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
INTEGRATED HOSPITAL AND COMMUNITY CARE
The literature reports that there is a number hospital outreach services that are designed to facilitate a smooth transition from acute to community based services.
The US literature relating to integration of hospital and community health care services is largely contained in the case-management literature. Qualitative research by Forbes (1999 USA) describes the important shift in the role of the case management nurse as a vital link in the interface between hospital and community-care. This case study revisits an acute facility where case management is well established and assesses the impact of managed care on nursing practice. Initially nurse case managers were advanced practice nurses who were based in specialty units and followed vulnerable patients in the community. The aim was to improve health outcomes by assisting to stabilize the client's condition through a collaborative relationship that built on the client's desire for self-management and the nurses' knowledge of wellness, disease processes and available community resources. Using a concept mapping approach, the researcher's claimed to discover that the nurse case-manager role had changed over time. The data presented however, did not support this claim. Instead, it identified that one of the major roles of the nurse case manager was to 'bridge the gaps' when client's needs were not met by the health care system. As such, the case manager acted as a change agent, responded to crises, acted as an advocate and was engaged in trouble-shooting.
A narrative paper by Bailey (1998 USA) again notes that the aging population is growing rapidly and that integrated health care services are essential in order to avoid complications after acute hospitalization. Bailey reports on a model of extended care services that includes a nurse care coordinator, a consultative geriatric assessment clinic, a primary care clinic and the provision of team-based care to members located in skilled nursing facilities (SNF's). The SNF's provide an intermediate level of care that 'fills the gap" between the acute hospital setting, nursing home type care and home care. The role of the nurse care coordinator is to initiate member screening, provide member orientation, supervise telephonic care coordination and organise a volunteer-based visiting program.
One Australian model for integration of acute and community services is Hospital in the Home (HITH). As the name suggests, HITH provides services that are traditionally provided to hospital patients in their own home environment. Hospital nurses' deliver care in the client's home, rather than community based nurses. It is a relatively new service and includes activities such as administration of intravenous therapy, administration of chemotherapy, complex wound care, anti-coagulation and neonatal services (Montalto & Karabatsos, 1998; McKenzie, 2000 AUS).
McKenzie (2000 AUS) reports that 12 HITH programs in Victoria, Australia administer cytotoxic drugs outside the controlled environment of the hospital. There is a wide variation of level of services provided and skills of staff delivering these services. The Victorian Centre for Ambulatory Care Innovation (VCACI) facilitated an expert committee to develop standards to guide chemotherapy practices in the community. The paper by McKenzie (2000 AUS) describes the pilot process initiated to evaluate the standards and criteria that form the measurable components of the standards. The study was small, consisting of a convenience sample of five HITH services reporting greater than fifty episodes of chemotherapy care in the previous 12 months. The research methodology was a written survey followed by structured interviews. The research findings validated the standards and identified new knowledge and skills required for their implementation. These findings led to the recommendation that future education programs should be structured to ensure nurses develop a combination of oncology and community nursing skills, and become familiar with quality improvement processes to support development of policies specific to their own services.
In 1996 Montalto (AUS) conducted a descriptive survey to examine the patients' and carers' satisfaction with hospital in the home care in Melbourne, Australia. The HITH service at that time predominantly provided intravenous antibiotic therapy to selected patients at home. The descriptive survey revealed that the preference for the convenience and comfort of home was the major reason for patient's agreeing to enter the HITH unit. Almost all patients and their carers reported that they would use the service again.
A small telephone administered structured survey (n=14) of Hospital in the Home coordinators/directors in Melbourne, Australia was conducted by Montalto and Karabatsos (1998 AUS). This research was prompted by the recognition of a greater emphasis on integration of health services between hospitals and primary health care providers yet a lack of information about GP involvement in such services. The research found that there is little GP involvement in these programs, instead 87.5% of services are nurse-led and nurse delivered. GP involvement was limited to management of intercurrent problems unrelated to the HITH care (21.4%) and even though the HITH coordinator informed the GP of the patient's admission to the program 42% of coordinators reported that these GP's had no current active role. The researcher's hypothesised that relationships between GP's and nurse coordinators may be inhibiting the GP involvement due to the coordinator's hospital backgrounds. This observation has implications for the knowledge and skills required for nurse-led hospital in the home programs. Not only do HITH nurses require sound clinical skills and the ability to work independently, but they also need knowledge of GP services and skills in adopting multi-disciplinary approaches to health care in a community setting. These findings are consistent with McKenzie's recommendations that HITH nurses not only require clinical expertise, but that they also need to develop expertise in community nursing.
The nature of the Australian rural practice context suggests that health care is characterized by a close relationship between acute and community services. In a narrative paper McMurray (1998 Aus) reports that changes in the Australian Healthcare service have meant an even greater shift towards community-based services, population health, and multi-disciplinary decision making in partnership with communities. This is of particular importance to the health of rural and remote communities where health status and mortality profiles identify there are significant 'at risk' populations. Underpinning the provision of these services is economic accountability and the need to demonstrate quantifiable clinical outcomes. Health professionals have responded by developing best practice protocols and practice guidelines that are transparent to the public and responsive to community health care needs. These protocols in turn are informed by recent and relevant evidence of their effectiveness. According to McMurray these changes in service delivery have meant that the role of rural nurses has become incredibly diverse. Activities undertaken by the rural community health nurse range from ensuring access to breast screening programs, to interventions dealing with rising levels of organochlorines in the food chain, and campaigns to reduce road trauma among rural youth.. In order to adjust to these changes nurses require new skills and knowledge relating to working in multi-disciplinary research teams, analysing and critiquing research findings, implementing evidence based research into clinical practice, and gaining proficiency in disseminating research findings. To support the acquisition of these skills, McMurray recommends the implementation of research mentorship programs, clinical-university partnerships, interdisciplinary rural seminars and study days, access to electronic journals and distance education modules.
McMurray's commentary on the changing face of rural health services is supported by qualitative research by McCarthy, Hegney & Pearson (2000 AUS). Based on data derived from a study of 129 rural health care facilities on 'The role and function of the rural nurse in Australia' McCarthy, Hegney & Pearson (2000 AUS) quantify the degree of change in reporting that 102 (79%) rural hospitals had experienced organisational change within the previous year. Significantly, re-structuring in these services was related to services changing from primarily acute medical services to primary healthcare or aged care services. Other changes included amalgamation or co-location of services, closure or downgrading of services and expansion of surgical and midwifery services. The need for greater accountability for service provision is evidenced by the implementation of case-mix/DRG related funding and major reform of health care services in preparation for Australian Council of Health Standards (ACHS) accreditation. The study found that changes to rural health services resulted in significant changes to the role and function of the rural nurse. They support McMurray's (1998 AUS) expert opinion and recommend that educational programs be implemented to ensure that nurses reacted positively to these changes. New knowledge and skills required relate to change management and the acquisition of strategies to improve interdisciplinary communication, and community involvement.
Nurse-Led Clinics
While it is important to highlight that Nurse-led clinics arose from the literature as a theme in their own right, the description of this change in service and subsequent impact on the role of the nurse is discussed in other sections of this review for contextual purposes. Accordingly, the literature relating to this theme is located under the headings Primary Focussed Care, Telemedicine/Telehealth, and services provided by specialist nurses/extended and expanded roles.
Family Provided Care
The literature relating to family caregivers includes several studies from the United States, United Kingdom and one Australian study. Themes emerging from the literature include the level of family care giver support, patient dependency, needs of family care givers, and the impact of increased home based care on the role of the community nurse.
Strategies to improve efficiency in health care in the United Kingdom have resulted in an increased emphasis on home- based care (Kirk and Glendinning, 1998 UK). Home-based care is used to decrease length of stay, prevent hospital admission and to provide service for people with terminal or complex care needs (Marks, 1991, 1992 cited in Kirk and Glendinning, 1998 UK). This home care is often unpaid, informal care, provided by family members (Kirk and Glendinning, 1998 UK). A substantial number of families are willing to provide home-based services for family members to keep them at home (Bond, Farrow, Gregson, Bamford, Buck, McNamee & Wright, 1999 UK).
The literature from the United States refers to family practice as treating the patient in the context of their family and community and confirms that cost cutting in acute care has precipitated a shift of care from the hospital to the home.. A large USA study by Doeschner, Franks and Saver (1999 USA) identified that family practice is more cost effective than individual practice. This one-year cross sectional survey of 35,000 individuals from approximately 14,000 households, found that there was a 14% reduction in costs when the family practice model was used.
The literature from the US also paints the picture of the chronic and consuming nature of cancer care-giving. While the narrative literature identifies strategies to assist family members providing healthcare services, there is little evidence to support the effectiveness of these strategies. Pasacreta, Barg, Nuamah and McCorkle (2000 USA) conducted a pre test-post test study (NHMRC level IV) from a convenience sample of 187 cancer care givers attending a 6 hour psychosocial education program. They found that the education provided to help family members provide cancer-care had positive effects. Participants reported that they were well informed and confident about caregiving after the program. They also reported that the program had improved their perceptions of their own health. However, the study raises the point that not all caregivers are willing or able to attend support programs and therefore service provision may be affected accordingly.
The literature on the level of family caregiver contribution is primarily narrative. Kirk and Glendinning (1998 UK) report that the increase in home-based care in the United Kingdom has seen a shift in family contribution from participation in care decisions to direct care provision. A large study in England attempted to quantify the level of support being provided by families. Bond, Farrow, Gregson, Bamford, Buck, McNamee & Wright (1999 UK) surveyed 1444 people aged 65 plus living at home or in long term care institutions. Of 1127 older people living at home, family delivered 93% of personal care support on a daily basis. Spouses were the primary providers (38%), closely followed by daughters (30%). The researchers concluded that there is a substantial commitment by families to keep the older person at home.
The amount and type of care provided by families has also changed. Patients are being discharged home with increased levels of technological support and families are providing care that was previously provided by doctors and nurses. The boundaries between the care provided by family care givers and nurses are now blurred. In an environment where family carers are delivering services that in the past have been provided by nurses the literature reports on the supportive role that nurses have now assumed. A study by Ward-Griffin and McKeever (2000 CAN) who interviewed 23 nurse-family pairs in Canada found that nurses initially provided primary care for the patient and families provided a support role. However after an adjustment phase nurses expected family caregivers to learn and take over significant amounts of care. The nurse role at this point was to monitor caregivers competence and skills. The study identified incompatible role expectations between the nurses and family caregivers. Family caregivers were not always able to provide the level of care that was being required of then and often experienced exhaustion, social isolation or became ill. Nurses are called on to relieve family care giver workload and stress through the provision of respite and additional home based support in order to ensure caregiver do not become the 'patient'. Kirk and Glendinning (1998 UK) report that nurses in the UK provide a key role in the education and supervision of family caregivers. Nurses are also ideally placed to provide information to potential informal carers to enable them to decide how involved home care they will be.
The literature relating to the needs of family caregivers is supported with evidence from studies in Canada, US and Australia. Ward-Griffin and McKeever (2000 CAN) interviewed 23 nurse-family pairs in Canada to identify the nature of the relationships between nurses in the community and family members caring for elderly relatives. Family caregivers reported exhaustion and social isolation as result of the burden of care giving and often became 'the patients' themselves. The study found that nurses initially provided primary care for the patient, and families provided a support role. However, after an adjustment phase nurses expected family caregivers to learn and take over significant amounts of care. British literature reports that where voluntary sector support is available this may decrease family caregiver stress and also reduce costs associated with care (Grant, Goodenough, Harvey and Hine 2000 UK).
Australian researchers Nankervis, Bloch, Murphy and Herman (1997 AUS) who conducted face to face and phone interviews with community counselors at 62 Victorian Health and Disability Organisations, report that little attention has previously been paid to identifying the problems experienced by family care givers. Yet this information is required to ensure an appropriate match between services and family care-givers needs. Family caregivers in this study sought help at critical points: during major changes and during new stages of the life cycle. The problems identified by family caregivers demonstrate the challenge in looking after their relative and the significant strain on their health and other relationships. Family caregivers felt socially isolated and reported negative impacts of their care giving on their marriage, children and other family relationships. Other challenges identified included having to deal with the stigma of the illness, changes in the patients' condition and care needs. Carers also reported feeling anger, bewilderment, grief, guilt, anxiety and helplessness. A lack of information provided about the patient's condition, prognosis and services was also viewed as a problem. Counsellors are called to be aware of the range of issues faced by carers and to actively seek to identify and explore these issues with family caregivers. Strategies to assist family caregivers may include education, advocacy, empowerment, increased resources or improved problem solving skills.
In Australia Dr Gwen Hartrick from the University of Victoria identifies benefits from a family approach to community nursing (Hartrick, 1997 AUS). Potentially family nursing enables the nurses to understand the meaning and experiences of families and illuminate the family's capacity to transform their experience. However, the current focus on health problems does not acknowledge the expertise and capacity of families to address their own health and healing needs. While changes such as improved collaboration and holism have occurred a problem management approach continues to exist. Hartrick proposes that a transformation of the existing system away from a health problem approach to an approach that enhances the health and healing capacity of families is required.
Care Delivered By Unlicensed Personnel
During the nurse shortages of the 1980's unlicensed staff were employed in the USA to cover the shortfall (Keepnews, 1997 USA). With increasing financial pressures in health care unlicensed staff are now being used to reduce costs (Keepnews, 1997 USA; Salmond, 1997 USA; Needham, 1996 UK; Badovinac, Wilson & Woodhouse 1999 USA; Bruser and Whittaker, 1998).
Unlicensed staff is also referred to as unlicensed assistive personnel (UAP), health care assistants, home health care aides and clinical support workers. Fundamentally all these terms refer to health care staff who are not nurses but who are employed to perform tasks that were previously performed by nurses. Evidence relating to unlicensed staff is predominately expert opinions from the USA and the UK, with very few high level studies. While unlicensed staff are used in Australia, predominately in aged care, no literature was identified exploring the Australian experience.
There does not appear to be a consensus within the literature regarding the benefits of unlicensed staff. The UK literature appears to support the introduction of an unlicensed staff role (Needham, 1996 UK; Poole, 1998 UK; Abbott, Johnson & Lewis, 2001 UK). In contrast the literature from the USA includes concern, (Keepnews, 1997 USA; Salmond, 1997 USA) and in some cases strong opposition to unlicensed practitioners (Bruser & Whittaker 1998 USA). Salmond (1997 USA) argues that an RN work force is in fact more cost effective, efficient and improves quality care and through put of patients compared to the service provided by unlicensed personnel requiring supervision by a nurse. Bruser and Whittaker (1998 USA) report on a campaign in the American Nurses Association against the increasing employment of unlicensed staff. Key concepts in the campaign are that 'every patient deserves a nurse' and nurses are called upon to report unsatisfactory care by unlicensed staff and promote the capabilities of nurses to policy-makers.
Of particular significance is a cross-sectional survey study (NHMRC level IV) comparing the impacts of unlicensed staff in the USA and the UK (McLaughlin, Barter, Thomas, Rix, Coulter & Chadderton, 2000 USA/UK). McLaughlin et al (2000) surveyed 342 Registered Nurses (RN) in the UK and USA to identify differences in the experiences of working with unlicensed staff. Statistically significant differences were noted with RN's in the UK having higher satisfaction with the ability of unlicensed staff to perform tasks, communicate pertinent information and provide more time for the RN to undertake professional activities. The researchers suggest the differences can be attributed to differences in training levels of the unlicensed staff and ratios of unlicensed staff between the two countries. The UK has National Vocational Qualification Standards, a set of competencies for unlicensed staff covering a number of key practices. No comparable national guidelines exist in the USA. Secondly in the UK the level of RN's is 85-95% compared to 50-55% in the USA. The researchers conclude there is a need to adopt standardised training requirements in the USA to ensure the successful implementation of unlicensed staff. Recommendations in relation to the ratios of unlicensed staff are not discussed.
The impact of unlicensed personnel on the nursing role is a recurrent theme in the narrative literature. It is suggested that the essence of nursing will be lost (Needham, 1996 UK) as nurses move away from the bedside to function in more of a supervisory capacity (Salmond, 1997 USA). This change is speculated to reduce the intrinsic and extrinsic rewards for nurses from direct patient care (Salmond, 1997 USA). There is also concern that breaking nursing activities into tasks will lead to a task focus (Needham, 1996 UK).
Another theme emerging is concern regarding the level of function of unlicensed staff. Training is considered to be inadequate and unlicensed staff are practicing beyond their level of training (Salmond, 1997 USA; Bruser and Whittaker, 1998 USA). Consequently RN's feel they are unable to trust or delegate to the unlicensed staff (Salmond, 1997 USA). Role confusion occurs (Salmond, 1997 USA; Bruser and Whittaker, 1998 USA; Needham, 1996 UK) and the quality of patient care is reduced (Keepnews, 1997 USA). Badovinac, Wilson and Woodhouse (1999 USA) used pre/post tests (NHMRC level IV) to determine the standard of service delivered by unlicensed personnel. These researchers surveyed 40 patients, 15 RN's and 9 unlicensed staff as part of a pilot study to examine the impact of the introduction of unlicensed staff in a short stay medical-surgical unit. Data was collected on patients' satisfaction and falls before and after implementation of unlicensed staff. Additionally, RN satisfaction with the unlicensed staff care model was measured after implementation. An increase in patient satisfaction was noted and there was no significant difference in the number of falls. RN satisfaction was relatively unchanged. The researchers did not explore factors that may have impacted on these results
In the UK Waters and Watson (1998 UK) interviewed 16 carers, line managers and nurses to identify the contribution of untrained staff to health care. Some unlicensed staff believe they do the same task as nurses with the exception of a few tasks such as medications. Half the managers interviewed believed the difference between qualification made no difference to quality of care. And half the managers did not now the differences between some of the roles. Abbott, Johnson and Lewis (2001 UK) who interviewed 99 continuing health care patients and /or their carers in 7 districts of England found that while community care nurses were valued by patients there was a need for more contact with nurses. The researchers suggest that given the demands already placed on community nurses, case managers who do not have health care training may be useful.
A number of narrative papers describe actions required for the successful introduction of unlicensed staff into health care settings. Authors in both the UK and the USA suggest that unlicensed staff are here to stay and recommend that nurses need to adapt to survive (Needham, 1996 UK). Health care institutions are advised not to underestimate the complexity of implementing unlicensed staff (Salmond, 1997 USA). The attitude of existing staff may add significant complexity to the implementation process (Treml and Schulman, 1999 USA). Small ward-base committees or governance groups may be useful forums for addressing these issues (Salmond, 1997 USA). Nurses are advised to invest their energy in taking charge of the change and developing effective systems rather than resisting the change (Needham, 1996 UK; Salmond, 1997 USA). Nurses may feel marginalised and have concerns regarding the impact on patient care (Strachan, 2000 UK) or experience confusion over the new roles and be unaware of the limits of unlicensed staff (Workman, 1996 UK; Needham, 1996 UK). As identified in the US research, Registered nurses in the UK may also be concerned that they are expected to supervise, delegate and mentor unlicensed staff without having had training in these skills (Poole, 1998 UK; Salmond, 1997 USA).
In a small case study Pischke-Winn and Minnick (1996 USA) describe the introduction of unit based multiskilled environmental workers into 30 patient care units in a medical centre in the USA. The authors identified a number of key lessons to assist in the successful implementation of such a program. In particular they are a clear vision, identification and working with resistance, visible communication, work redesign and publication of the project plan. They identified that another essential component was to involve nurses and to identify nursing and non-nursing tasks.
Mental Health Care
The literature reports that political and economic changes in Australia precipitated the process of deinstutionalization in mental health throughout the 1980's-1990's (Chapman, 1997 AUS). The narrative by Chapman (1997 AUS) describes the change in services that occurred when asylums were closed and mental health services were incorporated into mainstream healthcare facilities. This shift has resulted in a greater emphasis on community care and aims to provide improved accessibility of services to the general public. For those clients who do require institutionalized care, length of stay is significantly reduced in the majority of cases so they are returning home with community mental health follow-up. Community mental health nurses and multidisciplinary mental health teams provide these services.
Changes to service delivery have consequently dictated the clinical skills required by the healthcare professional. Nurses need to be reflective in their practice and to hone skills traditionally central in the clinical practice of other disciplines in the mental health field. Nurses also have a particular role in liaison with consumers and family who have developed a significant and active role in the treatment process. The narrative literature reveals that Mental Health nurses are more commonly being referred to as specialist nurse practitioners. Evidence at the level of case study supports this commentary. A case study undertaken in the USA looking at the introduction of Advanced Practice Nurses into specialty-based teams produced a positive result (Tucker, Sandvik, Clark, Sikkink, & Stears, 1999 USA). Improvements in team function were reported in areas including critical thinking, accountability, clinical skill development, and communication across the continuum of care, education and support for staff, an increase in the quality and quantity of research projects and presentations at conferences.
In the literature emanating from the United Kingdom there is an emphasis on the type of training made available for the Advanced Nurse Practitioner. Rolfe & Phillips (1996 UK) recommend that this education should be flexible and ongoing. These authors also report that there still remains some negative issues with the introduction of Advanced Practice Nurses in established teams and these are related to fears held by staff about their own job security and role confusion related to the Advanced Practice Nurse role.
Advanced Nurse Practitioner roles have been developed further in the USA where prescriptive authority has been made available for psychopharmacologic trained and Masters prepared nurses. However, due to the difficulty in the process of application for prescriptive authority only 21 % of nurses have received the authority (Kaas, Dahl, Dehn & Frank, 1998). The role itself is a collaborative prescribing role with the general practitioner or Psychiatrist but nurses in this role have experienced a poor acceptance of the role by other healthcare professionals and consumers due to lack of clarity regarding the role, while other nurses feel uncomfortable with the role itself. Some of the barriers highlighted by Kaas et al. include poor financial incentives for these Advanced Nurse Practitioners, a need for more professional development for nurses in the role and further development of the role within a setting that is conducive to the role.
In the United Kingdom early intervention programs for consumers in mental health require that mental health nurses have professional skills in lifestyle management, medication management, symptom management, personal development, stress management and self expression (Lloyd, Bassett, & Samra, 2000, UK). Mental health nursing has also evolved to the point where there is a greater emphasis on the acquisition of skills in research based clinical interventions in Advanced Clinical Nursing. Nurses are increasingly undertaking interventions traditionally undertaken by the psychiatrist and psychologists (Gournay, Birley & Bennett, 1998, UK: Schneider, Carpenter, & Brandon, 1999,UK). Counselling is fast becoming a central intervention for the mental health nurse as opposed to medication management that was once the core skill of the mental health nurse (Gournay & Gray, 1998,UK). These new skills are a result of new developments in drug treatment for the seriously mentally ill consumer and the development of evidence that medication and psychosocial support produce better treatment outcomes for consumers. Mental health nursing is changing and is diverse and the different perceptions held by community mental health nurses on the nature and focus of service delivery by community mental health nurses are reflected in the diverse range of post registration programmes (Barr, 2000, UK).
In the United Kingdom public mental health services provide a range of specialist services that are largely community based, and that are specifically targeted to people with serious mental illness. Some key responsibilities of the public mental health system include, assessment, treatment, support, consultation, transfer of care and communication. Service delivery is increasingly being provided through a coalition between service providers, where the general practitioner/psychiatrist and the nurse specialist work together to improve service accessibility through Primary Health Care Teams (King & Nazareth, 1996, UK). These teams emphasis a holistic approach across the continuum of care. The growing demand for nurses to work in partnerships in various mental health settings is supported by literature emanating from the UK, USA and Australia that highlights that these clinical demands can be generated (Ardern, 1999: Thornton, 1999: White & Brooker, 2001: Chapman, 1997).
Mental health nurses are key figures in mental health teams, where skills in leadership, communication, multidisciplinary contribution, advanced clinical skills, health promotion and prevention of mental illness are required. The 1996 UK National community mental health census of 3421 nurses (reported by White & Brooker, 2001 UK) found there was a 46% increase in the amount of referrals to community mental health nurses from general practitioners and psychiatrists. The census also revealed an increase of 22% in counseling as a clinical intervention by community mental health nurses. White and Brooker noted that the census revealed that levels of clinical supervision for community mental health nurses had increased. However, they suggested that additional pre and post registration training to enhance evidenced based clinical skills would help better equip these nurse specialists for increased case loads and role ambiguity within the service delivery framework.
Forensic Mental Health is another evolving community service in Australia. Previously service provision to mentally ill offenders was in either the penal system or a secure unit within an asylum. Today Forensic Mental Health services are provided by specialist community nurses and in specialty low security units. Development of the qualifications required to undertake this specialist role is moving towards more specific forensic nurse training in the undergraduate curriculum and postgraduate qualifications (Evans & Wells, 2001 AUS). Changes are seen in pre and postgraduate training, ongoing professional development, support from other professionals in the workplace and clinical supervision.
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