Quality care metrics for nurses working in general practice, mapping the evidence: a scoping review protocol

Orla Loftus Moran; Mary Casey; Laserina O'Connor; Walter Cullen

doi:10.12688/hrbopenres.13483.1

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Quality care metrics for nurses working in general practice, mapping the evidence: a scoping review protocol

[version 1; peer review: 2 approved with reservations]

Orla Loftus Moran ^1,2, Mary Casey¹, Laserina O'Connor¹, Walter Cullen³

PUBLISHED 21 Jan 2022

Author details Author details

¹ School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland
² General Practice, Castlebar Family Practice, Castlebar, Ireland
³ School of Medicine, Health Sciences, University College Dublin, Dublin, Ireland

Orla Loftus Moran
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation

Mary Casey
Roles: Data Curation, Investigation, Methodology, Project Administration, Writing – Review & Editing

Laserina O'Connor
Roles: Supervision, Writing – Review & Editing

Walter Cullen
Roles: Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: Irish general practice nursing roles have developed and grown exponentially in response to changing policy, clinical and workforce demands over the past three decades. However, as nursing care in general practice advances at pace, comprehensive evaluation of the general practice nurse (GPN) role has not been undertaken. Therefore, processes which enable robust data collection to carefully assess the role and facilitate development of services are required. Nursing quality care metrics (QCM) are an established mechanism which measure nursing care process, evaluate quality, and impact of care, and inform service development. The use of nursing QCM has been adopted within seven distinct healthcare settings in Ireland but not general practice. This scoping review is the first stage of a project which aims to inform development of QCM within Irish GPN settings.
Aim: To explore and map the literature regarding the use, application, and impact of nursing quality care metrics within a general practice, primary care setting.
Methods: The following five-stage methodological framework for scoping reviews proposed by Arksey and O’Malley will be used: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting/mapping the data and (5) collating, summarizing, and reporting results. The review will be conducted and reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR).
Conclusions: The focus of this scoping review relates to QCM which specifically measure the work of general practice nurses. It is envisioned that synthesis of international literature will give a broad perspective about QCM, their use in general practice or primary care settings, and enrich understanding of their development. It is anticipated that findings will provide key information to policy makers and health professionals interested in planning, strengthening, and delivering primary care in Ireland.

Keywords

Scoping Review, Practice Nurse, General Practice Nurse, General Practice, Family Practice, Quality Care Metrics, Quality Care Indicators, Care Process.

Corresponding author: Orla Loftus Moran

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2022 Loftus Moran O et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Loftus Moran O, Casey M, O'Connor L and Cullen W. Quality care metrics for nurses working in general practice, mapping the evidence: a scoping review protocol [version 1; peer review: 2 approved with reservations]. HRB Open Res 2022, 5:10 (https://doi.org/10.12688/hrbopenres.13483.1) First published: 21 Jan 2022, 5:10 (https://doi.org/10.12688/hrbopenres.13483.1) Latest published: 14 Apr 2022, 5:10 (https://doi.org/10.12688/hrbopenres.13483.2)

Introduction

The World Health Organisation (WHO) Astana declaration affirmed the role of primary care as the mainstay of efficient, effective, equitable health systems internationally. This declaration advocated that primary care be strengthened and supported with enhanced infrastructure and workforce capacity to enable its important role in disease prevention and health promotion (World Health Organisation, 2018). General practice is considered the cornerstone of primary healthcare delivery in most European countries (Kringos et al., 2013). In Ireland, healthcare policy, government and healthcare providers are advancing and adopting reorientation of service delivery into the community and primary care (Houses of the Oireachtas, 2017). This change comes at a critical time for Irish general practice, which is positioned at the centre of healthcare policy implementation. Currently demographic pressures, the rise of non-communicable diseases, multimorbidity, workforce capacity issues and the coronavirus disease 2019 (COVID-19) pandemic are contributing to increased pressure on general practice (Crosbie et al., 2020; McGlacken-Byrne et al., 2021).

Primary care nursing worldwide is evolving in tandem with health policy reform and general practice nursing has emerged as a new generalist model of nursing positioned within primary care which is integral to the future delivery of healthcare (Desborough et al., 2016; Freund et al., 2015; Groenewegen et al., 2015; Halcomb et al., 2017; International Council of Nurses, 2018; Lukewich et al., 2020; Maier & Aiken, 2016; World Health Organisation, 2021). General practice is a core component of primary care services, led by general practitioners (GPs) it is the place of first contact for most patients in need of health services, and offers accessibility, continuity, and comprehensive, coordinated care. According to O’Dowd et al. (2017) the distinct role of general practice within primary care is an important consideration as the terms ‘general practice’ and ‘primary care’ are often incorrectly used interchangeably. A more detailed definition of general practice or family medicine is further summarised as “General practice/family medicine is an academic and scientific discipline, with its own educational content, research, evidence base and clinical activity, and a clinical specialty orientated to primary care” (Mola et al. (2011) pp. 8).

Reflecting international trends Irish government health policy, Sláintecare, has embraced the concept of care reorientation from hospital-based models to primary care settings (Houses of the Oireachtas, 2017). Fundamental to Sláintecare policy is implementation of a universal, single-tier health system, and delivery of high quality, safe care to patients in their own communities. Implementation of this policy is evident in recent agreements between healthcare authorities and general practice providers, including the introduction of entitlements to free general practice care for those aged under six and over seventy years of age (Connolly & Wren, 2019; Health Service Executive, 2015b). In 2019, an agreement for reform and service development within general practice between government and general practice representatives, included a community-based structured chronic disease management programme (CDM) which became operational in 2020 (Health Service Executive, 2019b). This is a first step in implementing an integrated approach to chronic disease care, and GPNs are established as critical to its successful rollout (Collins & Homeniuk 2021; Darker et al., 2015; Irish College of General Practitioners, 2021).

Irish GPNs lead and deliver a broad range of the healthcare services, including primary infant and adult immunisation programmes, cervical screening, health promotion and education interventions, disease surveillance, wound care, and a complex range of generalist nursing services (Bury et al., 2021; McCarthy et al., 2012). Furthermore, GPNs adapted to challenges in delivery of services resulting from the COVID-19 pandemic, and were integral to continuation of services, particularly the delivery of the COVID-19 vaccination programme in general practice (Homeniuk & Collins, 2021; Health Service Executive, 2021; Lowry Lehnen, 2021). International research demonstrates that mobilisation of GPN workforce and advanced GPN roles can strengthen general practice, whilst providing benefits and safe care for patients (Halcomb & Ashley, 2019; Laurant et al., 2018; Norful et al., 2017; Poghosyan et al., 2018), additionally this research suggests that GPN roles may be underutilized.

Enabling the provision of high quality healthcare is a core concern for healthcare authorities worldwide (Health Information and Quality Authority (HIQA), 2012; World Health Organisation (WHO), 2006). In Ireland, Sláintecare policy endorses this drive towards accountability and performance within the health service. However, there is currently little evidence available on the quality of care, impact, and contribution of Irish GPNs to general practice. Nursing Quality Care Metrics (QCM) is a mechanism which can simultaneously address the issue of the provision of quality nursing care and GPN role evaluation. By compiling quantifiable measurements applicable to nursing care in general practice, development and improvements in nursing services and patient outcomes can be facilitated (Health Service Executive, 2015a). This data will also give more detailed information on the nursing activities of the general practice nurse.

Quality Care Metrics (QCM)

Quality Care Metrics is a method of measuring quality of care, placing safety and quality at the heart of service provision (Foulkes, 2011). Maben et al. (2013) report on the increasing use of initiatives which measure quality care in nursing both internationally and within the UK. They counsel that the development of nursing metrics should align with ‘what matters most’ to patients. Furthermore, they observed practitioner’s acceptance and participation in QCM projects was enhanced through fostering understanding of the purpose and benefits of the process for nursing services, and patient care. The Office of the Nursing and Midwifery Services Director (ONMSD) has led QCM implementation and evaluation in Irish healthcare settings and define nursing QCMs as “A measure of the quality of nursing and midwifery clinical care processes aligned to evidenced based standards and agreed through national consensus in healthcare settings in Ireland” (Health Service Executive (2015a) pp.10).

The Irish national QCM project adopted the Donabedian (1988) framework of quality care evaluation based on the structure, process, and outcome triad within which each element has a direct effect on the overall quality of care delivered. Within the Donabedian model, structure refers to the attributes specific to the healthcare working environment and characteristics of those who work within it such as education or experience, process examines how direct care is provided to patients from a technical and interpersonal perspective, and outcomes assess the end points of care achieved such as immunisation rates or patient experiences (Hanae Ibn El et al., 2013). The focus of QCM implemented by the ONMSD national project is on care specific to nursing processes, in other words scrutinising how nursing care is given, and how it is delivered. The areas which have adopted the use of metrics to date are acute care services, children’s services, intellectual disability services, older person services, mental health services, public health nursing services, and midwifery services (Health Service Executive, 2019a).

In the UK, Griffiths et al. (2008) observed that development of QCM had been dominated by in-patient settings and this is reflected in the Irish experience. Notably, Griffiths et al. (2008) conclude that metric themes and indicators developed for acute care and inpatient settings can be modified and applied to other care settings. According to Haycock-Stuart & Kean (2012) community settings are a care environment within which nursing plays a significant but often invisible role and they acknowledge the need for evidence of quality care delivery in this setting. In Ireland a report into the development process for a primary care setting, Public Health Nursing QCM published in 2018 demonstrates the feasibility of QCM implementation in a community setting (Health Service Executive, 2018). Utilising a rigorous process consisting of an initial systematic literature review, a two-round Delphi survey on identified metrics, followed by a two-round Delphi survey on associated indicators, and culminating with a stakeholder consensus meeting, 14 quality care process metrics and 69 associated indicators were developed. Central to the success of this project was establishment of a collaborative, participatory approach between key stakeholders, researchers, clinicians, and educators. This same process was used across all other six settings.

Method

As outlined by Pollock et al. (2021), scoping reviews map and synthesise research, address broader topics and wide-ranging study designs, report on the depth and extent of the literature, identify knowledge gaps, and is an appropriate methodology to clarify nursing concepts. Given the broad nature of the question posed by this study and taking into consideration the little evidence which exists regarding QCMs use in general practice nursing, a scoping review is deemed the most appropriate methodology. A key aspect of scoping review is the extensive range of literature from both published and grey sources which can be included in the review. This literature synthesis of general practice nursing and QCMs will help to identify what is already known about the topic, it will reveal research deficits and knowledge gaps, informing and enabling future research.

This scoping review will adhere to the five stage framework first described by Arksey & O'Malley (2005) which are:

Stage 1: identifying the research question.
Stage 2: identification of relevant studies.
Stage 3: study selection.
Stage 4: charting the data.
Stage 5: collating, summarising, and reporting the result.

Stage 1: Identifying the research question

Joanna Briggs Institute (JBI) argues that development of the main research question is one of the most important steps to consider and advises using the Population-Concept-Context (PCC) framework to guide this (Peters et al., 2020a). This review aims to establish a comprehensive understanding of how nursing QCMs have been developed and implemented. It seeks to map the evidence and identify knowledge gaps focusing primarily on nursing in general practice. As usual, objectives will be used to demonstrate the relationship to the principal research question. This review will address the following question.

Research question

What is known about the use of nursing (Population) quality care process metrics (Concept) within general practice nursing (Context) settings?

Review objectives

• To map the extent of evidence available regarding nursing QCM pertinent to general practice nursing, primary care settings within the literature.
• To identify methods used to develop general practice nursing quality care metrics and other nursing metrics as appropriate
• To ascertain the characteristics of general practice nursing QCM.
• To determine if the literature demonstrates implementation of nursing QCM in general practice, and if their use provides advantages for patient outcomes and or service delivery?

Stage 2: Identifying the relevant studies

In accordance with Peters et al. (2020b), the PCC framework will be used to develop search terms and align the eligibility criteria with study selection, and the assistance of a research librarian will be enlisted during all stages of this review. This will ensure an appropriate search strategy and database selection is in place (Pollock et al., 2021).

Eligibility of population or types of participants: This review will consider studies which focus on registered nurses working in general practice and primary care contexts. When discussing general practice nursing in an international perspective it is important to note there is some lack of uniformity in nomenclature (Annells, 2007; Keleher et al., 2009). This lack of uniformity will be addressed by inclusion and recognition of the broad range of terms used internationally when referring to nurses working within general practice or alongside a general practitioner or within family practice. The scope of the review will be limited to use of metrics in general practice nursing and relevant primary care settings.

Concept: Nursing quality care metrics are measurements of the quality of nurse performance when providing care to patients. Aligned with care, process metrics are indicators which give a framework within which nursing care can be measured (Foulkes, 2011). For the purposes of this review, the definitions specific to QCM of nursing process and associated quality process indicators are as follows, “Quality Care Process Metric: is a quantifiable measure that captures the quality in terms of how (or to what extent) nursing care is being done in relation to an agreed standard. Quality indicators associated with metrics are the tools or flags which demonstrate implementation of the nursing process.” (Health Service Executive (2018) pp.15). Therefore, in the context of this proposed review, a QCM looks at how and what nursing care processes are being performed by GPNs and what associated indicators were used to measure this care.

Context, General practice setting: Remaining cognisant of the distinctions between primary care and general practice, but to ensure a comprehensive synthesis of the literature, this review will aim to identify a broad scope of peer reviewed literature both published and grey which addresses implementation of nursing QCM in general practice, or equivalent primary care settings. Selection will be limited to publications in the English language. Conference abstracts will be excluded due to their limited data. The inception of Irish general practice nursing roles began in 1989 with the introduction of a subsidy from government to General Practitioners to support their employment therefore this study will limit itself to literature published since 1989 (Department of Health, 1989). Table 1 details inclusion and exclusion criteria.

A three-step process as recommended by JBI will be implemented to carry out a comprehensive search of electronic databases, bibliographic references and grey literature in conjunction with a research librarian (Peters et al., 2020a).

Table 1. Inclusion and exclusion criteria.

GPN=general practice nurse.

Criterion	Inclusion Criteria	Exclusion Criteria	Rationale
Participants	Registered nurses working in general practice and /or equivalent primary Care settings	Non-registered nurses or midwives	The focus of the protocol is on nursing
Types of articles	Peer reviewed empirical research journal publications, editorials and commentary articles, grey literature, academic theses, dissertations, reports. Guidelines and policy documents from Government and recognised professional nursing and medical bodies.	Conference abstracts.	To ensure that an extensive search as is reasonable, of available literature has been carried out, in keeping with the ethos of scoping reviews.
Location	All geographical locations.	No restriction.	To examine information from a broad range of locations.
Time Period	Literature published since 1989.	Research published prior to 1989, the initiation of formalised GPN roles in Ireland.	To assess how developments in GPN care processes have evolved over time.
Language	English language.	Languages other than English.

Step one - carry out a preliminary search of the PubMed to identify papers relevant to the research question. Key words and search terms will be developed from this initial search and adapted to inform the final search strategy.
Step two – a second search across all electronic databases will be carried out using the final search term strategy adopted for each specific database.
Step three - This will be followed by a secondary search of the bibliographic references cited in the included studies.

Utilising the advice and collaboration of a research librarian it is proposed this review will search the following databases. These databases have been selected in view of their extensive repertoire and relevancy to nursing.

• Cochrane Database of Systematic Reviews
• PubMed, Biomedical and life sciences database
• CINAHL, Nursing and Allied Health (CINAHL Plus)
• InterNurse Journals
• OpenGrey

Stage 3: Study selection

An initial search of article titles and abstracts will be carried out by two researchers and a librarian to determine if the search critera captures data pertinent to the review question. Following this, any modifications to the search strategy will be agreed. Once the search process is completed the identified citations will be imported into the reference management system Endnote X9, with duplicates removed. This process will be guided by Peters (2017) stepwise method of source selection using Endnote. As described in Pollock et al. (2021) an ‘elaboration document’ detailing all included and excluded documents will be drafted to chart this process. Any discordance regarding article selection between initial researchers will be moderated by a third researcher who will review and advise on the articles eligibility for inclusion.

As JBI (Peters et al., 2020a) advises, pilot testing will be carried out prior to source selection the framework suggested is as follows.

• Random sample of 25 titles/abstracts is selected.
• The entire team screens these using the eligibility criteria and definitions/elaboration document.
• Team meets to discuss discrepancies and make modifications to the eligibility criteria and definitions/elaboration document.
• Team only starts screening when 75% (or greater) agreement is achieved.

In keeping with JBI guidance the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews checklist (PRISMA-ScR) will be used to report the process of study selection (Tricco et al., 2018).

Stage 4: Charting the data

In order to ensure selected articles are in keeping with inclusion and excluson criteria charting of data will be undertaken using a data extraction document as recomended by JBI (Peters et al., 2020a). This document will be created using Microsoft Excel software using the JBI data extraction tool template. It will be piloted for applicability to this study by two researchers and amended as necessary.

The proposed extraction document criteria for this study will include but will not be limited to the following: Article title; Authors; Journal; Publication date; Methodology; Location of Study; Population; Context; Concept and Key Findings applicable to review question identified? Examples of key finding would include, methods used to develop nursing metrics, characteristics of identified general practice nursing metrics, Impact on patient outcomes or health service delivery.

Stage 5: Collating, summarising, and reporting the results

Inconsistent approaches in reporting scoping review findings have been highlighted by Bradbury-Jones et al. (2021) who have addressed this issue by developing the PAGER framework for improving the quality of scoping review reporting. The acronym PAGER refers to Patterns, Advances, Gaps, Evidence for Practice and Research recommendations. Therefore, to ensure careful and complete reporting of findings this metodology will be applied to reporting of this review. Initially a ‘Patterning chart’ outlining key themes discovered during this review will be generated. Following on from this reflective questions posed for each domain will be utilised to amplify findings and strengthen the quality of reporting of this review. Extracted data will be described in a thematic narrative report also providing a numerical analysis of the extent and nature of the identified studies. Reporting of this scoping review will utilise the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR) (Tricco et al., 2018), and a flow diagram will also be produced to chart the process.

Study status

At the time of publication of this protocol the study is at Stage 2, piloting and refining of search terms have begun. Full database searches will begin during January 2022.

Discussion

The importance of reflecting on the rationale and motivation of any scoping study and not only the methodological process is highlighted by Levac et al. (2010). The key concept leading to this review is that nurses have an important, albeit hidden role in general practice. If the role is to be optimised analysis to clearly ascertain quality, value and outcomes is required. The literature on nurse QCM primarly focuses on inpatient or secondary care settings as Griffiths et al. (2008) has indicated, this review will provide insights into the use of nursing QCM within general practice, a primary care setting. This evidence synthesis will inform the next part of a research study, which is identification, development and refinement of relevant general practice nurse QCM. Dissemination of findings will contribute to the literature, and will be of value to nursing authorities, general practitioners, policy makers and academics who seek to develop and strengthen primary care. Findings of this scoping review will be submitted for publication in a peer reviewed journal, made available electronically and presented at conferences.

Data availability

No data are associated with this article.

Faculty Opinions recommended

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Version 2

VERSION 2 PUBLISHED 21 Jan 2022

Author details Author details

Orla Loftus Moran
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation

Mary Casey
Roles: Data Curation, Investigation, Methodology, Project Administration, Writing – Review & Editing

Laserina O'Connor
Roles: Supervision, Writing – Review & Editing

Walter Cullen
Roles: Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

version 2

Revised

Published: 14 Apr 2022, 5:10

https://doi.org/10.12688/hrbopenres.13483.2

version 1

Published: 21 Jan 2022, 5:10

https://doi.org/10.12688/hrbopenres.13483.1

© 2022 Loftus Moran O et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Loftus Moran O, Casey M, O'Connor L and Cullen W. Quality care metrics for nurses working in general practice, mapping the evidence: a scoping review protocol [version 1; peer review: 2 approved with reservations]. HRB Open Res 2022, 5:10 (https://doi.org/10.12688/hrbopenres.13483.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Open Peer Review

Version 1

VERSION 1

PUBLISHED 21 Jan 2022

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Reviewer Report 21 Mar 2022

Anne Parkinson, Department of Health Services Research and Policy, Australian National University, Acton, ACT, Australia

Approved with Reservations

https://doi.org/10.21956/hrbopenres.14701.r31645

This work aims to inform the development of quality care metrics (QCM) to measure the work of general practice nurses in Ireland. This is a novel application of QCM in Ireland. It has been adopted for use in acute care services, children’s services, intellectual disability services, older person services, mental health services, public health nursing services, and midwifery services, but not for general practice.

This is a topic of value as primary care is the foundation of a successful healthcare system and general practice plays an important role in providing care and support to a diverse range of patients and their families and carers. The expanding scope of general practice nurses in line with increasing workforce demands requires monitoring and assessment to ensure the quality of care.

A scoping review is an appropriate first step to inform how to target future research on this topic and determine if it is needed. The introduction reads well, however, it could benefit from expansion to briefly consider the international situation (role of GPNs) as you will be drawing on their experiences in your literature search.
In the Methods, I suggest you use the version of Arksey and O'Malley enhanced by Levac et al.¹ that adds a sixth step, consulting relevant stakeholders (e.g. GPNs), which adds to rigour. I find this can be valuable as it incorporates the expertise of stakeholders and aids validation of the findings. If you do this, you will need to identify stakeholders you plan to consult and how you will collect, analyse and integrate the data in your work.
There is no mention in the methods about the type of studies to be included (e.g qualitative, quantitative, mixed methods) and how you will determine whether to include a mixed-methods study. This needs further explanation in the manuscript.
Also, how will you assess the quality of included studies? For example, CASP for qualitative studies, MMAT for mixed-methods. There are many options. This needs further explanation in the manuscript.
I think it would be useful to reflect on the strengths and limitations of the study. For an example of a relevant protocol that incorporates this, see Jolley et al.².
Stage 5: typo “methodology”.
As per Reviewer 1, you might like to consider using Covidence software if you have access to it for organising your results and screening as it enables multiple reviewers to work together https://www.covidence.org/.
Study status: I find it a little odd that the study has begun as it is a protocol. I respect your honesty but it is confusing because you now have search terms finalised, etc.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

References

1. Levac D, Colquhoun H, O'Brien KK: Scoping studies: advancing the methodology.Implement Sci. 2010; 5: 69 PubMed Abstract | Publisher Full Text
2. Jolley R, Lorenzetti D, Manalili K, Lu M, et al.: Protocol for a scoping review study to identify and classify patient-centred quality indicators. BMJ Open. 2017; 7 (1). Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Health services research, primary care, patient and public involvement, co-production, health experience

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 14 Apr 2022

Orla Loftus Moran, General Practice, Castlebar Family Practice, Castlebar, Ireland

14 Apr 2022

Author Response

We are very grateful for your time and expertise in reviewing this scoping review protocol. Amendments have been made in view of your insight and suggestions. We have replied to ... Continue reading We are very grateful for your time and expertise in reviewing this scoping review protocol. Amendments have been made in view of your insight and suggestions. We have replied to your comments, numbered below.

1. The introduction reads well, however, it could benefit from expansion to briefly consider the international situation (role of GPNs) as you will be drawing on their experiences in your literature search.

Thank you for highlighting this, discussion and references regarding international studies have been included in the Introduction section of the review. We agree that this gives a broader understanding of the importance of the role and its relevance to changing healthcare policy focus worldwide. As outlined in a response to a previous review, international research draws attention to the positive impact and potential of the role, but also identifies barriers to progress and the need for research to inform the future of nursing in general practice.

2. In the Methods, I suggest you use the version of Arksey and O'Malley enhanced by Levac et al.1 that adds a sixth step, consulting relevant stakeholders (e.g. GPNs), which adds to rigour. I find this can be valuable as it incorporates the expertise of stakeholders and aids validation of the findings. If you do this, you will need to identify stakeholders you plan to consult and how you will collect, analyse and integrate the data in your work.

This is a very important aspect of the review that the research team considered at length. As the primary reviewer is self-funded and limited by resources and time due to clinical work commitments, it was agreed to continue with the 5 stage model for the protocol. This may be open to reevaluation when advancing to the full scoping review.

3. There is no mention in the methods about the type of studies to be included (e.g qualitative, quantitative, mixed methods) and how you will determine whether to include a mixed-methods study.

We propose to include the following types of study designs. Peer-reviewed empirical research, including qualitative, quantitative, mixed methods, and action research studies. This is appropriate to the broad nature of scoping reviews within which study quality or methodological limitations are usually not appraised¹. This is outlined in Table 1. Inclusion and exclusion criteria.

4. How will you assess the quality of included studies?

It is our understanding that scoping reviews do not seek to report on the quality of evidence as reported by Munn¹ and referred to in point 3 above. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

5. It is useful to reflect on the strengths and limitations of the study.

We have included reflections on the strengths and limitations of this protocol in the discussion section of the document.

6. Stage 5: typo “methodology”.

Thank you – this is corrected.

7. Consider using Covidence software?

We have now proposed the use of Covidence, this is referenced in the ‘Stage 3: Study selection’ section of the document.

8. I find it a little odd that the study has begun as it is a protocol. I respect your honesty, but it is confusing because you now have search terms finalised, etc

Apologies for any confusion caused regarding the stage of the study. The review is currently in a preliminary phase; to date refinement of the scoping document based on reviewer commentary is being undertaken. Liaison is taking place with a librarian and piloting of search terms is being carried out to ensure an appropriate search strategy is in place for the full review.

References.
1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.
We are very grateful for your time and expertise in reviewing this scoping review protocol. Amendments have been made in view of your insight and suggestions. We have replied to your comments, numbered below.

1. The introduction reads well, however, it could benefit from expansion to briefly consider the international situation (role of GPNs) as you will be drawing on their experiences in your literature search.

Thank you for highlighting this, discussion and references regarding international studies have been included in the Introduction section of the review. We agree that this gives a broader understanding of the importance of the role and its relevance to changing healthcare policy focus worldwide. As outlined in a response to a previous review, international research draws attention to the positive impact and potential of the role, but also identifies barriers to progress and the need for research to inform the future of nursing in general practice.

2. In the Methods, I suggest you use the version of Arksey and O'Malley enhanced by Levac et al.1 that adds a sixth step, consulting relevant stakeholders (e.g. GPNs), which adds to rigour. I find this can be valuable as it incorporates the expertise of stakeholders and aids validation of the findings. If you do this, you will need to identify stakeholders you plan to consult and how you will collect, analyse and integrate the data in your work.

This is a very important aspect of the review that the research team considered at length. As the primary reviewer is self-funded and limited by resources and time due to clinical work commitments, it was agreed to continue with the 5 stage model for the protocol. This may be open to reevaluation when advancing to the full scoping review.

3. There is no mention in the methods about the type of studies to be included (e.g qualitative, quantitative, mixed methods) and how you will determine whether to include a mixed-methods study.

We propose to include the following types of study designs. Peer-reviewed empirical research, including qualitative, quantitative, mixed methods, and action research studies. This is appropriate to the broad nature of scoping reviews within which study quality or methodological limitations are usually not appraised¹. This is outlined in Table 1. Inclusion and exclusion criteria.

4. How will you assess the quality of included studies?

It is our understanding that scoping reviews do not seek to report on the quality of evidence as reported by Munn¹ and referred to in point 3 above. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

5. It is useful to reflect on the strengths and limitations of the study.

We have included reflections on the strengths and limitations of this protocol in the discussion section of the document.

6. Stage 5: typo “methodology”.

Thank you – this is corrected.

7. Consider using Covidence software?

We have now proposed the use of Covidence, this is referenced in the ‘Stage 3: Study selection’ section of the document.

8. I find it a little odd that the study has begun as it is a protocol. I respect your honesty, but it is confusing because you now have search terms finalised, etc

Apologies for any confusion caused regarding the stage of the study. The review is currently in a preliminary phase; to date refinement of the scoping document based on reviewer commentary is being undertaken. Liaison is taking place with a librarian and piloting of search terms is being carried out to ensure an appropriate search strategy is in place for the full review.

References.
1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.
Competing Interests: No competing interests declared. Close
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COMMENTS ON THIS REPORT

Author Response 14 Apr 2022

Orla Loftus Moran, General Practice, Castlebar Family Practice, Castlebar, Ireland

14 Apr 2022

Author Response

We are very grateful for your time and expertise in reviewing this scoping review protocol. Amendments have been made in view of your insight and suggestions. We have replied to ... Continue reading We are very grateful for your time and expertise in reviewing this scoping review protocol. Amendments have been made in view of your insight and suggestions. We have replied to your comments, numbered below.

1. The introduction reads well, however, it could benefit from expansion to briefly consider the international situation (role of GPNs) as you will be drawing on their experiences in your literature search.

Thank you for highlighting this, discussion and references regarding international studies have been included in the Introduction section of the review. We agree that this gives a broader understanding of the importance of the role and its relevance to changing healthcare policy focus worldwide. As outlined in a response to a previous review, international research draws attention to the positive impact and potential of the role, but also identifies barriers to progress and the need for research to inform the future of nursing in general practice.

2. In the Methods, I suggest you use the version of Arksey and O'Malley enhanced by Levac et al.1 that adds a sixth step, consulting relevant stakeholders (e.g. GPNs), which adds to rigour. I find this can be valuable as it incorporates the expertise of stakeholders and aids validation of the findings. If you do this, you will need to identify stakeholders you plan to consult and how you will collect, analyse and integrate the data in your work.

This is a very important aspect of the review that the research team considered at length. As the primary reviewer is self-funded and limited by resources and time due to clinical work commitments, it was agreed to continue with the 5 stage model for the protocol. This may be open to reevaluation when advancing to the full scoping review.

3. There is no mention in the methods about the type of studies to be included (e.g qualitative, quantitative, mixed methods) and how you will determine whether to include a mixed-methods study.

We propose to include the following types of study designs. Peer-reviewed empirical research, including qualitative, quantitative, mixed methods, and action research studies. This is appropriate to the broad nature of scoping reviews within which study quality or methodological limitations are usually not appraised¹. This is outlined in Table 1. Inclusion and exclusion criteria.

4. How will you assess the quality of included studies?

It is our understanding that scoping reviews do not seek to report on the quality of evidence as reported by Munn¹ and referred to in point 3 above. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

5. It is useful to reflect on the strengths and limitations of the study.

We have included reflections on the strengths and limitations of this protocol in the discussion section of the document.

6. Stage 5: typo “methodology”.

Thank you – this is corrected.

7. Consider using Covidence software?

We have now proposed the use of Covidence, this is referenced in the ‘Stage 3: Study selection’ section of the document.

8. I find it a little odd that the study has begun as it is a protocol. I respect your honesty, but it is confusing because you now have search terms finalised, etc

Apologies for any confusion caused regarding the stage of the study. The review is currently in a preliminary phase; to date refinement of the scoping document based on reviewer commentary is being undertaken. Liaison is taking place with a librarian and piloting of search terms is being carried out to ensure an appropriate search strategy is in place for the full review.

References.
1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.
We are very grateful for your time and expertise in reviewing this scoping review protocol. Amendments have been made in view of your insight and suggestions. We have replied to your comments, numbered below.

1. The introduction reads well, however, it could benefit from expansion to briefly consider the international situation (role of GPNs) as you will be drawing on their experiences in your literature search.

Thank you for highlighting this, discussion and references regarding international studies have been included in the Introduction section of the review. We agree that this gives a broader understanding of the importance of the role and its relevance to changing healthcare policy focus worldwide. As outlined in a response to a previous review, international research draws attention to the positive impact and potential of the role, but also identifies barriers to progress and the need for research to inform the future of nursing in general practice.

2. In the Methods, I suggest you use the version of Arksey and O'Malley enhanced by Levac et al.1 that adds a sixth step, consulting relevant stakeholders (e.g. GPNs), which adds to rigour. I find this can be valuable as it incorporates the expertise of stakeholders and aids validation of the findings. If you do this, you will need to identify stakeholders you plan to consult and how you will collect, analyse and integrate the data in your work.

This is a very important aspect of the review that the research team considered at length. As the primary reviewer is self-funded and limited by resources and time due to clinical work commitments, it was agreed to continue with the 5 stage model for the protocol. This may be open to reevaluation when advancing to the full scoping review.

3. There is no mention in the methods about the type of studies to be included (e.g qualitative, quantitative, mixed methods) and how you will determine whether to include a mixed-methods study.

We propose to include the following types of study designs. Peer-reviewed empirical research, including qualitative, quantitative, mixed methods, and action research studies. This is appropriate to the broad nature of scoping reviews within which study quality or methodological limitations are usually not appraised¹. This is outlined in Table 1. Inclusion and exclusion criteria.

4. How will you assess the quality of included studies?

It is our understanding that scoping reviews do not seek to report on the quality of evidence as reported by Munn¹ and referred to in point 3 above. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

5. It is useful to reflect on the strengths and limitations of the study.

We have included reflections on the strengths and limitations of this protocol in the discussion section of the document.

6. Stage 5: typo “methodology”.

Thank you – this is corrected.

7. Consider using Covidence software?

We have now proposed the use of Covidence, this is referenced in the ‘Stage 3: Study selection’ section of the document.

8. I find it a little odd that the study has begun as it is a protocol. I respect your honesty, but it is confusing because you now have search terms finalised, etc

Apologies for any confusion caused regarding the stage of the study. The review is currently in a preliminary phase; to date refinement of the scoping document based on reviewer commentary is being undertaken. Liaison is taking place with a librarian and piloting of search terms is being carried out to ensure an appropriate search strategy is in place for the full review.

References.
1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.
Competing Interests: No competing interests declared. Close
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Reviewer Report 22 Feb 2022

Julia Lukewich, Faculty of Nursing, Memorial University, Newfoundland, Canada

Approved with Reservations

https://doi.org/10.21956/hrbopenres.14701.r31343

This is a novel and important scoping review which aims to inform development of quality care metrics (QCM) within Irish general practice settings.

This is a topic that will be attractive to an international reader. Within

This is a novel and important scoping review which aims to inform development of quality care metrics (QCM) within Irish general practice settings.

This is a topic that will be attractive to an international reader. Within your Introduction, please broaden the discussion beyond Irish general practice/GPNs, e.g. what about this role in other countries such as Australia, Canada, New Zealand?
Within abstract, if there is space within journal guidelines/word restrictions, additional details regarding the methods should be provided, e.g. anticipated date of search.
Is there a difference between ‘quality care process metrics’ and ‘QCM’? These are both used interchangeably in the manuscript. I recommend being consistent.
With respect to your search strategy, did you consider search PsycINFO, Embase, Joanna Briggs Institute (JBI) Library of Systematic Reviews, and/or ProQuest Dissertations and Theses? It is possible that relevant nursing literature might be located within these databases. Will you conduct key author/journal searches?
Under ‘Eligibility of population or types of participants’, Barret et al.'s (2021¹) article may be useful when discussing lack of uniformity in nomenclature.
What types of study designs are considered for inclusion? You mention broad scope of peer reviewed literature and that conference abstracts will be excluded. However, I do not see anything specifically referring to study type/design.
Are you able to provide examples of quality care metrics?
Please clarify if advanced practice nurses/nurse practitioners or other classes of registered nursing are included/excluded within your review.
One of your objectives is to examine the use of QCM in providing advantages for patient outcomes and/or service delivery – however, your inclusion/exclusion criteria do not include anything related to reporting of outcomes within studies. Also, wouldn't this objective lend itself to a systematic review rather then a scoping review?
Have you considered using Covidence (or similar software) to manage references/screening process?
Please comment on how the quality of studies will be assessed.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Partly
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

References

1. Barrett C, Mathews M, Poitras M, Norful A, et al.: Job titles and education requirements of registered nurses in primary care: An international document analysis. International Journal of Nursing Studies Advances. 2021; 3. Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Primary care/family practice nursing

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Report a concern

Author Response 14 Apr 2022

Orla Loftus Moran, General Practice, Castlebar Family Practice, Castlebar, Ireland

14 Apr 2022

Author Response

We are very grateful for your time and expertise in reviewing our scoping review protocol, your critique is constructive and valuable. The scoping review has been revised in response to ... Continue reading We are very grateful for your time and expertise in reviewing our scoping review protocol, your critique is constructive and valuable. The scoping review has been revised in response to your review. We have replied to your comments, numbered below.

1. Within your Introduction, please broaden the discussion beyond Irish general practice/GPNs, e.g. what about this role in other countries such as Australia, Canada, New Zealand?

Your suggestion to broaden the discussion to include an international context has strengthened the arguments in favour of carrying out this review. The international dimension has been addressed in the Introduction section with the addition of relevant articles which outline important findings regarding general practice nursing. This research draws attention to the positive impact and potential of the role, but also identifies barriers to progress. These studies highlight many common themes of an impactful but invisible, undervalued workforce, requiring leadership and robust research which will inform policymakers and healthcare strategists.

2. Within abstract, if there is space within journal guidelines/word restrictions, additional details regarding the methods should be provided, e.g. anticipated date of search

Unfortunately, the constraints of the word count preclude this.

3. Is there a difference between ‘quality care process metrics’ and ‘QCM’? These are both used interchangeably in the manuscript.

Thank you for noting this. Quality care metrics is a broad term that may include three types of healthcare quality assessment: structure, process, and outcomes. This is discussed in the ‘Nursing Quality Care Process Metrics’ section of the review. Quality care process metrics (QCP-Ms) measure specifically the quality of care delivered by nurses. This concept has now been clarified, addressed, and integrated into the title and throughout the document. A working definition of quality care process metrics (QCP-Ms) is included within the ‘Stage 2: Identifying the relevant studies, Concept’ section of the document.

4. With respect to your search strategy, did you consider search PsycINFO, Embase, Joanna Briggs Institute (JBI) Library of Systematic Reviews, and/or ProQuest Dissertations and Theses?

As a self-funded researcher, limitations of resources & time would not allow searching all these databases; however, we have included Embase and Web of Science. Cochrane database is indexed on PubMed and Web of Science, therefore any relevant studies will be identified within these databases and included in the review.

5. Will you conduct key author/journal searches?

Yes, reference to this is included in section ‘Stage 2: Identifying the relevant studies’.

6. Under ‘Eligibility of population or types of participants’, Barret et al.'s (2021) article may be useful when discussing lack of uniformity in nomenclature.

Thank you for highlighting this excellent, research paper. Findings from this paper have been integrated and included within the ‘Eligibility of population or types of participants’ section of the review.

7. What types of study designs are considered for inclusion?

We have now clarified and will include the following types of study designs. All peer review empirical research, qualitative, quantitative, mixed methods, and action research studies will be included in this review. See Table 1. Inclusion and exclusion criteria.

8. Are you able to provide examples of quality care metrics?

Thank you for this suggestion. We have in version 2 of the review. We included examples of quality care metrics from public health nursing which may be relevant to general practice nursing. We have also included examples of metrics developed for ambulatory care nurses in the USA. See the section titled ‘Nursing Quality Care Process Metrics’.

9. Please clarify if advanced practice nurses/nurse practitioners or other classes of registered nursing are included/excluded within your review.

Research involving all classes of registered nurses will be included in this scoping review, including advanced nurse practitioners. This is now clarified in the ‘Eligibility of population or types of participants’ section.

10. One of your objectives is to examine the use of QCM in providing advantages for patient outcomes and/or service delivery – however, your inclusion/exclusion criteria do not include anything related to reporting of outcomes within studies. Also, wouldn't this objective lend itself to a systematic review rather than a scoping review?

Thank you for highlighting the potential difficulties surrounding reporting outcomes in this scoping review. We have considered your comments and agree with your observations re scoping v systematic review. Therefore outcome reporting has been omitted from the objectives of this review.

11. Have you considered using Covidence?

We will use Covidence, and this is referred to in the ‘Stage 3: Study selection’ section of the document.

12. Please comment on how the quality of studies will be assessed.

It is our understanding that scoping reviews aim to map the extent of evidence and do not seek to report on the quality of evidence as referred to by Munn¹. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

References.

1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.
We are very grateful for your time and expertise in reviewing our scoping review protocol, your critique is constructive and valuable. The scoping review has been revised in response to your review. We have replied to your comments, numbered below.

1. Within your Introduction, please broaden the discussion beyond Irish general practice/GPNs, e.g. what about this role in other countries such as Australia, Canada, New Zealand?

Your suggestion to broaden the discussion to include an international context has strengthened the arguments in favour of carrying out this review. The international dimension has been addressed in the Introduction section with the addition of relevant articles which outline important findings regarding general practice nursing. This research draws attention to the positive impact and potential of the role, but also identifies barriers to progress. These studies highlight many common themes of an impactful but invisible, undervalued workforce, requiring leadership and robust research which will inform policymakers and healthcare strategists.

2. Within abstract, if there is space within journal guidelines/word restrictions, additional details regarding the methods should be provided, e.g. anticipated date of search

Unfortunately, the constraints of the word count preclude this.

3. Is there a difference between ‘quality care process metrics’ and ‘QCM’? These are both used interchangeably in the manuscript.

Thank you for noting this. Quality care metrics is a broad term that may include three types of healthcare quality assessment: structure, process, and outcomes. This is discussed in the ‘Nursing Quality Care Process Metrics’ section of the review. Quality care process metrics (QCP-Ms) measure specifically the quality of care delivered by nurses. This concept has now been clarified, addressed, and integrated into the title and throughout the document. A working definition of quality care process metrics (QCP-Ms) is included within the ‘Stage 2: Identifying the relevant studies, Concept’ section of the document.

4. With respect to your search strategy, did you consider search PsycINFO, Embase, Joanna Briggs Institute (JBI) Library of Systematic Reviews, and/or ProQuest Dissertations and Theses?

As a self-funded researcher, limitations of resources & time would not allow searching all these databases; however, we have included Embase and Web of Science. Cochrane database is indexed on PubMed and Web of Science, therefore any relevant studies will be identified within these databases and included in the review.

5. Will you conduct key author/journal searches?

Yes, reference to this is included in section ‘Stage 2: Identifying the relevant studies’.

6. Under ‘Eligibility of population or types of participants’, Barret et al.'s (2021) article may be useful when discussing lack of uniformity in nomenclature.

Thank you for highlighting this excellent, research paper. Findings from this paper have been integrated and included within the ‘Eligibility of population or types of participants’ section of the review.

7. What types of study designs are considered for inclusion?

We have now clarified and will include the following types of study designs. All peer review empirical research, qualitative, quantitative, mixed methods, and action research studies will be included in this review. See Table 1. Inclusion and exclusion criteria.

8. Are you able to provide examples of quality care metrics?

Thank you for this suggestion. We have in version 2 of the review. We included examples of quality care metrics from public health nursing which may be relevant to general practice nursing. We have also included examples of metrics developed for ambulatory care nurses in the USA. See the section titled ‘Nursing Quality Care Process Metrics’.

9. Please clarify if advanced practice nurses/nurse practitioners or other classes of registered nursing are included/excluded within your review.

Research involving all classes of registered nurses will be included in this scoping review, including advanced nurse practitioners. This is now clarified in the ‘Eligibility of population or types of participants’ section.

10. One of your objectives is to examine the use of QCM in providing advantages for patient outcomes and/or service delivery – however, your inclusion/exclusion criteria do not include anything related to reporting of outcomes within studies. Also, wouldn't this objective lend itself to a systematic review rather than a scoping review?

Thank you for highlighting the potential difficulties surrounding reporting outcomes in this scoping review. We have considered your comments and agree with your observations re scoping v systematic review. Therefore outcome reporting has been omitted from the objectives of this review.

11. Have you considered using Covidence?

We will use Covidence, and this is referred to in the ‘Stage 3: Study selection’ section of the document.

12. Please comment on how the quality of studies will be assessed.

It is our understanding that scoping reviews aim to map the extent of evidence and do not seek to report on the quality of evidence as referred to by Munn¹. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

References.

1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.
Competing Interests: No competing interests to declare. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 14 Apr 2022

Orla Loftus Moran, General Practice, Castlebar Family Practice, Castlebar, Ireland

14 Apr 2022

Author Response

We are very grateful for your time and expertise in reviewing our scoping review protocol, your critique is constructive and valuable. The scoping review has been revised in response to ... Continue reading We are very grateful for your time and expertise in reviewing our scoping review protocol, your critique is constructive and valuable. The scoping review has been revised in response to your review. We have replied to your comments, numbered below.

1. Within your Introduction, please broaden the discussion beyond Irish general practice/GPNs, e.g. what about this role in other countries such as Australia, Canada, New Zealand?

Your suggestion to broaden the discussion to include an international context has strengthened the arguments in favour of carrying out this review. The international dimension has been addressed in the Introduction section with the addition of relevant articles which outline important findings regarding general practice nursing. This research draws attention to the positive impact and potential of the role, but also identifies barriers to progress. These studies highlight many common themes of an impactful but invisible, undervalued workforce, requiring leadership and robust research which will inform policymakers and healthcare strategists.

2. Within abstract, if there is space within journal guidelines/word restrictions, additional details regarding the methods should be provided, e.g. anticipated date of search

Unfortunately, the constraints of the word count preclude this.

3. Is there a difference between ‘quality care process metrics’ and ‘QCM’? These are both used interchangeably in the manuscript.

Thank you for noting this. Quality care metrics is a broad term that may include three types of healthcare quality assessment: structure, process, and outcomes. This is discussed in the ‘Nursing Quality Care Process Metrics’ section of the review. Quality care process metrics (QCP-Ms) measure specifically the quality of care delivered by nurses. This concept has now been clarified, addressed, and integrated into the title and throughout the document. A working definition of quality care process metrics (QCP-Ms) is included within the ‘Stage 2: Identifying the relevant studies, Concept’ section of the document.

4. With respect to your search strategy, did you consider search PsycINFO, Embase, Joanna Briggs Institute (JBI) Library of Systematic Reviews, and/or ProQuest Dissertations and Theses?

As a self-funded researcher, limitations of resources & time would not allow searching all these databases; however, we have included Embase and Web of Science. Cochrane database is indexed on PubMed and Web of Science, therefore any relevant studies will be identified within these databases and included in the review.

5. Will you conduct key author/journal searches?

Yes, reference to this is included in section ‘Stage 2: Identifying the relevant studies’.

6. Under ‘Eligibility of population or types of participants’, Barret et al.'s (2021) article may be useful when discussing lack of uniformity in nomenclature.

Thank you for highlighting this excellent, research paper. Findings from this paper have been integrated and included within the ‘Eligibility of population or types of participants’ section of the review.

7. What types of study designs are considered for inclusion?

We have now clarified and will include the following types of study designs. All peer review empirical research, qualitative, quantitative, mixed methods, and action research studies will be included in this review. See Table 1. Inclusion and exclusion criteria.

8. Are you able to provide examples of quality care metrics?

Thank you for this suggestion. We have in version 2 of the review. We included examples of quality care metrics from public health nursing which may be relevant to general practice nursing. We have also included examples of metrics developed for ambulatory care nurses in the USA. See the section titled ‘Nursing Quality Care Process Metrics’.

9. Please clarify if advanced practice nurses/nurse practitioners or other classes of registered nursing are included/excluded within your review.

Research involving all classes of registered nurses will be included in this scoping review, including advanced nurse practitioners. This is now clarified in the ‘Eligibility of population or types of participants’ section.

10. One of your objectives is to examine the use of QCM in providing advantages for patient outcomes and/or service delivery – however, your inclusion/exclusion criteria do not include anything related to reporting of outcomes within studies. Also, wouldn't this objective lend itself to a systematic review rather than a scoping review?

Thank you for highlighting the potential difficulties surrounding reporting outcomes in this scoping review. We have considered your comments and agree with your observations re scoping v systematic review. Therefore outcome reporting has been omitted from the objectives of this review.

11. Have you considered using Covidence?

We will use Covidence, and this is referred to in the ‘Stage 3: Study selection’ section of the document.

12. Please comment on how the quality of studies will be assessed.

It is our understanding that scoping reviews aim to map the extent of evidence and do not seek to report on the quality of evidence as referred to by Munn¹. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

References.

1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.
We are very grateful for your time and expertise in reviewing our scoping review protocol, your critique is constructive and valuable. The scoping review has been revised in response to your review. We have replied to your comments, numbered below.

1. Within your Introduction, please broaden the discussion beyond Irish general practice/GPNs, e.g. what about this role in other countries such as Australia, Canada, New Zealand?

Your suggestion to broaden the discussion to include an international context has strengthened the arguments in favour of carrying out this review. The international dimension has been addressed in the Introduction section with the addition of relevant articles which outline important findings regarding general practice nursing. This research draws attention to the positive impact and potential of the role, but also identifies barriers to progress. These studies highlight many common themes of an impactful but invisible, undervalued workforce, requiring leadership and robust research which will inform policymakers and healthcare strategists.

2. Within abstract, if there is space within journal guidelines/word restrictions, additional details regarding the methods should be provided, e.g. anticipated date of search

Unfortunately, the constraints of the word count preclude this.

3. Is there a difference between ‘quality care process metrics’ and ‘QCM’? These are both used interchangeably in the manuscript.

Thank you for noting this. Quality care metrics is a broad term that may include three types of healthcare quality assessment: structure, process, and outcomes. This is discussed in the ‘Nursing Quality Care Process Metrics’ section of the review. Quality care process metrics (QCP-Ms) measure specifically the quality of care delivered by nurses. This concept has now been clarified, addressed, and integrated into the title and throughout the document. A working definition of quality care process metrics (QCP-Ms) is included within the ‘Stage 2: Identifying the relevant studies, Concept’ section of the document.

4. With respect to your search strategy, did you consider search PsycINFO, Embase, Joanna Briggs Institute (JBI) Library of Systematic Reviews, and/or ProQuest Dissertations and Theses?

As a self-funded researcher, limitations of resources & time would not allow searching all these databases; however, we have included Embase and Web of Science. Cochrane database is indexed on PubMed and Web of Science, therefore any relevant studies will be identified within these databases and included in the review.

5. Will you conduct key author/journal searches?

Yes, reference to this is included in section ‘Stage 2: Identifying the relevant studies’.

6. Under ‘Eligibility of population or types of participants’, Barret et al.'s (2021) article may be useful when discussing lack of uniformity in nomenclature.

Thank you for highlighting this excellent, research paper. Findings from this paper have been integrated and included within the ‘Eligibility of population or types of participants’ section of the review.

7. What types of study designs are considered for inclusion?

We have now clarified and will include the following types of study designs. All peer review empirical research, qualitative, quantitative, mixed methods, and action research studies will be included in this review. See Table 1. Inclusion and exclusion criteria.

8. Are you able to provide examples of quality care metrics?

Thank you for this suggestion. We have in version 2 of the review. We included examples of quality care metrics from public health nursing which may be relevant to general practice nursing. We have also included examples of metrics developed for ambulatory care nurses in the USA. See the section titled ‘Nursing Quality Care Process Metrics’.

9. Please clarify if advanced practice nurses/nurse practitioners or other classes of registered nursing are included/excluded within your review.

Research involving all classes of registered nurses will be included in this scoping review, including advanced nurse practitioners. This is now clarified in the ‘Eligibility of population or types of participants’ section.

10. One of your objectives is to examine the use of QCM in providing advantages for patient outcomes and/or service delivery – however, your inclusion/exclusion criteria do not include anything related to reporting of outcomes within studies. Also, wouldn't this objective lend itself to a systematic review rather than a scoping review?

Thank you for highlighting the potential difficulties surrounding reporting outcomes in this scoping review. We have considered your comments and agree with your observations re scoping v systematic review. Therefore outcome reporting has been omitted from the objectives of this review.

11. Have you considered using Covidence?

We will use Covidence, and this is referred to in the ‘Stage 3: Study selection’ section of the document.

12. Please comment on how the quality of studies will be assessed.

It is our understanding that scoping reviews aim to map the extent of evidence and do not seek to report on the quality of evidence as referred to by Munn¹. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

References.

1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.
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VERSION 2 PUBLISHED 21 Jan 2022

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Julia Lukewich, Memorial University, Newfoundland, Canada
Anne Parkinson, Australian National University, Acton, Australia

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Reviewer Report

25 Views

21 Apr 2022 | for Version 2

Julia Lukewich, Faculty of Nursing, Memorial University, Newfoundland, Canada

25 Views Cite this report Responses(0)

Approved

Revisions are appropriate.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Primary care/family practice nursing

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

23 Views

20 Apr 2022 | for Version 2

Anne Parkinson, Department of Health Services Research and Policy, Australian National University, Acton, ACT, Australia

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Approved

The authors have adequately addressed my comments and justified their reasoning. As always, resources determine what can and cannot be done with regard to research and choices must always be made. I believe the paper is much improved after peer review and am happy to recommend the paper be indexed in its current form.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Health services research, primary care, patient and public involvement, co-production, health experience

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

54 Views

21 Mar 2022 | for Version 1

Anne Parkinson, Department of Health Services Research and Policy, Australian National University, Acton, ACT, Australia

54 Views Cite this report Responses(1)

Approved With Reservations

A scoping review is an appropriate first step to inform how to target future research on this topic and determine if it is needed. The introduction reads well, however, it could benefit from expansion to briefly consider the international situation (role of GPNs) as you will be drawing on their experiences in your literature search.
In the Methods, I suggest you use the version of Arksey and O'Malley enhanced by Levac et al.¹ that adds a sixth step, consulting relevant stakeholders (e.g. GPNs), which adds to rigour. I find this can be valuable as it incorporates the expertise of stakeholders and aids validation of the findings. If you do this, you will need to identify stakeholders you plan to consult and how you will collect, analyse and integrate the data in your work.
There is no mention in the methods about the type of studies to be included (e.g qualitative, quantitative, mixed methods) and how you will determine whether to include a mixed-methods study. This needs further explanation in the manuscript.
Also, how will you assess the quality of included studies? For example, CASP for qualitative studies, MMAT for mixed-methods. There are many options. This needs further explanation in the manuscript.
I think it would be useful to reflect on the strengths and limitations of the study. For an example of a relevant protocol that incorporates this, see Jolley et al.².
Stage 5: typo “methodology”.
As per Reviewer 1, you might like to consider using Covidence software if you have access to it for organising your results and screening as it enables multiple reviewers to work together https://www.covidence.org/.
Study status: I find it a little odd that the study has begun as it is a protocol. I respect your honesty but it is confusing because you now have search terms finalised, etc.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Health services research, primary care, patient and public involvement, co-production, health experience

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Author Response

14 Apr 2022

Orla Loftus Moran, General Practice, Castlebar Family Practice, Castlebar, Ireland

We are very grateful for your time and expertise in reviewing this scoping review protocol. Amendments have been made in view of your insight and suggestions. We have replied to your comments, numbered below.

1. The introduction reads well, however, it could benefit from expansion to briefly consider the international situation (role of GPNs) as you will be drawing on their experiences in your literature search.

Thank you for highlighting this, discussion and references regarding international studies have been included in the Introduction section of the review. We agree that this gives a broader understanding of the importance of the role and its relevance to changing healthcare policy focus worldwide. As outlined in a response to a previous review, international research draws attention to the positive impact and potential of the role, but also identifies barriers to progress and the need for research to inform the future of nursing in general practice.

2. In the Methods, I suggest you use the version of Arksey and O'Malley enhanced by Levac et al.1 that adds a sixth step, consulting relevant stakeholders (e.g. GPNs), which adds to rigour. I find this can be valuable as it incorporates the expertise of stakeholders and aids validation of the findings. If you do this, you will need to identify stakeholders you plan to consult and how you will collect, analyse and integrate the data in your work.

This is a very important aspect of the review that the research team considered at length. As the primary reviewer is self-funded and limited by resources and time due to clinical work commitments, it was agreed to continue with the 5 stage model for the protocol. This may be open to reevaluation when advancing to the full scoping review.

3. There is no mention in the methods about the type of studies to be included (e.g qualitative, quantitative, mixed methods) and how you will determine whether to include a mixed-methods study.

We propose to include the following types of study designs. Peer-reviewed empirical research, including qualitative, quantitative, mixed methods, and action research studies. This is appropriate to the broad nature of scoping reviews within which study quality or methodological limitations are usually not appraised¹. This is outlined in Table 1. Inclusion and exclusion criteria.

4. How will you assess the quality of included studies?

It is our understanding that scoping reviews do not seek to report on the quality of evidence as reported by Munn¹ and referred to in point 3 above. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

5. It is useful to reflect on the strengths and limitations of the study.

We have included reflections on the strengths and limitations of this protocol in the discussion section of the document.

6. Stage 5: typo “methodology”.

Thank you – this is corrected.

7. Consider using Covidence software?

We have now proposed the use of Covidence, this is referenced in the ‘Stage 3: Study selection’ section of the document.

8. I find it a little odd that the study has begun as it is a protocol. I respect your honesty, but it is confusing because you now have search terms finalised, etc

Apologies for any confusion caused regarding the stage of the study. The review is currently in a preliminary phase; to date refinement of the scoping document based on reviewer commentary is being undertaken. Liaison is taking place with a librarian and piloting of search terms is being carried out to ensure an appropriate search strategy is in place for the full review.

References.
1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.

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Competing Interests

No competing interests declared.

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Reviewer Report

61 Views

22 Feb 2022 | for Version 1

Julia Lukewich, Faculty of Nursing, Memorial University, Newfoundland, Canada

61 Views Cite this report Responses(1)

Approved With Reservations

This is a novel and important scoping review which aims to inform development of quality care metrics (QCM) within Irish general practice settings.

This is a topic that will be attractive to an international reader. Within your Introduction, please broaden the discussion beyond Irish general practice/GPNs, e.g. what about this role in other countries such as Australia, Canada, New Zealand?
Within abstract, if there is space within journal guidelines/word restrictions, additional details regarding the methods should be provided, e.g. anticipated date of search.
Is there a difference between ‘quality care process metrics’ and ‘QCM’? These are both used interchangeably in the manuscript. I recommend being consistent.
With respect to your search strategy, did you consider search PsycINFO, Embase, Joanna Briggs Institute (JBI) Library of Systematic Reviews, and/or ProQuest Dissertations and Theses? It is possible that relevant nursing literature might be located within these databases. Will you conduct key author/journal searches?
Under ‘Eligibility of population or types of participants’, Barret et al.'s (2021¹) article may be useful when discussing lack of uniformity in nomenclature.
What types of study designs are considered for inclusion? You mention broad scope of peer reviewed literature and that conference abstracts will be excluded. However, I do not see anything specifically referring to study type/design.
Are you able to provide examples of quality care metrics?
Please clarify if advanced practice nurses/nurse practitioners or other classes of registered nursing are included/excluded within your review.
One of your objectives is to examine the use of QCM in providing advantages for patient outcomes and/or service delivery – however, your inclusion/exclusion criteria do not include anything related to reporting of outcomes within studies. Also, wouldn't this objective lend itself to a systematic review rather then a scoping review?
Have you considered using Covidence (or similar software) to manage references/screening process?
Please comment on how the quality of studies will be assessed.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Partly
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Primary care/family practice nursing

Respond to this report

Responses (1)

Author Response

14 Apr 2022

Orla Loftus Moran, General Practice, Castlebar Family Practice, Castlebar, Ireland

We are very grateful for your time and expertise in reviewing our scoping review protocol, your critique is constructive and valuable. The scoping review has been revised in response to your review. We have replied to your comments, numbered below.

1. Within your Introduction, please broaden the discussion beyond Irish general practice/GPNs, e.g. what about this role in other countries such as Australia, Canada, New Zealand?

Your suggestion to broaden the discussion to include an international context has strengthened the arguments in favour of carrying out this review. The international dimension has been addressed in the Introduction section with the addition of relevant articles which outline important findings regarding general practice nursing. This research draws attention to the positive impact and potential of the role, but also identifies barriers to progress. These studies highlight many common themes of an impactful but invisible, undervalued workforce, requiring leadership and robust research which will inform policymakers and healthcare strategists.

2. Within abstract, if there is space within journal guidelines/word restrictions, additional details regarding the methods should be provided, e.g. anticipated date of search

Unfortunately, the constraints of the word count preclude this.

3. Is there a difference between ‘quality care process metrics’ and ‘QCM’? These are both used interchangeably in the manuscript.

Thank you for noting this. Quality care metrics is a broad term that may include three types of healthcare quality assessment: structure, process, and outcomes. This is discussed in the ‘Nursing Quality Care Process Metrics’ section of the review. Quality care process metrics (QCP-Ms) measure specifically the quality of care delivered by nurses. This concept has now been clarified, addressed, and integrated into the title and throughout the document. A working definition of quality care process metrics (QCP-Ms) is included within the ‘Stage 2: Identifying the relevant studies, Concept’ section of the document.

4. With respect to your search strategy, did you consider search PsycINFO, Embase, Joanna Briggs Institute (JBI) Library of Systematic Reviews, and/or ProQuest Dissertations and Theses?

As a self-funded researcher, limitations of resources & time would not allow searching all these databases; however, we have included Embase and Web of Science. Cochrane database is indexed on PubMed and Web of Science, therefore any relevant studies will be identified within these databases and included in the review.

5. Will you conduct key author/journal searches?

Yes, reference to this is included in section ‘Stage 2: Identifying the relevant studies’.

6. Under ‘Eligibility of population or types of participants’, Barret et al.'s (2021) article may be useful when discussing lack of uniformity in nomenclature.

Thank you for highlighting this excellent, research paper. Findings from this paper have been integrated and included within the ‘Eligibility of population or types of participants’ section of the review.

7. What types of study designs are considered for inclusion?

We have now clarified and will include the following types of study designs. All peer review empirical research, qualitative, quantitative, mixed methods, and action research studies will be included in this review. See Table 1. Inclusion and exclusion criteria.

8. Are you able to provide examples of quality care metrics?

Thank you for this suggestion. We have in version 2 of the review. We included examples of quality care metrics from public health nursing which may be relevant to general practice nursing. We have also included examples of metrics developed for ambulatory care nurses in the USA. See the section titled ‘Nursing Quality Care Process Metrics’.

9. Please clarify if advanced practice nurses/nurse practitioners or other classes of registered nursing are included/excluded within your review.

Research involving all classes of registered nurses will be included in this scoping review, including advanced nurse practitioners. This is now clarified in the ‘Eligibility of population or types of participants’ section.

10. One of your objectives is to examine the use of QCM in providing advantages for patient outcomes and/or service delivery – however, your inclusion/exclusion criteria do not include anything related to reporting of outcomes within studies. Also, wouldn't this objective lend itself to a systematic review rather than a scoping review?

Thank you for highlighting the potential difficulties surrounding reporting outcomes in this scoping review. We have considered your comments and agree with your observations re scoping v systematic review. Therefore outcome reporting has been omitted from the objectives of this review.

11. Have you considered using Covidence?

We will use Covidence, and this is referred to in the ‘Stage 3: Study selection’ section of the document.

12. Please comment on how the quality of studies will be assessed.

It is our understanding that scoping reviews aim to map the extent of evidence and do not seek to report on the quality of evidence as referred to by Munn¹. However, the PAGER framework for improving the quality of scoping review reporting will be used to ensure a consistent clear approach to analysis and reporting of the review findings².

References.

1. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 2018. 18(1): p. 143.
2. Bradbury-Jones, C., et al., Scoping reviews: the PAGER framework for improving the quality of reporting. International Journal of Social Research Methodology, 2021: p. 1-14.

View more View less

Competing Interests

No competing interests to declare.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Quality care metrics for nurses working in general practice, mapping the evidence: a scoping review protocol

Abstract

Keywords

Introduction

Quality Care Metrics (QCM)

Method

Stage 1: Identifying the research question

Stage 2: Identifying the relevant studies

Table 1. Inclusion and exclusion criteria.

Stage 3: Study selection

Stage 4: Charting the data

Stage 5: Collating, summarising, and reporting the results

Study status

Discussion

Data availability

References

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Reviewer Reports

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Quality care metrics for nurses working in general practice, mapping the evidence: a scoping review protocol

Abstract

Keywords

Introduction

Quality Care Metrics (QCM)

Method

Stage 1: Identifying the research question

Stage 2: Identifying the relevant studies

Table 1. Inclusion and exclusion criteria.

Stage 3: Study selection

Stage 4: Charting the data

Stage 5: Collating, summarising, and reporting the results

Study status

Discussion

Data availability

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

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