4. Emerging models of care

The Review Panel was asked to consider the types of skills and knowledge required to meet the changing needs of the nursing workforce and the changing context of nursing and health requirements. This chapter examines developments and trends in models of care, their impact on patterns of nursing and their implications for nursing and educational provision.

In considering these matters, we have adopted a broad approach, focusing on principles and directions to guide nursing education for the future (rather than specifying skills and knowledge sets), and used case studies to illustrate developments and responses. When examining the impact of developments on patterns of nursing and nurse education, we have used the term ‘competencies’ rather than ‘skills and knowledge’. It is important to recognise that in this context ‘competencies’ refer not just to skills but also to the related knowledge and attitudes. We use this rather than ‘skills and knowledge’ because it is comprehensive in nature, as competencies are built from combinations and packages of skills, related knowledge and attitudes. The use of the term ‘competencies’ highlights the importance of and interrelationships between the concepts of skills, knowledge and attitudes. It is also consistent with other areas of educational, training and practice development.

top

In considering emerging models of care, we were struck by the lack of Australian research on changed patterns of nursing. At the same time, submissions and consultations highlighted many instances of innovative education and training approaches in parts of Australia, in areas of nursing and between nursing and other professional disciplines, to meet the changing needs of the health, community and aged care sectors.

New models of care have been developed in response to:

• the move away from institutionalised care in hospitals, aged care, mental health, and for people with disabilities, to community-based approaches

• greater focus on providing seamless delivery of care particularly for the frail aged, chronically ill and those with other complex care needs

• improvements in efficiency, safety and quality of care.

Types of care offered, the ways they are provided and the competencies required by health professionals will continue to alter. For nursing, the following trends are evident:

• increasing specialisation and sub-specialisation in some areas of nursing

• a move to highly skilled generalists in others

• the combining of some specialisations with others

• multi-professional approaches.

These trends are not unique to nursing. They are occurring among other groups of health professionals—for example, the medical workforce is undergoing similar changes (Department of Health and Aged Care 2001). Examples of these trends are provided in the following sections.

top

Nurses have an important role in community care and in population health promotion and screening. In these settings their roles are diverse and developing. The following descriptions from Jones and Cheek (2001), who interviewed nurses in a range of work settings, testify to the complex roles that nurses undertake in the community.

The trend from institutional care to community care has been increasing. A greater share of pre- and post-operative care, management of chronic illnesses, mental health and aged care is now provided in the community. Specialities such as psychiatry, geriatrics, rehabilitation and palliative care are increasingly community-based.

Responsibility for primary and community care services is shared across Commonwealth, State and Territory and local governments. This split in responsibilities has created difficulties for the delivery of services. Many Review submissions commented on the problems that such division in responsibilities, service fragmentation and inflexibility in funding present for the provision of care to patients and their carers. However, some projects and strategies have developed to help reduce this fragmentation.

A number of efforts are under way by Australian governments to improve the capacity to provide continuing care and support people with chronic conditions or general frailty. One example of such an initiative is enhanced primary care packages. These help people with chronic illnesses and complex care needs (many of whom are older Australians), as well as their carers and the health professionals who look after them. Another is coordinated care trials to improve the integration of various health services and ensure clients’ needs are placed at the centre of service planning, funding and delivery.

Also, Australian governments have for the first time agreed on priority areas to improve services that build on past efforts (Department of Health and Ageing 2002c). Agreed priority areas centre on improving:

• continuity of care for consumers through developing and maintaining greater integration across the primary health and community care sector

• quality, appropriateness and cost effectiveness of care by strengthening the interface between hospital care and community-based care.

The latter includes a focus on improving relationships between hospitals, emergency departments, outpatient departments and general practice; pre- and post-hospital care provision; and strengthening the role of primary care providers in population health.

A common concern expressed in submissions and consultations was the focus of many government initiatives on medical care in which general practice is seen as the centre of primary care and enhanced primary care is largely expressed as enhanced medical care.

While much of the attention has been on initiatives that have a medical focus, nurses are essential to the delivery of services in the community. Their role in these services is expanding and the trend will place new demands on nurses’ professional roles, nursing education, training and professional development, and nursing work organisation and planning. Policy makers at all levels also need to consider the ways in which nursing is integrated into new models of primary care and community care to ensure effectiveness, efficiency and quality in service delivery, health outcomes and costs.

The scope of population health activities is expanding from traditional activities, such as population screening, immunisation, communicable disease control and surveillance, to areas such as surveillance of disease risk factors, management of healthy growth and development, mental health promotion and consumer product safety. Nurses’ work is also expanding in public health.

4.4 Integrated hospital and community care - combining specialisations

Coordinated care seeks to provide the right care at the right time to patients and clients. For many people with chronic and complex care needs, care is provided by a number of separate service providers and funded by different levels of government. Often the result is that people receive the care they can get rather than the care they need. Coordinated care aims to overcome traditional professional, organisational and funding boundaries by focusing on patients’ care needs. One major Australian initiative is the Coordinated Care Trials.

Coordinated Care Trials

Coordinated Care Trials are examining whether multi-disciplinary care planning and service coordination lead to improved health and wellbeing for people with chronic health conditions or complex care needs. The trials test different approaches to achieving this.

Funds-pooling between the Commonwealth and State and Territory governments is being tested to give funding flexibility to support a coordinated approach to service delivery. Funds have been pooled for health and community services for each trial’s participants.

Each client has a care coordinator who works with the client to develop a care plan. Care coordinators vary across and within trials and may include general practitioners, nurses, home care coordinators, and allied health professionals. The care coordinator draws on money from the funding pool to buy the full range of services set out in the plan. Trials are undertaken as joint collaborations across a range of health professional services, health and community services and other organisations including nursing.

Australia’s ageing population, healthcare delivery, health promotion and community support arrangements influence the educational needs of those working in aged care.

Aged care crosses all areas of the health sector and intersects with other sectors. Australia’s older population uses services provided for the general population (such as hospitals and community health services) and services provided specifically for older, frail people. The core elements of the Australian aged care system are:

• aged care assessment teams that determine eligibility for community aged care packages and for admission to residential aged care facilities

• home and community-based services provided through the Home and Community Care program

• community aged care packages

• residential aged care facilities.

Nursing care for older Australians is provided in all settings—residential, community, acute and non-acute. Aged care is another large and growing area of employment for nurses (registered and enrolled) and for trained care assistants (Johnson & Preston 2001).

Aged care has long been considered a low status area of nursing, with nurses preferring to work in acute care settings but often finding work in aged care because it suits family commitments or they are unable to gain suitable employment elsewhere (Pearson et al. 2001). Key concerns in aged care nursing are the retention and recruitment of a sufficient number of qualified nurses in the workplace and achieving an appropriate skill mix and education and training for nurses and care assistants to meet changing needs and models of care delivery for the elderly population.

Models of care that help people remain in their own homes as an alternative to being placed in low-level residential (hostel) aged care have been introduced as part of the shift from institutional aged care. Community Aged Care Packages provide a range of homebased care services with care coordinated by the care package provider. The Home and Community Care Program provides the bulk of home and community-based services, many of them by not-for-profit agencies. The program includes nursing services, delivered meals, home help and home maintenance services, transport and shopping assistance, paramedical services, home and centre-based respite care, and advice and assistance of various kinds.

An indication of the expansion in and volume of services provided to older Australians at home is provided by the Australian Institute of Health and Welfare (AIHW). In 1999, 13 725 care packages were provided representing 8 places per 1000 persons aged 70 years and over, compared with 1227 packages in 1994 (when packages were first introduced) and 6124 in 1997 (AIHW 2000a). In 1997–98, the Home and Community Care agencies provided 441 hours of home help per month per 1000 people aged 70 and over and 506 hours of centre-based respite care and 697 delivered meals per 1000 persons aged 70 and over. Some 127 hours of home nursing were provided per month per 1000 residents aged 70 and over (AIHW 2000a).

Australia’s residential aged care sector covers nursing homes and hostels. Its case mix is changing, with the sector now catering for an increasing proportion of high dependence residents. The AIHW reports that, between 30 June 1998 and 30 June 2001, the proportion of residents classified as high care rose from 58 per cent to 63 per cent while those classified as low care fell from 42 per cent to 37 per cent (AIHW 2002a).

Government hospitals also provide nursing-home type care to some patients. In 1997–98, there were some 10 548 separations of nursing-home type patients with an average length of stay of 109 days (AIHW 2000a). These trends are expected to continue.

Pearson, Nay, Koch, Ward, Andrews and Tucker in their recent study of recruitment and retention of nurses in residential aged care (2002), report on the lack of acknowledgment within the aged care sector and the general community of the complexity of competencies needed for the effective and appropriate nursing of older people. Factors cited as contributing to this situation include:

• the low participation rates of aged care nurses in specialist award courses in gerontological nursing

• the generally accepted view that while acute care nurses, such as those in intensive or emergency care require specialist, advanced knowledge or competencies, such a requirement is not expected for nursing older people.

The study considered that these factors also serve to devalue the role of aged care nursing and render it a low status pursuit.

Studies indicate that, within the aged care sector, there is significant variation in the proportion of different levels of nurses and care staff and the competencies they possess.

An inappropriate skill mix affects patient care, work satisfaction, effective recruitment and retention, and effective and efficient resource use. Pearson and team (2001) recommended examination of an appropriate nursing skill mix in the aged care sector. We support the thrust of this recommendation while noting that the examination should cover the appropriate level of competency for different groups of workers in care work as well the appropriate skill mix.

Collaborative efforts and multi-professional approaches need to be strengthened and promoted as part of ensuring that educational provision responds to the changing needs of the aged care sector and provides a sustainable aged care nursing workforce for the future.

Mental disorders are a major and growing cause of disease burden in all countries (AIHW 2000a). Mental health has been identified as a National Health Priority Area and mental health planning has been recognised by World Health Organization as a global concern.

Over the last decade, the delivery of services to mental health patients has shifted from a predominantly institutional approach to a mix of institutional and community-based services such as ambulatory and 24-hour residential care. De-institutionalisation occurred along with an emphasis on mainstreaming mental health services. Psychiatric wards moved from large, stand-alone psychiatric hospitals to become part of acute care hospitals. Acute psychiatric units are treating a more complex client group and community mental health teams provide crisis intervention and other outreach services including case management, psychiatric liaison and other specialist services.

Mental health nurses are core practitioners in both in-patient and community services. They deliver services in metropolitan, regional, rural and isolated settings. Mental health nurses are the largest component of the mental health workforce in Australia, accounting for 75 per cent of all mental health professionals (Carter 1999 cited in Clinton et al. 2001).

Multi-professional team approaches are an important feature of mental health practice.

Practice standards to support the move to multi-professional team approaches in mental health practice are under development as part of the National Mental Health Strategy. The National Practice Standards for the Mental Health Workforce are being developed in consultation with the five mental health professional disciplines of social work, occupational therapy, nursing, psychology and psychiatry (National Mental Health Education and Training Advisory Group 2001). These standards will provide a benchmark for mental health practitioners to work towards, with the aim of achieving the standards within two years of entering the mental health workforce. They also offer a strategic national framework for the education and training of the future mental health workforce which can be used by educators in the development of undergraduate and postgraduate curricula and continuing education programs.

Maintaining an effective mental health nursing workforce is critical. To achieve this all nurses require a strong foundation in mental health as part of initial education and training. In addition nurses with a specialisation in mental health are needed. Mental health could be an area for the development of enrolled nurse specialisation. Those with a specialisation are in short supply and numbers need to be increased.

Several groups are developing innovative approaches to undergraduate education on mental health issues aimed at attracting student nurses to ultimately specialise in mental health nursing. One example is the Grampian Psychiatric Services/University of Ballarat where service providers and educators are working collaboratively in undergraduate education and training in mental health  nursing.

Grampians Psychiatric Services/University of Ballarat

There are a number of factors that may influence a third year student’s decision to specialise in psychiatric nursing. One of the main factors is a student’s university experience. Few students consider psychiatric nursing before entering university. The university experience is the one area where the psychiatric nursing profession has the potential to make a difference, and students have identified the first clinical placement as the most critical factor in decisions made about mental health nursing. It can reinforce negative ideas or can create a major positive shift in the student’s thoughts on psychiatric nursing.

Recognition of these issues resulted in staff from the University of Ballarat and Grampians Psychiatric Services (GPS) getting together and coming up with a better way to deliver the psychiatric nursing component of the comprehensive nursing course. The basic agreement was that there would be an increased amount of theory, a coordinated approach to theory relating to practice, and more involvement by GPS staff across the program and support for students and staff. The model revolves around the development of four units of psychiatric nursing. These four new units were designed to provide as much theory as possible, to ensure that the theory related to practice and to emphasise the specialty of psychiatric nursing. Two units were allocated to each of second and third year.

It was decided to utilise as many GPS staff as possible in the delivery of lectures and tutorials. This gives staff working in the field the opportunity to share their experience, as well as offering students the opportunity to meet real psychiatric nurses, thereby breaking down some of the stereotypical images. Clinical placements take place in both second and third year. There is also opportunity for an extra psychiatric nursing placement in third year as an elective. Students are placed across all areas of the service.

A full evaluation report on this initiative will be available later in 2002. However, the University of Ballarat has advised that the outcomes achieved so far with this new model have exceeded original expectations. A preliminary student evaluation survey indicated that students viewed their clinical experience at Grampians Psychiatric Services as one of quality.

Approximately 80 per cent of students surveyed reported that they were able to achieve their learning objectives, apply theory to clinical practice and receive accurate assessments, and that they would consider a career in mental health nursing.

People living in rural and remote areas face particular health challenges and concerns that relate to their living conditions, social isolation and distance from services. The rural health workforce comprises nurses, medical practitioners, allied health, pharmacy, hospitality, administrative staff and others. Despite the need for all these groups, attention often centres on the perceived rural doctor shortage with numerous efforts undertaken to put in place a stable, sufficient and appropriately skilled medical workforce, particularly general practitioners (Best 2000). Comments to us often focused on the different approaches rural communities took to attract different health professionals.

The face of rural health services in Australia has changed considerably. There has been significant restructuring of services from primarily acute medical services to primary care or aged care services, amalgamation or collocation of services, closure or downgrading of services, expansion of midwifery and surgical services, and development of multi-purpose services and centres. Australian rural and remote practice is characterised by a close relationship between acute and community services.

Rural and remote areas are particularly dependent on nurses for their healthcare services.

Except for nurses, there is a much lower provision of health professionals in rural and remote areas. In 1999, approximately 16.1 per cent of the general medical workforce was located in rural and remote areas, despite 28.4 per cent of the population living in those areas. At the same time 30.4 per cent of the registered and enrolled nurse workforce were working in rural and remote areas (AIHW 2002c). For many isolated rural communities, registered nurses provide the first point of contact for a range of primary care functions that, in metropolitan areas, would often be provided by general practitioners and other health professionals.

Changes in rural health services have led to significant changes in the role and function of rural nurses. There has been a shift towards community-based services, population health and multi-disciplinary decision making in partnership with communities. Rural nursing practice is context-specific and highly generalist in nature. Activities undertaken by the rural community health nurse range from ensuring access to breast screening programs, to interventions dealing with rising organochlorins in the food chain, to campaigns to reduce road trauma among rural youth (Francis et al. 2001).

Common challenges identified in the literature include professional isolation, scarce resources, the expectation that practitioner skills will be more generalist than specialist in nature, limited scope to specialise, legal implications of practising an expanded role, and identifying professional boundaries of practice (Francis et al. 2001). As noted in Chapter 2, some States and Territories have explored the potential for nurses taking expanded roles as nurse practitioners to meet needs of rural and remote communities. Approaches have varied and progress has been slow, partly due to lack of support from parts of the medical profession, concerned about the impact of substitution on their practice, and a focus by some groups on payment arrangements under an independent fee-for-service practice model (Duckett 2000).

The demands of rural and remote practice pose challenges for the education, training and professional development and wellbeing of nurses and other health professionals. Educational provision must be responsive to the competencies required to practise effectively and efficiently in rural and remote settings and environments, as well as the problems nurses and other health professionals face in accessing education services and professional isolation. Innovative approaches to addressing these challenges are unfolding.

One example is the Rural Health Education Foundation, a not-for-profit organisation delivering live interactive television education to rural and remote health professionals through a network of over 450 satellite receiving sites. Some of these programs are specifically for nurses. Information about the Foundation is available at rhef.com.au/index.htm.

In all States and Territories, to work as a midwife, a person must hold current registration as a midwife or be authorised to work as a midwife. While this is the common requirement, there are inconsistencies across States and Territories in the education of Australian midwifery and the standard of preparation (Leap and Barclay 2001).

Shah and Burke (2001) report that the employment of registered midwives increased gradually over the period 1987–1999, with the last two years seeing a very substantial growth, reaching 10 000 by 2001. The number of registered midwives employed per 1000 births increased from 26 to 30 between 1987 and 1999. In 2000, it jumped to 42.

Between 1987 and 2001 there was a large increase in the proportion of midwives working part-time with a corresponding drop in the proportion working full-time. According to the AIHW, in 1997 almost 29 per cent of registered nurses with a post-initial qualification had that qualification in midwifery (Shah and Burke 2001). Midwifery is the most feminised of all nursing occupations with on average only 2 per cent of men. Shah and Burke (2001) report that, in contrast to the growth in registered midwives, there has been a 2.2 per cent decline in the number of births over the period 1987 to 2000.

The role of the midwife has been undergoing a process of reassessment in recent times in many countries including Australia. This is in response to several factors including:

• changes in birth rates

• falling demand for obstetric services

• the capacity of health systems to use midwives effectively and efficiently and provide career paths for people with a midwife-only registration

• demand for services that offer continuity of care and are woman-centred.

Nurses have adopted expanded roles, coordinating and leading obstetric care work within multi-disciplinary teams (Aitken et al. 2001). New models of maternity care have developed in Australia and overseas to better cater for childbearing women in a more woman-centred way and to offer continuity of care (for example, birthing centres).

Direct entry midwifery courses began in 2002 in two States. This has been a fairly controversial development. While it may well promote midwifery to those who do not to ‘nurse’ and so expand the pool of available applicants, the ease with which they will find employment is an issue that will need to be tested by market forces. There are concerns that many settings will not be able to employ midwives without nursing qualifications. For example, remote Australia and Indigenous communities, where the highest birth rates occur, are unlikely to be able to sustain multiple health practitioners. In remote settings it is likely that any midwife would also need nursing skills and knowledge. While there may well be a place in changing models of care for midwives without nursing qualifications, there will always be a need for programs for registered nurses to gain an additional qualification in midwifery.

There are differing views about education in midwifery, as the following quote from Review submissions highlights. Some advocate midwifery as a direct entry course. Others support retention of postgraduate midwifery and some are happy that both options are available. The following response to the Discussion Paper summarises some of the issues.

(School of Nursing and Midwifery, Curtin University of Technology, response to Discussion Paper)

The Australian Health Workforce Advisory Committee (AHWAC) has a project that is attempting to define a balanced supply of midwives to meet Australia’s current and emerging needs. It involves resolution of a complex set of matters that reflect the dynamic nature of health care needs and importance of health care service and educational provision responsiveness. It had not reported at the time of writing this report.

top

4.10 Indigenous communities

Indigenous Australians continue to experience much poorer health than the general population (AIHW 2000a). Improving the health status of Indigenous Australians by ensuring access to effective, high-quality care at the community level is a central concern.

Indigenous Australians represent a significant proportion of people living in remote areas.

Strategic approaches to improving the health of Indigenous Australians are based on the principles of community empowerment, participation and partnerships. They include:

• long-term partnerships between Indigenous communities and organisations and governments

• local health services providing integrated clinical and population health programs delivered in ways that actively engage individuals and communities in managing their health

• complementary action by mainstream and Indigenous specific services working together with local communities to increase access to services and address specific health problems and needs.

Some successes are already being documented in this regard. The Aboriginal Medical Services Alliance, Northern Territory (AMSANT) in its submission states that ‘Katherine West Health Board challenged the misinformation about community controlled health services by delivering better conditions, improved staff management and increased effectiveness of the health service’.

Building an Indigenous and non-Indigenous health workforce is recognised as integral to improving the health status of Indigenous Australians. Work is under way to put in place a consolidated and integrated workforce development framework that builds workforce capacity, training, recruitment, support and retention of Indigenous and non-Indigenous professionals in Indigenous health. The Aboriginal and Torres Strait Islander Health Workforce National Strategic Framework was developed by a drafting committee of theCommonwealth, State and Territory Government Standing Committee on Aboriginal and Torres Strait Islander Health (OATSIH 2002). The document was endorsed by the Australian Health Ministers’ Advisory Committee on 30 May 2002. The Workforce Strategic Framework presents a five to ten year reform agenda to build a competent health workforce to address the health needs of Aboriginal and Torres Strait Islander Australians.

Indigenous Australians are under-represented in all fields of health study except Indigenous health and public health training. In the period 1995–2000 the number of Aboriginal and Torres Strait Islander students commencing undergraduate health courses remained almost the same (312 in 1995 to 308 in 2000). In 2000 most of these students commenced undergraduate courses in nursing (82 students), general health support (81 students), and other health support (72 students), with 19 students commencing medicine (AIHW 2002c p. 275).

Some of the challenges of community empowerment for the education and practice ofnon-Indigenous nurses and other health professions are identified in the AMSANT submission to the Review:

(Submission No. 137)

top

Information technology is revolutionising the ways in which health services are delivered and organised, access to information and research, the nature of health records and modes of professional communication, education, training and development. Aitken and colleagues (2001) reviewed the literature on telemedicine/telehealth in the provision of health care and nursing services. Increasingly, information technology will be used in healthcare delivery and education and modes of use and their impact will continue to evolve. Educational provision must be responsive to this rapidly changing environment.

To deal with this environment, a range of responses will be needed including legislative, regulatory and other measures to protect and respect individuals’ rights. Nurses will need to understand a wider range of legislation than previously. In their education, greater emphasis on ethical considerations and professional boundaries will be necessary.

top

Developments and trends in models of care highlight the dynamic nature of health, community and aged care and the importance of building capacity within nursing and educational provision to respond effectively and promptly to emerging developments and changing needs. This poses several challenges for nursing and nursing education.

Nursing must define its work in terms of the needs of the health, community and aged care sectors and within a framework that respects and values the work of other health professionals. With the change in service models in health and aged care, nursing must regularly review the essential competencies required to function safely and effectively. Nationally agreed competencies offer a strategic national framework for the education and training of nurses.

Changing clinical requirements and settings

Traditionally, hospitals have been major places for clinical preparation and the focus of research. These roles have been key to hospitals attracting and retaining high calibre professional staff. The changing role of hospitals and residential care facilities and the shift of care to the community has important implications for nurse clinical preparation. Acute care hospitals will become inappropriate as the dominant context for the theoretical and clinical components of comprehensive undergraduate nursing programs. Neither will aged care facilities provide sufficient breadth of experience for the training of enrolled nurses.

Encouraging collaboration and partnerships

Collaborations and partnerships between the nursing profession, education and training providers and service delivery providers in the aged care and health sectors are essential to achieving quality education and training of nurses.

Multi-professional team approaches

A feature increasingly common in models of integrated and coordinated care is multi-professional team approaches to the provision of care to patients, clients and their unpaid carers. Models of education and training need to support multi-professional approaches to practice. Inter-disciplinary education is assisted by agreed practice standards for quality of care and partnerships between nursing and other health and social care professions.

Contents | Next

top