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
Patient Focused Care
Patient focused care is a change in service characterised by the re-organisation of health-care delivery to establish an integrated system of service provision. In turn, this change in service has lead to an integration and consolidation of service provider roles to eliminate fragmentation, improve coordination, produce improved outcomes and decrease the cost of providing services. As a result service partnerships that are oriented around patient care issues rather than the traditional segmentation of professional groups have been established (Routh & Stafford, 1996 USA; Cormack, Brady, Porter-O'Grady, 1997 USA; Knox & Irving, 1997 USA).
The literature relating to patient focused care emanating from the United States (USA) is predominately narrative and relates to the acute hospital sector. Key components include cross-training staff to provide up to 90% of care, flattened management structures, grouping similar patient populations together, organizing staff into work teams composed of various care partners, creating customized critical pathways for the management of care, and documenting by exception (Vietri, Poskitt, Slaninka, 1997 USA). In such an organisation the traditional physician lead approach has changed to multi-disciplinary team based 'primary care' (Porter-O'Grady, 1997 USA). The use of unlicensed staff in patient care situations is common. Caregiver roles have been developed and tasks identified for each role.
The introduction of the US model of primary care affects the scope and complexity of the role of the professional nurse. He/she now has a strong focus on management and coordination of activities of other professionals and supportive staff including supervision and delegation to unlicensed personnel (Knox & Irving, 1997 USA). In this role the professional nurse has primary accountability for assessment, planning, patient and family teaching, and evaluation of care. In addition to clinical skills the professional nurse also requires skills in leadership and cognitive and critical thinking processes and the ability to clearly define nursing and non-nursing tasks (Ross, Counsell, Gilbert, 1996 USA; Webb & Pontin, 1996 USA; Litwin, Beauchesne & Rabinowitz, 1997 USA; Ingersol, Cook, Fogel, Applegate & Frank, 1999 USA).
A low level of evidence is present in the literature relating to this model. One qualitative study reported that the introduction of a primary care model and the subsequent direct accountability for individual patients improved communication but nurses experienced fluctuations in workload, shortages of essential resources, and experienced difficulties relating to time pressures and meeting deadlines (Ingersol, Cook, Fogel, Applegate & Frank, 1999 USA).
The literature relating to patient focused care emanating from the United Kingdom (UK) is significantly different to that from the USA. In the UK, the patient focused care literature relates not to the acute sector, but to community based medicine. The role of the General Practitioner (GP) is central in this literature where primary care is defined as 'first contact care' (WHO, 1987; Meads, 1996 UK) and the aim is to provide a primary health care service as close to the client base as possible (Hibbs, 1996 UK). This literature is reviewed under section 2 (changes in the roles of health professionals which have impacted on nursing).
The Australian government has also adopted a population health approach with GP's having a central role as primary care providers. Once again, the literature relating to this service is reviewed in Section 2.
Like Australia, and the UK, Primary Health Care in Sweden is a publicly funded community service. Unlike Australia, Swedish nurses working in general practices do have a significant role in health promotion. A small purposeful study (n=39) by Bendtsen & Aklerlind (1999 SC) was conducted to evaluate changes in attitudes and practices among GP's and Nurses after the implementation of an educational program for early identification and intervention of alcohol related problems. Despite nurses and physicians completing the same program, nurses' response to training program was found to be poor. Accordingly, the researchers recommended that nurses require a different form of education than GP's with regard to alcohol interventions.
Community Nurse-Led Care
In the context of an aging population that is increasingly chronically ill and functionally impaired (Alexy & Elnitsky, 1996 USA; Moneyham & Scott, 1997 USA; Jeglin-Stoddard & DeNatale, 1999 USA; Oberski, Carter, Gray & Ross, 1999 UK; Marek & Rantz, 2000 USA) Community Nurses are challenged to take on the role of coordinating care in a multidisciplinary environment. In this role there is again an emphasis on population health and case management. Nurses are increasingly taking services to the client where they are met with complex situations that require advanced problem solving skills and the ability to make on-the-spot decisions.
Managed Care insurance plans have changed the face of community care in the United States. Managed care is primarily concerned with resource utilization and cost-containment to reduce the financial aspects of care. As a result, care is often fragmented with services that have traditionally been performed by community nurses being taken over by contracted specialist staff. For example, infusion and pathology services, rather than nurses, now carry out interventions such as intravenous administration and venepuncture (Brown & Neal, 1997 USA). In this context, it is increasingly important for care to be provided in a coordinated fashion.
There is a low level of evidence supporting these claims however, with the literature in this area being largely narrative. However, a case study by Storfjell, Mitchell and Daly (1997) reports that after three years of operation a visiting nurse service of New York's Community Nursing Organisation was able to provide fiscally appropriate care coordination. The visiting nurses in this project provided direct care services, frequently identified health care problems that required medical intervention, referred the client to appropriate medical treatment and coordinated care of patients requiring multiple services problems.
The largely narrative US literature places the community nurse in the ideal position to act as care-coordinator. Nursing is broad in scope, adopts a holistic perspective of client care, has foundations in the biological and behavioural sciences and nurses themselves have considerable skills in providing holistic assessment including actual and potential risks relating to physical, psychological and social needs of individuals and families (Moneyham & Scott, 1997 USA). There is low level evidence supporting these claims, with the literature in this area being largely narrative. However, a case study by Storfjell, Mitchell and Daly (1997 USA) reports that after three years of operation a visiting nurse service of New York's Community Nursing Organisation was able to provide fiscally appropriate care coordination. The visiting nurses in this project provided direct care services, frequently identified health care problems that required medical intervention, referred the client to appropriate medical treatment and coordinated care of patients requiring multiple services problems.
An important factor in the success of the New York Visiting Nurse Program was its population health focus whereby the nurse working with individuals and families in the community as care giver and care coordinator was able to identify trends and needs of specific community groups. This study reports that a focus on prevention emerged. The provision of such services is a recurrent theme in the community literature. It is supported by government policy that moves away from the traditional "medical" model of disease management toward a nursing model of prevention and early intervention (Gross & Reed, 1999 USA).
An important factor in the success of the New York Visiting Nurse Program was its population health focus whereby the nurse working with individuals and families in the community as care giver and care coordinator was able to identify trends and needs of specific community groups. From this data a focus on prevention emerged and the participating nurses implemented "wellness plans" that included education in the areas of stress management, health eating, arthritis, healthy heart, diabetes management and dance therapy. Blood glucose, blood pressure and cholesterol screenings were also a component of their case- load. The provision of such services is a recurrent theme in the community literature. It is supported by government policy that moves away from the traditional "medical" model of disease management toward a nursing model of prevention and early intervention (Gross & Reed, 1999 USA).
Another American case-study (Kosidlak, 1999 USA) describes an early intervention/health education program implemented by community health nurses. Services delivered by the community health nurses in this instance include the same as those provided by the New York visiting nurses and additional services including physical examination, breast, prostate and cervical cancer screening, immunizations, family planning, health education and referrals.
The research by Kosidlak (1999 USA) supports the value of such population based programs. This researcher reported that public awareness and public education regarding prevention increased when public health care resources were redirected into preventative programs that service the community rather than the individual. These findings were not quantified, and the author stated that not enough time had passed to determine effects on health indicators such as infant mortality, teenage pregnancies, and mortality related to leading causes of death or the prevalence of risk factor behaviors. Instead, the benefits were supported by citing specific examples. A new approach to prenatal care was reported to have decreased fragmentation of services and increased accessibility and availability. The introduction of an on-line computerised system led to better coordination of immunisation programs. Collaboration among community coalition members resulted in the receipt of a grant for a breast and cervical cancer-screening program. Pischke-Win & Minnick (1996 USA) document a higher level of evidence for the success of such preventative programs in a quasi-experimental study. Although the sample population was faculty staff at a United States university and not the broader community, the study found that the introduction of a nurse-led service increased compliance with self- breast examination but not mammography. It is significant to note that the preventative intervention adopted changed individual health behaviors, but not behaviors relating to accessing screening services
It is important to note that any change in practice does not occur without the appropriate educational preparation. A cross-sectional study by Murray (1998 USA) reported that home healthcare clinical experiences during basic education were insufficient to prepare nurses for the extended roles in the community. In order for nurses to function in the role of generalist care-coordinators the literature recommends knowledge and skills in chronic illness management, developing clinical practice guidelines, new models of care, change management practices and health screening methods, epidemiology, health prevention methods and health education. Sound skills in clinical care delivery, and resource management are deemed essential. Comprehensive assessment of physical, environmental, social, functional, cognitive/mental, psychological, economical status, and social and spiritual challenges of older adults is crucial to ensure that comprehensive care is coordinated, provided and evaluated (Brown & Neal, 1997 USA; Jamison, 1998 USA; Jeglin-Stoddard & DeNatale, 1998 USA). Specialist care coordinators are nurses prepared at degree level in one or more chronic illness such as multiple sclerosis, diabetes, congestive heart disease, chronic lung disease, or rheumatoid arthritis (Jamison, 1998 USA).
The 'Aging in place' model of community care in the United States recognises the challenge of the aging population who will need extensive health care services late in their lives. It offers care coordination and health care services to older persons residing in their own homes, specially designed senior apartments, senior private or public congregate housing. Motivated by research evidence that mental and physical deterioration occurs when frail older persons move from one setting to another the 'aging in place' model ensures that frail older persons will not have to move from one level of care delivery to another as their health care needs change. Instead, the type of care is separated from the place of care and all services a person may eventually need are provided as required in a single setting (Marek & Rantz, 2000 USA). In this model the care-coordinator maintains contact with his/her clients through home visits, telephone and electronic communications. Care coordinators use and develop clinical practice guidelines. Acute crisis are avoided through collaboration with other health team members to facilitate screenings, access to services and provides for transitions in care as conditions change. Self-care is promoted through patient and family education (Jeglin-Stoddard & DeNatale, 1999 USA).
Case study research by Jeglin-Stoddard & DeNatale (1999 USA) investigated the implementation of a prevention-assessment screening process for community nurses delivering an aging in place service. The researchers administered a prevention-assessment questionnaire to 32 participants who had English as their primary language. Using a grounded theory approach, the researchers analysed the surveys to identify patterns of difficulty and persons in need of assistance prior to crises. Individual and community interventions based on the survey results were then implemented. These included individualised treatment such as education relating to dehydration, medication management, management of respiratory and diabetic equipment, activity and exercise with chronic disease, self-monitoring and reporting of blood glucose levels, reaching the physician through the community nurse, counseling for anxiety and end-of life concerns, finding and using support groups and other resources specific to participant's chronic diseases. More generalised interventions included initiating regular health promotion sessions and a blood pressure clinic at a senior citizen's venue. A follow-up questionnaire administered six months later revealed that 64% of participants had an increased awareness of responsibility for their own health care needs and an improved ability to access health information. Participants who received individualised care were found to be empowered to continue their own care with appropriate links to resources or were continuing to access community service agencies appropriately.
To date there are no results published from a long-term study to identify the ability of the 'aging in place' model to prevent nursing home admissions. This study will compare aging in place participants to a control group of clients of similar acuity to evaluate the effectiveness of the model and examine both the quality of care and the cost of care to determine viability (Marek & Rantz, 2000 USA). There are however recommendations from both the completed (Jeglin-Stoddard & DeNatale 1999 USA) and incomplete (Marek & Rantz, 2000 USA) qualitative studies reports that Masters prepared nurses specially trained in case management are responsible for assessing and reassessing the client's needs, developing and implementing a plan of care, and monitoring the quality and efficacy of the services delivered. Educational preparation includes knowledge regarding services provided by professional and nonprofessional staff. Specific skills required for provision of nursing services are in the areas of medication education and management, nutrition and disease management, safety, delivery of wound and catheter care and communication with family, physicians and other health providers.
The literature relating to nurse-led community care coordination has primarily related to the needs of the urban population. The need to access nursing services to improve and maintain health status and participate in health promotion activities is especially problematic in rural situations. Similar to the urban environment, access for rural clients can be improved by taking services as close to the client as possible. Narrative by Alexy & Elnitsky (1996 USA) describes an alternative model of health care delivery for a rural area of the USA with limited health resources and care providers. In a second paper, these same authors report on the large case study (n=222) that evaluates the implementation of this model in the form of a nurse-led Mobile Rural Health Unit (Alexy & Elnitsky, 1998 USA). The nurse-led Mobile Rural Health Unit provided health care services by visiting a variety of sites in the rural area (generally senior citizen venues, shopping mall, post offices) three times per week and initiating home visits on the other two days. Similar to the New York Case study, services provided included breast and cervical cancer screening, blood glucose and cholesterol screening, blood pressure monitoring, immunizations, health education and referrals. A high level evidence (NHMRC Level IV) component of the case study was the utilisation of a pre/post test to evaluate the service. Selected measures were repeated 12-15 months after the baseline measurements. Results included an increased utilisation of preventative health resources and decreased utilization of intervention related resources; increased immunization rates for influenza, pneumonia and tetanus; decreased utilization of the emergency room and increased participant knowledge of primary care services available.
New skills and knowledge required by the nurses delivering a nurse-led rural service are similar to those relating to the introduction of urban services in New York. In addition, the participating nurses and physicians revealed the necessity for an increased appreciation of health care needs of the rural elderly. There is also an emphasis on interdisciplinary education, with one of the by-products of the rural case study being that physicians reported an increased appreciation of skills and competencies of participating nurses.
The literature emanating from the United Kingdom relating to nurse-led community health care services is closely linked to the literature relating to primary health care. Once again, emphasis is upon delivering care closer to the home. NHMRC Level IV evidence from two pertinent studies details the educational needs of community nurses.
Carr (2001 UK) identifies that context has an important impact on learning needs and explored whether different learning experiences are required in the community compared to those required by nursing students learning in the hospital setting. She used a triangulated approach including focus group discussions collecting retrospective data, non-participant observation and concurrent interviewing. Themes emerging from the data included the necessity to engage in learning experiences that exposed the student to the complexity of the community setting. There is a need particularly for the student to identify that the life details of clients are not easily categorised using a disease related model and that multiple practice agendas such as acute, chronic and acute care superimposed on chronic care create diverse care needs. It was deemed essential that students developed skills in context, repeatedly adjusting existing skills to new situations. Students also required experiences that would assist them to develop a wider scope of practice than in a hospital setting, acknowledging the extension of nursing activities and the need to guide informal carers. The ability to practise in an environment that is not controlled by the nurse was another key theme to emerge, with nurses needing to develop skills in accepting and accommodating to a wide variety of care environments. Another important dimension to community nursing care is that practitioners may need to deal with more than 'essential' health care in the form of the client's dilemmas with daily life.
The needs analysis conducted by Oberski, Carter, Gray and Ross (1999) recognises the growing demands placed on community nurses in the United Kingdom by the aging population. This research found that in contrast to hospital-based nurses caring for elderly patients, the nurse engaged in community care of older people does not need to specialise in gerontology. Instead, education needs to assist the nurse to become adaptable to the lifestyles of the elderly, be able to make rapid decisions concurrently with assessments, practice autonomously and be aware of boundaries with other professionals.
In this study Houston & Clifton (2001 UK) implemented a corporate model of shared practice, with health visiting nurses developing multidisciplinary partnerships, and operating in teams. All team members however, maintained individual accountability. In this model there is an emphasis on communication skills. The outcome of this model was the introduction of new services resulting from the collaborative group meetings where active listening allowed development of many new ideas. New services included a new parents course, a group for post-natally depressed women, a support group for teenage mothers, parental self-weighing of babies, and standardization of parental information offered via telephone services at the clinic. The health professionals themselves also benefited from the change in service. Each participant developed a portfolio to showcase professional knowledge, shared educational materials with others in the group and experienced a greater involvement in community development work. The service benefited as use of resources became more cost effective, a research and development profile was established and it became recognised as a magnet service with interest expressed by other professionals to develop similar models.
Narrative literature describes both traditional models of children's community nursing services and new models that articulate with the GP led primary care services, or are nurse-led in their own right. The nurses delivering these services may be general nurses, general paediatric nurses or specialist paediatric nurses. Educational preparation for nurses delivering these services places an emphasis on both community and paediatric knowledge. Counselling skills, communication/liaison skills and health education skills are essential pre-requisites for practice (Eaton, 2000 UK).
School nursing services are also a component of paediatric health care in the UK. Narrative literature (Narracott, Gatehouse & Baird, 1996 UK) identifies that school health services are now nurse-led and doctors who previously made all decisions are predominately called in for specialist referrals. In response to this change in leadership of school health services the role of the School Nurse has changed from the traditional "matron model" to a highly articulate group of nurses with a broad range of professional skills. These skills include health promotion, health assessment, sex education, and counseling. The paper by Narracott, Gatehouse & Baird (1996 UK) describes these changes and includes a testimonial that depicts the School Nurse role as proactive rather than reactive. Educational preparation focuses on a population model of healthcare delivery with once again, an emphasis on communication skills, care coordination, "wellness" models, health promotion and disease prevention.
Evans (2000 UK) discusses issues related to school nurses and sexual health in the United Kingdom. He indicates that the Department for Education and Employment have stated that school nurses should be leading a new approach to the 'sexual aspects of life' through education and service provision to children and adolescents. He identifies the training needs of school health nurses as incorporating not only a comprehensive understanding of issues relating to sexual health, but also how this relates to specific client groups. Specific client groups are identified as including marginalized and socially excluded individuals with special needs, such as those with learning and/or physical disabilities, those with low self-esteem, those being bullied, peers and school colleagues.
A narrative paper by Canadians Chalmers & Bramadat (1996 Can) describes the shift from individual community services to community development as an important current and future trend for the provision of public health. It has been recognized as one of the major underpinnings of the international health promotion movement and provincial governments in Canada have included it in their plans to reform and restructure health care services. Community development strategies play a key role in promoting the health of populations, especially groups at risk and disadvantaged populations. The purpose of community development is to identify issues and problems affecting community life (for example, environmental health or adolescent alcohol use) and to develop and implement plans for change, building community strength, self-sufficiency and well-being. Whilst it is not specifically designed as health intervention, an improvement in the community's health may result. A cited example is the Health Cities Movement/Healthy Communities movement launched in 1986 by WHO. The goal is to promote well-being and health of communities by collaborative action at a local level. Chalmers & Bramadat also cite empirical evidence that public health nurses have a current and future role in community development services. Knowledge and skills required for community development nursing include conducting community assessments, analysing epidemiological and other research data and the ability to organise community action groups without 'taking over'. Knowledge and skills required for community development nursing include conducting community assessments, analysing epidemiological and other research data and the ability to organise community action groups without 'taking over'.
Finland's community nursing services are state supported and consist of specialist nurses who facilitate long-term follow-through with children and families (Duffy, Vehvilainen-Julkunen, Huber & Varjoranta, 1998 SC/USA). The USA funding system in contrast does not allow long-term relationship building but instead consists of intermittent care in a complex public and private system. As a consequence, Finnish practice was found to focus on empowerment and emotional/informational interventions while US practice focuses on physical elements of health care. Accordingly, Finnish community nurses are deemed to be in a better position to respond to changing service needs than their US counterparts. A Scandinavian/US joint research paper using survey and interview techniques (Duffy, et al. 1998 SC/USA) provides qualitative evidence relating to community nursing practices in Finland and the USA. Both shared a practice context of increasing complexity of family care including the challenge of increasing demand for health care services in the context of rising unemployment. However, the ability to respond to respond to changing service requirements were found to be markedly different in each country due to the different funding models employed. Finland's state supported specialist community nurses are able to develop long-term professional relationships with children and families. The USA community nursing role is substantially different, consisting of intermittent care in a complex public and private system. The latter does not allow long-term relationship building. As a consequence, Finish nursing practice was found to focus on empowerment and emotional/informational interventions while US practice focuses on physical elements of health care. The researchers concluded that by virtue of their role, Finnish community nurses were better positioned to respond to changing service needs than their US counterparts.
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