Evidence-based interventions and nurse-sensitive outcomes in district nursing care: A systematic review

Background Measuring nursing interventions and nurse-sensitive outcomes in a standardized manner is essential because it provides insight into the quality of delivered care. However, there is currently no systematic overview of the interventions conducted by district nurses, the evidence for the effects of these interventions, or what nurse-sensitive outcomes should be measured. Objective 1) To provide an overview of interventions for community-living older people evaluated in district nursing care and evidence for the effects of these interventions and 2) to identify the nurse-sensitive outcomes that are used to evaluate these district nursing care interventions, how these outcomes are measured, and in which patient groups they are applied. Design A systematic review of the literature. Setting District nursing care. Data sources MEDLINE, CINAHL, PsycInfo, and EMBASE. Methods Only experimental studies evaluating district nursing care interventions for communkity-living older people were included. A data extraction form was developed to extract the study characteristics and evaluate interventions and nurse-sensitive outcomes. The methodological quality of the included studies was reviewed using the 13-item critical appraisal tool for randomized controlled trials by the Joanna Briggs Institute. Results A total of 22 studies were included. The methodological quality of the studies varied, with scores ranging from 6 to 11 on a scale of 0–13. The 22 interventions identified were heterogeneous with respect to intervention components, intervention delivery, and target population. The 44 outcomes identified were grouped into categories following the Nursing Outcome Classification and were measured in various ways and at various times. Conclusion This is the first systematic review summarizing the evidence for the effectiveness of nurse-led interventions conducted by district nurses on community-living older people. It is unclear what interventions are effective and what outcomes should be used to substantiate district nursing care effectiveness. Because only studies with experimental designs were included, this analysis may provide an incomplete assessment of the effectiveness of interventions in district nursing care. Therefore, it is highly necessary to produce methodologically strong evidence through research programs focusing on district nursing care.

Background: Measuring nursing interventions and nurse-sensitive outcomes in a standardized manner is essential because it provides insight into the quality of delivered care.However, there is currently no systematic overview of the interventions conducted by district nurses, the evidence for the effects of these interventions, or what nurse-sensitive outcomes should be measured.Objective: 1) To provide an overview of interventions for community-living older people evaluated in district nursing care and evidence for the effects of these interventions and 2) to identify the nurse-sensitive outcomes that are used to evaluate these district nursing care interventions, how these outcomes are measured, and in which patient groups they are applied.Design: A systematic review of the literature.Setting: District nursing care.Data sources: MEDLINE, CINAHL, PsycInfo, and EMBASE.Methods: Only experimental studies evaluating district nursing care interventions for communkity-living older people were included.A data extraction form was developed to extract the study characteristics and evaluate interventions and nurse-sensitive outcomes.The methodological quality of the included studies was reviewed using the 13-item critical appraisal tool for randomized controlled trials by the Joanna Briggs Institute.Results: A total of 22 studies were included.The methodological quality of the studies varied, with scores ranging from 6 to 11 on a scale of 0-13.The 22 interventions identified were heterogeneous with respect to intervention components, intervention delivery, and target population.The 44 outcomes identified were grouped into categories following the Nursing Outcome Classification and were measured in various ways and at various times.Conclusion: This is the first systematic review summarizing the evidence for the effectiveness of nurse-led interventions conducted by district nurses on community-living older people.It is unclear what interventions are effective and what outcomes should be used to substantiate district nursing care effectiveness.Because only studies with experimental designs were included, this analysis may provide an incomplete assessment of the effectiveness of interventions in district

Introduction
Worldwide, the demand for the delivery of all care at home is predicted to increase greatly in the coming decade.This is due to the rapidly growing ageing population in combination with the desire of the majority of older people to continue to live at home as well as the financial incentives and public demands of health insurers to provide care at home (Jarrín et al., 2019;Maybin et al., 2016;United Nations, 2017;World Health Organization, 2015).District nursing services are the key providers of nursing care in the community, in addition to other healthcare professionals, such as general practitioners and other (paramedic) professionals in primary care (Glasper, 2013;Stall et al., 2014).The organization of district nursing care, including its delivery and funding, varies worldwide (Genet et al., 2012;Jarrín et al., 2019;Van Eenoo et al., 2016).In this study, district nursing care was defined as any technical, medical, supportive or rehabilitative nursing care intervention or assistance with personal care for (older) people living at home (Van Eenoo et al., 2016).This definition is in accordance with the definition used for community-care nursing in Europe (Tarricone and Tsouros, 2008;Van Eenoo et al., 2016) and reflects district nursing care in the Netherlands (Maurits, 2019).
Measuring nursing interventions and nurse-sensitive outcomes in a standardized manner is essential and provides insight into the quality of delivered care, which could guide learning and development in district nursing practice (Jarrín et al., 2019;Pringle et al., 2002).To support nurses in providing care to patients, the nursing intervention classification (NIC) provides a comprehensive, research-based, standardized classification of interventions for nurses and other professionals (Butcher et al., 2018).Interventions are defined as "any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient outcomes" (Butcher et al., 2018).The Nursing Outcome Classification (NOC) is a comprehensive, standardized classification of outcomes to evaluate the impact of interventions provided by nurses or other professionals (Moorhead et al., 2018).Patient outcomes are needed to measure the effects of delivered healthcare services on patients' health and wellbeing (Mant, 2001;World Health Organization, 2006).For district nursing care, it is necessary to focus on nurse-sensitive outcomes, which are patient outcomes that are relevant to the nurses' scope and domain of practice and can be influenced by nursing input/interventions (Doran, 2011).
There is currently no systematic overview of the interventions conducted by district nurses or the nurse-sensitive outcomes they achieve for patients (Jarrín et al., 2019;Keleher et al., 2009).While the systematic review by Joling et al. (2018) identified 567 quality indicators for older people for community care, only 18 indicators focused on patient outcomes, of which nine were assessed as nurse-sensitive (Veldhuizen et al., 2021).It is unclear what outcomes are used in district nursing research.A study amongst district nursing care professionals from 17 countries identified a pressing need to generate an evidence base for district nursing care and evaluate home care services and outcomes for patients to guide district nursing care (Jarrín et al., 2019).This evidence is needed because district nursing care is a speciality nursing practice requiring specific nursing interventions and competencies (American Nurses Association, 2007;Community Health Nurses of Canada (CHNC), 2019;Department of Health, 2016;Mildon, 2011;Stuurgroep Kwaliteitskader Wijkverpleging, 2018).Because the literature on interventions and nurse-sensitive outcomes for district nursing care is scarce, a thorough systematic review of the literature is needed.
The aims of this review are 1) to provide an overview of interventions for community-living older people evaluated in district nursing care and evidence for the effects of these interventions; and 2) to identify the nurse-sensitive outcomes that are used to evaluate these district nursing care interventions, how these outcomes are measured, and in which patient groups they are applied.

Methods
An a priori research protocol was written for this systematic review and published in PROSPERO (CRD42017058768).To guide the systematic review, the steps described in the Joanna Briggs Institute Manual for Evidence Synthesis were followed to conduct the review (Lockwood et al., 2017).To guide the reporting of this manuscript, the Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) was followed (Moher et al., 2009) (SI Appendix 1).

Search strategy
Studies evaluating the effectiveness of district nursing interventions were identified using a systematic search.The following electronic databases were searched: MEDLINE, CINAHL, PsycInfo, and EMBASE.The search strategy used a combination of key terms related to nurse-led district nursing care interventions for older people (SI Appendix 2).The search strategy was developed with information specialists from the Cochrane Centre Netherlands and the University of Applied Sciences Utrecht.The database searches were conducted on the 12th of February 2020.

Inclusion criteria
Only empirical studies evaluating district nursing care interventions for community-living older people (aged 60+) and interventions conducted in patients with a mean age of 60 or older were included.Following the advice of the Effective Practice and Organization of Care (EPOC) Group from Cochrane, only randomized controlled trials, controlled clinical trials, controlled before-andafter studies, and interrupted time-series studies were included (Cochrane Effective Practice and Organization of Care Group (EPOC), 2002).Studies evaluating district nurse-led interventions were included.Studies reporting on nurses working in general practices or hospitals and studies in which the nurse's role was unclear were excluded.Studies with at least one face-to-face contact between the district nurse and the patient, either in person or via telehealth, were included.Interventions with only remote monitoring were excluded.To be included, at least one of the outcomes used in the studies had to be nurse-sensitive for district nursing care, following the definition by Doran (2011).No limits were applied on the control group or publication date.Findings from multiple articles reporting on the same study (i.e., reports of the same evaluation of an intervention) were combined.All publications that met the inclusion criteria were uploaded into Rayyan, a web application for systematic reviews that offers researchers a dashboard through which to work through the details of their processes while also allowing full transparency for reviewers (Ouzzani et al., 2016).

Study selection
After all publications were added to Rayyan, duplicate studies were removed.Two reviewers independently assessed the titles and abstracts of all potentially relevant studies for inclusion.In Rayyan, the reviewers were able to read the titles and abstract and make a decision to include or exclude the study.The full texts of studies deemed relevant were obtained, and the assessment of inclusion was repeated independently by two reviewers using Microsoft Excel.To guide the screening and selection of studies, an inclusion criteria screening tool was developed and used by both reviewers (SI Appendix 3).Any disagreements on inclusion were resolved by discussion (JDV and TBH).The results of articles that reported the same study were combined.The number of abstracts and papers identified and excluded, along with the reasons for their exclusion, were recorded.

Data extraction
A data extraction form was developed to extract relevant data from the included studies describing the study characteristics, evaluated interventions and outcomes.The study characteristics extracted were the author names, title, year, country, and design of the study.The intervention data extracted were the study population, sample size, description of the intervention, and a control group description.Regarding the outcomes, the name of the outcome, how the outcome was measured, the measurement instrument or data registry used, the time over which the outcome was measured, and the effects that were measured were extracted.The two reviewers initially piloted the data extraction process with two studies.In the next stage, each reviewer independently extracted data from half of the studies.After extraction, both reviewers checked the data extraction of the other reviewer.The data were compared, and differences were resolved by discussion between the two reviewers (JDV and TBH) until agreement was reached.

Critical appraisal of methodological quality
The studies' methodological quality was independently reviewed by two reviewers (JDV and TBH) using the 13-item critical appraisal tool for randomized controlled trials developed by the Joanna Briggs Institute (Tufanaru et al., 2017).The thirteen items were scored as zero if an item was not met or the item was unclear and as one if an item was clearly met.No single approach is considered the best practice for deciding when a study's quality is sufficient (Porritt et al., 2014).Therefore, the total score of the critical appraisals and risks of bias are presented.

Method of data synthesis
Due to the expected heterogeneity of the included studies, a narrative synthesis was performed to describe the studies in terms of study characteristics, evaluated interventions, and reported outcomes and to provide an overall description of the available evidence.Using content analysis, the outcomes and interventions were thematically categorized and presented narratively.The outcomes were organized into the following categories based on the Nursing Outcome Classification, which is one of the most commonly used standardized nursing terminology (Tastan et al., 2014): functional health, physiological health, psychosocial health, health knowledge and behaviour, perceived health, and family health.The categories of death and healthcare utilization were added following previous research (Akpan et al., 2018;Veldhuizen et al., 2021).Healthcare utilization was used instead of costs when both were described.The total costs of healthcare utilization or interventions were not included in the narrative synthesis.

Ethical approval, informed consent and registration
Ethical approval and informed consent were not required since no participants were involved in this systematic review of the literature.An a priori research protocol for this systematic review is published in PROSPERO (CRD42017058768).

Fig. 1. PRISMA flow diagram
Notes: * in total, 24 articles were included that described 22 studies.Two studies were described twice in separate articles.

Study selection
The search resulted in 5569 records.After removing duplicates, 3380 titles and abstracts were screened using the inclusion criteria, and 381 records were retrieved for full-text screening.After the final selection, 22 studies (reported in 24 articles) were included in this systematic review (Fig. 1).In the description of the results below, all studies will be referred to by their reference number between brackets.The reference number and corresponding full reference are provided in Table 1.

Methodological quality
Twenty-four articles reported on 22 studies, with two studies being described in two articles (5,6).The quality scores of the 22 studies ranged from 6 to 11, with a total possible score of 13 (Table 2).The mean and median quality scores of the studies were 8 (IQR: 2,25; Q1-Q3: 6,88-9,13).The weaknesses identified were a lack of blinding and limited description of reliable outcome measurements (i.e., unclear description of the reliability of measurements (Tufanaru et al., 2017)).In seven studies, the outcome assessors were not blinded to treatment assignment (1, 7), or it was unclear whether blinding occurred (2,(16)(17)(18)20).In three studies, the outcomes were measured in a reliable way (4,5,21).All studies stated that the outcomes were measured in the same way (i.e., the same instruments and measurement timing were used) between the intervention and control groups.The control group received no home visits.They could use or apply for all the regular services in the area as before.
Preventive home visits for older people.
• Mortality A significantly lower number of referrals to outpatient clinics was observed.No effects were found on other measures.

9/13
Notes: *Methodological quality of the studies, calculated using the 13-item critical appraisal tool for randomized controlled trials by the Joanna Briggs Institute.

Interventions
A total of 22 interventions were identified (Table 3).None of the included studies evaluated the same intervention.In nine studies, the interventions were conducted following a protocol (2-4, 6, 8, 12, 16, 20, 22), whereas in three studies, only part of the intervention was protocol-dependant (5,14,17).The interventions were heterogeneous in the type of patients, intervention components, and delivery.

Intervention components
In total, 20 of the 22 included interventions consisted of various components.None of the interventions or intervention components were comparable.Similar components amongst the interventions were assessment or problem identification (1-8, 11-14, 18-20); care planning, goal setting, action planning or defining needs and action priorities (2)(3)(4)(5)(6)(7)(8)11,12,15,16,18,19,21); referral or triage (1, 2, 5-7, 11, 12-15, 18, 20, 22); regular care interventions, physical examinations, or implementation of actions (e.g., helping a person with medication) (1-3, 5-7, 12, 15, 17, 19, 20); monitoring, evaluation or follow-up (2,3,7,10,12,13,16,18,19); education, information provision, health promotion or advice (4, 11, 14-16, 18, 20, 22); care coordination or care management (6,8,16,18); reflective dialogue or health theme discussion (21,22), and providing guidance or training (9, 17).In total, 18 interventions included three or more of the aforementioned components.The interventions were delivered via home visits (1, 3, 6-10, 14, 16-22) or a combination of home visits and telephone contact (2,4,5,(11)(12)(13)15).The number of contact moments via home visits or telephone calls varied between one and sixteen visits.In six interventions, it was possible to have additional contact if needed.The duration of the Notes: Q1: Was true randomization used for the assignment of participants to treatment groups?Q2: Was allocation to treatment groups concealed?;Q3: Were treatment groups similar at baseline?; Q4: Were participants blind to treatment assignment?; Q5: Were those delivering treatment blind to treatment assignment?; Q6: Were outcome assessors blind to treatment assignment?; Q7: Were treatment groups treated identically other than the intervention of interest?;Q8: Was follow-up complete, and if not, were differences between groups with respect to their follow-up adequately described and analysed?;Q9: Were participants analysed in the groups to which they were randomized?; Q10: Were outcomes measured in the same way in different treatment groups?; Q11: Were outcomes measured in a reliable manner?; Q12: Was an appropriate statistical analysis performed?; Q13: Was the trial design appropriate and any deviations from the standard randomized controlled trial design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?' Y = yes; N = no; U = unclear; * Total score is based on the number of questions answered with 'yes'.The intervention was conducted during routine visits.The protocol should be followed weekly or, for patients seen less frequently, at each visit.The duration of the visits was unclear.
Total duration of the intervention: unclear.
(continued on next page) J.D. Veldhuizen et al. contact moments ranged from 10-90 minutes.

Interventionists
The nurses delivering the interventions were referred to as home care practice nurses, home care (registered) nurses, (practical) nurses, district nurses, community (home) nurses, home (health) nurses, community-care registered nurses, or palliative care nurse case managers.In total, 413 nurses were involved in the included studies.In nine studies, it was not clear how many nurses were involved (1,3,10,13,15,17,18,20,22).A dental hygienist (9) or nursing student (5) conducted the intervention in combination with nurses in two studies.In 10 studies, other healthcare professionals were involved in conducting part of the study (e.g., for conducting a comprehensive assessment; for reference when medical attention was needed; or for discussing identified care needs, care provision or care coordination) (1-3, 6, 8, 11, 13, 14, 18, 19).In 14 studies, the nurses had special training on how to conduct the intervention (1-10, 12, 16, 19, 21).
Statistically significant effects of interventions were found in 27 of the 44 outcomes.Given the variation in the interventions and measured outcomes and to avoid misinterpretation, no effect sizes are provided.Favourable positive statistically significant effects were identified in 16 studies.In seven outcomes, the effect was partial, i.e., the effect was measured within groups instead of between groups or the effect was present at one but not all time points.The outcomes with positive (partial) statistical significance in two or more studies were activities of daily living (4, 19-21), concerns regarding falls (4, 20), knowledge of disease and healthcare (7, 18), hospital readmission (5, 8), quality of life (5, 17, 21), and satisfaction with the care provided (2, 5, 18).For four outcomes, the effect was unfavourable, i.e., the intervention had a negative statistically significant effect on the outcome; specifically, the participant in the intervention group had higher healthcare utilization regarding home nursing (6, 18) and nursing home admissions (6, 19) and less knowledge of aspects of the disease (21) or used more medications (7) than those in the control group.

Discussion
This is the first systematic review providing an overview of nurse-led interventions conducted by district nurses for communityliving older people.A total of 22 randomized controlled trials were identified and described in 24 articles.The studies were highly heterogeneous in methodological quality, the patient population on which the intervention focused, intervention components, and outcome measurements.Therefore, based on the results of this review, it is unclear what interventions are effective for whom and what nurse-sensitive outcomes can be used to show the value of district nursing care.
Our first aim of the review was to provide an overview of interventions evaluated in district nursing care and their effects.The included studies focused on the general population of older people (n=14) and older people with heart failure (n=4) or another specific problem or disease (n=4).This diversity in patient populations reflects district nursing care settings, where nurses perform a wide range of clinical interventions and fulfil a specialist-generalist role in providing care (Scotland's Chief Nursing Officer Directorate, The nurses in charge of the interventions had a wide range of positions, roles and job titles (e.g. home care (practice) nurses, district nurses, community (home) nurses, home (health) nurses, or (palliative care) nurse case managers).The studies do not clearly describe the roles or educational levels required for the nurses involved in the intervention.Therefore, it is unclear whether there were differences in the tasks and responsibilities of the nurses, making comparisons complicated.The literature shows that the organization of health and social services, including district nursing care, differs both between and within European countries (Genet et al., 2011).While this variation is needed and inevitable, it is necessary to be transparent about the roles, tasks and responsibilities of those conducting the intervention in district nursing research.
Variation in healthcare interventions is common.Most health care interventions are complex, i.e., include several components with possible interactions, leading to a range of potential and variable outcomes (Richards and Hallberg, 2015).There are many challenges in reviewing complex health interventions (Richards and Hallberg, 2015): it involves variations in intervention doses and patient characteristics, interactions between the intervention and context, and various measures of the same construct and outcomes (Pigott and Shepperd, 2013;Richards and Hallberg, 2015).Following the study by Pigott and Shepperd (2013), the heterogeneity of the studies included in this review was investigated.While some studies made similar comparisons, such as comparing district nursing care to a new intervention or with no care, the intervention components, dosage and delivery of the individual interventions were diverse.None of the intervention components were sufficiently comparable, rendering synthesis of the results using meta-analyses impossible.
Based on the statistically significant effects identified, no distinctive features between the interventions with and without effects were identified.Some of the effects were found only within groups instead of between groups, leading to possible overestimation of the outcome.This had also been identified by a review evaluating the effects of fundamental nursing care interventions, which showed frequent attempts to overestimate the outcomes of studies by claiming positive effects based on within-group effects rather than between-group effects (Richards et al., 2018).Ultimately, the authors decided not to draw any conclusions regarding the effectiveness of the interventions.
The second aim of this review was to identify nurse-sensitive outcomes that are used in studies evaluating district nursing care interventions.The 44 outcomes identified mainly focused on functional health, perceived health, and healthcare utilization.Of the 44 outcomes, 20 were nurse-sensitive, as identified by a Delphi study regarding nurse-sensitive outcomes in district nursing care (Veldhuizen et al., 2021).In contrast, three outcomes were not nurse-sensitive (mortality status, knowledge of the patient, and polypharmacy), and for eight outcomes, it was unclear if the outcomes were nurse-sensitive (SI Appendix 4).The outcomes with favourable (partial) statistical significance were activities of daily living, concerns about falls, knowledge of disease and healthcare, hospital readmission, quality of life and satisfaction with the care provided.These outcomes are potentially most useful for measuring the effect of district nursing interventions.The outcomes were measured in various ways at various time points using a variety of instruments.Therefore, it is currently unclear how these nurse-sensitive outcomes should be used to measure the quality of delivered district nursing care.The quality of the description of outcome measurements was limited in 19 studies.This may threaten the validity of statistical inferences on the existence and magnitude of the effect determined by the treatment (Tufanaru et al., 2017).The reliability of the outcome measurements being unclear or not described could be why only weak effects were identified in the studies.

Implications for practice and further research
This review shows that evidence for district nursing care interventions is scarce.This underlines the conclusion by Jarrín et al. (2019), emphasizing the pressing need to develop an evidence base for district nursing care.A first step in developing this evidence base is to pay attention to the methodological quality of the conducted studies.In this review, only a small number of randomized controlled trials were identified.Conducting experimental work through effective research programs focusing on the effects of interventions on outcomes is strongly encouraged (Melnyk, 2012;Richards et al., 2014).For nursing research in general, Richards et al. concluded that less than 10% of articles reported in nursing journals are randomized controlled trials (Richards et al., 2018).When interested in the effectiveness of interventions, more attention should be given to setting up intervention trials with experimental designs such as randomized controlled trials, interrupted time series, or a stepped-wedge design (Richards and Hallberg, 2015).We are, however, aware of the challenges researchers testing (district) nursing interventions face, such as difficulties with randomization.When it is not possible to conduct experimental studies, other study designs and statistical methods could be used to examine the effectiveness of interventions (e.g., causal inference in quasi-and nonexperimental studies).It would be valuable to conduct a review of studies investigating the effectiveness of interventions using other designs than those used in the present review.Additionally, it would be relevant to provide insight into other studies conducted in district nursing care (e.g. the experiences with or feasibility of interventions in district nursing care using qualitative or mixed-methods approaches) to provide insight into all evidence available for district nursing care.
In future research, more attention should be given to the reporting of studies.For complex interventions specifically, the criteria for reporting the development and evaluation of complex interventions in healthcare (CReDECI) should be followed (Möhler et al., 2012).It is essential to provide a thorough description of the outcome measurements, as this was the most critical methodological weakness in the included studies.Additionally, a more detailed and transparent description of who delivers what care, including a description of the roles, tasks and responsibilities, is needed to enhance replication.Also, this study shows great variation in how the outcomes were measured.It is important to measure nurse-sensitive outcomes in a systematic, standardized manner to ensure good transparency of the quality of the care delivered.With this, it is possible to provide guidance in quality monitoring and improve district nursing care quality (Pringle et al., 2002).To conclude, a systematic research program guided by a strong theoretical foundation and focusing on interventions and nurse-sensitive outcomes is needed to produce methodologically strong evidence for district nursing care that is reliable, replicable and robust.

Strengths and limitations
This is the first systematic review focusing on nurse-led interventions for community-living older people conducted by district nurses.A strength of this study was that it was conducted systematically following the Joanna Briggs Institute Manual for Evidence Synthesis (Tufanaru et al., 2017) and advice from information specialists from the Cochrane Centre Netherlands and the University of Applied Sciences Utrecht.Reporting was guided using the Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) (Moher et al., 2009).All steps of this review were conducted independently by two reviewers, minimizing selection bias.
To appreciate the findings of this review, some limitations need to be considered.First, although only studies with experimental designs were included in this review, this may potentially have led to missed interventions.In this study, we followed the advice of the Cochrane Effective Practice and Organization of Care (EPOC) group by including only randomized controlled trials, controlled clinical trials, controlled before-and-after studies, and interrupted time-series studies (Cochrane Effective Practice and Organization of Care Group (EPOC), 2002).However, studies with other designs, including quasi-and nonexperimental designs with rigorous statistical methods, could potentially provide evidence for the effectiveness of district nursing care.Second, it is possible that interventions were missed because the review focused solely on nurse-led interventions conducted by district nurses in the community.While various job titles for district nurses were included in the search strategy, it is possible that studies were missed due to other job titles being used.This was minimized by building the search strategy in collaboration with information specialists.Also, excluding studies conducted in other settings that could be potentially relevant for district nursing care could have led to an incomplete picture.Third, it was impossible to pool the data into a meta-analysis or synthesis; therefore, only a narrative synthesis was conducted.

Conclusions
This review shows that the evidence for district nursing care interventions following an experimental design is scarce and highly heterogeneous.None of the included studies evaluated the same intervention, and the studies varied in the type of patients, intervention components, and outcome measures, which complicated the comparison of studies.Therefore, evidence regarding the effects of district nursing care interventions is inconclusive.Additionally, it is unclear what outcomes can be used to demonstrate the value of district nursing care.There is a pressing need to produce methodologically strong evidence that is reliable, replicable and robust.Research programs guided by theory and focusing on interventions and nurse-sensitive outcomes in district nursing care are highly needed.It is important to measure nurse-sensitive outcomes in a standardized manner to provide insight into the quality of delivered care and to guide monitoring and improve the quality of district nursing care.

Table 1
Characteristics of included studies.

Table 1
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Table 3
Interventions identified and ordered by the target population.
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Table 3
(continued ) 22 -van Rossum et al. (1993).Preventive home visits for older During multiple home visits, the nurses discussed health topics,The nurses had been performing inhome care nursing for many years Four visits a year for three years with extra visits if necessary.In (continued on next page) J.D.Veldhuizen et al.

Table 3
(continued ) (continued on next page) J.D.Veldhuizen et al.

Table 3
(continued ) (continued on next page) J.D.Veldhuizen et al.

Table 4
Outcomes used in district nursing care.

Table 4
(continued )The numbers in each column are the reference numbers of the included studies from table 1. GARS: Groningen Activity Restriction Scale; SIP68: sickness impact profile short generic version; COOP/WONCA: The Dartmouth Corporation Functional Health Assessment Charts/World Organization of Family Doctors; SF-36: The Medical Outcomes Study 36-item Short-form Health Survey; FES-I: Falls Efficacy Scale-International; VIPS: wellbeing, integrity, prevention and safety; LHS: London Handicap Scale; ESAS: The Edmonton Symptom Assessment Scale; SCL-90: symptom checklist; MMSE: This underlines that district nursing care is a speciality nursing practice requiring specific nursing interventions and competencies.
Notes: Mini-mental State Examination; AMT: Abbreviated mental test; GHQ: General health questionnaire; GDS: Geriatric depression scale; CES-D: centre for epidemiological studies depression scale; LSI-A: Life Satisfaction Index-version A; CDSES: Chronic Disease Self-Efficacy Scale; ZBI: Zarit Burden Interview; CarerQol: Caregiver quality of life; SSL12: social support list of interactions; PRQ-85: Personal Resource Questionnaire; IDI: Interpersonal dependency inventory; DART: Drug Related Problem Risk Assessment Tool; LHFQ: The Minnesota Living with Heart Failure Questionnaire; CHQ: chronic heart failure questionnaire; EQ-5D: European Quality of Life-5 Dimension; SF-20: Medical Outcomes Study 20-item Short Form Survey Social functioning score; IIQ: Incontinence impact questionnaire; QL-Index: Quality of life index; HUI-Mark3-HRQL: Health Utilities Index Mark 3 health related quality of life.2017).