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
Acute Care
Narrative papers by Hillman (1999 AUS) and Vincent (1996 USA) provide a background to the changing nature of acute healthcare services and the subsequent impact on the roles of healthcare providers. Hillman focuses on the evolution of the Australian public hospital. Until 40 years ago hospitals were mainly places for bed rest and convalescence. Large public hospitals arose to address the needs of the poor. A physician visited for several hours each week and surgeons had their own operating theatre, theatre nurse, ward, ward nursing staff and junior doctors. Healthcare personnel and healthcare the healthcare workplace was organised in a hierarchical way. Hillman claims that the legacy of these arrangements is that public health care has grown in a haphazard way, with scarce resources allocated according to specific initiatives of medical directors and the political climate at the time.
An explosion of medical knowledge occurred in the 1950's. Whereas previously all hospitals provided a similar range of options for patients, hospitals became more complex and began to limit their services to specific medical specialties. Increasingly in-hospital patients had more complex problems and a greater number of co-morbidities. The explosion of technology in the last twenty years has added further to the complexity of care delivered in acute hospitals. Buus-Frank (1999 USA) reports on some of the technological innovations that challenge nurses and encourages nurses to use these innovations to preserve the human elements of nursing. This expert author states that there is a blurring of diagnostic testing and clinical monitoring. Devices that have in the past only provided a singular value are now being placed at the bedside to provide continuous data. Innovations such as automatic or invasive blood pressure monitoring, pulse oximetry, and continuous electrocardiac, and electroencephalographic monitoring are now commonplace. Not so commonplace are non-invasive methods of glucose and arterial blood gas measurement. Cerebral oximetry using infrared spectroscopy to monitor cerebral blood flow and oxygenation of cerebral microvasculature are also available in specialized units. Computerized impedance cardiography is a non-invasive method of monitoring cardiac output, contractility indices and other hemodynamic parameters. On-line ischemia analysis is another emerging tool that will prove to be valuable in the early diagnosis of myocardial ischemia and cardiac dysfunction.
While this technology is challenging for the health professionals that use it, it is often overwhelming for patients, their friends and family. With this in mind, Baby CareLink was developed. Baby CareLink is a program designed to demystify interventions in a neonatal intensive care unit (NICU) and provide enhanced medical, informational and emotional support to families of very low birth weight (VLBW) infants during and after their admission. Baby CareLink itself is a technological innovation. It is a telemedicine program that is multifaceted, incorporating videoconferencing and the world wide web (www) that is accessed from the family's home during the infants stay in the NICU. Videoconferencing facilitates virtual visits and distance learning during the admission period and provides virtual house calls and remote monitoring after discharge. The www site provides information relating to issues confronting the family. It may is also used as an electronic interface for data distribution between health care professionals. A randomized control trial (NHMRC level II) was conducted by Gray, Safran, Davis, Pompilio-Weitzner, Stewart, Zaccagnini & Pursley (2000 USA) to evaluate the efficacy and benefits of Baby CareLink. The control family group (n=30) received care as usually practiced in the NICU while a multimedia computer with access to the www and videoconferencing equipment was installed in the homes of the 26 families randomly allocated to the intervention group. Outcome measures included family satisfaction scores (using the standard satisfaction form), infant length of stay, family visits to the NICU and family interactions with their infant and NICU staff. The researchers found a higher level of satisfaction with care from the Baby CareLink group, with a lower number of problems being reported compared to the control group (3% and 13% respectively). The intervention group reported greater satisfaction with the physical environment of the NICU and visiting policies. Very small infants (< 1000 gms) had shorter lengths of stay and all Baby CareLink infants were discharged directly to home and not via community hospitals like 20% of infants in the control group. The researchers concluded that these results supported the hypothesis that Baby CareLink improves family satisfaction; lowers costs associated with hospital-to-hospital transfer and facilitates earlier discharge to home for VLBW infants.
Videoconferencing technology has also been implemented in the adult Intensive Care (ICU) setting. Much of the literature discussed later in the review describes the use of telemedicine to overcome geographical barriers that separate patient's from the physician in an acute facility. Conversely, this innovation described by Breslow (2000 USA) and Dorman (2000 USA) overcomes the barrier of distance between physicians located in a site remote from patients in an acute ICU. In this way, the specialist physician is not prohibited from leaving the ICU and a single specialist physician can provide care to patients in multiple ICU's.
Such technological innovations necessity the development of specialised nursing skills. Accordingly, the role of Clinical Nurse Specialist (CNS) has arisen in acute settings. Lincoln (2000, USA) distinguishes the role of the Clinical Nurse Specialist from that of the Nurse Practitioner discussed later in this review. Lincoln used a non experimental, descriptive survey (n=310) to compare the differences between CNS and NP roles. This was a replication of Williams and Valdivieso's (1992 USA) study to review the current implementation of role activities. The results showed that both groups performed direct patient care, consultation, education, administration and research. However it was only in the analysis of time spent in activities and the focus of the activities that differences presented. CNS were predominantly found in hospital settings, where as the NPs were found mostly in the ambulatory care area and they performed mostly direct care. CNSs distributed their time evenly between all roles. Lincoln argued that the CNS role was more vulnerable to the changing health care system whereas the NP role was far more stable and well defined. These findings are consistent with other studies comparing roles (Miller, 1995 UK).
Bousfield (1997, UK) also used a qualitative approach to examine the role of the clinical nurse specialist. She found that CNSs are experienced practitioners who use advanced knowledge, expertise, and leadership in multidisciplinary environments. The priority for the CNS role is patient care with additional role components of consultation, education, and research. Bousfield argued that organizations can be positively influenced by the individual CNS if given sufficient supported and autonomy. They make a valuable contribution to multidisciplinary team.
In addition, there is a large volume of literature on clinical nurse specialists in the form of opinion papers. Several of these papers note a transition in the CNS role to more case management activities. The role of the nurse case manager is discussed in the Case Management section of this review. Team collaboration and the role of the CNS in facilitating communication in areas such as discharge planning, pain oncology, cardiovascular, and perioperative areas is also promoted (Conger, 1996 USA; Wells, 1996 USA; Kee & Borchers, 1998 USA; O'Neal, P., Kozeny, D., Garland, P., Gaunt, S., & Gordon, S., 1998 USA amongst others).
The perioperative area is particularly rich in technological innovations (Riley & Peters, 2000 AUS). Virtual reality applications including augmented neurosurgery are being implemented in the Operating Suite. Precision gloves that would facilitate computer mapping and emulation of precise movements of the nurses' or physician's hands during technical procedures are also the subject of laboratory trials. Surgical robotics is a reality as Geis, Kim, Brennan, McAfee and Wang describe in a 1996 publication. These authors conducted a case series (NHMRC level IV) study to identify the feasibility and efficiency of using robotic arm enhancement in complex minimally invasive surgical procedures. Their study included the surgeon acting alone (without the need for a surgeon assistant or scrub nurse to manipulate the equipment) on 24 occasions. There were no incidents or mishaps during the procedures and all surgical procedures were completed successfully in shorter or comparable times compared to those performed without the robotic arm. Three additional devices were tested in combination with the robotic arm. This included head mounted display optics, a 3-D laparoscope and a harmonic scalpel. This combination significantly enhanced operative times as the need for de-fogging the laparoscope was reduced. The researchers concluded that implementing these innovations will reduce costs, and minimize risks if there is a simultaneous educational investment in team development.
While the above development may reduce the requirements for a scrub nurse, the need for a Registered Nurse in the Operating Room is the subject of the paper by Christiansen (2000 CAN). This paper reviews the skills required by the circulating nurse in order to assess whether unlicensed personnel may perform this role. They conclude that unlicensed personnel are unsuitable for the circulating nurse role even in an ambulatory short stay setting. Their conclusion is based upon the necessity for the circulator to be able to engage in a high level of critical thinking, and use or trouble-shoot highly complex equipment. The circulator is required to anticipate the potential for complications during surgery and/or anaesthesia, address the same when they arise and function with a high level of autonomy. Finally, the circulating role requires an ability to respond to varied availability of resources. They concluded that unlicensed personnel did not have the educational preparation to undertake such complex functions. These authors also note that the more complex the environment, the higher the category of caregiver required to provide a comprehensive service that can address an ever changing environment and a full range of care requirements. They draw attention to the need for the practitioner to assess changes, re-establish priorities and recognize the needs for additional resources, as they are required.
The subject of unlicensed personnel is explored elsewhere in this review, however it is appropriate to mention at this point the driving forces behind the introduction of non-nursing staff in the acute setting. According to Vincent (1996 USA) work redesign and re-engineering became the 'catch phrases' of health care in the 1990's. These terms are often used in the context of patient-focused care, organizational restructuring, and process innovation. Interest arose in the introduction of unlicensed personnel in the context of decreased resources, the necessity to contain costs, provide quality care and the notion of multi-skilled health care workers. To achieve redesign it is necessary to have employees who can function autonomously, are self-directed, are knowledgeable, flexible, empowered and require little supervision. Conversely, the author claims that the use of unlicensed personnel (UP) is inappropriate in such a context, as they do not meet these requirements. Instead UP increase the need for traditional supervision and multiskilling has the potential to create a reductionistic and mechanistic view of nursing and the pt. She advises that nurses working with UP should examine the impact of the increased accountability and delegation. Work re-design has provided a great challenge for nurses. In addition, nurses need to identify how much money using UP is saving and add the increased costs of supervision and management to consider whether cost savings are being realized when working with less skilled and knowledgeable staff.
While on the one hand, nurses are considering delegating activities to unlicensed personnel, at the other end of the scale, nurses in the acute setting are undertaking tasks once performed by junior doctors (Hopkins, 1996 UK; Carver, 1998 UK). In her narrative paper, Hopkins reports that changes in the roles of all health care workers in the UK have been precipitated by a considerable changes in the health care system brought about by government initiatives. These initiatives include the "National Vocational Qualifications for health-care support workers", "Project 2000", "Scope of Professional Practice", "NHS and Community Care Act", "Patient's Charter", "Health of a Nation", and an imperative to reduce junior doctor's hours. In the acute setting, there has been both extension and expansion of the nurses' role. The literature defines 'extended' roles as performance of additional tasks that were previously undertaken by other professions, whereas acquisition of additional skills that fall within the boundaries of nurse education, theory and practice is considered to be consistent with role expansion (Hopkins, 1996 UK; Carver, 1998 UK; Magennis, 1999 UK). Accordingly, role expansion appears to indicate nursing roles developing to address unmet needs, whereas role extension appears to indicate nurses increasingly taking on roles traditionally performed by medical colleagues. Hopkins warns that where roles are extended there is a danger of nursing returning to a more task orientated profession. She recommends that role extension only take place when there are clear indications that patient care may be improved and that the tasks are incorporated into the work of nursing rather than happening at the expense of the caring role of the nurse. She highlights the need for appropriate educational programs to support the acquisition of new skills and those tasks are performed within the Code of Professional Conduct and legal guidelines in order to safeguard both the nurse and the patient. Finally, Hopkins reports on a successful venture at the Royal Hallamshire Hospital in Sheffield, UK where the new tasks assumed by nurses were seen to enhance their roles as well as assisting with the reduction of junior doctor's hours.
Carver (1998 UK) provides empirical support to Hopkins' opinion paper. Carver undertook a qualitative study using a phenomenological approach to analyse the impact of reduced junior doctor's hours on the role of the nurse in an acute regional cardiology centre. Carver conducted four individual interviews and one focus group interview. Emergent concepts relating to role change included that role expansion was locally driven and that the influence of the practice environment was a major factor determining acquisition of specific skills to expand the role of the nurse. She found that the nurses' scope of practice was determined by increasing competency that arose from increased knowledge. She also found evidence to reinforce Hopkin's concern that nurses were simply relieving doctors workload at the expense of their own. From the themes emerging from the interviews, Carver concluded that nurses were taking on tasks previously assumed by physicians that did not necessarily complement the role of the nurse and did not directly improve patient care. However, nurses did experience a degree of freedom from reliance on medical intervention once these skills were acquired. For example nurses developed skills in intravenous cannulation so they did not have to call a physician in the middle of the night. In this context, extension of practice could lead to more holistic patient care.
Another qualitative study conducted by Magennis (1999 UK) examined whether nurses viewed extension or expansion of their traditional roles in a positive light. This research was prompted by the Scope of Practice initiative. Magennis used a self-administered survey questionnaire mailed to 40 nurses randomised from a potential sample of 160. This sample was drawn from all registered nurses in the cardiology unit, intensive care unit and one general medical ward of a general hospital in one Health and Social Services Trust. Respondents indicated their agreement or disagreement to 17 questions on a five point Likert Scale. T-test analysis revealed that cardiology nurses viewed role expansion significantly more favourably than general or ICU nurses. This was attributed to greater emphasis on psychological support, health promotion holistic care in the cardiology setting. 60% of respondents felt that extended roles were due to doctors unloading what they considered to be mundane tasks and 72% of respondents saw this as a cost cutting exercise. They were concerned that these extended activities decreased their ability to expand the scope of their practice in the nursing domain. This was of significance as expansion of the nursing role was seen in a much more positive light. Extension of activities was not the only barrier to role expansion, with 78% identifying that training for expanded roles was inadequate. Significantly, those nurses who had received further education were more positive towards role expansion. Hopkins opinion relating to the need for protection against litigation was also confirmed by responses to this study.
Two articles from the United Kingdom consider a nurse-led anticoagulant service. The first (Taylor, Gray, Cohen, Gaminara, Ramsay, & Miller 1997), a level III-2 study, compares the conduct and outcomes of a consultant service with a nurse specialist service over two six month periods. Group A comprised consecutive patients newly referred to the anticoagulant clinic. Group B comprised a random selection of patients who had been attending the clinic for a period of one year or more. Specialist staff trained two nurses over a three-month period in specific aspects of anticoagulant care. Results showed no difference in the primary outcome measure, the time each patient spent within their INR target range, or the secondary outcome measures, number of general practitioner consultations and in-patient episodes arising from adverse events related to anticoagulant therapy. There was no significant difference in the volume and cost of resources used by the patients between the two services. The authors conclude "... the provision of out-patient anticoagulation by the nurse specialist service was not a more expensive option than the consultant service despite the introduction of a domicilliary (sic) service, the training costs of the nurse specialists and longer anticoagulant clinic hours of the nurse specialist service. ... (it) was as safe as the consultant service" (p. 827).
In the second study (Hennessey, Vyas, Duncan, & Allard, 2000 UK) a nurse led anticoagulant service was introduced because of an increase in patient numbers at a clinic in Middlesex. This level III-3 compared the previous consultant led service with the nurse led service which included a computerised support system. The nurse initially counselled patients about their warfarin and then followed them up in clinic until their dosage was stabilised. The nurse also addressed telephone queries. Results showed that anticoagulant control was not affected by the service change and the authors concluded that the nurse led service allowed them to accommodate 21% more patients while improving quality, efficiency and cost-effectiveness of the service and patient care.
Scientific developments in epilepsy management have given rise to specialist neurology units in the acute care setting. A Cochrane systematic review (Bradley & Lindsay, 2001) of all randomised controlled and quasi-randomised controlled trials (level 1 evidence) compared specialist epilepsy nurse interventions with standard or alternative care. While eleven studies were found eight were excluded mainly on the basis of non-randomised selection. The three trials included were heterogenous and so results could not be pooled. The intervention described involved multiple interviews with the specialist epilepsy nurse in addition to standard care. There was some evidence that newly diagnosed patients whose knowledge about epilepsy was poor may improve their knowledge scores after nurse intervention. However there was no convincing evidence that specialist epilepsy nurses improve outcomes for people with epilepsy overall. The authors do say it is plausible that specialist epilepsy nurses could improve quality of care but further research would be required before this could be ascertained.
Genetics is an area where a number of controversial ethical issues are arising. However, there is also promise of great benefits through the application of gene therapy to disease management. Crosbie, Brewer, Campbell, & MacKay (1998 UK) describe in detail the process and results of their first experience of breast cancer gene 1 testing in 23 family members in the United Kingdom. They suggest a unique role within cancer genetics for specialist nurse practitioners in genetic testing and counseling.
Another theme arising from the acute care literature relating to the impact of service on role expansion is related to organ procurement. In the setting of an ever increasing need for solid organs suitable for transplantation, Noah, and Morgan(1999 USA) report that nurses no longer can simply be involved in supporting families during the experience of procurement without specific training as a "designated requestor". Roark (2000 USA) reports on an educational program that addresses this issue by preparing nurses as organ donation requestors. In this program nurses learn about the steps involved in confirming brain death, issues relating to family acceptance and understanding of brain death, cultural and ethical issues relating to brain death, bereavement and initiating the request for donor organs. They also become familiar with family support services.
Finally, clinical practice guidelines on the National Health and Medical Research Council Internet site (http://www.health.gov.au/nhmrc/publications/pdf/) make some specific recommendations that have implications for nursing roles in the acute care setting. The clinical practice guideline (1999 AUS), in addition to both the general practitioner (1999 AUS) and the patient family and friends (2000 AUS) "Guidelines for the prevention, early detection and management of colorectal cancer" discuss the pre-operative and post-operative role of the stomal therapy nurse in the provision of information, siting of the stoma and support of the patient.
The "Familial aspects of cancer: a guide to clinical practice (1999 AUS)" suggest that an oncology nurse with experience in genetics would be one type of professional who could provide counselling in a familial cancer clinic. Education of the public and health professionals is noted to be vital in cancer genetics, and both nurses and the Royal College of Nursing are mentioned in relation to this.
While the Australian "Clinical practice guidelines: Management of diabetic retinopathy 1997" do not include specific references to nurses in the recommendations a quick reference guide for optometrists, nurses and other health practitioners, "Preserving vision in diabetes" has been produced indicating a role for the nurse alerting diabetic patients to the need for regular ophthalmic checks.
It is worth noting however, that Thomas, McColl, Cullum, Rousseau, Soutter & Steen (1998 UK) conducted a systematic review (NHMRC level I) aimed at identifying evaluations of clinical practice guidelines in nursing, midwifery and professions allied to medicine. He also examined the effectiveness and cost effectiveness of guidelines as strategies for promoting improved professional practice and enhanced patient outcomes. Through this review Thomas et al found that guidelines containing educational interventions were more beneficial than those using passive approaches and those incorporating multiple interventions are more likely to bring about behavioral change than those containing single interventions. The review identified that further research is clearly required in this area.
Any comments or queries should be sent to: highered@dest.gov.au
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last updated on Tuesday, 04 December 2001
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