Aspects of Nursing Education: The Types Of Skills And Knowledge Required To Meet The Changing Needs Of The Labour Force Involved In Nursing - Literature Review
- The Current Literature - Satisfaction with the Nurse Practitioner Role
- The Current Literature -Nurse Practitioner Contexts/Settings
- Nurse Practitioner and Physician's Assistants
Summary of the Skills and Knowledge required by Nurse Practitioners
A wide variety of descriptions of the functional roles or behaviours of the nurse practitioner have been found in the literature. Commonalities can be seen in the nurse practitioner role in various specialty areas and across different countries. A list of nurse practitioner role components included in the literature is given below under the headings used by Mick and Ackerman (2000): direct comprehensive care, support of systems, education, research and publication and professional leadership. Only those activities that have been mentioned frequently in the examined literature are listed
Direct comprehensive care:
- complete comprehensive physical and psychosocial assessment;
- make differential diagnoses within specialty scope of practice;
- initiate and interpret diagnostic tests;
- use well developed problem solving/clinical decision making skills;
- perform specialty-specific procedures;
- initiate and maintain continuity of care;
- provide advice/counselling;
- coordinate patient care;
- collaborate/consult with other health professionals;
- make referrals to and receive referrals from other health professionals;
- provide preventive care;
- use protocols and guidelines to guide practice;
- empower patients;
- support family/care givers;
- facilitate efficient movement of patient through health care system.
Support of systems:
- write clinical, audit and research reports;
- develop collaborative policies, procedures and guidelines
- participate in committees;
- provide leadership in development, implementation and evaluation of standards of practice; and
- serve as a mentor.
Education:
- provide health promotion information;
- serve as formal/informal educator and clinical preceptor for nursing and other students;
- provide education for patients and family;
- act as a resource and consultant for staff/others.
Research:
- critically evaluate published literature;
- participate in investigations to monitor and improve care
- collaborate in research projects; and
- implement findings.
A number of authors break down aspects of the role to make explicit, activities such as undertaking physical examinations, taking a medical history and prescribing medications. In addition Pastorino (1998 USA) includes another component of the role - participation in health policy. A number of authors stress the need for negotiation and assertiveness skills (Martin & Hutchinson, 1997 USA and Lambert & Lambert, 1996 USA), while other discuss the need for nurse practitioners to have entrepreneurial skills if they are considering independent practice (Blair, 1997 USA and Lambert & Lambert, 1996 USA).
Regardless of context nurse practitioners require skills and knowledge in advanced physical assessment, advanced physiology, pathophysiology, health promotion, pharmacology and clinical decision-making. Other useful skills/knowledge appear to be research, advanced communication, information about trends in health care, local health policies, funding and legislation. Very specific skills related to the context or setting where the nurse practitioner is working are also required however these are dependent on the specific role undertaken. Management, marketing and entrepreneurial skills may be necessary depending on the role.
The Current Literature - Satisfaction with the Nurse Practitioner Role
As mentioned in a number of the articles already reviewed patient satisfaction with nurse practitioner services is good (Venning et al 2000 USA, Chang, Daly, Hawkins, McGirr, Fielding, Hemmings, O'Donoghue, & Dennis, 1999 AUS; Kinnersley et al 2000 UK; Bond et al 1999 UK; Wan et al 1999 AUS; Williams et al 2000 UK; Reveley 1998 UK). Mundinger's randomised controlled trial (2000 USA) found no significant differences in the scores between nurse practitioners and physicians for any of the satisfaction factors after the first visit, however at six months patients rated physicians higher on the provider attributes score. This score consisted of the provider's technical skill, personal manner and time spent with the patient. A study of 149 consumers of nurse practitioner services demonstrated a high level of acceptance of the role of the nurse practitioner in a rural community in Nebraska (Schweser 1998 USA).
User satisfaction was also identified in a limited number of studies. Nurse practitioners participating in the Australian pilot in the emergency department (Chang, Daly, Hawkins, McGirr, Fielding, Hemmings, O'Donoghue & Dennis 1999 AUS) found their job satisfying and rewarding. The nurse practitioner and clinician involved in the telesigmoidoscopy evaluation were highly satisfied (Wan et al 1999 AUS).
The Current Literature -Nurse Practitioner Contexts/Settings
A summary of the contexts/settings where nurse practitioners work is provided below. The first list is from the Virginia Board of Nursing/Virginia Board of Medicine Regulations. Unlike many States in the USA it incorporates nurse anaesthetist and nurse midwife under the heading nurse practitioner. Most other states list these roles separately under the umbrella term, advanced practice nurse as mentioned previously.
- adult nurse practitioner;
- family nurse practitioner;
- paediatric nurse practitioner;
- family planning nurse practitioner;
- obstetric/Gynecologic nurse practitioner;
- emergency nurse practitioner;
- geriatric nurse practitioner;
- certified registered nurse anaesthetist;
- certified nurse midwife;
- school nurse practitioner;
- medical nurse practitioner;
- maternal child health nurse practitioner;
- neonatal nurse practitioner;
- women's health nurse practitioner; and
- acute care nurse practitioner.
Other practice areas included in the literature are:
- nurse practitioner sigmoidoscopy / gastroenterology nurse practitioner
- primary care
- nurse practitioner management of heart failure
- nurse practitioner management of least urgent triage categories in an ophthalmic casualty
- nurse practitioner management of urinary continence and
- comprehensive breast clinic nurse practitioner.
In addition to these, pilot projects in Australia have been or are being carried out in the following areas:
- primary care for 'at risk' youth and sex workers
- primary care for homeless persons
- hospital maternity
- haematology
- wound care
- paediatric eczema
- peri-operative pre-admission
- psychiatric consultation-liaison
- primary care for well women
- sexual health
- military
- diabetes
- stomal therapy/continence/wound care and
- palliative care
Nurse Practitioner and Physician's Assistants
In addition to nurse practitioners, physician's assistants are also being used in primary care practice and to an extent in hospitals.
Jacobsen, Parker and Coulter (1999 USA) conducted an exploratory qualitative study to identify the nurse practitioner and physician's assistants role across nine health maintenance organizations and multispecialty clinics in which nurse practitioners and physician's assistants had been successfully integrated, to varying degrees, over an extended period of time. Interviews at each site with several nurse practitioners, physician's assistants, and physicians, and at least one representative of the institution's administration. At the sample institutions nurse practitioner and physician's assistants were treated as interchangeable for the provision of primary care. Both groups reported undertaking tasks that could be grouped as diagnosis (physical assessments and test ordering), medical treatment (monitoring diabetes and hypertension), writing prescriptions (although in many instances these required countersigning by the physician) and providing minor surgical treatment (biopsies and mole removal). In addition they provided non-hospital acute care (minor trauma) and well care (Pap smears and breast examinations). Things of interest in scope of practice in this study were that the physicians generally treated the most complex cases and that nurse practitioner and physician's assistants were not held accountable in the same way as physicians. The overall responsibility for medical judgement rested with the physicians.
The American Academy of Pediatrics Committee on Hospital Care (1999 USA) indicates that the role of the nurse practitioner and physician's assistant in paediatrics has been expanded from the primary care focus to include the care of hospitalised patients. It recommends that the physician direct the management of such patients and that written protocols be required. It also suggests hospitals establish credentialing processes delineating privileges in the same way it is done for medical staff albeit that nurse practitioners would go through nursing channels and physician's assistants would through the medical staff process as they work directly under the supervision of a physician.
A further article indicates that both nurse practitioners and physician's assistants may be used in the future in intensive care units (ICUs). Lustbader and Fein (2000 USA) reviewed the literature related to the models of patient care used in ICUs, the role of intensivists, the financial aspects of 24-hour on-site intensivist coverage and the advent of telemedicine. In their conclusion they surmise that community hospitals "... may rely on specially trained nurse practitioners or physician assistants to provide more on-site coverage during off hours."
The final article in the area of physician assistant describes their emerging role in the delivery of dermatologic health care (Clark, Monroe, Feldman, Fleischer, Hauser & Hinds, 2000 USA). The number of dermatology physician's assistants has increased from approximately six in 1993 to more than three hundred, most of whom work with dermatologists in private practice. While the role of physician's assistant currently does not exist in Australia it should be noted that there is the potential for nurse practitioners in this field since one of the first nurse practitioner pilot projects in Victoria involved paediatric eczema.
Section 2:Changes in the roles of health professionals which have impacted on nursing
The Primary Care/client focused health care strategy in the UK is operationalised by General Practitioner's (GP's) commissioning and providing local services based on the needs of local populations. Commissioning is the strategic response to meeting local health needs through service developments including developing new services, changing existing services, and downsizing services where supply exceeds demand. Purchasing refers to negotiation of contracts with local providers for the provision of these services. While the health authorities still have an overview of health needs and ensure that appropriate services are provided, it is a major change from health authorities being the major fund-holder's for services with GP's assistance, to GP's becoming responsible for allocating funds with health authority assistance (Felvus & Andrews-Evans, 1996 UK). Fund-holding is voluntary and is linked to the number of patients in the GP practice. 53% UK population is registered with standard fundholders. Most GP's purchase staff, drugs, diagnostic tests and community health services but not hospital activity. A pilot study increases GP's funding to purchase all hospital and community health services on behalf of their patients (Hibbs,1996 UK).
New developments arising from this initiative include pre-admission clinics, early pregnancy assessment units, admission units, consultant outreach clinics, practice-based counseling and physiotherapy services, community hospital beds, primary care-led minor injury units, team midwifery services and hospital at home schemes.
Although most of the literature is narrative, of particular significance is the literature relating to the impact that this change has had upon the provision of primary care services by nurses. The literature reveals that there is high level evidence in the form of case studies and randomised control trials (NHMRC level II) for nurses as partners in the provision of patient focused care and for nurses to expand their roles to assume tasks previously carried out by GP's.
Research includes a qualitative study by Luker, Austin, Hog, Ferguson & Smith (1998 UK) that reports patient satisfaction and in some case preference over a GP for community nurses and home visit nurses to prescribe treatment and provide care relating to diabetes, wound management, asthma and baby care. Preference for the nurse-patient relationship versus the GP-patient relationship was attributed to lack of social distance and gender issues including the 'caring' capacity attributed to the female nurse. The practice of home visits was also preferable compared to doctor's rooms. Such preferences have implications for other GP services that may be assumed by nurses. For example, a cross-sectional survey of adult victims of violent crime (n=195) revealed that although assault is a relatively common event in the lives of women who consult their GP, women rarely disclosed their distressing experiences to the GP (Mezey, King & MacClintock, 1998 UK). The case study by Goodman, Knight, Ina & Hunt (1997 UK) describes the collaborative relationship between GP's and district nurses in managing terminal care.
Prior to the introduction of the GP contract, the practice nurse was an emerging occupation in the UK. The Government predicted that nurses would have a vital role to play (Lipley, 1998 UK) and indeed following the changes to the primary health service there has been a six-fold increase in practice nurse numbers (Broadbent, 1998 UK). In addition, there is high level evidence to support an expanded role for practice nurses in order to meet the demands of the change in primary health services. A small qualitative study (n= 34 practices) found that practice nurses were carrying out health promotion activities that were a priority of the new service but that GP's had yet to embrace (Broadbent, 1998 UK). Positive outcomes when practice nurses engage in health promotion activities were reported in a large (n=1173) multi-centre trial (NHMRC level IV) in Northeast Scotland (Campbell, Thain, Deans, Ritchie, Rawles & Squair, 1998 UK). In this study secondary prevention clinics conducted by practice nurses for patients with a working diagnosis of coronary heart disease were found to improve patients' health and reduce hospital admissions.
Fall, Walters, Read, Deverill, Lutman, Milner & Rodgers (1997 UK) conducted a prospective observational cohort study (NHMRC level III-2) comparing health outcomes and resource use for patients with ear or hearing problems treated by nurses trained in ear care with similar patients treated by standard practice. Specialized training in the structure and functioning of the ear and basic audiometry training were given to practice nurses in eight practices in the United Kingdom. These nurses then practised for six months. A further nine practices where the training had not been given were chosen and outcomes compared. The authors conclude "nurses trained in ear care reduce costs, GP workload, and the use of systemic antibiotics, while increasing patient satisfaction with care." (p 699)
Clients with Psychiatric morbidity constitute a significant proportion of general practice workload. The findings of a small (n=70) randomised control trial (NHMRC level II) relating to the extension of nurses skills in the area's of mental health assessment and counseling (Mynors-Wallis, Davies, Gray, Barbour & Gath, 1996 UK), are reinforced by a large (n=655) rural randomised control trial (NHMRC level II) by Mann, Blizard, Murray, Smith, Botega, Macdonald & Wilson, (1998 UK). Mann et al that found training practice nurses to work alongside GP's in assessing patients and providing follow-up care was associated with outcomes consistent with GP provided care. The necessity for appropriate training in this area however was highlighted by a large (n=1710) multicentre randomised control (NHMRC level II) trial by Plummer, Gournay, Ritter & Blizard (2000 UK). This study reported a low mean detection rate for psychiatric morbidity by practice nurses for patient's whose symptoms were not severe.
Patients requesting same day appointments for minor illnesses also represent a large proportion of general practice workload. Evidence for an extension to the practice nurses' role in this area appears in the literature as a case study and two large multi-centre randomised control trial's. The large (n=1263) case study Gallagher, Huddart and Henderson (1998 UK) reported that ~50% same-day requests were handled by the practice nurse either via a telephone or face-to-face consultation. GP workload fell by 54% with only 7.8% of these patients requiring a GP consultation. The follow-up patient satisfaction survey (n=325) found that 88% of patients were satisfied with the telephone advice from the nurse. Two large (n= 1815 & 1716) randomised control trial's (NHMRC LEVEL II)'s relating to prescribing and provision of minor illness services (Shum, Humphreys, Wheeler, Cochrane, Skoda & Clement, 2000 UK; Venning, Durie, Roland, Roberts & Leese, 2000 UK) concur that there are satisfactory outcomes and no significant increases in cost when nurses provide services in these areas. In these studies, when prescriptions were required they were completed by the practice nurse and signed by the GP.
Caldow, Bond & Russell (2001 UK) surveyed 433 practice nurses in general practice across Scotland. The 385 questionnaires suitable for inclusion in the study showed that over 90% of the respondents applied for the job because working independently and the variety of work involved appealed to them. Much of their work involves conditions where evidence based advice is the main or only intervention. In general most practice nurses would be willing to diagnose certain self-referrals and prescribe within strict protocols, however training in both areas was required.
In all studies new knowledge and skills relating to assessment, clinical decision- making, and treatment were required to undertake the new roles. These were obtained through varying models of education ranging from tertiary courses to Mentoring by professional medical colleagues.
With a growing focus on population health and delivery of primary care services, GP's in Australia are now expected to engage in health promotion activities. A large cross-sectional survey (n=13,017) revealed that there were discrepancies between patients' expectations of the doctor's role in promoting healthy life styles and their likelihood of receiving advice (Richmond, Kehoe, Health, Wodak and Webster, 1996 AUS).
The role of multi-disciplinary health care teams is recognised in the primary health setting (Sims, Kerse, Naccarella & Long, 2000 AUS). With the de-institutionalisation of Mental Health Care, there are particularly strong partnerships between GP's and community mental health nurses. A comparison of the old integrated model and new consultation-liaison model (n=100) for providing mental health care in general practice in New south Wales revealed that the closer liaison between GP's and community mental health in the new model had many benefits (Harmon, Carr, & Lewin, 2000 AUS). In order to maximise these outcomes the study recommended that rather than focusing education solely on educating the GP in mental health, that there is an outstanding need to educate mental health nurses to enable them to work more effectively in a collaborative team with the GP's.
The literature reveals that role of the practice nurse is not well developed in Australia. Two qualitative studies shed some light on the current role of the practice nurse and recent role developments. A questionnaire survey of 452 general medical practices in Victoria conducted by Bonawit & Watson (1996 AUS) attracted responses from 277 practices, many of which did not employ nurses. The 93 respondents from 85 practices who were nurses reported that while the majority of time was spent in clinical procedures, at least 30% of their working week was spent on clerical tasks. Few were involved in health promotion, educational or advisory work and relied heavily on the GP for their own continuing education. Twenty four percent of respondents visited patients at home.
A small qualitative study (n= 8 practices) by Condon, Willis & Litt (2000 AUS) reports minor changes to the roles recounted in the earlier research. Using purposeful sampling for 4 urban practices, convenience sampling in 4 rural practices, GP's and practice nurses were interviewed and the emerging themes analysed. The practice nurse has traditionally carried out a largely receptionist role in Australia, however this research found that practice nurses are now occupied in largely nursing work with little time spent on clerical duties. Clerical duties when carried out were most likely to be directly related to patient care. Nursing duties were largely procedural (venepuncture, preparing for GP procedures, wound dressings, ECG's, Imunisations, Pulmonary Function tests), with some triage duties and education/health promotion activities. Unlike their British counterparts, the relationship between the GP and the practice nurse is rarely collaborative, with the nurse being seen as a resource to the GP's practice rather than a professional colleague with her own domain of knowledge and practice. Various innovations were introduced by the physician, but implemented by nurses. In the majority of cases where practice nurses acted more autonomously, this was seen to undermine the GP role rather than constitute a valued service. While most practice nurses saw opportunities to develop the role in terms of gaining more procedural skills, they felt that significant education was required to expand their role in health promotion and health education. Those GP's and practice nurses who saw potential to develop the practice nurse role in the areas of heath promotion and health education were prevented doing so by the current funding structure. This structure requires the GP to sight the practice nurse's work in order to receive financial remuneration for the same.
Section 3:Summary of Required Skills and Knowledge
The main themes relating to skills and knowledge of the nurse across all service settings and roles are coordination of care, patient/client assessment, clinical decision making, education, research, counselling and organisational management.
Coordination of quality, cost-effective multidisciplinary care is a skill that recurs across the literature. Coordination aims to ensure continuity of care between sectors and facilitate health service delivery. In order to do this, nurses coordinating care require high-level communication and liaison skills; the ability to delegate to, supervise and evaluate professional and unlicensed staff; knowledge of professional boundaries of practice; and knowledge of available services, providers and health funding.
The need to have assessment skills appears frequently but varies somewhat between settings or roles. Nurses in case management/coordinated care roles require skills and knowledge in comprehensive assessment of physical, environmental, social, functional, cognitive, psychological and economic status. Where the nurse is located in the community the assessment skills are different to those required by the nurse working in the acute care sector. Nurse practitioners and clinical nurse specialists, regardless of setting, require advanced assessment skills and knowledge related to the specialty area in which they practice so that they can make differential diagnoses.
Advanced problem solving and clinical decision making skills are also deemed essential in many roles with the nurse having the ability to adjust their skills to new situations.
The nurses' changing role in education is described in many articles. A larger component of education given by nurses, particularly in the UK and USA, is related to screening, health promotion and disease prevention. This includes teaching school children about sexual health and drug issues. The nurses' role in teaching across disciplines is particularly noted where nurse practitioners are employed, however the teaching of family care givers is also an important role identified in the literature. Teaching skills required by nurses include the identification of learning needs, use of different teaching methodologies and the facilitation of learning. The increase in multimedia use in education also requires nurses to be competent in this area.
The requirement for research skills is evident in the literature, particularly in relation to evidence based practice and quality of care. A number of articles indicate that nurses need skills and knowledge in analyzing and critiquing research findings and implementing evidence based research into clinical practice. Other articles indicate that nurses should have the ability to monitor the quality and efficacy of care which requires them to be have skills in the identification of outcome measures, collection and analysis of data.
The counseling role of the nurse is increasing particularly in the mental health field but also in other fields of nursing. Nurses need knowledge and skills in this area. A number of support groups established by nurses both in the community and acute care sector are documented.
The role of nurse executives and middle managers has changed with the move to decentralized management structures. The role has evolved to one that has non-nursing departments reporting to it, and the new manager is expected to have knowledge and skills in financial, human resource and change management; strategic planning; leadership; and mentoring. Nurse practitioners and nurse midwives in independent practice are also required to have entrepreneurial and business skills in addition a number of the skills required by managers.
Any comments or queries should be sent to: highered@dest.gov.au
This page was
last updated on Tuesday, 04 December 2001
Department of Education, Science and Training
Copyright © Commonwealth of Australia
DEST Web Site Privacy Statement
Disclaimer