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
Chapter 2
Literature Review
General Context of Practice
The main objective for the health system in the new millennium is to establish a balance between social expectations and human rights against decreasing availability of resources.
By 2016 there is a projected increase in aged population to 16% or 3.5 million (AIHW, 1998). Given that age is the most accurate indicator for health and welfare services (Fuchs, 1984), the community has to deal with declining mortality rates and a growing disproportion of females to males. The aging trend also creates a significant increase in multi-system disorders that exacerbate both physical and mental frailty (Stevens and Onley, 2000).
Increasing consumer involvement requires clinicians to have a broader perspective of client management that includes an emphasis on the individual's context of health. Consumers expect safer, more personalised health care, greater involvement in decision making, larger choice and access to services. They tend to experiment with complimentary therapies and increasingly seek further information via resources such as the internet (AHMAC, 1996).
Progressively more sophisticated technology has lead to significant improvement in patient management through accurate diagnosis and treatments. Technology has precipitated new and innovative healthcare, shortening length of stay in hospitals and improving patient outcomes. However the high cost of technology and supporting resources has limited its availability to consumers. There is an emphasis on cost containment and public accountability for health care decisions surrounding resource usage. Thus, the emergence of evidence based practice has been a global phenomenon to assist clinicians decision making in the current climate.
New diseases, changing patterns of existing diseases and environmental threats pose further problems for the community. While technological advances such as minimally invasive surgery, genetic engineering and cybernetics are revolutionizing health care, a consequence is an increased demand for specialist professional services to care for these patients. Inadequate numbers of trained personnel to meet the needs of the health system leads to unsafe work practices, intolerable workloads and high stress.
To meet the increased demands associated with increasing health care expenditure, economic rationalization has been employed to ensure greater efficiencies in the system. As a response to the increased focus on costs and outputs, health care systems have seen the introduction of Diagnostic Related Groups (DRGs), case mix funding and managed care models, as well as a shift from predominantly acute care services to community and home care. The primary health care model ensures linkage between care systems reflecting continuum of care rather than isolated treatments and experiences. The shift also moves from a curative model to an increasingly preventative model with a focus on lifestyles to achieve longevity.
In summary, the health system is in a constant state of change in a climate of consumerism, risk management, accountability, professionalism and managerialism. All of these environmental variables influence nurses and nursing.
Review of the literature will be divided into three sections. The first section describe the changes in the types of service provided, including what, where and how those services are provided, over the past five years which have impacted on nursing and changes in the roles of health professionals, which have impacted on nursing. The second section describes changes in the roles of health professionals that have impacted on nursing. The third section summarises narratively how the above impact on the skills and knowledge required by the nursing workforce. The country of origin is either explicitly revealed, or noted as an abbreviation with the in-text reference. A key to the abbreviations is included in Appendix B. The terms patient, client or consumer are used interchangeably as they appear in the literature reviewed.
Section 1: The Changes In The Types Of Service Provided Impacting On Nursing
Case-Management/Managed Care
The concept of case management revolves around innovation, resource management and interagency collaboration. It has developed based on the tenets of primary nursing whereby a key person is accountable for the care of the patient from admission to discharge. As a health delivery process it now applies to the coordinated care delivered by a multidisciplinary team. As such, it is both disciplinary and interdisciplinary. Each participant aims to provide quality health care, decrease fragmentation of services to enhance the client's quality of life, while at the same time containing costs. There is an emphasis on problem solving, collaboration, and maximizing efficiency. The growth of case management is often related to the impact of the aging population and an increasing requirement for long-term health care planning. In the United States Case Management is particularly linked to the insurance driven managed care movement that requires accountability relating to service provision. Accordingly, the tools associated with case management include critical pathways, protocols and outcome measurements that relate service delivery to cost efficiency, morbidity and mortality and length of stay (Waterman, Waters, & Awenat, 1996 USA; Coile, & Matthews, 1999 USA; Reed & Hepburn, 1999 USA; Wayman, 1999 USA; Huber, 2000 USA).
Waterman, Waters, and Awenat (1996, USA) report that Case Managers fall into two different groups. The first provide both direct care and care coordination. The second deal solely with 'high risk' patients to monitor and coordinate long term care over repeated hospital visits. The latter case manager group does not provide direct care. He/she generally manages patients belonging to a specific diagnostic related group, utilize predetermined plans of care, and act upon any deviation from the care plan and document by exception. Despite this rather standardised approach to care, patient involvement is also essential to achieve successful individual outcomes.
While case managers are not necessarily nurses, many health insurers have shifted to nurse case managers as a more cost-effective way to fund case management and to provide direct services (Coile & Matthews, 1999 USA). Nurses have the appropriate disciplinary knowledge and skills to act as case managers. This includes the ability to conduct client/family assessments, formulate a comprehensive family and client treatment plan, facilitate health service delivery, act as a client advocate, to individualise needs and goals and to evaluate client/family outcomes (Zink, 2001 USA).
The literature relating to Case Management emanates from the United States and is largely narrative. There is however, an evidential base relating to the implementation of this model of care, the changes in service and role that have accompanied its development over the last ten years, and educational preparation for nurses acting as case managers. This literature falls into three major categories. These categories are based on the nature of the healthcare practice settings and include: acute care setting, community care setting, and rural care setting.
Acute care case management was adopted as a model for nursing practice in the late 1980's. It recognized that nurses are in a key position to manage the care of patients throughout their hospital stay and avoid the pitfalls of fragmented specialized services. Central to this model is the recognition that nursing is not a task-based activity, but incorporates knowledge-based professional practice. An advanced practice nurse role in case management has developed in response to continuing evolution of the nurse case manager role. The advanced practice case management nurse (APCMN) may work in either the hospital or outpatient setting and utilises data analyses to identify a population that would benefit from interdisciplinary management. The APCMN then builds an interdisciplinary team that create a coordinated service plan that includes a clinical pathway based on established outcomes, but tailor made to the patient's individual situation. The APCMN works autonomously as a clinical expert and analyst and adopts a population-focused, leadership and research-orientated role. Case Management nursing education will need to respond accordingly. It is anticipated that nurses with bachelor degrees and extensive clinical experience who have high level skills in communication and collaboration will undertake Masters level preparation to take on the APCMN roles outlined above (Wayman,1999 USA).
The literature relating to case management in acute care is largely comprised of case studies.A case study by Waterman, Waters and Awenat (1996 USA) using participant observation and interview techniques provides research evidence relating to a change of service resulting from the introduction of an acute care case management model. Conducted in an American rehabilitation ward, the themes arising from analysis of data identified specific educational needs for nurses assuming the new role of case managers. Of primary importance was the need to learn new skills and knowledge relating to patients they otherwise would not care for. Equally important was the need to learn more about critical pathways. Finally, the nurses required new knowledge to understand accountability issues.
Novak (1998 USA) reports that nursing has responded to the challenges of shorter hospital lengths-of-stay and increased patient acuity in the context of an increasing aging and chronically ill population by adopting a case management model. The literature review in this paper identifies a paucity of research evidence documenting the essential role attributes of the nurse case manager. In order to address the situation this study of 15 nurse case managers at a 658 bed regional medical centre in southeastern United States uses a Delphi technique to obtain expert opinions about the role from successive rounds of questionnaires. The study also included two focus group discussions that added reliability to the findings. Results included the following definition of the nurse case manager: 'coordinator of a multidisciplinary treatment plan which addresses a patient/family's continuum of care needs while ensuring clinical quality that is cost effective and organizationally efficient" (p235). Critical skills required to support this role were identified as the ability to coordinate quality, cost effective care; possessing expert clinical knowledge, clinical expertise and being able to effectively manage time. Well-developed communication skills, the ability to provide clear explanations and provide appropriate health education were also identified as key skills.
A case study by Murray, Broad, & Welnick (1999 USA) describes the introduction of an associate case manager. A graduate with a Bachelor or Associate Degree in human services, social work or behavioural science performs this role. The associate does not complete assessments or develop a plan of care. Instead, he/she complete various delegated aspects once the plan of care is formulated. The case study on the implementation of this role claimed that the associate made substantial contributions to the coordinated care teams and enhanced their ability to provide quality patient care, but did not provide supportive evidence for this claim. The introduction of a role of this nature however, would require nurse case managers to be prepared with knowledge and skills relating to supervision of care delivered by non-nursing staff including delegation and evaluation, and human resource management.
The literature relating to models of case management in the community setting is discussed in the section entitled: Community Nurse-Led Healthcare Services.
As described by Stanton and Packa (2001 USA), Nurse Case Management in American Rural Communities has a distinct character created by the unique needs of rural residents and rural communities. While urban nurse case managers typically coordinate care for clients placed in disease related groups, there are often too few clients in one group for rural case managers to implement disease management programs. Instead, rural nurse case managers (RNCM's) are generalist rather than specialists and require excellent research and administrative skills as they often work without the traditional support systems that are available to their urban counterparts. The normal tools of case management such as critical pathways may not be applicable and RNCM's need to know how to access evidence-based practice guidelines to develop models of care, databases and outcome measures specific to their individual rural practice settings. Furthermore, the RNCM not only practices in a setting that has limited healthcare services by virtue of distance, but they also need to understand the impact of distance and limited financial resources upon their client's ability to access healthcare services. RNCM's also play a major role in the community's health and well-being by assuming social and political roles in the community and shaping policy and healthcare support systems. As such they are involved in designing and implementing a system of care for the whole community. For example, they may work with public health and school officials to implement injury prevention and environmental health programs.
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