’s degree in Nursing,

and had been certified as an APN for three years. There were seven registered nurses

that held bachelor’s degrees in nursing working in the labor and delivery unit.

The 863-bed regional hospital, where approximately 3,500 women gave

birth annually, had 10 obstetricians on service. The APN at this site cared for child

birth preparation patients, held a master’s degree in Nursing, and had been certified as

an APN for three years. The labor and delivery unit where the APN practiced had 19

nurses, 17 of them with a bachelor’s degree in Nursing, and 2 of 19 had completed a

master’s degree in Nursing.

The 800-bed university hospital, where approximately 4,800 women gave

birth annually, had 6 obstetricians providing services. The APN at this site specialized

in providing care to women with gestational diabetes mellitus, held a master’s degree

in Nursing, and had been certified as an APN for two years. The four postpartum

wards where the APN practiced had 47 registered nurses providing services; 42 of 47

held bachelor’s degrees in Nursing, while 1 of 47 registered nurses had completed a

master’s degree in Nursing. In addition, 4 of 47 registered nurses held master’s

degrees in areas other than Nursing.

Process of APNs practice

1. Preterm Labor

The APNs that had specialized in preterm labor used APN competencies to

provide patient education, educate the nursing staff concerning preterm labor,

encourage the nursing staff and health care team to stick together with clinical

practice guideline, gave medications and treatments. She collaborated with nurses at

antenatal care clinic regarding essential health education about preterm labor that

needed to be taught to the pregnant women and also develop the leaflet about preterm

labor to provide to pregnant women. The APN also worked with the health care team

to formulate guidelines of care, and coordinated care between nurses and physicians

in order to care promptly for preterm labor patients.

2. Teenage pregnancy

The APNs that specialized in teenage pregnancy provided care for clients,

applied competencies in several practice areas, including patient education, care

management for pregnant adolescent with health problem, nursing staff education,

34

doing treatments, and coordinating care between other healthcare providers and

physicians in order to properly provide care for teenage pregnancy patients. And she

also coordinated care with nurses in the labor and delivery unit regarding childbirth

preparation for pregnant adolescents.

3. Childbirth preparation

APNs who specialized in childbirth preparation developed childbirth

preparation programs, which included both physiological and psychological

preparations for the childbirth period. Pregnant women who attended the programs

were taught and trained by APNs in several topics such as the process of labor and

delivery, relaxation practice, and exercise. APNs also informed staff nurses and

physicians concerning childbirth preparation programs.

4. Gestational diabetes mellitus (GDM)

The APN, whose specific population was a woman with gestational diabetes

mellitus (GDM) practiced using coordination and collaboration with many parties.

She coordinated care with nurses in the antenatal clinic regarding health education.

She collaborated with a dietitian regarding essential dietary education that needed to

be taught to the women with GDM. The APN also worked with the hospital diabetic

working group to formulate guidelines of care and to determine essential health

education content for patients with GDM. In the postpartum ward, GDM patients

were trained in diet and exercises as well as other self-care practices to prevent over

DM.

Sample

The study sample consisted of both APNs and patients. The APN sample

included five APNs who had been certified more than one year and were currently

active in providing maternal and child care services.

There were three group of patient samples in this study: 1) 362 women who

received care from maternal and child APNs after introduction of maternal and child

APN practice at the hospital sites; 2) 143 women who received care from health care

providers at the same hospital sites where maternal and child APNs worked during a

year before introduction of maternal and child APN practice; 3) 321 women who

35

received care from maternal and child APNs during data collection period.

Women’s data who received maternity care from health care providers in the

year prior to introduction of maternal and child APNs were used as baseline data to

compare with woman’s data who received care from maternal and child APNs. The

investigator would call the years when maternal and child APNs were introduced

‘year 0 (zero)’. The year before introduction of maternal and child APN was ‘year -1’.

The year after introduction of maternal and child APN was ‘year +1’, ‘year + 2’…

and ‘year + n’. Thus, women charts from the ‘year -1’ and all charts of women who

received care from maternal and child APNs in ‘year + 1’, ‘year + 2’ …and ‘year + n’

were study population. Data for ‘year 0’ were not collected because this period was

considered a ‘transitional year’.

In order to have sample groups with similar characteristics that are

associated with pregnancy outcomes, matching was used for maternal age, anemia for

the teenage patients, number of deliveries, doctor private case for childbirth

preparation patients, history of cesarean section, and type of gestational diabetes

mellitus (GDM) were used for GDM patient group.

Sample size estimation

Because a number of women who received care from maternal and child

APN each year not to be equal; so, the smallest number of women received care from

APN per year (for years ‘year + 1’,…’year + n’) were used to determine a sample

size for the ‘year – 1’ and any of the ‘plus-years. Sample for charts of women was

estimated to be equal sample sizes for ‘year-1’, ‘year + 1’, ‘year + 2’…and ‘year + n’

Sampling frame for maternal and child APN with a smallest number

of cases

The sampling frames applied for maternal and child APN were as follows:

1. The year that maternal and child with a smallest number of cases was

determined. All of the charts from that year were recruited to be study samples.

2. After the investigator got an accounting of number of APN patients,

simple random sampling was employed. In order to obtain comparable sample groups,

matching technique was applied using maternal age. The hospital number list was

divided into 5 strata (20 years or less, 20-24 years, 25-29 years, 30-34 years, and 35

years or more). A number of charts of each stratum were used to estimate sample size

36

for ‘year-1’.

3. The patients’ hospital numbers list from ‘year + 1…and ‘year + n’ were

divided into 5 strata. A patients’ charts were randomly selected from each stratum of

each year (‘year + 1’, … ‘year + n’) with equal sample size as the specified smallest

number of cases.

Sampling frames for maternal and child APNs, eligible charts, and chart

sample were given in Figure 1.

Period of time to estimate sample size for a year before and after

introduction of maternal and child APN practice as shown in Table 2. A number of

samples for each group are summarized in Table 3.

To ensure that the sample groups (before & after the introduction of

maternal and child APN) for patient outcomes and health service use study were

comparable, hence inclusion and exclusion criteria were as follow:

Inclusion criteria

1. to obtain antenatal care and delivery at the hospital where maternal and

child APNs were working.

2. singleton pregnancies only (no multiple births).

Exclusion criteria

1. Women were referred from other hospitals.

Sample for measure patient satisfaction was clients received care from

maternal and child APNs. The women who obtained maternal and child APN

services during October 2009 and March 2010 were included as a study samples. The

inclusion criteria for this group were: 1) obtained maternal and child APN service at

least two times and 2) must be able to read and write in Thai.

37

Hospital number list of

women received care from

health care providers

1 year before (year -1) 1 year after (year +1)

Hospital number list of

women received care from

maternal and child APN

Hospital number list of

women received care from

maternal and child APN

Exclusion

criteria

Exclusion

criteria

Exclusion

criteria

Inclusion

criteria

Inclusion

criteria

Inclusion

criteria

2 years after (year+2)

A least number of

eligible charts

Eligible charts Eligible charts

n1 = n6= n11 n2 = n7 = n12 n3 = n8 = n13 n = sample size for each group

n1 n2 n3

n = n1 + n2 + n3 + n4 + n5

Randomly select

n6 n7 n8

n = n6 + n7 + n8 + n9 + n10

Randomly select

n11

n12

n13

n = n11 + n12 + n13 + n14 + n15

Age

<20

Age

20-24

Age

25-29

Age

30-34

Age

≥ 35 Age

<20

Age

20-24

Age

25-29

Age

30-34

Age

≥ 35

n14 n15

Age

<20

Age

20-24

Age

25-29

Age

30-34

Age

≥ 35

n4 n5

n9 n10

n4 = n9 = n14 n5 = n10 = n15

Figure 1 Sampling frame and chart sample of maternal and child APN

37

38

Table 2 Sample size of each patient group before and after the introduction of

certified APNs

Group of patient receiving care

from maternal and child APNs

year-1 year+1 year+2 year+3 year+4

n n n n n

Preterm labor

(2003)

30

(2005)

30

(2006)

30

(2007)

30

(2008)

30

Teenage pregnancy

(2003)

31

(2005)

31

(2006)

31

(2007)

31

(2008)

31

Childbirth preparation 1*

(2005)

26

(2007)

26

(2008)

26

- -

Childbirth preparation 2**

(2005)

10

(2007)

10

(2008)

10

- -

Gestational Diabetes Mellitus

(2006)

46

(2008)

46

- - -

* Community hospital ** Regional hospital

Instruments

Data collection forms and client satisfaction questionnaire were used to

collect data.

1. Data collection forms

The data collection forms used to collect data from patient charts and

maternal and child APNs were developed by the investigator. The forms comprised

APN demographic characteristics, client demographic characteristics, maternal and

newborn summary, acute care visit, hospitalization, transfer, and rehospitalization.

The content validity for these forms was judged by five experts including four

faculties from Burapha University and one faculty from Maha Sarakham University

2. Satisfaction questionnaire and step of the instruments translation

The Client Satisfaction Tool

The Client Satisfaction Tool (CST) developed by Bear and Bowers (1998)

is based on Cox’s (1982) Interactional Model of Client Health Behavior (IMCHB)

39

that was used to measure the Senior Health Clinic user’s perception of the quality of

the services received. The CST is a Likert-type scale that consists of 12 items with

response range from strongly agree (5) to strongly disagree (1). The total range of

possible scores is 12 to 60, with a score of 60 representing the highest satisfaction

score obtainable. The CST comprises of six qualities of care domains: 1) affective

support; 2) health information; 3) decisional control; 4) technical competencies; 5)

accessibility; 6) overall satisfaction. Reliability testing showed high internal

consistency (Cronbach’s alpha coefficient was .96) and high stability (r = .97) (Bear

and Bowers, 1998).

Step in the instruments translation

The combined translation techniques that suggested by Brislin (1970) are

used as follows:

1. The CST is translated into the Thai language by the investigators.

2. The translated version is confirmed by two doctoral prepared bilingual

(Thai and English) experts. Both are faculty members of Faculty of Nursing, Burapha

University.

3. The Thai translated version is back translated to English by another

bilingual expert in English and Thai who have never seen the English version of this

instrument.

4. Two monolingual English-speaking persons compared the original

English version and the back-translated English version. They were asked to rate

their agreement independently based on a 7-point Likert-type scale from 1 (not at all)

to 7 (strongly agree). For those items with average scores of less than 4, revisions

were necessary.

5. The Thai translated version is judged by two Thai experts in Thailand to

ensure content equivalence/cultural validity. These experts were asked to rate

independently the degree of cultural relevance of each item of the translated version

on a 4-point Likert-type scale: 1= not relevant, 2 = somewhat relevant, 3 = quite

relevant, and 4 = very relevant. They were asked to suggest improvements to items

and response statements.

40

6. A pilot study is conducted to test internal consistency reliability of the

CST Thai–versions with 30 postpartum women in a postpartum ward,

Sawanpracharuk and Sakon Nakhon hospital and a Cronbach’s Alpha of the CST was

0.84.

Protection of human subjects

The study was approved by the institutional review board of the Graduate

School of Burapha University. The study was also approved by the institutional

review board of each hospital. Permission to conduct the study was obtained from

each hospital before data collection. The researcher gave participants both written

and oral information about the study and the fact that confidentiality for potential

participants would be secure. Women’s names and hospital numbers were not

included in the data collection form. The samples were reassured that no individual

names were associated with the report of findings. The samples were informed that

they could have been terminated their participation at any time if they chose to do so.

Confidentiality of the clinical records was maintained through control of electronic

data under lock and key. Data were available only to the investigator. Records were

removed from the sites after data collection so local staffs could not refer to them.

The demographic data were presented in aggregates; the identities were not linked.

Data collection

Data were obtained by using two methods of data collection. The first was

clinical document reviewed. The second method of data collection was survey.

1. Clinical document reviewed

Clinical document reviewed was used to collect data as follow.

Patient outcomes

a. maternal outcomes prenatally including number of prenatal visit,

hemoglobin level, weight gain, blood pressure level, blood sugar level,

hypo/hyperglycemia, preterm labor, and preeclampsia/severe preeclampsia/eclampsia,

b. maternal outcomes during delivery including intrapartum hemorrhage,

amount of analgesics used, duration of labor, gestational age, birth weight and

41

fetal/infant outcomes including birth asphyxia, neonatal admission to special care

nursery or ICU,

c. maternal outcomes during postpartum including, postpartum hemorrhages,

and postpartum infections.

Health service use

a. health service used prenatally including acute care visits, hospitalizations,

length of hospital stay, rehospitalizations, and antenatal transfers,

b. health service used during delivery including intrapartum transfers,

c. health service used during postpartum including length of hospital stay,

acute care visit, and rehospitalization.

2. Survey

The survey was used to collect data on patient satisfaction with maternal and

child APN care.

Procedure for collection of data on patient outcomes and health service

use

Data on patient outcomes and health service use were extracted from

women’s charts. The investigator reviewed the patient information records of

antenatal units, labor units, and postpartum wards to determine if they had met

inclusion criteria. After obtaining the hospital numbers, the investigator contacted the

registration office personnel to obtain the medical records or charts to be used in this

study. Data on patient outcomes and health service used were collected by the

investigator.

Procedure for collection of data on patient satisfaction with APN

practice

Patient satisfaction was collected only from women who received maternal

and child APN services during data collecting period. No comparison between before

and after introduction of maternal and child APN was made for patient satisfaction.

The investigator contacted the head nurse of each unit in hospital settings to explain

the purpose of the study and the data collection procedure. After obtaining women’s

names, the research assistant approached those women who met the sample criteria

and briefly explained the purpose of the study and the procedure for data collection to

42

the women. The women were informed about confidentiality and they could stop

participating in the study at any time. The research assistant obtained a signed consent

form the sample.

The Client Satisfaction Tool (CST) was administered in the postpartum ward

for women in childbirth preparation group and in the discharge date for women with

preterm labor. Only women who received care at antenatal care unit from maternal

and child APN specific area of practice in teenage pregnancy were asked to complete

the CST after receiving care.

Data analysis

Statistical significance was established at p < .05 in this study. Data

collected was statistically analyzed as described for each research question.

Research question 1

ANOVA and t-test were used to compare a difference in patient outcomes

and health service use. For skewed data, Kruskal-Wallis, Chi-square test, and Mann-

Whitney test were used.

Research question 2

Descriptive statistics, including mean and standard deviation were used to

describe patient satisfaction with maternal and child APN care.

43

Table 3 Maternal and child APN specific area of practice, outcome variables, data collection plan, and instrumentations

APN specific

area

Variables Number

of APN

Data Collection Plan Instrumentations

2003 2004 2005 2006 2007 2008 2009

Childbirth

preparation

Patient Outcomes

- Amount of analgesic use

- Duration of labor

- Type of delivery

-Maternal and Newborn

summary form 2 y-1** y0* y+1*** y+2*** y+3***

Patient Satisfaction Oct09-

Mar10

- Client satisfaction tool

Preterm labor Patient Outcomes

Preterm Labor

- Gestational age

- Birth weight

-Neonatal complication

Health Service Use

- Length of stay

- Hospitalization

- Rehospitalization

- neonatal admission to

special care nursery or ICU

1

y-1**

y 0*

y+1***

y+2***

y+3***

y+4***

-Maternal and Newborn

Summary Form

-Hospitalization Form

- Rehospitalization Form

- Transfer Form

Patient Satisfaction Oct09-

Mar10

- Client Satisfaction

Tool

* The year that maternal and child APN is introduced ** The year before introduction of maternal and child APN

*** The year after introduction of maternal and child APN

44

Table 3 (continued)

APN specific

area

Number

of APN

Data Collection Plan Instrumentations

2003 2004 2005 2006 2007 2008 2009

Teenage

pregnancy

Patient Outcomes

- Number of prenatal visit

- maternal complication

- Hemoglobin level

- Gestational age

- Birth weight

-Neonatal complication

Health Service Use

- Hospitalization

- Rehospitalization

- neonatal admission to

special care nursery or

ICU

1

y-1**

y0*

y+1***

y+2***

y+3***

y+4***

- Maternal and Newborn

Summary Form

- Hospitalization Form

- Rehospitalization Form

- Transfer Form

Patient Satisfaction Oct09-

Mar10

- Client Satisfaction Tool

* The year that maternal and child APN is introduced

** The year before introduction of maternal and child APN

*** The year after introduction of maternal and child APN

45

Table 3 (continued)

APN specific

area

Variables Number

of APN

Data Collection Plan Instrumentations

2003 2004 2005 2006 2007 2008 2009

Gestational

diabetes

mellitus

Patient Outcomes

- Blood sugar level

- Maternal complication

-Neonatal complication

Health Service Use

- Acute care visit

- Length of stay

- Hospitalization

- Postpartum transfer

- Neonatal admission to

special care nursery or

ICU

- Rehospitalization

1

y-1**

y0*

y+1***

- Maternal and Newborn

summary form

- Acute care visit form

- Hospitalization form

- Transfer form

- Rehospitalization form

Patient satisfaction Oct09-

Mar10

- Client satisfaction tool

* The year that maternal and child APN is introduced

** The year before introduction of maternal and child APN

*** The year after introduction of maternal and child APN

CHAPTER 4

RESULTS

The results of the study on outcomes of advanced practice nurses in maternal

and child health are presented in this chapter. A description of maternal and child

advanced practice nurses (APNs) demographic, sample demographic and results

according to two research questions are presented.

Description of maternal and child APNs demographic

Table 4 Maternal and child APNs demographic

Preterm

labor

Teenage

pregnancy

Childbirth

preparation

1

Childbirth

preparation

2

GDM*

Age 49 39 35 38 43

Clinical experienced

as registered nurse

(years)

21 13 13 13 20

Clinical experience

as APN (years)

5 5 3 3 2

% of time provided

direct care for

clients

20 40 30 20 20

% of time work as

member of nursing

care team

20 10 30 20 40

% of time used for

teaching, coaching,

mentoring

10 10 10 20 10

47

Table 4 (continued)

Preterm

labor

Teenage

pregnancy

Childbirth

preparation

1

Childbirth

preparation

2

GDM*

% of time used for

counseling

20 10 10 20 5

% of time used for

other tasks such as

quality working

group,

administrative,

committee

secretariat

30 30 20 20 25

Note * GDM = Gestational Diabetes Mellitus

From table 4, there were five maternal and child advanced practice nurses

(APNs) samples in this study. The mean age of APNs was 40.8 years. Ages ranged

from 35 to 49 years. For APN samples, the mean number of years of clinical

experience as registered nurse of APN samples was 16 years; and the mean number of

years experience as an APN was 3.6 years.

It was found that APNs did not work as full time APNs. From 100 percent

of work time, all of them used 20 to 40 percent of their time to provide direct care for

their clients, while 10 to 40 percent of their time was spent working as a member of a

nursing care team. They also performed other tasks such as nurse administration,

serving as secretariat of a hospital scholarly committee, and acting as a member of

quality working groups, which took 20 to 30 percent of their time.

48

Description of sample demographic

1. Maternal and child advanced practice nurse (APN) specific area of

practice in preterm labor

Table 5 Demographic data of the samples cared for by APN with specific area of

practice in preterm labor

year-1 a

n (%)

year+1 b

n (%)

year+2 b

n (%)

year+3 b

n (%)

year+4 b

n (%)

Age

15-19 years

20-24 years

25-29 years

30-34 years

35-39 years

≥ 40 years

Total (%)

7(23.3)

10(33.3)

4(13.3)

5(16.7)

4(13.3)

0(0)

30(100)

7(23.3)

10(33.3)

4(13.3)

5(16.7)

4(13.3)

0(0)

30(100)

7(23.3)

10(33.3)

4(13.3)

5(16.7)

4(13.3)

0(0)

30(100)

7(23.3)

10(33.3)

4(13.3)

5(16.7)

4(13.3)

0(0)

30(100)

7(23.3)

10(33.3)

4(13.3)

5(16.7)

4(13.3)

0(0)

30(100)

Gravida

1

2

3

≥4

Total (%)

16(53.3)

9(30.0)

3(10.0)

2(6.7)

30(100)

13(43.3)

7(23.3)

7(23.3)

3(10.0)

30(100)

13(43.3)

9(30.0)

6(20.0)

2(6.7)

30(100)

15(50.0)

8(26.7)

4(13.3)

3(10.0)

30(100)

13(43.3)

10(33.3)

6(20.0)

1(3.3)

30(100)

Para

0

1

2

3

≥4

Total (%)

16(53.3)

12(40.0)

1(3.3)

0(0)

1(3.3)

30(100)

14(46.7)

8(26.7)

5(16.7)

3(10.0)

0(0)

30(100)

16(53.3)

9(30.0)

4(13.3)

1(3.3)

0(0)

30(100)

18(60.0)

8(26.7)

3(10.0)

0(0)

1(3.3)

30(100)

15(50.0)

8(26.7)

7(23.3)

0(0)

0(0)

30(100)

49

Table 5 (continued)

year-1a

n (%)

year+1b

n (%)

year+2 b

n (%)

year+3 b

n (%)

year+4 b

n (%)

Number of ANCc visit

< 4

4-8

8-12

> 12

Total (%)

5(16.7)

20(66.7)

5(16.7)

0(0)

30(100)

6(20.0)

18(60.0)

6(20.0)

0(0)

30(100)

2(6.7)

16(53.3)

10(33.3)

2(6.7)

30(100)

5(16.7)

16(53.3)

7(23.3)

2(6.7)

30(100)

5(16.7)

15(50.0)

9(30.0)

1(3.3)

30(100)

Delivery type

Normal labor

Vacuum extraction

Forceps extraction

Cesarean section

Total (%)

17(56.7)

0(0)

0(0)

13(43.3)

30(100)

20(66.7)

0(0)

0(0)

10(33.3)

30(100)

18(60.0)

1(3.3)

1(3.3)

10(33.3)

30(100)

16(53.3)

2(6.7)

0(0)

12(40.0)

30(100)

15(50.0)

1(3.3)

0(0)

14(46.7)

30(100)

Gestational age

< 37

37-42

> 42

Total (%)

30(100.0)

0(0)

0(0)

30(100)

28(93.3)

2(6.7)

0(0)

30(100)

25(83.3)

5(16.7)

0(0)

30(100)

28(93.3)

2(6.7)

0(0)

30(100)

23(76.7)

7(23.3)

0(0)

30(100)

Note a = Before introduction of maternal and child APN practice (2003)

b = After introduction of maternal and child APN practice (2005 to 2008)

c = ANC = antenatal care

Descriptive analysis (see table 5) revealed that in year-1 (2003), year+1

(2005), year+2 (2006), year+3 (2007), and year+4 (2008), most of the samples in the

maternal and child (MCH) advanced practice nurse (APN) group, with a specific area

of practice in preterm labor, were age 20 to 24 years old (33.3%) and 15 to 19 years

old (23.3%). The majority of them were primigravida. For type of delivery, the

majority of them in the year 2003, 2005, 2006, 2007, and 2008 had normal labor

(56.7%, 66.7%, 60.0%, 53.3%, and 50.0%, respectively). Most of the samples had

50

visited an antenatal clinic 4 to 8 times in the year 2003, 2005, 2006, 2007, and 2008

(66.7%, 60.0%, 53.3%, 53.3%, 50.0%, respectively). In the year 2003, none of them

gave birth at a gestational age of more than or equal to 37 weeks. However, in the

year 2005, 2006, 2007, and 2008, there were the samples who gave birth at gestational

ages of more than or equal to 37 weeks 6.7%, 16.7%, 6.7%, and 23.3%, respectively.

2. Maternal and child advanced practice nurse (APN), specific area of

practice in teenage pregnancy

Table 6 Demographic data of the samples cared for by APN with specific area of

practice in teenage pregnancy

year-1a

n (%)

year+1b

n (%)

year+2b

n (%)

year+3b

n (%)

year+4b

n (%)

Age

15

16

17

18

19

Total (%)

3(9.7)

4(12.9)

11(35.5)

8(25.8)

5(16.1)

31(100)

2(6.5)

5(16.1)

15(48.4

8(25.8)

1(3.2)

31(100)

2(6.5)

5(16.1)

11(35.5)

10(32.3)

3(9.7)

31(100)

4(12.9)

8(25.8)

6(19.4)

7(22.6)

6(19.4)

31(100)

2(6.5)

5(16.1)

9(29.0)

6(19.4)

9(29.0)

31(100)

Gravida

1

2

Total (%)

27(87.1)

4(12.9)

31(100)

29(93.5)

2(6.5)

31(100)

26(83.9)

5(16.1)

31(100)

28(90.3)

3(9.7)

31(100)

24(77.4)

7(22.6)

31(100)

Para

0

1

Total (%)

29(93.5)

2(6.5)

31(100)

29(93.5)

2(6.5)

31(100)

29(93.5)

2(6.5)

31(100)

29(93.5)

2(6.5)

31(100)

29(93.5)

2(6.5)

31(100)

51

Table 6 (continued)

year-1a

n (%)

year+1b

n (%)

year+2b

n (%)

year+3b

n (%)

year+4b

n (%)

Number of ANC visit

< 4

4-8

9-12

> 12

Total (%)

3(9.7)

16(51.6)

11(35.5)

1(3.2)

31(100)

0(0)

12(38.7)

16(51.6)

3(9.7)

31(100)

0(0)

15(48.4)

15(48.4)

1(3.2)

31(100)

1(3.2)

15(48.4)

13(41.9)

2(6.5)

31(100)

1(3.2)

10(32.3)

20(64.5)

0(0)

31(100)

Delivery type

Normal labor

Vacuum extraction

Forceps extraction

Cesarean section

Total (%)

26(83.9)

2(6.5)

0(0)

3(9.7)

31(100)

26(83.9)

2(6.5)

0(0)

3(9.7)

31(100)

23(74.2)

0(0)

0(0)

8(25.8)

31(100)

26(83.9)

1(3.2)

0(0)

4(12.9)

31(100)

28(90.3)

0(0)

0(0)

3(9.7)

31(100)

Gestational age

< 37

37-42

> 42

Total (%)

7(22.6)

24(77.4)

0(0)

31(100)

2(6.5)

29(93.5)

0(0)

31(100)

5(16.1)

26(83.9)

0(0)

31(100)

2(6.5)

29(93.5)

0(0)

31(100)

2(6.5)

29(93.5)

0(0)

31(100)

Note a = Before introduction of maternal and child APN practice (2003),

b = After introduction of maternal and child APN practice (2005 to 2008),

ANC = Antenatal care

Descriptive analysis (see table 6) revealed that in year-1 (2003), year+1

(2005), year+2 (2006), and year+3 (2007), most samples who gave birth were 17

years old. In year-1 (2003), year+1 (2005), year+2 (2006), year+3 (2007), and year+4

(2008), the majority were primigravida (87.1%, 93.5%, 83.9%, 90.3%, and 77.4%,

respectively). For type of delivery, most of them, in the year 2003, 2005, 2006, 2007,

and 2008 had normal labor (83.9%, 83.9%, 74.2%, 83.9%, and 90.3%, respectively).

In the year 2003, most samples visited an antenatal clinic 4 to 8 times, while samples

52

visited an antenatal clinic 9 to 12 times in years 2005, 2005, and 2008. The majority

of them (64.5%) visited an antenatal clinic 4 to 8 times in 2007. The year before, and

all three years after introduction of APN, the majority of them gave birth at 37 to 42

weeks of gestation.

3. Maternal and child advanced practice nurse, specific area of practice

in childbirth preparation

3.1 Community hospital

Table 7 Demographic data of the samples cared for by APN, with specific area of

practice in childbirth preparation at a community hospital

(year-1)a

n (%)

(year+1)b

n (%)

(year+2)b

n (%)

Age

15-19 years

20-24 years

25-29 years

30-34 years

Total (%)

9 (34.6)

6 (23.1)

6 (23.1)

5 (19.2)

26 (100)

9 (34.6)

6 (23.1)

6 (23.1)

5 (19.2)

26 (100)

9 (34.6)

6 (23.1)

6 (23.1)

5 (19.2)

26 (100)

Gravida

1

2

3

4

Total (%)

14 (53.8)

8 (30.8)

4 (15.4)

0 (0)

26 (100)

14 (53.8)

9 (34.6)

3 (11.5)

0 (0)

26 (100)

15 (57.7)

5 (19.2)

4 (15.4)

2 (7.7)

26 (100)

Para

0

1

2

Total (%)

16 (61.5)

7 (26.9)

3 (11.5)

26 (100)

16 (61.5)

7 (26.9)

3 (11.5)

26 (100)

16 (61.5)

6 (23.1)

4 (15.4)

26 (100)

53

Table 7 (continued)

(year-1)a

n (%)

(year+1)b

n (%)

(year+2)b

n (%)

Delivery type

Normal labor

Vacuum extraction

Forceps extraction

Cesarean section

Total (%)

24 (92.3)

1 (3.8)

0 (0)

1 (3.8)

26 (100)

24 (92.3)

1 (3.8)

0 (0)

1 (3.8)

26 (100)

26 (100)

0 (0)

0 (0)

0 (0)

26 (100)

Note a = Before introduction of maternal and child APN practice (2005)

b = After introduction of maternal and child APN practice (2007 to 2008)

Descriptive analysis (see table 7) revealed that in the year-1 (2005), year+1

(2007), year+2 (2008), most samples in the maternal and child APN childbirth

preparation group at community hospital were primigravida (53.8%, 53.8%, 57.7%,

respectively). For type of delivery, the majority of samples in the year-1 and year+1

had normal labor (92.3% and 92.3%, respectively). And in year+2, the type of labor

was 100 percent normal labor.

3.2 Regional hospital

54

Table 8 Demographic data of the samples cared for by APN with specific area of

practice in childbirth preparation at regional hospital

(year-1)a

n (%)

(year+1)b

n (%)

(year+2)b

n (%)

Age

25-29 years

30-34 years

Total (%)

4 (40.0)

6 (60.0)

10 (100.0)

4 (40.0)

6 (60.0)

10 (100.0)

4 (40.0)

6 (60.0)

10 (100.0)

Gravida

1

Total (%)

10

10 (100.0)

10

10 (100.0)

10

10 (100.0)

Para

0

Total (%)

10

10 (100)

10

10 (100)

10

10 (100)

Delivery type

Normal labor

Vacuum extraction

Forceps extraction

Cesarean section

Total (%)

3 (30)

2 (20)

1 (10)

4 (40)

10 (100)

5 (50)

1 (10)

0 (0)

4 (40)

10 (100)

6 (60)

2 (20)

0 (0)

2 (20)

10 (100)

Note a = Before introduction of maternal and child APN practice (2005)

b = After introduction of maternal and child APN practice (2007 to 2008)

Descriptive analysis (see table 8) revealed that in the year-1 (2005), year+1

(2007), year+2 (2008), most samples (60 %) in maternal and child APN, specific area

of practice in childbirth preparation at regional hospital were age 30 to 34 years old.

All of them were primigravida. For type of delivery, 40% in year-1 had cesarean

section (40%). In contrast, 50% and 60% had normal labor in year+1 and year+2,

respectively.

4. Maternal and child advanced practice nurse, specific area of practice in

gestational diabetes Mellitus (GDM)

55

Table 9 Demographic data of the samples cared for by maternal and child APN with

specific area of practice in GDM

(year-1)a (year+1)

b

n (%) n (%)

Age

15-19 years

20-24 years

25-29 years

30-34 years

35-39 years

≥ 40 years

Total (%)

1 (2.2)

2 (4.3)

8 (17.4)

15 (32.6)

15 (32.6)

5 (10.9)

46 (100)

1 (2.2)

2 (4.3)

8 (17.4)

15 (32.6)

15 (32.6)

5 (10.9)

46 (100)

Gravida

1

2

3

≥4

Total (%)

16 (34.8)

13 (28.3)

9 (19.6)

8 (17.4)

46 (100)

13 (28.3)

17 (37.0)

11 (23.9)

5 (10.9)

46 (100)

Para

0

1

2

3

Total (%)

19 (41.3)

16 (34.8)

9 (19.6)

2 (4.3)

46 (100)

18 (39.1)

21 (45.7)

5 (10.9)

2 (4.3)

46 (100)

Note a = Before introduction of maternal and child APN practice (2006)

b = After introduction of maternal and child APN practice (2008)

56

Table 9 (continued)

(year-1)a (year+1)

b

n (%) n (%)

Gestational age

< 37

37-42

> 42

Total (%)

6 (13.0)

40 (87.0)

0 (0)

46 (100)

4 (8.7)

42 (91.3)

0 (0)

46 (100)

Delivery type

Normal labor

Vacuum extraction

Forceps extraction

Cesarean section

26 (56.5)

1 (2.2)

0 (0)

19 (41.3)

28 (60.9)

3 (6.5)

1 (2.2)

14 (30.4)

Note a = Before introduction of maternal and child APN practice (2006)

b = After introduction of maternal and child APN practice (2008)

Descriptive analysis (see table 9) revealed that in the year before (2006) and

the year after (2008) the introduction of APN, 32.6 percent were 30 to 34 years and

32.6 percent were 35 to 39 years old. In the year before the introduction of APN, most

of them were primigravida (34.8%) whereas in the year after the introduction of APN

the majority were in their second pregnancy (37.0%). For type of delivery, the

majority of samples had normal labor (56.5% and 60.9% in 2006 and 2008,

respectively).

For gestational age, the majority of them gave birth at 37 to 42 weeks of

gestation both before and after the introduction of APN.

57

Results related to research questions

This section presents discussion concerning the results related to the two

research questions. Statistical analysis of the research questions and findings will be

presented.

Research question 1

The first research question addressed was, “Before and after the introduction

of maternal and child advanced practice nurses in hospital settings, are there

differences in patient outcomes and health service use?”

To determine if patient outcomes and health service use before and after

introduction of APN practice differed, one-way ANOVA, independent t-test was

performed. The Kruskal-Wallis test, the Chi-square test, and the Mann-Whitney test

were used when appropriate. The result of analysis was presented for each APN

specific area of practice as follow.

1. Maternal and child APN, specific area of practice in preterm labor

Table 10 Comparison of outcomes before and after the introduction of APN in the

preterm labor patient group

Outcomes Before After p

year-1 year+1 year+2 year+3 year+4

mean mean mean mean mean

Preterm (n = 30 each year)

Patient outcomes

Apgar score at 1

minute

7.73 8.23 8.30 8.30 8.53 .050

Apgar score at 5

minute

8.67 9.10 9.00 8.93 8.97 .289

Health service use

Neonatal LOS 11.77 9.80 9.63 11.03 12.63 .945

Note LOS = Length of stay

58

In terms of Apgar score at 1 minute; the mean of Apgar score at 1 minute

before introduction of APN was 7.73. There was a trend towards higher mean scores

at 1 minute in the years after the introduction of APN. In the year before introduction

of APN, Apgar scores were 8.23, 8.30, 8.30, and 8.53 in year+1, year+2, year+3, and

year+4, respectively. Comparing for differences in Apgar scores at 1 minute before

and after the introduction of APN using the Kruskal-Wallis test, it was found that

there were no significant differences in Apgar score at 1 minute (p = .050).

The mean of Apgar score at 5 minute before the introduction of APN, was

8.67 and there was a trend towards a higher mean Apgar score at 5 minutes in the

years after the introduction of APN (9.10, 9.00, 8.93, and 8.97 in year+1, year+2,

year+3, and year+4, respectively). Comparing for differences in Apgar score at 5

minutes before and after the introduction of APN, using ANOVA, it was found that

there was no significant difference in Apgar score at 5 minutes (F 4,145 = 1.259, p =

.289).

The mean of neonatal LOS in year-1 was 11.77 days. And it was found that

the means of neonatal LOS in the years after introduction of APN were lower than

before introduction of APN for year+1, year+2, year+3 (9.80, 9.63,

11.03,respectively) but not for year+4 (12.63 days). Comparing for differences in

neonatal LOS using the Kruskal-Wallis test, it was found that there was no

statistically significant difference in neonatal LOS (p = .945)

59

Table 11 Comparison of proportion of outcomes in preterm labor patient group

before and after the introduction of APN

Outcomes Before After Chi-

square

df p

year-1 year+1 year+2 year+3 year+4

(%) (%) (%) (%) (%)

Preterm labor (n = 30 each year)

Patient outcomes

Gestational

age at delivery ≥

37 weeks

0.0 6.7 16.7 6.7 23.3 10.774 4 .029*

Birth weight

< 2500 grams

83.3 53.3 73.3 66.7 56.7 8.100 4 .088

Health service use

Maternal

rehospitalization

13.3 26.7 16.7 26.7 43.3 8.670 4 .070

Neonatal

admission to

special care

nursery or

NICU

93.3 60.0 70.0 83.3 63.3 12.266 4 .015*

Note * p < .05, NICU = Neonatal intensive care unit

In terms of gestational age (see table 11), none of the women gave birth at a

gestational age greater than or equal to 37 weeks, before the introduction of the APN.

After introduction of APN, however, there was a trend towards a gestational age

greater than or equal to 37 weeks (6.7%, 16.7%, 6.7%, and 23.3% in year+1, year+2,

year+3, and year+4, respectively). Comparing proportions of gestational ages using a

Chi-square test showed that there was a statistically significant difference in

gestational age (Chi-square = 10.774, df = 4, p = .029). By using a multiple

comparison procedure, it was found that the proportion of preterm women with a

gestational age at delivery of greater than or equal to 37 weeks in year+4 was higher

than in year-1 (Chi-square = 5.822, df = 1, p = .011).

60

In terms of birth weight (see table 11), 83.3% of preterm women had babies

whose birth weight was less than 2500 grams in year-1. However, the percentage of

babies born with a birth weight of less than 2500 grams was lower in the year after

introduction of APN (53.3%, 73.3%, 66.7%, and 56.7% in year+1, year+2, year+3,

and year+4, respectively). Comparing proportions of birth weights using a Chi-square

test showed that there was no statistically significant difference in birth weight

(Chi-square = 8.100, df = 4, p = .088).

In terms of maternal rehospitalization (see table 11), 13.3% of samples were

re-hospitalized in year-1 and 26.7%, 16.7%, 26.7%, and 43.3% were re-hospitalized

in year+1, year+2, year+3, and year+4, respectively. Comparing proportions of

rehospitalization using a Chi-square test showed that there was no statistically

significant difference in rehospitalization (Chi-square = 8.670, df = 4, p = .070).

In terms of neonatal admission to a special care nursery or NICU, 93.3% of

sample in year-1 were admitted to special care nursery. For the year after the

introduction of APN, 60.0%, 70.0%, 83.3%, and 63.3% were admitted in year+1,

year+2, year+3, and year+4, respectively. Comparing proportions of neonatal

admission to a special care nursery or NICU using the Chi-square test showed that

there was a statistically significant difference in the proportion of neonatal admission

to a special care nursery or NICU (Chi-square = 12.266, df = 4, p = .015). By using

the multiple comparison procedure, it was found that proportion of neonatal

admissions to special care nursery or NICU in year+1 was lower than year-1 (Chi-

square = 7.547, df = 1, p = .005), the proportion of neonatal admissions to special care

nursery or NICU in year+2 was lower than year-1 (Chi-square = 4.007, df = 1, p =

.042), and the proportion of neonatal admissions to special care nursery or NICU in

year+4 lower than year-1 (Chi-square = 6.285, df = 1, p = .010).

61

Table 12 Comparison of the proportion of neonatal complications in preterm labor

patient group before and after the introduction of APN

Outcome Before After Chi-

square

df p

year-1 year+

1

year+

2

year+

3

year+

4

(%) (%) (%) (%) (%)

Neonatal complication

Low birth

weight

50.0 43.3 56.7 63.3 40.0 4.374 4 .358

Preterm

infants

6.7 16.7 10.0 16.7 13.3 2.049 4 .727

Mild and

moderate birth

asphyxia

6.7 3.3 0.0 3.3 0.0 3.596 4 .463

Respiratory

distress

syndrome of

newborn

16.7 6.7 3.3 16.7 13.3 4.379 4 .357

Unspecified

respiratory

distress of

newborn

13.3 0.0 0.0 3.3 0.0 12.414 4 .015*

Unspecified

congenital

pneumonia

16.7 6.7 0.0 6.7 3.3 7.500 4 .112

Unspecified

bacterial

sepsis of

newborn

16.7 26.7 23.3 20.0 23.3 1.010 4 .908

62

Table 12 (continued)

Outcome Before After Chi-

square

df p

year-1 year+

1

year+

2

year+

3

year+

4

(%) (%) (%) (%) (%)

Neonatal

jaundice

associated

with preterm

delivery

0.0 30.0 43.3 36.7 26.7 16.581 4 .002*

Unspecified

neonatal

jaundice

36.7 0.0 10.0 3.3 6.7 25.608 4 < .001*

neonatal

hypoglycemia

13.3 16.7 23.3 23.3 20.0 1.453 4 .835

Note * p < .05

Table 12 indicates that unspecified respiratory distress of newborn was

present 13.3% in year-1 and 3.3% in year+3. Comparing the proportion of neonatal

complications difference using a chi-square test showed that there were statistically

significant differences in the proportion of unspecified respiratory distress of new

born (Chi-square = 12.414, df = 4, p = .015). By using the multiple comparison

procedure, however, there was no statistically significant difference.

For neonatal jaundice associated with preterm delivery, there was no infant

with neonatal jaundice associated with preterm delivery in year-1 but there were

30.0%, 43.3%, 36.7%, and 26.7% in year+1, year+2, year+3, year+4, respectively.

Comparing the proportion of neonatal jaundice associated with preterm delivery

difference using a chi-square test showed that there was statistically significant

difference (Chi-square = 16.581, df = 4, p = .002). By using the multiple comparison

procedure, it was found that there were statistically significant differences between

year-1 and year+1 (Chi-square = 8.366, df = 1, p = .002), year-1 and year+2 lower

63

(Chi-square = 14.141, df = 1, p < .001), year-1 and year+3 (Chi-square = 11.132, df =

1, p < .001), and year-1 and year+4 (Chi-square = 7.067, df = 1, p = .005).

For unspecified neonatal jaundice, it was reported that there were 36.7%,

0%, 10.0%, 3.3% and 6.7% of infants with unspecified neonatal jaundice in year-1,

year+1, year+2, year+3, and year+4, respectively. Comparing the proportion of

unspecified neonatal jaundice before and after the introduction of APN using a chi-

square test showed that there was a statistically significant difference (Chi-square =

25.608, df = 4, p <.001). By using the multiple comparison procedure, it was found

that there were statistically significant differences between year-1 and year+1

(Chi-square = 11.132, df = 1, p < .001), year-1 and year+2 (Chi-square = 4.565,

df = 1, p = .030), year-1 and year+3 (Chi-square = 8.438, df = 1, p = .002), and year-1

and year+4 (Chi-square = 6.285, df = 1, p = .010).

2. Maternal and child advanced practice nurse, specific area of practice in

teenage pregnancy

Table 13 Comparison of outcomes before and after the introduction of APN in

the teenage pregnancy patient group

Outcomes Before After p

year-1 year+1 year+2 year+3 year+4

mean mean mean mean mean

Patient outcomes (n = 31 each year)

Number of

ANC visit

7.55 9.13 8.52 8.61 8.58 .183

Hct at 32 weeks 34.10 34.77 34.50 35.65 35.55 .224

Gestational age

at delivery

37.61 38.81 38.16 38.26 38.45 .277

Birth weight 2866.13 3099.68 3120.65 2953.23 3053.87 .141

Apgar score at 1

minute

8.77 8.81 8.84 8.90 8.81 .886

64

Table 13 (contiuned)

Outcomes Before After p

year-1 year+1 year+2 year+3 year+4

mean mean mean mean mean

Apgar score at 5

minute

9.74 9.68 9.77 9.39 9.48 .009*

Health service use

Maternal LOS 2.82 3.06 3.45 2.85 2.81 .300

Neonatal LOS 2.61 3.48 3.71 4.26 2.97 .021*

Note * p < .05, ANC = Antenatal care, Hct = Hematocrit, LOS = Length of stay

In terms of the number of antenatal care (ANC) visit; the mean number of

ANC visits before the introduction of APN was 7.55. The mean number of ANC visits

in the years after the introduction of APN were 9.13, 8.52, 8.61, and 8.58 in year+1,

year+2, year+3, and year+4, respectively. Comparing for differences in numbers of

ANC visits before and after the introduction of APN using ANOVA, it was found that

there was no significant difference in number of ANC visits (F 4,150 = 1.577,

p = .183) (see table 13).

In terms of hematocrit (Hct) level; the mean of Hct before the introduction

of APN was 34.10. There was a trend towards a higher Hct mean at 32 weeks in the

years after the introduction of APN (34.77, 34.52, 35.66, and 35.55 in year+1, year+2,

year+3, and year+4, respectively). Comparing for different numbers of ANC visits

before and after the introduction of APN using ANOVA, there was no significant

difference in the Hct mean at 32 weeks (F 4,150 = 1.439, p = .224).

In relation to gestational age (GA) (see table 13), the GA mean in the year

before the introduction of APN was 37.61. It was found that there was a higher GA

means in the years after the introduction of APN than there was in the year before the

introduction of APN (38.81, 38.16, 38.26, and 38.45 in year+1, year+2, year+3, and

year+4, respectively). Comparing differences of GA means using the Kruskal-Wallis

test showed that there was no statistically significant difference in GA means

(p = .277).

65

In terms of birth weight (BW) (see table 13), the mean of BW in year-1 was

2866.13. The BW means in the year after the introduction of APN were 3099.68,

3120.65, 2953.23, and 3053.87 grams in year+1, year+2, year+3, and year+4,

respectively. Comparing differences in BW means using the Kruskal-Wallis test

showed that there was no statistically significant difference in BW means (p = .141).

In terms of Apgar scores at 1 minute, the mean of Apgar scores at 1 minute

before the introduction of APN was 8.77 and there were a trend towards a higher

Apgar mean score at 1 minute in the years after the introduction of APN (8.81, 8.84,

8.90, and 8.81 in year+1, year+2, year+3, and year+4, respectively). Comparing for

differences in Apgar scores at 1 minute before and after introduction of APN using

the Kruskal-Wallis test, it was found that there were no significant differences in

Apgar scores at 1 minute (p = .886).

For Apgar scores at 5 minute, the mean of Apgar scores at 5 minutes before

the introduction of APN was 9.74. The mean Apgar scores at 5 minutes in the years

after the introduction of APN were 9.68, 9.77, 9.39, and 9.48 in year+1, year+2,

year+3, and year+4, respectively. Comparing for differences in Apgar scores at 5

minutes before and after the introduction of APN using the Kruskal-Wallis test;

significant differences in Apgar scores at 5 minutes were found (p = .009). By using

the multiple comparison procedure, it was found that there were statistically

significant differences between year-1 and year+3 (p = .007) and year+2 and year+3

(p = .004).

In terms of neonatal length of stay (LOS), the mean of neonatal LOS in the

year-1 was 2.61 days. The means of neonatal LOS in year+1, year+2, year+3, and

year+4 were 3.48, 3.71, 4.26, and 2.97, respectively. Comparing for differences in

neonatal LOS using the Kruskal-Wallis test; significant differences in neonatal LOS

were found (p = .021). By using the multiple comparison procedure, it was found that

there was statistically significant differences between year-1 and year+2 (p = .003).

66

Table 14 Comparison of the proportion of outcomes before and after the introduction

of APN in the teenage pregnancy patient group

Outcomes Before After Chi-

square

df p

year-1 year+1 year+2 year+3 year+4

(%) (%) (%) (%) (%)

Patient outcomes (n = 31 each year)

Maternal

complications

48.4 25.8 45.2 38.7 41.9 3.925 4 .416

Gestational

age at delivery

< 37 weeks

22.6 6.5 16.1 6.5 6.5 6.663 4 .155

Birth weight

< 2500 grams

12.9 0.0 9.7 6.5 9.7 4.155 4 .385

Neonatal

complications

22.6 19.4 29.0 16.1 22.6 1.658 4 .798

Health service use

Maternal

rehospitalization

19.4 22.6 16.1 22.6 32.3 2.583 4 .630

Neonatal

admission to

special care

nursery or

NICU

9.7 6.5 16.1 16.1 6.5 3.039 4 .551

Note NICU = Neonatal intensive care unit

For maternal complications (see table 14), the study found 48.4%, 25.8%,

45.2%, 38.7%, and 41.9% of the teenage pregnancy patient group presented maternal

complication in year-1, year+1, year+2, year+3, and year+4, respectively. Comparing

proportion of maternal complication using the Chi-square test showed that there was

no significant difference in the proportion of maternal complications in the teenage

patient group (Chi-square = 3.925, df = 4, p = .416).

67

In relation to gestational age (GA) (see table 14), it was found 22.6% of

teenage pregnant women gave birth at a GA of less than 37 weeks in year-1. And in

year+1, year+2, year+3, and year+4 there were 6.5%, 16.1%, 6.5%, and 6.5%,

respectively gave birth at a GA of less than 37 weeks. Comparing proportions of

gestational age using the Chi-square test showed that there was no statistically

significant difference in proportions of gestational age (Chi-square = 6.663, df = 4,

p = .155).

In terms of birth weight (BW) (see table 14), it was found 12.9 % were low

birth weight infants in the teenage pregnancy patient group in the year before the

introduction of APN. There were 0%, 9.7%, 6.5%, and 9.7% low birth weight infants

in year+1, year+2, year+3, and year+4, respectively. Comparing proportions of BW

using the Chi-square test showed that there was no statistically significant difference

in BW (Chi-square = 4.155, df = 4, p = .385).

For neonatal complications, it was found to be 22.6 % in year-1; and 19.4%,

29.0%, 16.1%, and 22.6% in year+1, year+2, year+3, and year+4, respectively.

Comparing proportions of neonatal complications using the Chi-square test showed

that there was no statistically significant difference in neonatal complications (Chi-

square = 1.658, df = 4, p = .798).

In terms of maternal rehospitalization (see table 14), 19.4 % of samples were

re-hospitalized in year-1; and 22.6%, 16.1%, 22.6%, and 32.3% were reported

re-hospitalied in year+1, year+2, year+3, and year+4, respectively. Comparing

proportions of rehospitalization using the Chi-square test showed that there was no

significant difference in rehospitalization rates in the teenage pregnancy patient group

(Chi-square = 2.583, df = 4, p = .630).

In relation of neonatal admission to special care nursery or NICU, 9.7% of

samples in year-1 were admitted. For the years after the introduction of APN, 6.5%,

16.1%, 16.1%, and 6.5% were admitted in year+1, year+2, year+3, and year+4,

respectively. Comparing proportions of neonatal admissions to special care nurseries

or NICUs using the Chi-square test showed that there was no statistically significant

difference in proportions of neonatal admissions to special care nurseries or NICUs

(Chi-square = 3.039, df = 4, p = .551)

68

3. Maternal and child advanced practice nurse, specific area of practice in

childbirth preparation

3.1 Community Hospital

Table 15 Comparison of outcomes before and after the introduction of APN in the

childbirth preparation patient group at a community hospital

Outcomes Before After p

year-1 year+1 year+2

mean mean mean

Patient outcomes (n = 26 each year)

Duration of 1st

stage of labor

562.08 597.17 857.25 .127

Duration of 2nd

stage of labor

21.29 16.04 16.29 .422

Blood loss 264.00 160.42 152.08 .001*

Apgar score at 1

minute

9.15 9.04 9.08 .119

Apgar score at 5

minute

9.92 9.85 9.85 .695

Note * p < .05

Comparing differences among means in patient outcomes of samples in the

childbirth preparation group at the community hospital using the Kruskal-Wallis test

showed that the only patient outcomes that differed significantly was blood loss

(p = .001). Duration of the 1st stage of labor, duration of the 2

nd stage of labor, Apgar

scores at 1 minute and Apgar scores at 5 minutes showed no significant difference

(see table 15). The results of pos-hoc analysis revealed that the amount of blood loss

in ‘year+1’ was lower than ‘year-1’ (p = .004) and year+2 was lower than year-1

(p < .001).

69

Table 16 Comparison of the proportion of outcomes before and after the introduction

of APN in the childbirth preparation patient group at a community hospital

Outcomes Before After Chi-

square

df p

year-1 year+1 year+2

(%) (%) (%)

Patient outcomes (n = 26 each year)

V/E, F/E, C/S 7.7 7.7 0.0 2.108 2 .349

Note V/E = Vacuum extraction; F/E = Forceps extraction; C/S = Cesarean section

For type of delivery, it was found that 7.7%, 7.7% and 0% of samples gave

birth by V/E, F/E, or C/S in year-1, year+1, and year+2, respectively. Comparing

proportions of types of delivery using the Chi-square test showed that there was no

significant difference in proportions of V/E, F/E, or C/S in the childbirth preparation

patient group (Chi-square = 2.108, df = 2, p = .349).

3.2 Regional Hospital

Table 17 Comparison of outcomes before and after the introduction of APN in the

childbirth preparation patient group at the regional hospital

Outcomes Before After p

year-1 year+1 year+2

mean mean mean

Patient outcomes (n = 10 each year)

Duration of 1st

stage of labor

536.25 576.25 380.00 .032*

Duration of 2nd

stage of labor

27.00 16.50 10.50 .234

Blood loss 225.00 187.50 150.00 .345

Apgar score at 1

minute

8.90 9.10 8.90 .275

Apgar score at 5

minute

9.80 9.80 9.80 .793

Note * p < .05

70

Comparing differences among means in patient outcomes of samples in the

childbirth preparation group at the regional hospital using the Kruskal-Wallis test

showed that the only patient outcomes with a significant difference was the duration

of the 1st stage of labor (p = .032). While the duration of 2

nd stage of labor, blood loss,

Apgar scores at 1 minute and Apgar scores at 5 minutes were not significantly

different (see table 17). The results of post-hoc analysis revealed that the duration of

1st stage of labor in ‘year+2’ lower than ‘year-1’ (p = .020) and year+2 lower than

year+1 (p = .039).

Table 18 Comparison of the proportion of outcomes before and after the introduction

of APN in the childbirth preparation patient group at the regional hospital

Outcomes Before After Chi-

square

df p

year-1 year+1 year+2

(%) (%) (%)

Patient outcomes (n = 10 each year)

V/E, F/E, C/S 70.0 50.0 40.0 1.875 2 .392

Analgesic use 16.7 50.0 12.5 2.889 2 .236

Note V/E = Vacuum extraction; F/E = Forceps extraction; C/S = Cesarean section

In relation to type of delivery, the proportion of childbirth preparation

sample at the regional hospital whose type of delivery was vacuum extraction, forceps

extraction, or cesarean section in year-1, year+1, and year+2 were 70%, 50%, and

40%, respectively. There was a trend towards a lower percent of instrument delivery

in the year after the introduction of APN. Comparing proportions of types of delivery

using the Chi-square test showed that there was no statistically significant difference

in the proportion of type of delivery (Chi-square = 1.875, df = 2, p = .392) (see table

18).

In terms of analgesic use, 16.7%, 50.0%, and 12.5% of samples reported use

of analgesic in year-1, year+1, and year+2, respectively. Comparing the proportions

of analgesic use using the Chi-square test showed that there was no statistically

71

significant difference in analgesic use (Chi-square = 2.889, df = 2, p = .236) (see table

18).

4. Maternal and child advanced practice nurse, specific area of practice in

gestational diabetes mellitus (GDM)

Table 19 Comparison of outcomes before and after the introduction of APN in the

gestational diabetes mellitus (GDM) patient group

Outcomes Before After p

year-1 year+1

mean mean

Patient outcomes (n = 46 each year)

FBS at 6 weeks

postpartum

100.67 93.61 .007*

BS 2 hours PG

at 6 weeks

postpartum

140.78 137.57 .426

Birth weight 3259.57 3208.52 .485

Apgar score at 1

minute

7.73 8.23 .249

Apgar score at 5

minute

8.67 9.10 .167

Health service use

Maternal LOS 5.37 4.98 .212

Neonatal LOS 11.77 9.80 .230

Note * p < .05; FBS = Fasting blood sugar; BS = blood sugar; PG = Post load

glucose; LOS = Length of stay

In terms of fasting blood sugar (FBS) at six weeks of postpartum (see table

19), the mean of FBS in the year after the introduction of APN (year+1) was 93.61

mg%, whereas the mean of FBS in the year before the introduction of APN practice

(year-1) was 100.67 mg%. Comparing mean differences before and after the

72

introduction of APN using the Mann-Whitney test found that there were significant

differences in FBS levels at 6 weeks postpartum (p = .007).

In terms of blood sugar (BS) 2 hours post glucose load (PG) at six weeks of

postpartum (see table 18), the mean of BS 2 hours PG in the year after the

introduction of APN (year+1) was 137.57 mg%, whereas the mean of BS 2 hours PG

in the year before the introduction of APN (year-1) was 140.78 mg%. Comparing

mean differences before and after the introduction of APN practice using the Mann-

Whitney test found that there was no significant difference in BS 2 hours PG at 6

weeks postpartum (p = .426).

In terms of infant birth weight (see table 19), the mean birth weight in the

year after the introduction of APN (year+1) was 3,208.52 grams, while, the mean

birth weight in the year before the introduction of APN (year-1) was 3,259.57 grams.

Comparing mean differences of infant birth weight before and after the introduction

of APN using a t-test, found that there was no significant difference in infant birth

weight (t90 = .470, p = .639).

In terms of Apgars score at 1 and 5 minutes after birth (see table 19), the

mean Apgar scores at 1 and 5 minutes in the year after introduction of APN (year+1)

were 8.23 and 9.10. While, the mean Apgar scores at 1 and 5

minute in the year before

the introduction of APN (year-1) were 7.73 and 8.67. Comparing mean differences of

Apgar scores at 1 and 5 minutes before and after the introduction of APN using the

Mann-Whitney test found that there was no significant difference in Apgar scores at 1

minute (p = .249) and Apgar scores at 5 minutes (p = .167).

In relation to maternal length of stay (LOS), the mean of maternal LOS in

the year after the introduction of APN (year+1) was 4.98 days, whereas the mean of

maternal LOS of the year before the introduction of APN (year-1) was 5.37 days. By

using the Mann-Whitney test, it was found that there was no significant difference in

maternal LOS one year before and one year after the introduction of APN (p = .212)

(see table 19).

In terms of neonatal length of stay (LOS), the mean of neonatal LOS in the

year after the introduction of APN (year+1) was 9.80 days, whereas the mean of

neonatal LOS in the year before the introduction of APN (year-1) was 11.77 days. By

using the Mann-Whitney test, there was no significant difference in neonatal LOS one

73

year before and one year after the introduction of APN (p = .230) (see table 19).

Table 20 Comparison of the proportion of outcomes before and after the introduction

of APN in the gestational diabetes mellitus (GDM) patient group

Outcomes Before After Chi-

square

df p

year-1 year+1

(%) (%)

Patient outcomes (n = 46 each year)

Maternal complication 21.7 17.4 .069 1 .793

V/E, F/E, C/S 43.5 39.1 .045 1 .832

Neonatal complication 58.7 32.6 5.301 1 .021*

Health service use

Neonatal admission

to special care nursery

or NICU

26.1 19.6 .247 1 .620

Note * p-value < .05; V/E = Vacuum extraction; F/E = Forceps extraction; C/S =

Cesarean section; NICU = Neonatal intensive care unit

In terms of maternal complication (see table 20), in 21.7% of samples

maternal complications were presented in year-1 while 17.4% of samples had

maternal complications in the year+1. By using the Chi-square test, the result showed

no significant difference in the proportion of maternal complication between year-1

and year+1 in the GDM patient group (Chi-square = .069, df = 1, p = .793).

In terms of type of delivery (see table 20), there were 43.5% of samples

whose type of delivery was abnornal labor (V/E, F/E, C/S) in year-1, while 39.1%

reported that the types of delivery was abnormal labor (V/E, F/E, C/S) in the year+1.

By using the Chi-square test, the result showed no significant difference in the

proportion of type of delivery between year-1 and year+1 in the GDM patient group

(Chi-square = .045, df = 1, p = .832).

In terms of neonatal complication (see table 20), it was found that the

percentage of neonatal complication in year+1 was lower than year-1 (32.6% vs.

74

58.7%). By using the Chi-square test, the results showed significant differences in the

proportion of neonatal complications between year-1 and year+1 in the GDM patient

group (Chi-square = 5.301, df = 1, p = .021).

In relation to neonatal admission to a special care nursery or NICU, it was

found that the percentage of neonatal admission to a special care nursery or NICU in

year+1 was lower than year-1 (19.6% vs. 26.1%). By using the Chi-square test,

however, the result showed no significant difference in the proportion of neonatal

admission to a special care nursery or NICU between year-1 and year+1 in the GDM

patient group (Chi-square = .247, df = 1, p = .620) (see table 20).

Research question 2

The second research question addressed, “How satisfied are patient with the

service of maternal and child APNs?”

To describe how satisfied are with the service of maternal and child APNs,

means and standard deviations were used. The results are described as follow.

Table 21 Descriptive statistics of patient satisfaction by items (n = 321)

Items Strongly Strongly

agree disagree

5

n (%)

4

n (%)

3

n (%)

2

n (%)

1

n (%)

1. The clinic staff were

understanding of my health

concerns.

M = 4.26, SD = .66

117(36.4 172(53.6) 30(9.3) 1(0.3) 1(0.3)

2. The clinic staff gave me

encouragement in regard to

my health problem.

M = 4.27, SD = .59

108(33.6) 194(60.4) 18(5.6) 0(0) 1(0.3)

75

Table 21 (contiuned)

Items Strongly Strongly

agree disagree

5

n (%)

4

n (%)

3

n (%)

2

n (%)

1

n (%)

3. I got my question answered

in an individual way.

M = 4.45, SD = .63

164(51.1) 138(43.0) 18(5.6) 0(0) 1(0.3)

4. The information I received

at the clinic helped me to

take care of myself at home.

M = 4.45, SD = .61

160(49.8) 148(46.1) 11(3.4) 1(.3) 1(0.3)

5. I was included in decision

making.

M = 4.06, SD = .67

79(24.6) 186(57.9) 52(16.2) 4(1.2) 0(0)

6. I was included in the

planning of my care.

M = 3.99, SD = .70

70(21.8) 186(57.9) 59(18.4) 5(1.6) 1(0.3)

7. The treatments I received

were of high quality.

M = 4.19, SD = .62

90(28.0) 208(64.8) 19(5.9) 2(.6) 2(.6)

8. Decisions regarding my

health care were of high

quality.

M = 4.03, SD = .58

60(18.7) 212(66.0) 49(15.3) 0(0) 0(0)

9. The clinic staff were

available when I needed

them.

M = 4.17, SD = .73

111(34.6 159(49.5) 47(14.6) 3(.9) 1(0.3)

76

Table 21 (continued)

Items Strongly Strongly

agree disagree

5

n (%)

4

n (%)

3

n (%)

2

n (%)

1

n (%)

10. The appointment time at

the clinic was when I

needed it.

M = 3.79, SD = .72

40(12.4) 189(58.5) 80(24.8) 11(3.4) 2(0.6)

11. Overall, I was satisfied

with my health care.

M = 4.24, SD = .52

87(26.9) 227(70.3) 8(2.5) 0(0) 1(0.3)

12. The care I received at the

clinic was of high quality.

M = 4.25, SD = .55

93(28.8) 221(68.4) 7(2.2) 0(00 2(0.2)

A total of 321 patients of maternal and child advanced practice nurses

participated in the study. For childbirth preparation group, 250 patients were from the

community hospital and 13 patients were from the regional hospital. Thirty-one

patients were from teenage pregnancy group at the provincial hospital. Fourteen

patients were from the preterm labor group at the provincial hospital. Thirteen

patients were from the gestational diabetes mellitus group at the university hospital.

The possible range of scores on patient satisfaction instrument was 10 - 60.

The actual scores ranged from 16 - 60. The average patient satisfaction score was

50.14. For each item, the mean satisfaction score was skewed toward strongly agree

which indicated high satisfaction with care received from the maternal and child

APNs.

For each item, the highest mean score of 4.45 was rated for item 3 “I got my

question answered in an individual way” and item 4 “The information I received at

the clinic helped me to take care of myself at home”.

77

The lowest mean score was 3.79 for item 10 “The appointment time at the

clinic was when I needed it”.

For the affective support domain which consist of item 1 and 2, the mean

scores ranged from 1 to 5 (M = 4.26, SD = .47). For the health information domain

which consist of item 3 and 4, the mean scores ranged from 1 to 5 (M = 4.45,

SD = .49). For the decision control domain which consist of item 5 and 6, the mean

scores ranged from 1.5 to 5 (M = 4.03, SD = .63). For the technical competencies

domain which consist of item 7 and 8, the mean scores ranged from 2.5 to 5

(M = 4.11, SD = .48). For the accessibility domain which consist of item 9 and 10, the

mean scores ranged from 1 to 5 (M = 3.97, SD = .58). For overall satisfaction domain

which consist of item 11 and 12, the mean scores ranged from 1 to 5 (M = 3.98,

SD = .58) (data not shown in the table).

CHAPTER 5

CONCLUSIONS AND DISCUSSION

This chapter is organized to include conclusions, discussion of study

findings, limitations, and implications for nursing and health policy.

Conclusions

This study compared the outcomes of maternal and child health one year

before and four years after the introduction of certified maternal and child advanced

practice nurses (APNs) at the same health care settings. The study sample consisted of

both APNs and patients. The APN sample included five APNs who had been certified

more than one year and were currently active in providing maternal and child care

services. The patient sample included women who received health care before (n =

143) and after (n = 362) the initiation of certified APNs providing maternal and child

care practices, were examined in order to compare outcome differences.

Patient outcomes and health service use data were analyzed separately in

relation to maternal and child APNs’ patient group i.e. preterm labor, childbirth

preparation, gestational diabetes mellitus (GDM), and teenage pregnancy. To compare

outcomes differences, one-way ANOVA, independent t-test were used. For skewed

data, Kruskal-Wallis, Chi-square test, and Mann-Whitney test were used.

Additionally, 321 patients who seek maternal and child APN services during

data collection period was recruited during October 2009 and March 2010 to assess

their satisfaction with maternal and child APN services.

The results of study revealed that for preterm labor patient group, gestational

age was higher, the proportion of neonatal complications were lower, and the

proportion of neonatal admission to special care nursery or neonatal intensive care

unit was lower compared to before initiation of APN. For childbirth preparation group

found shorter time use in first stage of labor and lower amount of blood loss

compared to before introduction of APNs. Additionally, for gestational diabetes

mellitus patient group found that fasting blood sugar level at 6 weeks postpartum and

the proportion of neonatal complications lower than before the introduction of APN

79

practice. Except for teenage pregnancy patient group that found a mean Apgar score

at 5 minute lower and a mean neonatal length of stay higher than before introduction

of APN practice.

For patient satisfaction with maternal and child APN care, it was found that

the possible range of scores on client satisfaction instrument was 10 - 60. The actual

scores ranged from 16 - 60. The average client satisfaction score was 50.14. The

mean satisfaction score for each item skewed toward high satisfaction. For the

affective support domain, the mean scores ranged from 1 to 5 (M = 4.26, SD = .47).

For the health information domain, the mean scores ranged from 1 to 5 (M = 4.45,

SD = .49). For the decision control domain, the mean scores ranged from 1.5 to 5

(M = 4.03, SD = .63). For the technical competencies domain, the mean scores ranged

from 2.5 to 5 (M = 4.11, SD = .48). For the accessibility domain, the mean scores

ranged from 1 to 5 (M = 3.97, SD = .58). For overall satisfaction domain, the mean

scores ranged from 1 to 5 (M = 3.98, SD = .58)

Discussion

The results of the study be disused and compared with previous studies.

Discussion of the study findings is presented and organized according to research

questions.

Research question 1: “Before and after the introduction of maternal and

child advanced practice nurses in hospital settings, are there differences in patient

outcomes and health service use?”

Study results in improvement in patient outcomes and health service use

after implementation of APNs are consistent with those of the earlier studies in the

U.S. by Brooten et al. (2001), Garcia-Patterson et al., (2003), Jackson et al. (2003),

and Ruiz et al. (2001).

There was also a trend toward positive outcomes i.e higher hematocrit level,

higher birth weight, higher Apgar score at 1 minute, lower cesarean section and

instrument birthing, over year-1, although none reached statistical significance. These

results are consistent with the systematic review of APN outcomes by Newhouse,

Bass, Steinwachs, Stanik-Hutt, Zangaro, Gheindel, White, Wilson, Weiner, Johantgen

80

and Fountain (2011) that reported when comparing certified nurse-midwives (CNM)

and physicians, the certified nurse-midwives groups have lower rates of cesarean

section, similar infant Apgar score, and equivalent levels of low birth weight infants.

Influenced of structure, process on outcomes

Structure

Donabedian emphasized that structure influences process and process

influences outcomes. The significant differences in some of the study’s outcomes

after the introduction of APNs may be influenced by some factors explained as

follow. Structure in this study included characteristics of the APNs’ practice settings,

i.e., type of hospital, number of specialist physicians, and nurses’ educational

background. The hospitals where participating APNs worked consisted of community,

general, regional, and a university hospital where the number of specialist physicians

varied by type of hospital. For example, the community hospital did not have a

specialist physician on service; whereas the general, regional, and university hospital

had a number of specialist physicians working depending on hospital size.

In this study, the university hospital had 6 obstetricians, the regional hospital had 10

obstetricians, the provincial hospital had 8 obstetricians and 11 pediatricians, on

services while the community hospital had no specialist physician work. Thus,

determining outcomes of APN care in this study can be difficult since APNs often

provide care as part of the healthcare team or in collaborative practice (Kleinpell &

Gawlinski, 2005).

Furthermore, it should be taking into account that during 2005 to 2006, or

the years after the introduction of APN in the provincial hospital, were the years

preparing for the hospital re-accreditation of the provincial hospital (Center of quality

development, 2006). Thus, in addition to the process of care by APN who cared for

preterm labor patient and APN who cared for teenage pregnancy patient, the process

of hospital preparation and reorganization for hospital re-accreditation may effect on

patient outcomes and health service use in that hospital.

Moreover, there were 3 staff nurses who graduated master degree in nursing

work with nursing care team in APN practice settings i.e., 2 nurses work in the

practice site of APN specialty in childbirth preparation at the regional hospital and 1

nurse work in the practice site of APN specialty in GDM at the university hospital. In

81

Thailand, graduated nurses with mater degree in nursing were taught and trained the

essential concepts for APN practice because the curriculums for master degree in

nursing were designed to prepare a nurse to be an APN. Thus, when taking care for

patient after graduated, they may apply their knowledge into practice automatically

and may affect APN practice outcomes.

Process

The outcomes of this study also provide evidence of the influence of APNs’

practice competencies such as direct care, empowering, educating, coaching,

collaboration (Thailand Nursing and Midwifery Council, 2010) in providing health

care for their patient. However, the competency that APNs in this study mostly used

was direct care. And there was variation in activities was performed and time was

devoted to the direct care function across role, setting, and patient populations.

Variation in time and activities providing direct care for patient that may resulted in

the nonsignificant differences in some of the study’s outcomes after the introduction

of APN practice may be explained as follow.

Like others APNs in Thailand, APNs in this study usually were assigned

many tasks in addition to their primary responsibility (Wongkpratoom et al, 2010)

including hospital quality development, and functioning as assistant head nurse.

Additionally, APNs indicated that they had only 20 to 40 percent of their time

allocated to provide APN care for clients in the APN role. This finding suggests that

the APNs may not have had adequate time to provide continuity of care for their

clients. After the introduction of APN, pregnant adolescences in this study were cared

for by APN about 1 to 4 times from over 10 times of their ANC visit. For childbirth

preparation patient group, APNs prepared pregnant women for delivery but all

women did not delivered by APNs especially for the APN who practice setting was in

the regional hospital. Furthermore, if a woman delivery date was APNs’ holiday or

off-hour mean that APN could not provided care for that woman. For APN cared for

preterm labor patient, she may not has had enough time to provide continuity of care

for her patient because she has had to go for meeting of the administrative committee

or participating in hospital accreditation working group in order to additional tasks

were assigned. As Brooten et al. (2003) found, patient groups that had greater mean

time with an APN and greater APN contact per patient, had greater improvements in

82

care outcomes and greater healthcare cost saving. Thus, APNs’ health care services in

the current study may not have been sufficient to reach optimum health care goals.

Moreover, although all patient who cared for by APNs in this study were

received tailor health education and information, the model of care provided for some

patient group seem not quite fit to specific characteristic of that group. For instance,

pregnant adolescents were scheduled to individual visit at antenatal clinic in the same

place and same day with adult pregnant women. And the nurse who cared for them

each visits may not the same. While there is research to suggest that model group of

care and with multidisciplinary team may provide benefit to pregnant adolescents

(Baldwin, 2006; Scarr, 2002).

Another explanation was APNs may confuse in their role and scope of

practice and competencies. The role of APN is a new form of certification for nurses

in Thailand. The first APN cohort in Thailand was certified by the Thailand Nursing

and Midwifery Council (TNMC) in 2003, while the scope of practice and competencies

of the APN role recently reached consensus and was issued by the TNMC in 2008

(Thailand Nursing and Midwifery Council, 2010). APNs participating in this study

consisted of the second (certified in year 2004), the fourth (certified in year 2006),

and the fifth (certified in year 2007) cohort of APNs certified by the TNMC. In

addition, the study time frame was set during two to five year after the first cohort of

APNs was introduced into Thai healthcare system. Thus, it could be that the APNs

that participated in this study were pioneers in introducing the APN role in Thailand,

and may have faced problems during process of APN practice (Langkarpint, 2005).

There are many factors that have been identified that impede APN role

development and APN activities including lack of role models and mentors, lack of

clear role definitions and boundaries, unclear expectations of role, lack of

understanding of the APN role, lack of a peer network, increasing workloads,

increases in administrative tasks, lack of effective interprofessional relationships, lack

of resources, and nursing staff shortages (Jones, 2005; Lindeke, 2005).

Wongkpratoom, Srisuphan, Senaratana, Nantachaipan, and Sritanyarat

(2010) studied role development of APNs in Thailand and found that the greatest

barriers in role development were lack of a clearly delineated organizational structure

and unclear organizational policies, work assignments not reflective of advanced

83

practice nursing and uncooperative behavior by members of multidisciplinary teams,

and work assignments in non-advanced practice situations. Thus, undoubtedly, APNs

in this study may have had to face various barriers to APN practice as described

above and this may have influenced outcomes of APN care.

As pioneer APNs in Thailand, the APNs in this study may well have faced

barriers such as lack of role models and mentors, lack of clear role definitions and

boundaries. Consequently, confusion about the scope and nature of APN roles may

have serious implications for performance and development of the APN role (Bonsall

& Cheater, 2008) and resulted in APNs could not identified desirable outcomes for

their practice thus APNs could not designed process of nursing care that definite

effect on outcomes of APN practice. As reported in the study on successful APN

practice in Thailand, APNs who clearly understood the scope of practice and APN

competencies usually could identify desirable outcomes for their APN practice

(Hanucharurnkul et al., 2008).

Research question 2: “How satisfied are patient with the service of

maternal and child APNs?”

In this study, the actual scores of patient satisfaction ranged from 16 - 60.

The average patient satisfaction score was 50.14. For each item, the mean satisfaction

score was skewed toward strongly agree which indicated high satisfaction with care

received from the maternal and child APNs. The result of patient satisfaction found in

this study consistent with several previous studies by Bryant and Graham (2002),

Brooten et al. (2001), Dana and Wambach (2003), Hayes (2007), and Lieu et al.

(2000).

The CST, which measure patient satisfaction in this study, consist of six

qualities of care domains; affective support, health information, decisional control,

technical competencies, accessibility, and overall satisfaction. It was found that the

mean score of six domains were placed in high level. The highest mean score was

rated for the health information domain (M = 4.45, SD = .49) that consistent with the

care activity that APNs in this study mostly used was provided patient education.

The lowest mean score was rated for the accessibility domain (M = 3.97, SD = .58)

that comprised the items about availability of APN and appointment time. This result

84

may reflect Thai healthcare system culture that normally had a specific scheduled to

visit at a clinic for each patient.

Limitations

There were some limitations of this study. First, this study was a comparative,

retrospective document reviewed. A comparative design and retrospective document

reviewed cannot fully control for bias like experimental research designs (Brink &

Wood, 1998), thus the investigator can control bias for extraneous variables only from

the sample’s information available at the time data was collected. Therefore internal

validity may not be completely supported, due to the limitations of the study design,

although simple random sampling was applied to select the sample.

Second, external validity and generalizability could not be supported due to

the small sample size of some APNs’ patient group, such as childbirth preparation

group. In order to control for internal validity, selected characteristics were used for

matching, to make sure that the patient sample in the years before and after

introduction of APNs practice equivalent in characteristics (Burns & Grove, 2005). So

the final sample for each year was matched with the sample of another year. If the

samples in each year could not be matched because there were differences in

characteristics, those samples were excluded. For that reason, the sample remaining

for some groups of patients were too small.

Third, if the study is considered as a whole, the samples seem heterogeneous

because there is: a preterm labor patient group, a teenage pregnancy patient group, a

childbirth preparation patient group, and a gestational diabetes mellitus patient group.

However, in order to bridge the gap to present the outcomes of maternal and child

APNs care in Thailand, the investigator did not present the results of the study as a

whole, due to not only the different sample characteristic, but also because there were

different outcomes for each patient group.

Thus, there might be other hospital-level extraneous factors in addition to

APNs that may affect patient outcomes such as; number of board-certified physicians,

number of master degree nurses working in the settings, availability of technology,

the organizational policy of the hospitals, and hospital size. As a result, differences in

85

patient outcomes and health service use are cautiously interpreted. Conclusions

drawn from this research cannot necessarily be used for comparisons with other

studies, because of differing methodologies and defining variables in a different

manner. In addition, limited information is provided by the patient records, and a

problem of recorded errors might have occurred.

Implications

Finding from this study confirm positive outcomes in previous studies in

related to maternal and child APNs health care programs. Hospital settings that do not

employ APNs should consider the importance of acquiring this type of nursing

professional to offer improved maternal and child health care.

Implication for Nursing Practice

The results of this study indicated a need to schedule more time for APNs to

provide direct care for their patients. The APNs should work full time as APNs. The

scope of APN practice should be clarified depending upon the type of hospital and

required services. This can assure that APNs have enough time to provide continuity

of care for their patients. Furthermore, APNs should try to identify their desirable

outcomes of for their practice. Importantly, they should have a systematic way to

collect data and also evaluate outcomes of their practice.

Implication for Nursing Research

In Thailand, although problems with accessibility of data, data availability

and consistency of data, still exist; prospective studies are needed to compare

outcomes across varying time periods, to show the effects of maternal and child APNs

care. There is also a need to study outcomes of APN practice in heterogeneous groups

of patients such as those with pregnancy induced hypertension, gestational diabetes

mellitus, and preterm labor using a prospective study or experimental design to reflect

the effectiveness of the APN practice across the country. Furthermore, there is a need

to study influence of structure, process on outcomes of practice of APN in maternal

and child health.

86

Implication for Policy

In order to improve maternal and child health outcomes and lower healthcare

cost, the study results imply an adoption of appropriate policies and plans for

allocating maternal and child APNs to health care settings. The results also reflect a

need to optimize nurse staffing levels, resource planning, and to decrease adverse

events and health care costs. Results indicate that it is important that APNs in

maternal and child health continue to upgrade their nursing expertise. To improve

patient outcomes, important consideration should be made regarding educational

background and experience of nurses when planning resource allocation. Being an

APN, staff nurse requires educational preparation, and continuous updating of

knowledge and skills in order to care for maternal and child patients who have

complex problems.

In summary, the benefits of maternal and child APNs’ practices are

documented in the maternal and newborn outcomes in this study. Results indicated

that four years after the implementation of APNs in practice: infant gestational ages

were higher in the group of women with preterm labor; neonatal complications were

lower; the numbers of neonatal admission to the special care nursery or the neonatal

intensive care unit were lower; time in the first stage of labor and the amount of blood

loss were less; and fasting blood sugar levels at 6 weeks postpartum were lower

compared to the one year period before APNs were in practice.

These findings document the differences APNs made in the outcomes of

maternal and child care in Thailand using their in-depth knowledge and skills in this

area of practice. Study results document the need to increase the numbers and use of

APNs in the Thai health care system in order to improve maternal and child health.

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W. (2010). Role development of advanced practice nurses in Thailand.

Pacific Rim International Journal of Nursing Research, 14(2), 162-177.

Woodward, V. A., Webb, C., & Prowse, M. (2006). Nurse consultants: Organizational

influences on role achievement. Journal of Clinical Nursing, 15, 272-280.

World Health Organization [WHO]. (2004). Improving maternal newborn and child

health: Thailand. Retrieved December 20, 2007, from

http://www.searo.who.int/Link Files /Improving_maternal_newborn_and_

child_ health_thailand.pdf

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Wortansw, J., Happell, B., & Johnstone, H. (2006). The role of the nurse practitioner

in psychiatric/ mental health nursing: exploring consumer satisfaction.

Journal of Psychiatric and Mental Health Nursing, 13, 78-84.

York, R., Bhuttarowas, P., & Brown, L. P. (1999). The development of nursing in

Thailand and its relationship to childbirth practice. The American Journal of

Maternal/Child Nursing, 24(3), 145-150.

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APPENDICES

97

APPENDIX A

Approval of the Study by Institutional Review Boards

98

99

100

101

102

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APPENDIX B

Research Instruments

105

Maternal and Newborn Summary Form

Maternal age……………….

Delivery Date……………Time…………….GA at delivery…………..weeks

Prenatal Summary:

Gravida……….Para……….Gestational ages at 1st prenatal visit……….weeks

Number of prenatal visit…………………

Hemoglobin 1…...................Hematocrit 1…………………

Hemoglobin 2…………….. Hematocrit 2…………………

1st visit 2

nd visit 3

rd visit 4

th visit 5

th visit 6

th visit 7

th visit

GA

BW

BP

Urine

Protein

Edema

Urine

Sugar

Others Labs…………………………………………………………………………….

………………………………………………………………………………………….

Medication…………………………………………………………………………….

………………………………………………………………………………………...

…………………………………………………………………………………………

Complication during pregnancy ( ) no ( ) yes, identify……………………………

Other labs……………………………………………………………………………..

Complication treatment………………………………………………………….........

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

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Maternal transfer ( ) no

( ) yes, place………………………reason………………………….

Labor& Delivery Summary:

Type of delivery ( ) NL ( ) V/E, indication……………………….

( ) F/E, indication…………………………..

( ) C/S , indication…………………………………

( ) Others…………………………..

Analgesic use ( ) no ( ) yes, identify………………………………………………..

Duration of labor 1st stage………………2

nd stage……………….3

rd stage………….

Estimated blood lost…………………cc

Complication during labor and delivery ( ) no ( ) yes, identify………………………

Complication treatments………………………………………………………………

………………………………………………………………………………………….

………………………………………………………………………………………….

………………………………………………………………………………………….

Maternal transfer ( ) no

( ) yes, place………………………reason………………………….

Postpartum Summary:

Postpartum complication ( ) no ( ) yes, identify………………………………………

Complication treatment…………………………………………………………………

………………………………………………………………………………………….

………………………………………………………………………………………….

………………………………………………………………………………………….

Postpartum transfer ( ) no

( ) yes,

place………………………reason…………………………

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Maternal discharge date…………………..

Total days in Hospital……………………

Neonate

Birth weight………………grams Discharge weight……………grams

Apgars score 1 min = …………5 min = …………

Neonatal complication ( ) no ( ) yes, identify………………………………………

Complication treatments………………………………………………………………..

………………………………………………………………………………………….

………………………………………………………………………………………….

Neonatal transfer ( ) no

( ) yes, place…………………………reason………………………

Neonatal discharge date…………………..

Total days in Hospital…………………….

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Data Collection Form

Acute Care Visits

Subject

#

Hospital

Name

Maternal

and Child

APN

Defined

Population

Date Labs

or

Other

Assessments

Diagnosis Treatment Admission

Yes No

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Data Collection Form

Complication during Pregnancy

Subject

#

Hospital

Name

Maternal

and Child

APN

Defined

Population

Date Gestational

Age

(GA)

Labs

or

Other

Assessments

Diagnosis Treatment

110

Data Collection Form

Hospitalization

Subject

#

Maternal

and Child

APN Defined

Population

Admission

Date

Discharge

Date

Labs

or

Other

Assessments

Diagnosis Treatment Hospital

Name

111

Data Collection Form

Rehospitalization

Subject

#

Maternal

and Child

APN

Defined

Population

Readmission

Date

Discharge

Date

Lab

or

Other

Assessments

Diagnosis Treatment Hospital

Name

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Patient Demographic Data

Subject #.......................................

Instruction: Please fill in the blank and mark the answer which best describes

you.

1. Age………………years.

2. Marital status

……. (1) Married (registered)

……. (2) Married (not register)

……. (3) Others (For example, living together, please specify)…………………

3. Highest level of education completed

…… (1) No education

…… (2) Grade 1-6

…… (3) Grade 7-9

…… (4) Grade 10-12

…… (5) Vocational

…… (6) Bachelor’s degree

…… (7) Master’s degree

…… (8) Doctoral degree

…… (9) Others (please specify)

………………….

4. Monthly household income

( ) 10,000 baht or below

( ) 10,001- 20,000 baht

( ) 20,001- 30,000 baht

( ) 30,001- 40,000 baht

( ) 40,001 – 50,000 baht

( ) 50,001 baht or over

5. Method of health care service fee payment

..….. (1) 30 Baht scheme

…… (2) Social security scheme

.….. (3) Civil servants medical benefit scheme

.….. (4) Other (please specify)……………..

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6. How would you rate your overall health right now?

……. (1) Poor

……. (2) Fair

……. (3) Good

……. (4) Very Good

7. Number of times in the past 2 years that you have seen the advanced practice

nurse……………..

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Client Satisfaction Tool (CST)

Please circle the one number which best represents your perception of the care

provided by the advanced practice nurse.

Items

Strongly Strongly

agree disagree

5 4 3 2 1

1. The clinic staff were understanding of my health

concerns.

5 4 3 2 1

2. The clinic staff gave me encouragement in

regard to my health problem.

5 4 3 2 1

3. I got my question answered in an individual

way.

5 4 3 2 1

4. The information I received at the clinic helped

me to take care of myself at home.

5 4 3 2 1

5. …………………………………………………..

6. …………………………………………………..

7. …………………………………………………..

8. …………………………………………………..

9. …………………………………………………..

10. …………………………………………………

11. Overall, I was satisfied with my health care. 5 4 3 2 1

12. The care I received at the clinic was of high

quality.

5 4 3 2 1

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แบบสอบถามความพงพอใจของผรบบรการ 1. ลกษณะทวไปของผรบบรการ ค าแนะน า: กรณาตอบค าถามขอ 1-7 และกาเครองหมาย หนาขอททานเลอกตอบซงตรงกบตวทานมากทสด 1. อาย……………..ป 2. สถานภาพสมรส ……….(1) โสด ……….(4) หมาย ……….(2) สมรส (ไมไดอยดวยกน) (5) หยา ……….(3) สมรส (อยดวยกน) ……….(6) อน ๆ โปรดระบ…………………. 3. ระดบการศกษาสงสด ...….. (1) ไมไดรบการศกษา …… (2) ประถมศกษา …… (3) มธยมตน …… (4) มธยมปลาย

…… (5) อาชวศกษา/อนปรญญา …… (6) ปรญญาตร …… (7) ปรญญาโท …… (8) ปรญญาเอก …… (9) อนๆ โปรดระบ………………….

4. รายไดเฉลยของครอบครวตอเดอน……………………………….บาท 5. สทธในการรกษาพยาบาล ……… (1) บตรประกนสขภาพถวนหนา ……… (2) ประกนสงคม

(3) ใชสทธขาราชการ/พนกงานรฐวสาหกจ ………(4) อนๆ โปรดระบ………………………..

6. ทานคดวาภาวะสขภาพโดยรวมของทานขณะนเปนอยางไร ……. (1) ไมด ……. (2) คอนขางด

(3) ด (4) ดมาก

7. จ านวนครงทไดรบการดแลจากผปฎบตการพยาบาลขนสงสาขามารดาและทารกหรอจ านวนครงทนอนรกษา ตวในหอผปวยโดยไดรบการดแลจากผปฏบตการพยาบาลขนสง ในชวง 1 ปทผานมา………………ครง

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2. ความพงพอใจของผรบบรการ ค าชแจง กรณาท าเครองหมายวงกลมทตวเลขเพยงตวเลขเดยวทตรงกบความรสกของทานมากทสด เกยวกบการดแลทไดรบจากผปฏบตการพยาบาลขนสง

รายการ เหนดวย ไมเหนดวย อยางยง อยางยง 5 4 3 2 1

1. พยาบาลเขาใจความกงวลเกยวกบสขภาพของฉน

5 4 3 2 1

2. พยาบาลใหก าลงใจฉนเกยวกบปญหาสขภาพของฉน

5 4 3 2 1

3. ค าถามทฉนถามพยาบาล ไดรบการตอบทตรงกบสงทฉนอยากร

5 4 3 2 1

4. …………………………………………. 5 4 3 2 1 5. ………………………………………… 5 4 3 2 1 6. ………………………………………….. 5 4 3 2 1 7. ………………………………………….. 5 4 3 2 1 8. …………………………………………… 5 4 3 2 1 9. …………………………………………… 5 4 3 2 1 10. …………………………………………. 5 4 3 2 1 11. โดยภาพรวมฉนรสกพงพอใจกบบรการการดแลสขภาพท ไดรบจากพยาบาล

5 4 3 2 1

12. บรการดแลสขภาพทฉนไดรบจากพยาบาลมคณภาพสง

5 4 3 2 1

ขอขอบคณในความรวมมอของทาน

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Maternal and Child APN Demographic Data

Code Number…………….

Instruction: Please fill in the blank and mark the answer which best describes

you.

1. How many years have you practiced as an advanced practice nurse?.......................

2. How many years have you practiced as registered nurse

before certified to be an APN?.......................................

3. What is your age………………

4. What is your salary range that reflects your current income?

( ) 10,000 baht or below

( ) 10,001- 20,000 baht

( ) 20,001- 30,000 baht

( ) 30,001- 40,000 baht

( ) 40,001 – 50,000 baht

( ) 50,001 baht or over

5. Which of the following educational programs have you completed?

( ) Master degree in nursing

( ) Master degree in a health-related field

( ) Master degree in a field other than health

( ) Other, please specify…………………………………..

6. Where are you employed?

( ) Primary Care Unit

( ) Community Hospital

( ) General Hospital

( ) Regional Hospital

( ) University Hospital/ Tertiary care level hospital

( ) Other (please specify)…………………………

7. Indicate the patient group you work with in the majority of time (your defined

population)

1. ……………………………………………………

2. ……………………………………………………

3. ……………………………………………………

4. ……………………………………………………

APPENDIX C

Consent Form

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ขอมลส ำหรบผเขำรวมวจย กำรศกษำเรอง : การปฏบตการพยาบาลขนสงสาขามารดาและทารกในประเทศไทย: ผลตอผลลพธทางดานผปวย, การใชบรการทางดานสขภาพ, และความพงพอใจของผรบบรการตอการดแลของผ ปฏบตการพยาบาลขนสงสาขามารดาและทารก ชอผวจย: กชพร สงหะหลา วท.ม. (การเจรญพนธและวางแผนประชากร) นสตปรญญาเอก คณะพยาบาลศาสตร มหาวทยาลยบรพา ชออำจำรยทปรกษำ: รองศาสตราจารย ดร. วรรณ เดยวอศเรศ คณะพยาบาลศาสตร มหาวทยาลยบรพา สถำนทวจย: โรงพยาบาลมหาราชนครศรธรรมราช, โรงพยาบาลทาศาลา จ. นครศรธรรมราช, โรงพยาบาลสงขลา, วทยาลยแพทยศาสตรกรงเทพมหานครและวชรพยาบาล ผสนบสนนกำรวจย: บณฑตวทยาลย มหาวทยาลยบรพา เรยน ผเขำรวมวจยทกทำน ทานเปนผทไดรบเชญใหเขารวมการศกษาวจยเรอง “การปฏบตการพยาบาลขนสงสาขามารดาและทารกในประเทศไทย: ผลตอผลลพธทางดานผปวย, การใชบรการทางดานสขภาพ, และความพงพอใจของผใชบรการ” กอนททานตกลงเขารวมการศกษาดงกลาว ขอเรยนใหทานทราบถงเหตผลและรายละเอยดของการศกษาวจย ในครงน

ในหลาย ๆประเทศ โดยเฉพาะอยางยงในสหรฐอเมรกา ไดแสดงใหเหนวาการมผ ปฏบตการพยาบาลขนสงใหบรการในระบบบรการสขภาพสามารถชวยพฒนาคณภาพของการบรการ ผรบบรการไดรบการบรการทมคณภาพสง คมคาคมทน และผรบบรการมความพงพอใจในบรการสขภาพทไดรบ การมผปฏบตการพยาบาลขนสงใหการดแลสามารถท าใหปญหาสขภาพของมารดาและทารกลดลง ภาวะสขภาพของมารดาและทารกดขน รวมทงชวยลดคาใชจายทเกยวของกบการดแลภาวะสขภาพของมารดาและทารก ในประเทศไทยไดมผปฏบตการพยาบาลขนสงสาขามารดาและทารกสอบผานและไดรบวฒบตรจากสภาการพยาบาลเปนคนแรกเมอ พ.ศ. 2546 นบตงแตนนจนถงป พ.ศ. 2551 ไดมผสอบผานและไดรบวฒบตรเปนผมความรความช านาญเฉพาะ

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ทางการพยาบาลและการผดงครรภหรอผปฏบตการพยาบาลขนสงสาขามารดาและทารกจากสภาการพยาบาลทงสน 25 คน แตอยางไรกตามในปจจบนยงไมมการศกษาเกยวกบผลของการปฏบตการพยาบาลขนสงสาขามารดาและทารกทมตอผลลพธในดานผใชบรการ การใชบรการทางดานสขภาพ และความพงพอใจของผใชบรการในประเทศไทย

ผลของการศกษาวจยนจะเปนประโยชนตอการสงเสรม พฒนาหรอปรบปรงเกยวกบการปฏบตการพยาบาลขนสงสาขามารดาและทารกในประเดนดานการบรหาร, การปฏบตการพยาบาล, การวจยทางการพยาบาล, และการศกษาพยาบาล นอกจากนยงจะเปนประโยชนตอการพฒนาคณภาพงานอนามยแมและเดก ในประเดนการวางแผนเกยวกบบคลากรทางดานสขภาพเพอใหการดแลในดานอนามยแมและเดก

การศกษาวจยนเปนสวนหนงของการศกษาระดบปรญญาเอก คณะพยาบาลศาสตร มหาวทยาลยบรพา ถาทานยนดเขารวมโครงการวจยน ทานจะไดรบแบบสอบถาม 2 ชด พรอมทงค าอธบายในการตอบแบบสอบถาม ระยะเวลาในการตอบแบบสอบถามประมาณ 5 นาท อนตรำยและควำมเสยงจำกกำรเขำรวมกำรวจย: ไมมอนตรายหรอความเสยงใดใด อนอาจจะเกดขนจากการเขารวมโครงการวจยน ทานเพยงแตเสยเวลาในการตอบแบบสอบถามเลกนอย (ประมาณ 5 นาท) ผลประโยชน: การเขารวมโครงการวจยโดยการใหความรวมมอในการตอบแบบสอบถามของทาน จะเปนการใหขอมลทมคณคาซงจะท าใหไดทราบถงผลของการใหบรการของผปฏบตการพยาบาลขนสงสาขามารดาและทารก และสามารถใชเปนขอมลเพอพฒนาคณภาพบรการเกยวกบอนามยแมและเดกของโรงพยาบาลตางๆ ได ทานจะไมไดรบผลประโยชนเปนพเศษจากการเขารวมในโครงการวจยน กำรรกษำควำมลบในขอมลของทำน: ขอมลทไดจากทานถอเปนความลบตามกฎหมาย ขอมลทไดจากทานจะใชเพอการศกษาวจยเทานน ขอมลจะถกน าเสนอโดยใชตวเลขและน าเสนอเปนรายกลม จะไมมการเปดเผยชอของทานในทกกรณ ผวจยหรอผชวยเกบขอมลจะเปนผรวบรวมขอมลและรบแบบสอบถามคนจากทานโดยตรง ขอมลทไดจากทานจะถกบนทกไวในคอมพวเตอรสวนตวทมรหสปองกนบคคลอนนอกจากผวจย ไมใหสามารถเปดได เอกสารขอมลของทานจะถกเกบไวในต/ลนชกทมกญแจลอก และผวจยเทานนทมกญแจเปดปด และเอกสาร/แผน CD/ไฟล ขอมลของทานจะถกเกบไวเปนเวลา 5 ป หลงจากสนสดการวจย และผวจยจะเปนผรบผดชอบในการดแลใหขอมลตางๆ เหลานนถกเกบอยในต/ลนชกทมกญแจลอกตลอดระยะ 5 ปทเกบขอมลไว ทงนผวจยจะท าลายเอกสาร/ไฟลขอมลของทานเมอครบ 5 ป หลงจากสนสดการวจย

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สทธในกำรถอนตวจำกกำรวจย: ทานสามารถถอนตวจากการเขารวมการวจยไดตลอดเวลาโดยการไมตอบแบบสอบถาม การปฏเสธหรอการถอนตวของทานจะไมมผลเสยใดๆ ตอตวทาน คำใชจำย: ทานไมตองเสยคาใชจายใดๆทงสนในการเขารวมโครงการวจยน คำตอบแทน: ทานจะไมไดรบคาตอบแทนใดๆในการเขารวมโครงการวจยน หากทานมปญหา หรอขอสงสยประการใด กรณาตดตอ นำงสำวกชพร สงหะหลำ หนวยงาน คณะพยำบำลศำสตร มหำวทยำลยมหำสำรคำม ต.ขำมเรยง อ. กนทรวชย จ. มหำสำรคำม โทร 084-6842138 ซงยนดใหค าตอบแกทานทกเมอ

ขอขอบพระคณในความรวมมอของทานมา ณ ทน

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ใบยนยอมเขำรวมกำรวจย

------------------------ หวขอดษฎนพนธ เรอง การปฏบตการพยาบาลขนสงสาขามารดาและทารกในประเทศไทย: ผลตอผลลพธทางดานผปวย, การใชบรการทางดานสขภาพ, และความพงพอใจของผรบบรการตอการดแลของผปฏบตการพยาบาลขนสงสาขามารดาและทารก วนใหค ายนยอม วนท………เดอน…………………………พ.ศ. ………………. กอนทจะลงนามในใบยนยอมเขารวมการวจยน ขาพเจาไดรบการอธบายจากผวจยถงวตถประสงคของการวจย วธการวจย ประโยชนทจะเกดขนจากการวจยอยางละเอยดและมความเขาใจดแลว ขาพเจายนดเขารวมโครงการวจยนดวยความสมครใจ และขาพเจามสทธทจะบอกเลกการเขารวมในโครงการวจยนเมอใดกได และการบอกเลกการเขารวมการวจยน จะไมมผลกระทบใด ๆ ตอขาพเจา ผวจยรบรองวาจะตอบค าถามตาง ๆ ทขาพเจาสงสยดวยความเตมใจ ไมปดบง ซอนเรนจนขาพเจาพอใจ ขอมลเฉพาะเกยวกบตวขาพเจาจะถกเกบเปนความลบและจะเปดเผยในภาพรวมทเปนการสรปผลการวจย ขาพเจาไดอานขอความขางตนแลว และมความเขาใจดทกประการ และไดลงนามใน ใบยนยอมนดวยความเตมใจ ลงนาม…………………………………………………………ผยนยอม (…………………………………………………………) ลงนาม…………………………………………………………พยาน (…………………………………………………………) ลงนาม…………………………………………………………ผท าวจย (…………………………………………………………)

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ขาพเจาไมสามารถอานหนงสอได แตผวจยไดอานขอความในใบยนยอมนใหขาพเจาฟงจนขาพเจาเขาใจดแลว ขาพเจาจงลงนามหรอประทบลายนวหวแมมอของขาพเจาในใบยนยอมน ดวยความเตมใจ ลงนาม………………………………………………………ผยนยอม (…………………………………………………………) ลงนาม…………………………………………………………พยาน (…………………………………………………………) ลงนาม…………………………………………………………พยาน (…………………………………………………………) ลงนาม…………………………………………………………ผท าวจย (…………………………………………………………) ในกรณทผถกทดลองยงไมบรรลนตภาวะ จะตองไดรบการยนยอมจากผปกครองหรอผแทนโดยชอบดวยกฎหมาย ลงนาม………………………………………………ผปกครอง/ ผแทนโดยชอบดวยกฎหมาย (…………………………………………………………) ลงนาม…………………………………………………………พยาน (…………………………………………………………) ลงนาม…………………………………………………………ผท าวจย (…………………………………………………………)

APPENDIX D

Validators of the Instrument

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Expertises

1. Associate Professor Dr. Rachanee Sunsern Faculty of Nursing

Burapha University

2. Associate Professor Dr. Jintana Watcharasin Faculty of Nursing

Burapha University

3. Associate Professor Dr Promjit Hornboonherm Faculty of Nursing

Mahasarakham University

4. Assistant Professor Dr. Areerut Khumyu Faculty of Nursing

Burapha University

5. Assistant Professor Dr. Usa Chuahorm Faculty of Nursing

Burapha University

6. Dr. Janelle Gamble Faculty of Humanities and Social

Science

Burapha University

7. Dr. Jim Siman Faculty of Humanities and Social

Science

Burapha University

8. Associate Professor Dr. Sumeth Deoisres Administrative Court

Bangkok

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BIOGRAPHY

Name Miss. Kochaporn Singhala

Death of birth May 26, 1969

Place Mahasarakham, Thailand

Present address 4/1 Thammawongsawad Road Soi 8

Muang , Mahasarakham 44000

Position held Assistant Professor Employment history

1992-1997 Registered Nurse

Obstetric Ward 3, Ramathibodi Hospital,

Thailand

1997-2005 Lecturer

Faculty of Nursing, Mahasarakham University,

Thailand

2005-2011 Assistant Professor

Faculty of Nursing, Mahasarakham University,

Thailand

Education

1988-1991 Bachelor of Nursing Science

Ramathibodi School of Nursing,

Mahidol University, Thailand

1994-1997 Master of Science (Human Reproduction and

Population Planning)

Mahidol University, Thailand

2007-2011 Doctor of Philosophy in Nursing Science

Burapha University, Thailand

Scholarship

2009 Scholarship from the Thailand Nursing and

Midwifery Council for conducting dissertation

2008 Scholarship from the Graduate School,

Burapha University for conducting dissertation

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2005-2007 Scholarship from the Higher Education

Commission for Ph.D. study