Community health nursing in Australia: a critical literature review and implications for professional development

Quality indicators for a community-based wound care centre: An integrative review

The purpose of this review was to identify the role and contribution of community-based nurse-led wound care as a service delivery model. Centres increasingly respond proactively to assess and manage wounds at all stages - not only chronic wound care. We conducted an integrative review of literature, searching five databases, 2007-2018. Based on inclusion and exclusion criteria, we systematically approached article selection and all three authors collaborated to chart the study variables, evaluate data, and synthesise results. Eighteen studies were included, representing a range of care models internationally. The findings showed a need for nurse-led clinics to provide evidence-based care using best practice guidelines for all wound types. Wound care practices should be standardised across the particular service and be integrated with higher levels of resources such as investigative services and surgical units. A multi-disciplinary approach was likely to achieve better patient outcomes, while patient-centred care with strong patient engagement was likely to assist patients' compliance with treatment. High-quality community-based wound services should include nursing leadership based on a hub-and-spoke model. This is ideally patient-centred, evidence-based, and underpinned by a commitment to developing innovations in terms of treatment modalities, accessibility, and patient engagement.

Development and psychometric evaluation of the community care competency scale in multi-ethnic undergraduate nursing students

Preparing healthcare students for community care has been emphasised due to the global ageing population. An instrument to measure students' community care competency is lacking. This study aimed to develop and evaluate the psychometric properties of a new scale known as Community Care Competency Scale (CCCS) for measuring nursing students' community care competency. CCCS consists of 21 items derived from literature review and community care standards. Content validity was established through a panel of seven experts in the areas of knowledge with a content validity index of 0.96. A cross-sectional study was undertaken in a university in Singapore by using an anonymous self-administered questionnaire to nursing students, and obtained a response rate of 87% (n = 283). Psychometric properties were explored using convergent and known-group validity testing, exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and Cronbach's alpha test. The results showed good convergent and known-group validity. EFA and CFA showed a coherent construct of the 21 items of CCCS in a one-factor model. The Cronbach's alpha of 0.94 indicated excellent internal consistency. The CCCS is a valid, reliable and easy-to-administer instrument that measures community care competency. This instrument will contribute to the empirical body of knowledge on evaluating the effectiveness of community care educational programmes for nursing students to prepare future healthcare professionals.

ENsCOPE: Scoping the Practice of Enrolled Nurses in an Australian Community Health Setting

INTRODUCTION

A continuing shift of healthcare delivery from hospital to the community has increased the acuity and complexity of care provided in the home. Global financial crises and nursing shortages have prompted policies supporting two tiers of nursing and expansion of the licensed practical nurse, second level or enrolled nurse role and evoked debate surrounding roles traditionally undertaken by registered nurses. Community nursing offers unique challenges for enrolled nurses wanting to enact their full scope of practice.

AIM

To compare and describe registered and enrolled nurse opinions of their current and potential enrolled nurse scope of practice in the community health setting.

METHODS

A cross-sectional survey of 136 nurses (115 registered and 21 enrolled nurses) was undertaken within a large community nursing team in Australia. Participants reported their opinions of enrolled nurse scope of practice based on 27 core community nursing skills.

RESULTS

Although substantial agreement was evident, there were statistically significant differences between registered nurse and enrolled nurse opinions in core skill areas; 'Patient Education' and 'Clinical Observation'. Registered nurses identified some specialized skills-catheter and gastrostomy care-that could be undertaken by enrolled nurses with further education.

CONCLUSION

We confirm that registered nurses do agree with extending the skills of enrolled nurses. Education approaches that build shared confidence in enrolled nurse advanced skills are recommended.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

The future supply of nurses is at risk. There are limited resources and increasing demand for quality health care where people live and work. While there may be opportunities internationally to improve productivity through advanced nursing roles, these policies should prioritize efficiency by firstly promoting the full enactment of nursing skills in these settings.

Factors influencing community nursing roles and health service provision in rural areas: a review of literature

AIMS

This review sought to better understand the issues and challenges experienced by community nurses working in rural areas and how these factors shape their role.

METHODS

Databases were searched to identify relevant studies, published between 1990 and 2015, that focussed on issues and challenges experienced by rural community nurses. Generic and grey literature relating to the subject was also searched. The search was systematically conducted multiple times to assure accuracy.

RESULTS

A total of 14 articles met the inclusion criteria. This critical review identified common issues impacting community nursing and included role definition, organisational change, human resource, workplace and geographic challenges.

CONCLUSION

Community nurses are flexible, autonomous, able to adapt care to the service delivery setting, and have a diversity of knowledge and skills. Considerably more research is essential to identify factors that impact rural community nursing practice. In addition, greater advocacy is required to develop the role.

An analysis of the adaptability of a professional development program in public health: results from the ALPS Study

Background

Professional development is a key component of effective public health infrastructures. To be successful, professional development programs in public health and health promotion must adapt to practitioners’ complex real-world practice settings while preserving the core components of those programs’ models and theoretical bases. An appropriate balance must be struck between implementation fidelity, defined as respecting the core nature of the program that underlies its effects, and adaptability to context to maximize benefit in specific situations. This article presents a professional development pilot program, the Health Promotion Laboratory (HPL), and analyzes how it was adapted to three different settings while preserving its core components. An exploratory analysis was also conducted to identify team and contextual factors that might have been at play in the emergence of implementation profiles in each site.

Methods

This paper describes the program, its core components and adaptive features, along with three implementation experiences in local public health teams in Quebec, Canada. For each setting, documentary sources were analyzed to trace the implementation of activities, including temporal patterns throughout the project for each program component. Information about teams and their contexts/settings was obtained through documentary analysis and semi-structured interviews with HPL participants, colleagues and managers from each organization.

Results

While each team developed a unique pattern of implementing the activities, all the program’s core components were implemented. Differences of implementation were observed in terms of numbers and percentages of activities related to different components of the program as well as in the patterns of activities across time. It is plausible that organizational characteristics influencing, for example, work schedule flexibility or learning culture might have played a role in the HPL implementation process.

Conclusions

This paper shows how a professional development program model can be adapted to different contexts while preserving its core components. Capturing the heterogeneity of the intervention’s exposure, as was done here, will make possible in-depth impact analyses involving, for example, the testing of program–context interactions to identify program outcomes predictors. Such work is essential to advance knowledge on the action mechanisms of professional development programs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0903-3) contains supplementary material, which is available to authorized users.

The impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial)

BACKGROUND

The risk factors for chronic disease, smoking, poor nutrition, hazardous alcohol consumption, physical inactivity and weight (SNAPW) are common in primary health care (PHC) affording opportunity for preventive interventions. Community nurses are an important component of PHC in Australia. However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice. This study aimed to address this gap in our knowledge.

METHODS

The study was a quasi-experimental trial involving four generalist community nursing (CN) services in New South Wales, Australia. Two services were randomly allocated to an 'early intervention' and two to a 'late intervention' group. Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients. Those in the late intervention group provided usual care for the first 6 months and then received training. Clients aged 30-80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected. Data on their SNAPW risk factors, readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline, 3 and 6 months. Analysis compared changes using univariate and multilevel regression techniques.

RESULTS

804 participants were recruited from 2361 (34.1%) eligible clients. The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group (from 12.9 to 23.3% and 12.3 to 19.1% respectively) as did the proportion who recalled being referred for dietary or physical activity interventions (from 9.5 to 15.6% and 5.8 to 21.0% respectively). There was no change in the late intervention group. There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group. Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months.

CONCLUSION

The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity, this did not translate into significant changes in lifestyle behaviours or weight. This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses.

TRIAL REGISTRATION

ACTRN12609001081202.

The impact of a team-based intervention on the lifestyle risk factor management practices of community nurses: outcomes of the community nursing SNAP trial

BACKGROUND

Lifestyle risk factors like smoking, nutrition, alcohol consumption, and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care is an appropriate setting to address these risk factors in individuals. Generalist community health nurses (GCHNs) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time. The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practices of GCHNs.

METHODS

The trial used a quasi-experimental design involving four generalist community nursing services in NSW, Australia. The services were randomly allocated to either an intervention group or control group. Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessments and interventions. The control group provided usual care. A sample of 129 GCHNs completed surveys at baseline, 6 and 12 months to examine changes in their practices and levels of confidence related to the management of SNAP risk factors. Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice.

RESULTS

Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers. Nurses in the intervention group reported assessing physical activity, weight and nutrition more frequently, as well as providing more brief interventions for physical activity, weight management and smoking cessation. There was little change in referral rates except for an improvement in weight management related referrals. Nurses' perception of the importance of 'client and system-related' barriers to risk factor management diminished over time.

CONCLUSIONS

This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practices of GCHNs. Barriers to referral remained. The service model needs to be adapted to sustain these changes and enhance referral.

TRIAL REGISTRATION

ACTRN12609001081202.

Is there scope for community health nurses to address lifestyle risk factors? the community nursing SNAP trial

Background

This paper examines the opportunity and need for lifestyle interventions for patients attending generalist community nursing services in Australia. This will help determine the scope for risk factor management within community health care by generalist community nurses (GCNs).

Methods

This was a quasi-experimental study conducted in four generalist community nursing services in NSW, Australia. Prior to service contacts, clients were offered a computer-assisted telephone interview to collect baseline data on socio-demographics, health conditions, smoking status, physical activity levels, alcohol consumption, height and weight, fruit and vegetable intake and 'readiness-to-change' for lifestyle risk factors.

Results

804 clients participated (a response rate of 34.1%). Participants had higher rates of obesity (40.5% vs 32.1%) and higher prevalence of multiple risk factors (40.4% vs 29.5%) than in the general population. Few with a SNAPW (Smoking-Nutrition-Alcohol-Physical-Activity-Weight) risk factor had received advice or referral in the previous 3 months. The proportion of clients identified as at risk and who were open to change (i.e. contemplative, in preparation or in action phase) were 65.0% for obese/overweight; 73.8% for smokers; 48.2% for individuals with high alcohol intake; 83.5% for the physically inactive and 59.0% for those with poor nutrition.

Conclusions

There was high prevalence of lifestyle risk factors. Although most were ready to change, few clients recalled having received any recent lifestyle advice. This suggests that there is considerable scope for intervention by GCNs. The results of this trial will shed light on how best to implement the lifestyle risk factor management in routine practice.

Professional boundary work in the face of change to generalist working in community nursing in Scotland

AIM

The present study explored how community nurses and managers constituted changes towards generalist working.

BACKGROUND

Following international trends moving from acute care towards community care, changes within community nursing in the United Kingdom have been subject to debate in recent years. Sociological insights into 'boundary work' in professional disciplines are informative for understandings about proposed new roles in community nursing. Recently, radical changes to the role of the community nurse from specialist disciplines to a generalist community health nurse model were proposed in Scotland and tested in four health boards.

METHODS

Focus group discussions were held with 27 community nurses and semi-structured interviews with three managers during January-March 2009 in a purposive sample from one health board. Discussions were audio-recorded and transcribed verbatim. Initial thematic analysis was used to highlight key themes from the data and later a discursive analysis focused on the rhetorical strategies used by participants.

FINDINGS

Four key themes were identified along with the rhetorical devices associated with these including: the undermining of the generalist model through the 'jack of all trades, master of none' metaphor through associations of loss of specialisms; how the re-establishment of specialist discipline boundaries occurred; how current roles were validated and how managers and nurses accounted for future changes to the profession.

CONCLUSION

The qualitative study explored here has implications for discussions about future role change debates within community nursing as well as the specialist-generalist debate internationally. Managers and policy-makers involved in organizational changes are required to give greater credence to the perceived professional status of community nursing.

Whole of Client Health Care in a Gridlocked System: An Insider Dialogue Between the Theory and Practice of Community Case Management

This article blends theory with empirical qualitative research to investigate the present practices of Community Case Management and develop a new and informed model driven by a whole of client approach rather than agency ownership. The Case Management Society of Australia presents an idealistic model that has never been fully implemented. Our exploration of the gap between this theory and the actual real-world practice demonstrates that a whole of client focus has been marginalized and frustrates full implementation. Recent Australian government policy changes to the Home and Community Care program have encouraged competitive, market-oriented delivery in an attempt to reempower the client, but it has come at the expense of collaboration. Introducing competition has added another dimension to impediments to client-centered care that include funding pressures, turf wars, territorialism, and organizationally induced gridlocked systems, all of which shift the focus from the client to the organization. In the face of this, it is paramount that case managers remain client focused and be willing to collaborate/communicate with all parties involved in the cares of the client. Failure to do so may lead to the eventual failure of the Home and Community Care program.

The work, education and career pathways of nurses in Australian general practice

There is little understanding about the educational levels and career pathways of the primary care nursing workforce in Australia. This article reports on survey research conducted to examine the qualifications and educational preparation of primary care nurses in general practice, their current enrolments in education programs, and their perspectives about post-registration education. Fifty-eight practice nurses from across Australia completed the survey. Over 94% reported that they had access to educational opportunities but identified a range of barriers to undertaking further education. Although 41% of nurses said they were practising at a speciality advanced level, this correlated with the number of years they had worked in general practice rather than to any other factor, including level of education. Respondents felt a strong sense of being regarded as less important than nurses working in the acute care sector. Almost 85% of respondents reported that they did not have a career pathway in their organisation. They also felt that while the public had confidence in them, there was some way to go regarding role recognition.

Occupational health-related experiences in rural Tasmania

This descriptive, explorative study sought to identify the occupational-related health experiences of community nurses in their workday within rural North West Tasmania. Tasmania is one of eight states and territories that form Australia. The findings indicate the majority of community nurses consider their health average or better, although 30% reported being overweight; 5% reported smoking; 60% reported feeling tense, anxious or depressed sometimes during the week. In the 12 months prior to survey 48% of participants had experienced a work-related injury or illness. At least two thirds of participants spent an average of 1.5 hours teaching nursing students and 2 hours teaching medical students, per week. Hazards (needlestick injury, items obstructing passageways, debris within homes), dogs and use of mobile telephones were regularly associated with weekly work incidents. Interestingly, more time was spent in a day on documentation than with clients or professional development.

Community health nursing vision for 2020: shaping the future

As health care is shifting from hospital to community, community health nurses (CHNs) are directly affected. This descriptive qualitative study sought to understand priority issues currently facing CHNs, explore development of a national vision for community health nursing, and develop recommendations to shape the future of the profession moving toward the year 2020. Focus groups and key informant interviews were conducted across Canada. Five key themes were identified: community health nursing in crisis now, a flawed health care system, responding to the public, vision for the future, and CHNs as solution makers. Key recommendations include developing a common definition and vision of community health nursing, collaborating on an aggressive plan to shift to a primary health care system, developing a comprehensive social marketing strategy, refocusing basic baccalaureate education, enhancing the capacity of community health researchers and knowledge in community health nursing, and establishing a community health nursing center of excellence.

Practice nursing in Australia: A review of education and career pathways

BACKGROUND

Nurses in Australia are often not educated in their pre registration years to meet the needs of primary care. Careers in primary care may not be as attractive to nursing graduates as high-tech settings such as intensive or acute care. Yet, it is in primary care that increasingly complex health problems are managed. The Australian government has invested in incentives for general practices to employ practice nurses. However, no policy framework has been developed for practice nursing to support career development and post-registration education and training programs are developed in an ad hoc manner and are not underpinned by core professional competencies. This paper reports on a systematic review undertaken to establish the available evidence on education models and career pathways with a view to enhancing recruitment and retention of practice nurses in primary care in Australia.

METHODS

Search terms describing education models, career pathways and policy associated with primary care (practice) nursing were established. These search terms were used to search electronic databases. The search strategy identified 1394 citations of which 408 addressed one or more of the key search terms on policy, education and career pathways. Grey literature from the UK and New Zealand internet sites were sourced and examined. The UK and New Zealand Internet sites were selected because they have well established and advanced developments in education and career pathways for practice nurses.Two reviewers examined titles, abstracts and studies, based on inclusion and exclusion criteria. Disagreement between the reviewers was resolved by consensus or by a third reviewer.

RESULTS

Significant advances have been made in New Zealand and the UK towards strengthening frameworks for primary care nursing education and career pathways. However, in Australia there is no policy at national level prepare nurses to work in primary care sector and no framework for education or career pathways for nurses working in that sector.

CONCLUSION

There is a need for national training standards and a process of accreditation for practice nursing in Australia to support the development of a responsive and sustainable nursing workforce in primary care and to provide quality education and career pathways.