A community-oriented primary care nursing model in an international setting that emphasizes partnerships

PURPOSE: To present an interdisciplinary, community-oriented primary care nursing model that effectively draws upon the strengths of advanced practice nurses (APNs), both nurse practitioners and community health nurses. DATA SOURCES: Articles in professional nursing journals, international data sources, and the clinical experiences of the authors, both domestic and international. CONCLUSIONS: The model, developed domestically, was utilized successfully by APNs internationally in a medical mission endeavor in rural Haiti. Many partners, domestic and Haitian, worked as an interdisciplinary team to deliver quality health care to an impoverished population. Graduate nursing students participated in the program, which offered opportunities and challenges for both novice and expert nurses. IMPLICATIONS FOR PRACTICE: Nurse practitioners, community health nurses, and nursing faculty members can use this model to enhance their professional practice. They can learn that clients can be optimally cared for whether the community served is domestic or international. Nursing faculty can teach graduate nursing students about the value of partnerships and collaboration.     

APN-directed transitional home care model: achieving positive outcomes for patients with COPD

Advanced practice nurses (APNs) have not been widely used in home care, despite evidence of their effectiveness with a variety of patient groups. This study examined the use of the transitional model for home care patients with chronic obstructive pulmonary disease. The study found patients cared for by an APN-directed visit team had fewer nursing visits, rehospitalizations, and acute care visits. Depressive symptoms were also less, and functional abilities increased compared with patients cared for by a usual care model.     

The nursing faculty shortage: Is there hope?

The present nursing faculty shortage is linked to the general nursing shortage. Without enough nurse educators to teach the increasing number of nurses that are needed, the health of U.S. residents is at stake. This article examines progress made on solutions proposed over the past decade such as increasing graduate and certificate programs for nurse educators, more aggressive recruitment of graduate students into faculty roles, and delayed retirement of current faculty. Potential new solutions are proposed. These include: fast-track bachelor's of science in nursing to doctor of philosophy curricula; recruiting advanced practice nurses (APNs) into faculty roles with arrangements made for clinical practice time; raising the image of nursing education as a prestigious career; developing national certification for nurse educators; and partnering with health care agencies. Linking the general nursing shortage with the faculty shortage may provide a stronger case for public policy and funding initiatives. There are signs that some initiatives are working. Present faculty need to maintain a culture of hope while potential solutions are being implemented.     

Registered nurses' clinical reasoning in home healthcare clinical practice: A think-aloud study with protocol analysis

BackgroundThe home healthcare context can be unpredictable and complex, and requires registered nurses with a high level of clinical reasoning skills and professional autonomy. Thus, additional knowledge about registered nurses' clinical reasoning performance during patient home care is required.ObjectivesThe aim of this study is to describe the cognitive processes and thinking strategies used by recently graduated registered nurses while caring for patients in home healthcare clinical practice.DesignAn exploratory qualitative think-aloud design with protocol analysis was used.SettingsHome healthcare visits to patients with stroke, diabetes, and chronic obstructive pulmonary disease in seven healthcare districts in southern Norway.ParticipantsA purposeful sample of eight registered nurses with one year of experience.MethodsEach nurse was interviewed using the concurrent think-aloud technique in three different patient home healthcare clinical practice visits. A total of 24 home healthcare visits occurred. Follow-up interviews were conducted with each participant. The think-aloud sessions were transcribed and analysed using three-step protocol analysis.ResultsRecently graduated registered nurses focused on both general nursing concepts and concepts specific to the domains required and tasks provided in home healthcare services as well as for different patient groups. Additionally, participants used several assertion types, cognitive processes, and thinking strategies.ConclusionsOur results showed that recently graduated registered nurses used both simple and complex cognitive processes involving both inductive and deductive reasoning. However, their reasoning was more reactive than proactive. The results may contribute to nursing practice in terms of developing effective nursing education programmes.     

Role of nursing students at rural nurse-managed clinics

With stiff competition for clinical sites, one Midwestern university partners nursing students with faculty who provide primary healthcare to clients in 2 rural nurse-managed clinics. Some students are also assigned to follow select clients during weekly home visit rotations for their public health clinical course. The result has been a successful faculty practice and preceptor model that benefits rural communities, a clinical setting that provides opportunities for students to experience client care needs of the underinsured or uninsured in small communities, and student exposure to the financial burdens and challenges of today's healthcare environment in the United States.     

Advanced practice nurses' perspectives on the use of health optimization strategies for managing chronic disease among older adults in different care settings: pushing the boundaries of self-management programs

This study examines the intention of advanced practice nurses (APNs) to utilize health optimization programs (HOPs) for addressing clients' chronic disease in various work settings (i.e., nursing homes or other care settings). A paper-based survey was administered to 270 APNs at a continuing education conference to determine their intentions to refer patients to HOPs for chronic disease management. APNs working in nursing homes were 0.23 times as likely to utilize HOPs for management of their patients' chronic disease compared with their counterparts working in other care settings (odds ratio = 0.23, confidence interval = 0.06-0.80, P = .021). APNs who had previously used a HOP for management of their patients' chronic disease were 5.2 times as likely to do so again relative to those who had not previously used a HOP for management of their patients' chronic disease (odds ratio = 5.17, confidence interval = 1.78-14.99, P = .002). Educational and organizational interventions are recommended to disseminate further HOPs for chronic disease in nursing home settings as part of an overall health optimization strategy.     

Implementation of nursing services in community corrections: A community-academic partnership

Persons who are incarcerated (PWAI) suffer from a disproportionately higher number of physical and mental health conditions. While most jails and prisons provide onsite healthcare, community correctional centers often do not and accessing community healthcare is challenging due to insurance issues, inadequate health literacy, mistrust, and long waits for appointments. A registered nurse-led wellness clinic provides a viable solution to addressing the healthcare needs of PWAI in a community correctional setting. Through a community-academic partnership between a college of nursing and two community correctional transitional centers for men, a registered nurse (RN) faculty member and nursing students provide onsite healthcare. Services include, but are not limited to, acute and chronic disease management, case management, healthcare navigation, and health education. In the first 2 years of operation, there have been 587 new resident health assessments, 882 RN visits, and 152 group education sessions. RN visits have been primarily for: connection to resources (42.6%), medication management (15.6%), and acute conditions (12%). A RN-led wellness clinic is an innovative way to address health needs for PWAI. While this model of care focuses on an academic RN faculty practice at community correctional centers it could be replicated across community settings.     

Faculty mentorship: support for nurse practitioner students and staff within the rural community health setting

As pointed out in the introduction, there are certain practical concepts within our base of nursing knowledge that can only be taught through experience. Many things are easier to teach by example. As we turn back the clock in nursing, we can see how Florence Nightingale, Clara Barton, and Lillian Wald were role models to their nursing peers in their era. They taught nursing by example, by role modeling their clinical expertise. Today, this model is still effective and faculty mentoring of nurse practitioner students and CHNs in a compassionate and collegial leadership results in higher quality of health care for our nation's needy clients and their families. But greater yet are the opportunities for flexible nurse practitioner faculty practice and personal interactions on many levels for nursing faculty who wish to share their expertise. Mentorship by nurse practitioner faculty for nurse practitioner students and CHNs in a rural clinical setting has revealed many positive aspects in providing quality care for rural clients and growth for nurses. Exposure to the rural community health system helps us, as nurses, to identify the many strengths it possesses for innovative rural nursing practice.     

Community based and community focused: nursing education in community health

Nurses have always cared for individuals, families, groups, and communities in their practice. Recently there has been an increase in the focus on nurses working outside of the hospital, primarily in community-based settings that focus on individuals and families. There is also increasing emphasis on community-focused nursing care with the community as the client. In some nursing programs, nurse educators have tried to adjust to this change by increasing the amount of time that nursing students spend in the community. The focus of this experience ranges from individuals to populations. This article describes a one-semester community health course in a baccalaureate nursing program that gives students both theoretical and practical knowledge in caring for individuals, families, groups, and communities. This allows for practice and understanding of both community-based and community-focused nursing care.     

Enhancing cultural competencies of advanced practice nurses: health care challenges in the twenty-first century

Shifting population demographics will have a major impact on the practice of advanced practice nurses (APNs). The ethnic composition of people in this country is becoming increasingly diverse. Massachusetts and, in particular, the city of Worcester is also experiencing changes in the diversity of its population. These trends testify to the great need for APNs who are sensitive to and competent to care for culturally diverse populations. To address these changes, specific curricula enhancements focused on ethnically diverse populations were implemented for the nurse practitioner specialties at the Graduate School of Nursing (GSN), University of Massachusetts Worcester. The processes used for this project included visiting community and clinical sites, identifying key curricular components, and evaluating existing didactic and clinical learning experiences. The GSN faculty developed a systematic plan for integrating these components into the graduate nursing core, advanced practice core, and specialty courses of the respective curricula. A major outcome of this project was the enhanced preparation of APN students to meet the multifaceted needs of ethnically diverse patients, families, and communities.     

Challenges to implementing an APN-facilitated falls management program in long-term care.

Although several clinical studies have demonstrated success in reducing falls among nursing home residents, the degree of adherence to these strategies varies widely among studies and facilities, especially following the removal of external consultants or advance practice nurses (APNs). This article identified contextual factors that challenged the effective implementation of a falls reduction program. For nurses, the major problems with implementing the project involved inadequate nursing assessment and clinical decision making. APNs who influence nursing staff behavior via education and individual resident consultation may fill the critical gap in professional nursing care in nursing homes.     

Expanding nurses' roles in telemedicine & genetics services

This article presents nursing roles in telemedicine and genetics services. Telemedicine offers a promising solution to delivering comprehensive genetics services to children and families when travel, distance, and shortage of genetics professionals interfere with access. Nurses are already using telemedicine to provide nursing and healthcare services but have become involved in the delivery of genetics services via telemedicine only recently. Involving nurses in the development of telemedicine systems for genetics services is essential as they serve as a vital link between the patient, the healthcare system, and the community. Some of the emerging nursing roles in telemedicine include genetic family-health risk assessment, evaluation and counseling at the advanced practice level and at the primary care level, referral, participation in genetic evaluation and counseling, and family- and community-based care coordination and management. The Genomics Nurse Case Coordinator role as described by is presented as a means of further expanding the maternal-child health nursing role in supporting women and families to manage their own genomic health. Telemedicine offers nurses an opportunity to assure and provide quality genetic healthcare tailored to the individual and family's specific needs within their own community.     

Valuing tacit nursing knowledge during the COVID-19 pandemic

Public health nurses in Ontario, Canada, support the healthy growth and development of children across the province through a variety of programs including home visits for pregnant individuals and families with young children. During the COVID-19 global pandemic the needs of families increased while access to health and social services decreased. During this time, home visiting teams closely involved in supporting families also experienced staff redeployment to support pandemic efforts (e.g., case and contact management, vaccinations) and changes to the nature of home visiting work, including shifts to remote or virtual service delivery. To support nursing practice in this new and evolving context, a framework for capturing and sharing the tacit or how-to knowledge of public health nurses was developed. A valuing of this type of knowledge for informing future public health nursing practice – well beyond the pandemic response – was recognized as a pandemic silver lining when reflecting on two years of supporting home visiting teams in our province.     

Public health nursing student home visit preparation: the role of simulation in increasing confidence

The purpose of this study is to evaluate the role of simulation in preparing senior nursing students for their first home visit and to determine comfort and confidence levels of these students as they prepare for their first home visits. This exploratory study used a convenience sample of public health nursing students (n = 115). A pretest posttest design evaluated the effectiveness of the simulation using a 5-point Likert scale to detect changes in student confidence. Significant differences were noted on the majority of mean scores (p <.001) post-simulation. This approach could also be used to prepare newly hired home health care nurses and inexperienced nurses who are making the transition to home care from another aspect of nursing practice.     

Maximizing services along the continuum of care from inpatient to home

The nurse managers of the inpatient pediatric units and home care division of Robert Wood Johnson University Hospital met to restructure and optimize the quality of care delivered to children and their families in the home setting. A program was developed using inpatient pediatric staff nurses to perform home visits to children requiring follow-up after an inpatient hospital stay. The nurse managers found home visits could comfortably be delivered by pediatric inpatient nurses if they were appropriately oriented and precepted by experienced home care nurses. When home visits were performed by the nurses who cared for the patient in the hospital, both the child and the family appeared to have an increase in comfort and self-confidence in caring for their child. The program also was successful in reducing the costs associated with pediatric home care. This was achieved by facilitating the downsizing of the inpatient units in periods of low census, as well as in cost avoidance associated with not paying benefits to additional employees that otherwise would have been hired by the home care department. This program could be implemented successfully in institutions that support communication, coordination, and continuous improvement of the programs provided to children and families.     

The process of becoming: from specialty practice to community-based nursing

This article reports on the experience of the School of Nursing at Creighton University in cross-educating faculty to community-based nursing. In the late 1990's the Helene Fuld Health Trust recognized the importance of preparing nursing faculty for community-based nursing because of changing trends in the health care system. Placed in the historical context of the early beginnings of nursing practice in the community, this renewed emphasis led to seeking grant support from the Trust to strengthen the place of community-based nursing for faculty and students alike to be responsive to future changes in health care.     

Nurse-sensitive outcomes of advanced practice

Advanced practice nurses (APNs) in the USA are registered nurses who hold masters or doctoral degrees in a specialized area of nursing. They provide advanced clinical care to clients, manage health care systems and influence health care decision-making through expert clinical reasoning and research and theory-based action. APN impact on health care outcomes is supported by studies using physician-focused indicators, although a few studies have identified several that are sensitive to or reflective of advanced practice nursing. A modified Delphi survey was conducted during May 1997-December 1998 to determine the outcome indicators APNs recommend for use in measuring their effect on care delivery outcomes. A convenience sample of 66 APNs attending a statewide outcomes conference identified 27 potential outcome indicators. These indicators were included in a mailed survey sent to APNs working in Tennessee. Respondents were asked to rate each indicator for validity, sensitivity, feasibility, utility and cost. In the second round of the survey, they were asked whether or not they agreed with the rank ordering of indicators, which was determined by the means calculated from responses in the first round. The 10 highest ranked indicators were satisfaction with care delivery, symptom resolution/reduction, perception of being well cared for, compliance/adherence with treatment plan, knowledge of patients and families, trust of care provider, collaboration among care providers, frequency and type of procedures ordered and quality of life. APNs identified both direct and indirect measures of effect on care delivery outcomes. Some of these are currently used as indicators of advanced practice, but many are not. Additional research is needed to determine whether the indicators proposed are valid and sensitive to advanced practice care by nurses.     

Home care of high risk pregnant women by advanced practice nurses: nurse time consumed

This study examined the time spent by advanced practice nurses (APNs) in providing prenatal care to women with high risk pregnancies. The results indicate that the overall mean APN time spent in providing prenatal care was 51.3 hours per woman. The greatest amount of time was spent in the clinic and women with pregestational diabetes consumed the most APN time and required the most contacts. Historically, home care services have been measured by number of visits or contacts. This study assists home care nurses and administrators to consider additional measurements including time spent.     

APN Knowledge,Self‐Efficacy,and Practices in Providing Women's Healthcare Services to Women with Disabilities

Women with disabilities require the same gynecological and reproductive healthcare services as women without disabilities, yet they often experience difficulty obtaining them. Advanced practice nurses (APNs) increasingly provide primary care services that include women's health care, yet their influence on this population has not been systematically examined. This study examined the practices, environments, knowledge, and self‐efficacy of APNs in Texas regarding provision of women's health care to women with disabilities. The study's respondents are 744 women who replied to a mailed survey. The results reveal that while nurses do not lack knowledge, work environments do not support competent care of women with disabilities and practices do not always follow national guidelines. Predictors of self‐efficacy in provision of health care to women with disabilities were status as a women's health nurse practitioner, previous rehabilitation experience, high knowledge scores, and a working environment perceived as accessible. Until changes are made in APN education and environmental barriers are addressed, APNs may not be able to provide optimal women's healthcare services to women with disabilities.     

Clinical practice: new challenges for the advanced practice nurse

This report describes the challenges for advanced practice nurses (APNs) relative to supply and demand issues. The article also includes opportunities with the Balanced Budget Act, physician acceptance of Advanced Practice Nurses, and expanding practice opportunities. The challenges include the nursing shortage (both in nursing students and faculty), the aging of the nursing workforce, and a lag in nursing salaries; increased demand for nursing based on aging baby boomers, increasing patient acuity and technology, and new arenas for practice. The Balanced Budget Act of 1997 provided new opportunities for advanced practice nurses, including enhanced autonomy to provide services and bill independently of physicians. With these changes come new opportunities for advanced practice nurse entrepreneurs in the areas of independent practice, including opportunities to positively impact the health of families and communities in alignment with the Federal government's vision for "Healthy People 2010." As physician acceptance of advanced practice nurses continues to grow and in light of the changes in medical practice and education (residency reduction), opportunities to expand collaborative practice arrangements also exist. APNs are best suited to make the most of these changes. One example of an opportunity for independent practice, a Community Wellness Center, is developed as an entrepreneurial venture benefiting both the APN and the health of a community. Who better than registered nurses (RNs), especially those practicing at the advanced level, can ensure that these opportunities and challenges are addressed in an ethical manner and focused on the needs and health of the community?