The School of Nursing and Midwifery at UniSA is one of the largest schools of its type in Australia and provides a range of undergraduate, postgraduate and higher degree programs. The School has a substantial program of multidisciplinary research that addresses issues related to clinical practice, health, safety and quality, teaching and learning. As part of this research, the School accepts Honours, Masters by Research and PhD students seeking to have an outstanding research education under the supervision of experienced academic staff. Our research students undertake a wide range of exciting research projects which form an important component of the School’s research outputs with an emphasis on knowledge translation and delivering first-class innovative solutions to real world problems. There are a number of projects with researchers from the School of Nursing and Midwifery within the following Research Theme Groups:
Some of these Honours projects are collaborative ventures between the School and its industry partners. As a result, some projects have both an academic and clinical supervisor to support you during your progress through the Honours program. These projects will not only provide the research experience that is the central component of the Honours program, they will also allow you to make an important contributions to nursing, midwifery and health care. If you are interested in any of these Honours research projects I encourage you to contact the supervisors to discuss the project and the Honours program.
Prof CarolGrech RN, DipApSc(Nsg), BN (Ed), GradDip(CritCare), MN, PhD.
Head: School of Nursing and Midwifery
University of South Australia
Education in Nursing, Midwifery and Health Science Research (ENMHSR)
Research Theme Group Leader: A/Prof Rachael Vernon
This group is committed to engaging in rigorous educational research activities. These activities inform the development of quality research evidence to inform and enhance teaching and learning practices within the School and contribute to the body of knowledge about educational practices in nursing, midwifery and health sciences locally, nationally and internationally. Some examples of or the group’s research interests include: Clinical Decision-making; Simulation in teaching and learning; Clinical facilitation models; Assessment; and Technologies and learning.
ERNM 4: The effectiveness of inquiry based learning versus problem-based learning in undergraduate nursing programs: a systematic review
Supervisors: Dr Rasika Jayasekara, A/Prof Rachael Vernon
The aim of this study is to systematically review the literature on the effectiveness of inquiry based learning versus problem-based learning in undergraduate nursing programs. Problem-based learning (PBL) is a student-centred approach to learning that enables the students to work cooperatively in small groups for seeking solutions to situations/problems. McMaster University first introduced PBL in the mid-1960s, however emerging literature identifies a shift towards student-centred learning in a variety of formats, such as inquiry based learning (IBL). The effectiveness of PBL and IBL for undergraduate nursing programs and students learning outcomes has not yet been systematically assessed. Given prevailing uncertainty over the comparative effectiveness of PBL and IBL approach as a teaching and learning strategy in nursing education, a high quality systematic review is required to inform and update education practices in nursing education programs.
Safety and Quality in Health (SQH)
Research Theme Group Leader: Prof Carol Grech
This group is based at UniSA’s School of Nursing and Midwifery situated in the Sansom Institute for Health Research. We contribute to the Institute’s Population Health, Practice and Policy theme specifically addressing the key priority of improving health systems and services. Safety and quality in health is of interest to health planners, providers and users worldwide. Group members uphold the principles of ensuring health services are consumer centred, driven by information and organised for safety. Members of the group have a specific interest in optimising health delivery and service improvement by investigating a range of clinical questions across acute and criticl care, workforce development and how ageing populations live with complex conditions. This group is committed to making consumer/resident care better each day, across all parts of our health and aged care system. Some examples of the group's research interests include: contemporary role of nursing and nurses within complex health care systems; quality use of medicines, early onset dementia, harm minimisation in delivery of complex care in hospitals; evaluation of services and clinician decision-making.
SQH 2: Medication omission in patients admitted to a Medical Unit: prevalence and implications for patient safety.
Supervisors: Prof Carol Grech, Dr Angela Kucia, Dr Catherine Hall
Preventable medication errors in hospitalised patients are a leading cause of unintended patient harm and have been associated with increased length of stay and unplanned admissions to intensive care units. A considerable body of knowledge now exists to assist clinicians identify and correct workplace factors that precipitate medication errors, however, they continue to feature prominently in reports of adverse events in Australia and internationally. Common types of medication errors associated with adverse events include the wrong dose, wrong drug or a wrong route of administration. What is less understood is the prevalence of non-therapeutic medications being omitted in patients, in this case those in the surgical unit of a large tertiary teaching hospital in South Australia. Non-therapeutic medication omission refers to incidents where the reason for the drug to be omitted is either not provided on the medication record (as per the National Inpatient Medication Chart (NIMC) omissions codes). Conversely, a therapeutic omission is when the drug is not administered based on a clinical decision/medical order documented in the patient case notes.
SQH 4: Medication omission in patients presenting to the Emergency Department with symptoms of acute coronary syndrome: prevalence and implications for patient safety.
Supervisors: Dr Angela Kucia, Prof Carol Grech, Dr Catherine Hall
Medication omissions and delays are common within the ED. Preventable medication errors in hospitalised patients are a leading cause of unintended patient harm and have been associated with increased length of stay and unplanned admissions to intensive care units. Chest pain/symptoms of ACS represent one of the most common presentations to the ED. These patients undergo a process of risk stratification to high, intermediate or low risk of ACS, and spend a variable amount of time in the ED, depending upon ward bed availability or availability of diagnostic tests such as exercise stress testing to facilitate discharge. Patients who spend more than 8 hours in the ED are at increased risk of medication omission (Marconi et al 2012). The majority of patients who present with symptoms of ACS will be stratified to low risk if there is no objective evidence of ACS, and these patients usually undergo exercise stress testing (EST) prior to discharge. A systolic blood pressure of greater than 180mm Hg is a contraindication to EST and therefore omission of antihypertensive medications can lead to delay in provocative testing. Hypertension is a risk factor for the development of cardiovascular disease and patients presenting to ED with ACS are commonly taking prescribed antihypertensives. This group of patients often have existing cardiac disease for which they may be taking prescribed antianginals, and/or other comorbidities such as dyslipidaemia or Type 2 Diabetes Mellitus for which they are on regular medication. Whilst this study looks specifically at non-therapeutic omission of antihypertensive medications, it is reasonable to assume that the results could be extrapolated to other medications.
SQH 5: What competencies do registered nurses require to effectively supervise care workers in the aged care setting? Perspectives of registered nurses and care workers
Supervisors: Dr Terri Gibson, Dr Catherine Hall, Dr Anne Hofmeyer, Ms Megan Corlis
Registered nurses are required to supervise care workers in the aged care setting to ensure safe, quality care. While there are competencies defining the registered nurse role broadly, further work is required to understand how they apply in the aged care setting. This qualitative descriptive study will use focus groups with participants to identify the aged care specific supervision competencies required by registered nurses. Specifically, the study will explore the perspectives of registered nurses and care workers to better understand the enablers of and barriers to effective supervision in this setting. Data will be analysed inductively using a thematic analysis approach. The perspectives will provide new understandings about the specific supervision competencies required by registered nurses to promote the provision of safe, quality care to older people in aged care settings.
SQH 6: What are the barriers and enablers for graduate registered nurses transitioning into the aged care workforce?
Supervisors: Dr Catherine Hall, Dr Terri Gibson, Dr Anne Hofmeyer, Ms Megan Corlis
There has been a recent trend toward employment of graduate registered nurses in the aged care setting earlier in their nursing career. This has required aged care organisations to consider how best to facilitate recruitment, transition and retention of graduate registered nurses in the aged care workforce. This qualitative descriptive study will use focus group interviews with participants to explore barriers to, and enablers of, successful transition of graduate nurses into the aged care workforce. Data will be analysed inductively using a thematic analysis approach. The findings of the study will provide new knowledge to guide aged care organisations in developing strategies to promote successful transition and retention of graduate nurses in aged care settings.
SQH 7: Barriers and enablers to developing personal resilience in the aged care workplace: Perspectives of registered nurses – what works?
Supervisors: Dr Anne Hofmeyer, Dr Terri Gibson, Dr Catherine Hall, Ms Megan Corlis
Resilience has been defined as the ‘ability to adjust to adversity’ (Jackson et al 2007). Personal resilience has been identified as a factor in assisting registered nurses to cope with challenges and stressors in the health care workplace. Studies have shown that nurses who build personal resilience are more likely to thrive and manage adversity in the workplace. This qualitative descriptive study will use focus group interviews to explore the perspectives of registered nurses in aged care to better understand the challenges and stressors in the workplace and the enablers of, and barriers to developing personal resilience. Data will be analysed inductively using a thematic analysis approach. The perspectives will provide new knowledge about the range of strategies that registered nurses can use to build their personal resilience and support their ability to stay in the role and provide safe, quality care to older people in residential aged care.
SQH 8: Social networking technologies and professional boundaries: do undergraduates understand the issues?
Supervisors: Dr Andrew Gardner
Nurses and other health professionals need to be constantly aware of the professional boundary in their interactions with clients. However as “Millennials” enter the workforce with the advent of various social media technologies that are available today, the potential to blur the boundary between the professional and the personal have taken a new path. The establishment of a professional boundary defines a space or distance between individuals; which in this case is defined as the neutral space between a professional and a patient. However, various social media technologies have created a new dilemma for all health professionals. The establishment and maintenance of professional boundaries and professional relationships are complex, with constantly changing dynamics. In addition there are grey zones within professional boundaries that are often difficult to identify, yet are easy to cross placing both the client and the professional at risk. The aim of this project is to explore undergraduate students’ understandings of social networking technologies on professional boundaries.
SQH 9: Social media and the blurring of professional boundaries; What are the issues and concerns for the “Millennial” generation as they enter the health professional workforce?
Supervisors: Dr Andrew Gardner
Nurses and other health professionals need to be constantly aware of the professional boundary in their interactions with clients. However, as “Millennials” enter the workforce with the advent of various social media technologies that are available today, the potential to blur the boundary between the professional and the personal have taken a new path. The establishment of a professional boundary defines a space or distance between individuals; which in this case is defined as the neutral space between a professional and a patient. However, various social media technologies have created a new dilemma for all health professionals. The establishment and maintenance of professional boundaries and professional relationships are complex, with constantly changing dynamics. In addition, there are grey zones within professional boundaries that are often difficult to identify, yet are easy to cross placing both the client and the professional at risk. This project will examine what is known about the potential risks for the professional and a vulnerable client in the use of various social media technologies (such as Facebook, Tumblr and Twitter, and how nurses and other health professionals can protect themselves against potential boundary violations in this new space.
SQH 10: Opportunities and challenges for older nurses employed in residential aged care
Supervisors: Dr David Evans, Prof Carol Grech, Dr Andie Xu
In Australia, 40% of practicing nurses and midwives are aged 50 years or older, and 14% of practicing nurses are 60 years and older. An older workforce means conditions that more commonly occur in later stages of adulthood following retirement may develop while the person is still working. However, relatively little is known about the difficulties that this older population of nurses face while at work. Therefore, the aim of this qualitative study is to explore the challenges and opportunities of older nurses working in residential aged care. This exploration will be achieved through interviews with older nurses and then a thematic analysis to identify, analyse and report the patterns in the interview data.
ERNM 2: Anticipated career choices after the first year of practice: where do graduate nurses go?
Supervisors: Dr Luisa Toffoli
Increasingly nursing literature reports that graduate nurses are leaving the professional nursing workforce following the completion of their TPPP in Australia. While the reasons for leaving the nursing workforce are well documented (e.g. Burnout, workforce fatigue, horizontal violence), very little is documented about new graduates expectations of nursing wok on first entering the nursing workforce. Also, the media continue to emphasise the nursing workforce shortage yet in the 41 universities in Australia, more than 10, 000 students can be enrolled in the nursing undergraduate program meaning that a comparable number graduate each year to enter the workforce. This study aims to find out what indicators influence graduates to make career choices that do not include continuing work as a professional registered nurse.
Mothers, Babies and Families (MBF)
Research Theme Group Leader: Prof Mary Steen
Drawing upon UniSA's recognised strengths in nursing and midwifery, the Mothers, Babies and Families: Health Research Group aims to optimise health outcomes by contributing to research in a variety of population health areas including pregnancy/prenatal health and wellbeing, women's health, the health of infants, children and young people, family health, and men's health.
Members' individual research interests are broad and include midwifery models of care, breastfeeding, substance use and pregnancy, postnatal depression and mental health, midwifery and infant health in developing countries and Indigenous communities, cross-cultural issues, midwifery education, men’s health, paternal and family supports, and complementary and alternative medicine.
Part of the Nursing, Midwifery and Mental Health research concentration within the Sansom Institute for Health Research, the group is based at the School of Nursing and Midwifery at UniSA's City East campus.
MBF 1: Emotional Intelligence in Midwifery Practice: A concept analysis
Supervisors: Dr Lois McKellar, Cathy Kempster
As part of the National Competency Standards for the Midwife (ANMC 2006), midwives are expected to provide clinical supervision for midwifery students in the clinical setting. The type of skills required to successfully fulfil this role have not been well articulated. This study is designed to formulate an understanding of Emotional Intelligence (EI) in relation to midwifery practice in order to develop the role of the midwife as a clinical supervisor. This study will use a concept analysis and focus groups.
MBF 3: Midwives and trauma: are we caring for ourselves?
Supervisors: Dr Jane Warland, A/Prof Jill Dorrian
This project will provide important information regarding midwives’ levels of secondary traumatic stress. Using two well validated scales the student will learn how to administer, measure, and then interpret data arising from these psychometric scales.
MBF 4: Medical practitioner’s views and experiences of water immersion for labour and birth
Supervisors: Dr Megan Cooper, Prof Mary Steen, A/Prof Jane Warland
Research to date suggests that medical practitioners may be averse to or non-supportive of the use of alternative options including the use of warm water immersion during labour and birth. However, there has been little research undertaken to capture the experiences and views of medical professionals in regards to the use of water immersion for labour and birth. The project will be informed by a previous study examining the experiences of midwifery practitioner’s experiences and will involve surveying obstetricians, paediatricians, anaesthetists and general practitioners to capture this information and address a current shortfall in the literature. This project will involve the development of a survey using the SurveyMonkey platform.
MBF 5: Women’s descriptions of foetal movements
Supervisors: A/Prof Jane Warland, A/Prof Pauline Glover
Women’s perception of reduced foetal movements (RFMs) in late pregnancy is associated with adverse pregnancy outcomes. Many late term stillbirths are preceded by a period of reduced foetal movements (RFM) and IUGR rates are also increased in women with RFM. Understanding how women usually describe foetal movement may assist the maternity health care provider working with the women to identify foetuses at risk. Since reporting of foetal movement depends on the mother’s perception of what is usual for her baby, it is important for midwives and other maternity care providers to be able to accurately describe how foetal movements typically feel to women and be able to determine if the woman’s descriptions of foetal movements match or differ from the norm. This project will provide valuable information for women and maternity care providers regarding usual descriptions to use when describing foetal movements.
MBF 6: Women's views, experiences and perceptions of water immersion for labour and birth
Supervisors: Dr Megan Cooper, Prof Mary Steen, A/Prof Jane Warland
This study seeks to address a large paucity in research and work towards making recommendations for care provision and more specifically, water immersion as an option for labouring and birth women. The findings will ultimately inform future recommendations relating to the option of water immersion for labour and/or birth and foster further research pertaining to the area. Focusing on the experiences, views and perceptions of women who have used water immersion during labour and/or birth, this project will be qualitative in nature and include semi-structured interviews and focus groups.
Mental Health and Substance Use (MHSU)
Research Theme Group Leader: Prof Nicholas Procter
With an estimated one in five Australians affected by mental illness at some point in their lives, mental health is now emerging as a critical priority on the research landscape. Significant co-morbid substance use can also occur, with reports as high as 70% of those with mental illness also suffering from a substance use problem. UniSA’s Mental Health and Substance Use Research Group is a small, high profile research team, established in 2010. Based at UniSA's School of Nursing and Midwifery, the group is part of the Nursing, Mental Health and Midwifery research concentration within the Sansom Institute for Health Research. The group is supported by grants from both state and federal governments to build mental health research and practice development capacity and further mental health and substance use related research in South Australia, nationally and internationally, tackling the most important mental health issues of society. The group currently comprises of several Honours, Masters and PhD students, clinicians and academics working on a range of research projects and consultancies. The research activity arising from the group spans mental health risk assessment and management, refugee and asylum seeker mental health, vulnerability assessment and management, physical activity for people with serious mental illness, older adults in suicidal crisis, and sentinel events evaluation. The group has extensive collaborations with the non-government sector and SA Health's Acute Matters. It works closely with clinical leaders to convene a highly successful twice yearly risk assessment and management symposium, along with a series of mental health master classes delivered by mental health clinicians from across South Australia. More than 500 clinicians from across South Australia have taken part in mental health symposiums and master classes over the past 24 months.
MHSU 1: People who care for a friend or family member from a culturally and linguistically diverse (CALD) background at risk of suicide: Challenges and coping strategies
Supervisors: Prof Nicholas Procter, Dr Amy Baker
Suicide is a significant and complex public health issue that is difficult to predict and prevent. Risk factors for suicide amongst people from culturally and linguistically diverse (CALD) backgrounds include social isolation, racism and a sense of hopelessness. People from migrant and refugee backgrounds may be reluctant to seek professional help for mental health issues for many reasons, including cultural and linguistic barriers, stigma and limited knowledge about the local health system. Family members and friends play a vital role in reducing the risk of suicide of people from CALD backgrounds and assisting them to remain well. Yet, the challenges families and friends of people from migrant and refugee backgrounds face, and subsequent coping strategies and steps taken to respond to situations of suicidal crisis, are largely unknown. The aims of this project are to understand the nature and scope of challenges and subsequent coping strategies of people who care for a friend or family member from a CALD background at risk of suicide. Through interviews with family and friends, this project will provide information which will be valuable to carers and consumers of mental health services from CALD backgrounds as well as service providers. In particular, improved understanding of the beliefs, challenges, help-seeking behaviours and coping strategies of friends and family members will help to increase knowledge about pathways to care for people at risk of suicide from CALD backgrounds and enhance support for carers.
MHSU 3: Trauma-informed care in older person’s mental health setting: Clinicians’ understandings, and barriers and enablers to practice
Supervisors: Prof Nicholas Procter, Dr Monika Ferguson, Dr Mark Loughhead
Forensic mental health consumers have often been exposed to numerous traumas and are at risk of re-traumatising experiences. One potential way to reduce this risk is for mental health clinicians to engage in trauma-informed care. ‘Trauma-informed care is an approach to engaging people with histories of trauma that recognises the presence of trauma symptoms and acknowledges the role that trauma has played in their lives’ (SAHMSA 2015). A trauma-informed care environment enables clinical mental health staff to engage with those in criminal custody with a methodology of care that will prevent exacerbations of conflict, altercations and heightened emotional outbursts. It can provide the mental health consumer with an atmosphere of mutual respect and dignity, rather than a punitive (command and control) environment. To date, however, understandings of the use of trauma-informed care have largely been limited to the general inpatient mental health setting, particularly outside of Australia. This study will explore South Australian older person’s mental health clinicians’ understandings of trauma-informed care, as well as their perceived barriers to and enablers of this approach in practice. This information will be used to provide recommendations as to what is needed to support staff to engage in trauma-informed care in the older person’s mental health setting.
MHSU 4: Shared Decision Making in Mental Health Care- clinician and consumer perspectives on supported practice
Supervisors: Prof Nicholas Procter, Dr Monika Ferguson, Dr Mark Loughhead
This study extends an increasing interest of Shared Decision Making within contemporary health practice as a key way for improving health literacy and a range of health outcomes for consumers. The project explores the experience of Shared Decision Making within mental health care, from consumer, carer and clinical perspectives. It seeks to improve understandings of how SDM can be better supported and implemented as a key practice in health services. The project will involve review of the relevant literature, engagement with consumer, carer and clinical leaders, recruitment of participants for focus groups, data analysis and report writing.
MHSU 5: Lived experience learning methodologies for recovery
Supervisors: Prof Nicholas Procter, Dr Monika Ferguson, Dr Mark Loughhead
Lived experience learning for recovery is a research project which will have direct relevance for a number of new developments occurring with mental health care in Australia. Tied to the increasing activity of peer workers in the public and NGO services, and in the development of recovery educational organisations, this research will focus on consolidating current understandings of effective methods for teaching recovery from a lived experience basis. This will involve literature review, as well as interviewing and surveying consumers who have benefited from lived experience education. The research will seek to improve understandings of how learning methods have positive impacts on reported health/ recovery outcomes of consumers.
MHSU 6: Carer Perspectives on Nursing Care and Related Practices for Family Members Diagnosed with Borderline Personality Disorder
Supervisors: Professor Nicholas Procter, Dr Mark Loughhead
This project is sponsored by Sanctuary BPD Carer Support and the Mental Health and Substance Use Research Group. The aim is to better understand the nature, scope and consequences of nursing care and related practices from the perspective of carers and supporters following discharge from either hospital or the emergency department (ED) of a person diagnosed with Borderline Personality Disorder (BPD). The research will involve up to 15 interviews with carers and supporters as little is known from their perspective about events and experiences they have in the ED and following discharge from hospital or the ED. This project will examine how the system works, what might happen next, and the flow of the consumer between hospital and community.
Cancer Care Research Group (CCRG)
Research Theme Group Leaders: Prof Marion Eckert
Cancer Care has a specific focus on advancing the contribution of nurses and nursing in cancer prevention and management research. Cancer prevention and management is one of the university’s six research themes, which are underpinned by the concept ‘Understanding and Decision Making’.
Research undertaken by the CCRG relates to:
- cancer screening and cancer prevention,
- improving the quality of cancer care and cancer treatments,
- promoting recovery, and
- supportive care of survivors and their families across the life-course.
Members of the CCRG also plan to create opportunities for transdisciplinary research activity and engage with the community about their research.
CCRG 1: Exploration of models of online peer communication programs to support people living with and in the shadow of cancer.
Supervisors: Prof Marion Eckert, Dr Amanda Bobridge; Dr Peter ‘Kevin’ O’Shaughnessy
This project will be a scoping review of literature to explore the acceptance of an online peer support program and potentially an ‘app’ that could be made available to a wide range of consumers in the survivorship phase of a cancer diagnosis. Critical to the exploration of the peer support app will be the minimum data required to inform outcomes related to quality of life. Given the nature of peer support there is an emphasis on those with particularly ‘isolating’ factors (i.e. distance to major city, cultural barriers, younger age at diagnosis, rare cancer).
The emerging trend for supportive health care apps in Australia presents an opening to be leaders in the area of ‘peer support’ for people impacted by cancer. The current Australian apps from an initial market search do not address the full extent of consumer needs in this area and therefore presents an opportunity. This project would explore the opportunity to deliver and monitor the effectiveness of a peer support app in Australia.
CCRG 2: Systematic review (or scoping review) of the effectiveness of coordinated cancer prevention screening programs on increased participation rates and health outcomes.
Supervisors: Prof Marion Eckert, Dr Amanda Bobridge, Dr Peter ‘Kevin’ O’Shaughnessy
This project will seek to explore the published and grey literature related to coordinated cancer screening prevention programs. Up to 50% of cancers are preventable when people participate in cancer screening program and consider lifestyle modifications. Yet the participation in cancer screening programs in in Australia is poor. New approaches need to be considered and proposed to increase screening participation. The proportion of people over the age of 50 not actively participating in cancer screening or general health assessments could increase if effective strategies and health promotion models are not understood and developed. If more people engaged in these, a number of chronic diseases and cancer deaths could be prevented. This project will identify effective models in place to increase consumer participation in cancer screening programs and also consider improved health benefits of the coordinated model.
Rosemary Bryant AO Research Centre
Research Centre Director: Prof Marion Eckert
The Rosemary Bryant AO Research Centre is a partnership between the Australian Nursing and Midwifery Federation (SA Branch) and the University of South Australia, which aims to strengthen the nursing & midwifery workforce across the health system through the development of evidence-based healthcare. The RBRC is developing a comprehensive research program focused on advancing the discipline of nursing & midwifery and patient care related to population and public health, workforce reform, safety and quality, clinical practice, patient outcomes, and integration into education. Its objective is to enhance innovative partnerships for healthcare research, to inform strategies for: 1) Extending the capacity and capabilities of nurses and midwives to build a resilient, sustainable and collaborative workforce, 2) health system planning and resourcing, 3) clinical care outcomes, and 4) translation of evidence into practice.
RBAORC 1: Identifying what constitutes effective nurse led wellness centres models of care
Supervisors: Prof Marion Eckert, Greg Sharplin
This project is a scoping review of related literature to explore community based nurse led wellness centres, the clinical and community benefit. Nurse led models of care are dynamic healthcare innovations that provide accessible, affordable, high-quality, patient-centred care that integrates mind and body, seeks to achieve high patient satisfaction, and produces outcomes that can have a significant health impact on the individual. Nurse-managed wellness centres, like other models of nurse-managed centres, are community focused and managed by registered nurses who have highly tuned assessment skills. The concept of ‘nurse- managed wellness’ involves the management of wellness of a client by an advanced practice nurse. Understanding quantifiable measures that establish effective outcome metrics will be a valuable part of this review.