The 1990s and Beyond: Determining the Need for Community Health and Primary Care Nurses for Rural Populations*

ABSTRACT: Increased numbers of primary care and advanced practice nurses with unique generalist skills will be required to meet the accelerating physiologic and sociocultural health care needs of rural populations. Several factors have been identified that will influence the demands and position of community-based nurses in rural practice settings during the next decade. A back-to-basics type of health care offered out of a growing elderly population; technological breakthroughs that make it possible for more chronically ill patients to live at home; serious substance abuse and other adolescent problems; AIDS; and high infant morbidity and mortality statistics are only some of the concerns that will demand nursing intervention. These changes speak to the need for improved nursing coordination, stronger collegial relationships, and better communication between physicians and nurses. Health care is moving in new directions to offer more efficient and technologically sophisticated care. These changes enhance the need for clinically expert educators who teach and jointly practice in programs with a rural focus. Telecommunications, and heightened computer literacy, will play a major role both in nursing education and clinical practice. The goals of kindergarten through 12th grade health promotion and disease prevention strategies in school health will be the norm and will require better prepared, and positions for, school nurses. More midwives and public health nurses will be needed to care for the growing population of sexually active adolescents who are in need of family planning and prenatal care. Underinsured and indigent populations will continue to fall within the purview of midlevel practitioners, as will providing anesthesia services in small rural hospitals. The transition of some rural hospitals into expanded primary care units (e.g., EACHs and RPCHs), and new models of case management will greatly influence nursing demands. This paper will further identify critical areas of advanced practice nursing within community settings, including new relationships with other health care providers, and will introduce strategies upon which rural health policy recommendations for the 1990s can be addressed.     

Community group practices in Canada: are they ready to reform their practice?

INTRODUCTION: Governments and healthcare organizations in Canada are reforming the clinical practice structures and policies to deliver primary care to the population. A key component of primary healthcare reform is the establishment of an interdisciplinary, community-based team approach to patient care. This study was undertaken to provide in-depth insight regarding primary healthcare providers' beliefs and attitudes in regard to their current group practice, what changes they believe are occurring and those necessary to reform group practice settings, their willingness to embrace changes, and the challenges they face to realize the proposed reform. METHODS: This study employed a mixed-method research design (qualitative and quantitative data collection techniques) through day-long focus groups of primary healthcare professionals (eg, family physicians, specialists, dieticians, psychologists) from across Canada. RESULTS: There is considerable variation in the composition of primary care group practices across Canada. Respondents report that group practices are little more than an economic convenience to facilitate sharing of resources. Even when a practice is composed of several disciplines, there is little to no organized or systematic interaction among healthcare professionals aimed at improving patient care, lack of clarity as to identified leaders/managers of the team, and inconsistencies in the model of care provided to patients. However, there is a perception of value and benefit in working in a cohesive group practice to improve patient care. DISCUSSION: Findings revealed that although healthcare providers report themselves ready to make the necessary changes and willing to move to interdisciplinary team-based practices, there are substantive challenges that impede a movement to truly effective interdisciplinary team practice and functioning. These challenges include the type and allocation of funding, interprofessional healthcare provider education, changing the healthcare provision model, and barriers among healthcare professionals regarding shared and equitable team accountability for patient health outcomes.     

The 1990s and Beyond: Determining the Need for Community Health and Primary Care Nurses for Rural Populations*

Increased numbers of primary care and advanced practice nurses with unique generalist skills will be required to meet the accelerating physiologic and sociocultural health care needs of rural populations. Several factors have been identified that will influence the demands and position of community-based nurses in rural practice settings during the next decade. A back-to-basics type of health care offered out of a growing elderly population; technological breakthroughs that make it possible for more chronically ill patients to live at home; serious substance abuse and other adolescent problems; AIDS; and high infant morbidity and mortality statistics are only some of the concerns that will demand nursing intervention. These changes speak to the need for improved nursing coordination, stronger collegial relationships, and better communication between physicians and nurses. Health care is moving in new directions to offer more efficient and technologically sophisticated care. These changes enhance the need for clinically expert educators who teach and jointly practice in programs with a rural focus. Telecommunications, and heightened computer literacy, will play a major role both in nursing education and clinical practice. The goals of kindergarten through 12th grade health promotion and disease prevention strategies in school health will be the norm and will require better prepared, and positions for, school nurses. More midwives and public health nurses will be needed to care for the growing population of sexually active adolescents who are in need of family planning and prenatal care. Underinsured and indigent populations will continue to fall within the purview of midlevel practitioners, as will providing anesthesia services in small rural hospitals. The transition of some rural hospitals into expanded primary care units (e.g., EACHs and RPCHs), and new models of case management will greatly influence nursing demands. This paper will further identify critical areas of advanced practice nursing within community settings, including new relationships with other health care providers, and will introduce strategies upon which rural health policy recommendations for the 1990s can be addressed.     

THE STATUS OF RURAL NURSING IN AUSTRALIA: A REVIEW

ABSTRACT: While much has been written about the practice roles of remote area nurses in Australia, less is known about the role and function of the rural nurse. The majority of rural nurses practise in rural hospitals, community health settings and nursing homes. In contrast, the remote area nurses work setting is generally involved with Aboriginal and Torres Strait Islander primary health care services. Rural nurses' practice setting is usually located in a larger organisation than that of the remote area nurse. There is usually at least one medical practitioner in the town or on-call close by. Nurses who are employed in the smaller rural hospitals have what has been described as a 'specialist generalist' role. This means that they are required to be multi-skilled and competent in a wide range of nursing and non-nursing practice. In contrast, nurses who work in base/provincial hospitals, may have either a generalist or specialist role. This paper provides a summary of the literature on Australian rural nurses and develops some of the themes contained therein.     

Partnership working by default: district nurses and care home staff providing care for older people

Older people residents in care homes that only offer residential care rely on primary healthcare services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary healthcare team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on‐site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community‐based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community‐based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.     

WORKING TOGETHER: THE ADVANCED RURAL NURSE PRACTITIONER AND THE RURAL DOCTOR

ABSTRACT: This paper discusses the complex and interrelated roles of the rural nurse and doctor. These roles are viewed as being complementary to each other in any healthcare setting, but more so within the context of rural Australia. The current move towards the development of advanced nurse practitioner roles is often clouded by unnecessary medical fears that nurses are attempting to displace doctors. In contrast, this paper argues that the development of new rural nursing roles identifies rural nursing as a major specialist area within the wider profession of nursing and, at the same time, recognises the reality of practice for many rural nurses. Individual public figures may perceive the solution to the shortage of rural doctors to lie in their replacement with nurses. The nursing profession, however, will resist this approach. Nursing is not the first rung on the ladder to a career in medicine. Nurses are educated and acknowledged to focus their practice on the clients' responses to healthcare problems and not the practice of medicine. The primary role of the nurse is to provide care. The primacy of care should not be set aside by those nurses seeking to develop their practice, nor should advanced practice be defined in terms of taking on tasks previously carried out by other healthcare professionals.     

陕西省基层医疗卫生机构护理人员现状调查

目的了解陕西省基层医疗机构护理人员现状和护理人员执业能力。方法抽取陕西省1市10县医药卫生体制综合改革试点市县,通过座谈、问卷调查及实地走访等形式,在县乡医疗卫生机构开展调研。结果陕西省基层护理专业人员结构概况:农村地区平均每千人拥有注册护士1.62人;基层护理人员中女性占96%,男性占4%;学历以大专为主,其次为中专和本科;职称结构中以初级职称为主,占88%;从事护理专业5年及5年以下者占40.8%,6年-10年占23.8%。基层护理人员执业能力整体状况良好,健康教育及预防保健能力、科研能力、社区护理能力评价较低。结论基层卫生机构护理人力资源匮乏,护理队伍结构不合理;基层护理人员执业能力较强,能够胜任一般护理工作,基本能够满足用人单位的需求,但仍需进一步加强沟通能力、急危重症患者的监护处置能力,提高科研意识,强化社区护理意识和能力。     

RURAL INTERDISCIPLINARY HEALTHCARE TRAINING IN HAWAII: A CROSS-CULTURAL PROJECT

ABSTRACT: In 1993, a federally funded project began at the University of Hawaii to educate students from a variety of health professions (nursing, medicine, dental hygiene, psychology, public health, and social work) about the challenges of working as an interdisciplinary team in rural health settings. After nine months of study, this education culminated in students participating in interdisciplinary team projects in rural areas of Hawaii. The development and funding of interdisciplinary rural health projects across the United States reflects the growing awareness that limited resources and access to health in rural areas requires resource sharing, both physical and non-physical. Exposing students to information about rural health care, and then providing hands-on opportunities for teamwork with fellow students in a rural setting, can serve an additional and critical function: to recruit to rural areas healthcare workers who are already aware of the challenges and rewards of this type of practice.     

EVIDENCE-BASED PRACTICE AND RURAL NURSING: A LITERATURE REVIEW

ABSTRACT: This literature review is an exploration of issues related to evidence-based practice and rural nursing. Given the contribution that nursing research can make to improved client care in rural areas, it is important that nurses' awareness and understanding of evidence-based practice be enhanced, and that strategies for fostering the development of clinically relevant programs of nursing research be identified for rural health services. The review highlights the deficiencies in the current metropolitan-based approaches to evidence-based practice that may disadvantage rural clients and nursing practitioners, because they do not accommodate the inherent differences in rural and metropolitan healthcare cultures. It emphasises the need to seek approaches to research-based practice that arise from the specific needs of the rural setting.     

About the culture of in-home nursing

As nurses assume a multitude of roles in health care, public and professional perspectives of nursing vary and, consequently, both clients and providers, including nurses themselves, do not fully appreciate the nature of in-home nursing. In this study ethnographic methods were used to capture participants' perspectives of the actions, practices, values, and beliefs that collectively comprise the culture of nursing in the context of home nursing services in rural Australia. Findings reveal how nurses' and clients' experiences of in-home nursing differ from the textbook picture, and how interactions between nurses' practice approaches and care recipients' enactment of the client role create a cultural context affecting clients' health and well-being. Given similar findings in other countries, the insights gained merit consideration by all professionals concerned about refining home care service approaches in keeping with currently espoused valuing of client-centered, empowering care partnerships.     

Too frightened to care? Accounts by district nurses working with clients who misuse substances

Drug misusers have complex health and social care needs, and experience considerable difficulties in accessing the assessment, care and treatment that they require. Despite the development of specialist services in many parts of the UK, substance misuse is often marginalised within mainstream general healthcare, and many practitioners are unprepared for the challenges of working with this client group. The present paper reports findings from a qualitative study that aimed to explore district nurses' understandings and practices in relation to discrimination and inequalities issues. The research took place during 2003 in two city-based primary care trusts in the North of England. Semistructured interviews were undertaken with 18 'G' grade district nurses. The authors present findings that highlight some of the challenges and tensions district nurses encounter when providing care to clients who misuse substances. The discourses of 'prejudice' and 'risk' were intertwined throughout the data, and served to shape service provision for clients who misuse substances. This was reflected in the district nurses' accounts of their own practice and that of other services, suggesting that these clients receive suboptimal care. The discourse of 'risk' was also used by district nurses to construct themselves as 'vulnerable', and this helped to explain some of their own practices of care provision. Many participants acknowledged their limited knowledge and experience of working with this client group. There is an urgent need for district nurses and other health professionals to develop their practice with these clients, who may present as both vulnerable and dangerous, in order to ensure that care is provided equitably and safely.     

Were practice nurses distributed equitably across England and Wales, 1988-1995?

OBJECTIVE: To examine whether variations in the number of whole-time equivalent (wte) practice nurses across family health services authorities (FHSAs) can be explained by population characteristics and the organisation of general practice. METHODS: Analysis of nine health and 16 social indicators for 98 FHSAs identified three factors underlying health care needs. These factors and seven practice characteristics were analysed by stepwise regression. A formula for allocating health care resources and a logistic growth model were used to estimate the 'expected' number of nurses. RESULTS: Past trends indicate an eventual (wte) practice nurse workforce of 12,500 (95% CI +/- 3500). Although geographical disparities have declined, there was a two-fold variation in nurse numbers across FHSAs. Around 2000 (wte) posts would be required to bring under-provided areas, mostly in northern England and metropolitan districts, up to the highest level of provision. There were more nurses in areas with higher proportions of elderly people but fewer where deprivation, morbidity and mortality levels were above average. The number of general practitioners was the most significant predictor of practice nurse provision (t = 5.0); population needs and practice characteristics explained 24% of the variation. CONCLUSIONS: The distribution of practice nurses scarcely corresponded with health care needs at the FHSA level. Despite a lack of evidence that nurses are a cost-effective addition to the primary health care team, their role and numbers will be driven by the extent to which they take on responsibilities performed by doctors. Achieving equity in practice nurse provision probably requires explicit consideration in a formula for allocating primary care funds, backed by audit of the services they provide.     

Palliative care: community nurses' perceptions of quality

OBJECTIVES: To identify community nurses' perceptions of quality care provision for patients requiring palliative care. DESIGN: Semi-structured interviews were conducted with community nurses working within the district nursing service. An adaptation of Flanagan's critical incident technique was employed to elicit factors associated with high or poor quality palliative care. Interviews were tape recorded and transcribed. Data were analysed using thematic content analysis, recurrent themes being agreed by the research team. SETTING: One community healthcare trust. SUBJECTS: 62 members of the district nursing team (grades B-H). RESULTS: Respondents recounted the context in which high quality palliative care could be provided, the actions required, and the indicators that suggested the desired level of care had been achieved. Key factors identified were: the early referral of patients to the district nursing service, family circumstances, the availability of time, the accessibility of services and equipment, and the relationship with other healthcare professionals and informal carers. There was a general view that a positive outcome had been achieved when patients retained control over their circumstances and died a peaceful death, in the place of their choice, supported by their family. CONCLUSIONS: Community nurses were able to articulate clearly the essential components of high quality care. Whilst these factors do not represent a comprehensive list, they are put forward as a useful starting point for standard setting and subsequent audit.     

Recruiting and Retaining Mental Health Professionals to Rural Communities: An Interdisciplinary Course In Appalachia

CONTEXT: Faculty from 5 disciplines (health administration, nursing, psychology, social work, and special education) collaborated to develop and teach a distance-learning course designed to encourage undergraduate and graduate students to seek mental health services employment in rural areas and to provide the skills, experience, and knowledge necessary for successful rural practice. METHODS: The primary objectives of the course, developed after thorough review of the rural retention and recruitment literature, were to (1) enhance interdisciplinary team skills, (2) employ technology as a tool for mental health practitioners, and (3) enhance student understanding of Appalachian culture and rural mental health. Didactic instruction emphasized Appalachian culture, rural mental health, teamwork and communication, professional ethics, and technology. Students were introduced to videoconferencing, asynchronous and synchronous communication, and Internet search tools. Working in teams of 3 or 4, students grappled with professional and cultural issues plus team process as they worked through a hypothetical case of a sexually abused youngster. The course required participants to engage in a nontraditional manner by immersing students in Web-based teams. FINDINGS: Student evaluations suggested that teaching facts or "content" about rural mental health and Appalachian culture was much easier than the "process" of using new technologies or working in teams. CONCLUSIONS: Given that the delivery of mental health care demands collaboration and teamwork and that rural practice relies increasingly more on the use of technology, our experience suggests that more team-based, technology-driven courses are needed to better prepare students for clinical practice.     

Program helps nurses develop spiritual care skills

Recognizing the registered nurse's (RN's) important role in providing spiritual care, the Catholic Health Association of Wisconsin has created a program to prepare nurses to identify and respond to patients' spiritual needs. The program features instruction in theological and ethical issues and a three-month practicum, during which nurses evaluate their abilities to incorporate an awareness of spirituality into professional practice. A patient questionnnaire enables an objective measurement of the program's effect on nurses' care-giving skills. The program's ultimate goal is to formalize the RN's role as a member of the spiritual care team in the Catholic health care facility. The program represents not only an opportunity to contribute to the RN's professional growth but also to advance the Catholic health care mission.     

Situation analysis and proposals for improving primary care nursing in Mallorca: study with focal groups

BACKGROUND: The primary care reform (PCR) has give rise to some major changes in the nursing profession. The objectives of this study are to analyze the achievements made by the nurses, to identify the problems they currently have in primary care and to suggest some lines along which work can be done for the future. METHOD: Qualitative research (focal group method). Eight groups were made segmented by occupational category and the position held. Scope of the analysis: the role of nurses, services supply and organization, participation and management, marketing and training. RESULTS: In the opinion of those surveyed, the PCR has entailed a broadening of the nurses' skills, although their role is still well-defined. The nurses are of the opinion that there is no listing of services inherent to nursing despite the leading role they obviously play in home care and health education. The need has been identified of assess the existing health programs in terms of results. Concerning to health services organization, main problems were related to the lack of adapting staffing in keeping with the rise in population and difficulties of internal communications within the health professional teams and the very small degree to which nursing services are disseminated. The need is felt of broadening pre-diploma training with regard to some subjects (health education) and skills (teamwork). CONCLUSIONS: Although the PCR has meant improvements for the nurses, solutions have as yet to have been provided to some aspects (including defining a listing of services, adapting staffing, internal communications, marketing, training) and given the opportunity the transferring of authorities over health care entail, further progress must be made toward innovative proposals to improve the health services.     

Assessing the educational needs of community sexual healthcare practitioners

There is wide variation in the quality and nature of community sexual health service delivery in the UK, which has led to a number of professional and Government-led directives to improve service provision. One key target is the provision of appropriate training and updating of staff in order to maintain an appropriate skill level. To identify the educational development needs of community sexual health nursing and medical staff, preparatory to commissioning appropriate educational provision, a training needs analysis survey was conducted. This involved using a customised psychometrically valid and reliable instrument, which was administered to all relevant staff for self-completion. Fifty-four (67.5%) of all doctors and nurses working in a community sexual health directorate responded. For the whole sample, the following categories of development need were identified: professional development; research; legal issues; clinical practice; and communication/interpersonal skills. When the nursing and medical subsamples were analysed separately, the same generic training needs emerged, although the nurses and doctors identified 22 and 25 significant training needs, respectively. The reported skills deficits cluster into super-ordinate groups which resonate with other available literature. This suggests that each category could be reliably used to inform a short course or series of modules, either for the whole sample or for each professional group. The results also suggest that the instrument is viable for use with healthcare professionals working in this specialty. Consequently, if this approach to identifying skill deficits was adopted, limited educational budgets could be used to provide courses which would meet the real training needs of staff, and if offered as a shared learning opportunity, could promote multidisciplinary team-working. In this way, improved local healthcare provision could be readily realised, with the potential for reducing current variations in the quality of community sexual health provision.     

Sickness absence and the organization of nursing care among hospital nurses

OBJECTIVES: Primary nursing and team nursing are two different ways of organizing nurses' work in hospital wards. This study examined whether primary nursing is associated with lower sickness absence rates than team nursing is. METHODS: Altogether 1213 nurses from 13 primary nursing wards and 13 team nursing wards participated in a 3-year observational study. The nurses' sickness absence records were linked with information on the organization of nursing in the wards. RESULTS: After adjustment for demographic and ward characteristics, primary nursing, compared with team nursing, was associated with 26-42% higher annual rates of short (1-3 days) spells of sickness absence (P<0.05). The corresponding adjusted excess rates varied between 26% and 36% for the long (>3 days) absences, depending on the year (P<0.05). Among the primary and team nurses who had no sickness absence in the first year, primary nursing was associated with a 41% higher incidence of short-term sickness absence in the second year and a 56% higher incidence in the third year. CONCLUSIONS: The expected benefits of primary nursing for nurses' health are not supported by data on recorded sickness absences. Recommendations to implement primary nursing in team nursing wards cannot be justified simply on the basis of potentially favorable effects on employee health.