Nursing in Croatia: past, present, and future

In the health care system of the Republic of Croatia there are 30000 nurses. More than 7000 of them have college or university professional qualifications. Nursing education consist of secondary vocational education followed by two cycles of university education – baccalaureate and diploma cycle. A PhD cycle, which would allow the development of scientific career for nurses, does not exist. The secondary vocational school qualifications are not recognized by the European Union educational system, requiring a necessary reform in that field. The education of nurses should be attuned with the needs of health care institutions, and nursing care should be based on modern categorization of patients, standards of nursing practice, and clearly defined spheres of responsibility. However, the Croatian Ministry of Health has not yet defined the necessary number of nurses in Croatia or their required educational level. The license for independent work for nurses is another great problem that the health care system is facing, since Croatian nurses with only vocational secondary school qualifications do not meet the requirements to be licensed. The current legislation on nursing is still only formal and not implemented on a wide scale in the health care system. Considering the new trends, nurses in Croatia should work on developing a new systematization of workplaces and more accurate assessing of the job complexity index and the ratio of personal incomes.     

Interdisciplinary preoperative patient education in cardiac surgery

Patient education in cardiac surgery is complicated by the fact that cardiac surgery patients meet a lot of different health care providers. Little is known about education processes in terms of interdisciplinary tuning. In this study, complete series of consecutive preoperative consultations of 51 cardiac surgery patients with different health care providers (physicians, nurses and health educators) were videotaped. The information exchange between patients and providers was analyzed directly from the video recordings by using an adaptation of the Roter Interaction Analysis System (RIAS) and a checklist of relevant informational topics. Results pointed to overlaps and gaps as well as to a lack of a patient-centered approach. The physicians were mostly overlapped by the nurses, who spent almost 30% of the time on talking about medical issues. Gaps were found in giving psycho-educational information and emotional support, needed to establish effective patient education. The findings provided a sound basis for developing guidelines and changes in the organization of the education process.     

¿A quién recomendarías como excelente enfermera comunitaria? Orientaciones para la formación en enfermería a partir de las historias de vida de enfermeras paradigmáticas

ObjectivesTo reconstruct the biographical account of community nurses, acknowledged by their peers as highly reputed, and to describe their characteristic attributes; to search for guidelines to optimise training in nursing at community level according to their experience.MethodBiographical narrative method (life history) under the constructivist paradigm. Three nurses, chosen unanimously by significant peers as excellent nurses, were interviewed by means of in-depth interviews. The resulting texts were analysed using two qualitative content analysis procedures that contribute to the comprehension of the representation of an exemplar community nurse, a) data categorisation from a time perspective, and b) categorise the content of the interviewed attributes and their perspectives and practices as regards nursing education.Results discussion and conclusionsThe results show a homogeneous representation of being a nurse, highlighting the traditional subjects of a caring vocation, a sense of ethics, and courage. At the same time, is an autonomous professional, a leader that conceives his/her job as systemic.It is remarkable to find accounts of psychological undermining as consequence of conflicts with authoritarian head nurses and the unanimous criticism of the social conditions. They attribute to the neoliberal economy, nevertheless they omit the political dimension in their arguments. As regards nursing education, they consider humanized nursing and a reflective practice as essential.In view of these results, it is suggested, from the point of view of ethics of care, that a proposal on the concept of mature care should be included in nursing education that might promote ethic reflection in current social conditions.     

The significance of cognitive modeling in building healthcare interfaces

BACKGROUND: Although there are many reasons that widespread adoption of healthcare information systems has not transpired, one reason is a failure to take into account the cognitive needs of the users. AIM: To understand the cognitive needs of nurses and physicians and determine how these needs should influence the design of healthcare interfaces. DESIGN OF STUDY: A qualitative and quantitative study that compares how nurses and physicians comprehend patient information. SETTING: Twenty-four registered nurses and twenty-four physicians working in the specialties of gastrointestinal or internal medicine. METHODS: Each clinician reviewed two mock electronic medical records and summarized the cases using a think-aloud protocol. All verbalizations were coded for medical and conceptual information. RESULTS: The nurses included a larger mean proportion (p<0.001) of recalls than did the physicians. As compared to the nurses, the physicians included a statistically significant (p<0.001) larger mean proportion of inferences, conditional statements, and interventions. The nurses concentrated on functional problems, whereas the physicians focused on diagnosis, treatment, and management. CONCLUSION: The main cognitive differences between the physicians and the nurses are explained through the differences in their practice models. Therefore, healthcare IT must develop separate interfaces for each discipline to address their unique needs.     

Nursing Homes as Primary Care Sites for Psychological Practice

Speer and Schneider (2003 ; this issue) reviewed the literature on the mental health needs of older adults in primary care sites. Their conclusions are especially salient for the nontraditional nursing home primary care setting. Health care providers in nursing homes must routinely address multiple psychiatric and medical comorbidities. Most nursing home medical directors have limited training in psychological issues resulting in few mental health referrals. Psychologists have sparse research findings to guide their practice due to lack of inclusion of nursing home residents in research studies. The need to implement a multidisciplinary approach is essential in nursing home primary care settings.     

In search of a Croatian model of nursing education

Aim

To analyze the present status and ongoing reforms of nursing education in Europe, to compare it with the situation in Croatia, and to propose a new educational model that corresponds to the needs of the Croatian health care system.

Methods

The literature on contemporary nursing education in Europe and North America was reviewed, together with European Commission directives and regulations, as well as pertinent World Health Organization documents. In addition, 20 recent annual reports from 2003-2009, submitted by national nursing associations to the Workgroup of European Nurse Researchers, were studied.

Results

After appraisal of current trends, the Working Group on Reform of Nursing Education drafted The Croatian Model for Education in Nursing and developed a three-cycle curriculum with syllabus. The proposed curriculum is radically different from traditional ones. Responding to modern demands, it focuses on outcomes (developing competencies) and is evidence-based.

Conclusions

A new, Croatian concept of nursing education is presented that is concordant with reforms in nursing education in other European countries. It holds promise for making nursing education an integral part of a unified European system of higher education.At the beginning of 2010, the Ministry of Health and the Ministry of Science and Education of Croatia jointly concluded that nursing education in this country is not on the level of European standards. This was considered an important issue, in part, because of the imminent accession of Croatia to the EU, and they launched a reform process. The National Council for Higher Education appointed one of the authors (S.J.), from the University of Split School of Medicine, and Professor Siniša Volarević from the University of Rijeka School of Medicine to explore the issue and to report their findings. In February 2010, S.J. established an experts’ ad hoc, ad interim working group at Split University School of Medicine and Split University Hospital Center, to consider the issue of nursing education. The working group reviewed the literature, studied European Commission directives and regulations (1-8), both sectoral and general, and World Health Organization documents pertinent to nursing education (8-17). They also evaluated current trends and drafted The Croatian Model of Nursing Education.There is still great diversity in how the education of health professionals is organized, not only among EU member states but also among non-members. It is not easy to define “European standards” or, consequently, to follow and adopt them. The need for defining rigorous standards and standardizing them across the EU is apparent, due to the dramatic changes in nursing practice over the last decades, as well as the changing position and role of nursing staff in the health care structure.Traditionally, nurses have provided care on the basis of the medical diagnosis and the physician''s instructions; thus, nurses have served the physician, not the patient. While assisting the physician in his curative role is an important function of the nurse, it is not his or her primary role. For nurses today, the principal responsibility is to identify and address patient needs, develop a plan for nursing care, provide care, and assess the outcomes. Obviously, this is a complex intellectual process and requires a wide range of knowledge and skills (18).During the past century, nursing responsibilities have proliferated from one fairly limited set of skills that any nurse was expected to have into approximately 70 positions in the health care system, each requiring well-defined skills and experience (19). Today, nurses in acute settings manage an increasingly complex range of health care interventions that incorporate advances in technology and disease management. In primary care settings, the principal task of nurses is to manage the increasing burden of chronic disease, handle the malaises accompanying old age, and help patients manage their own health. In such contexts, nurses are obliged to undertake more work traditionally carried out by physicians. Such new obligations and responsibilities require different competencies in the nursing profession; a radically new paradigm of nursing education is required in order to acquire these competencies.In this frame of reference, authorities responsible for the education of health professionals have had to develop new operating principles in order to create a new paradigm. The task is a considerable one: all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, with an emphasis on evidence-based practice, quality improvement, and intensive use of health-related information technology.Recent development of a system of peer review to assess educational standards has provided an opportunity to build an international community of professionals and formulate “European standards.” The linkages among nurse associations, academic centers, and even individual health care institutions is creating a framework of communication, exchange, and mutual growth and development, which is breaking down barriers of traditional attitudes and ignorance. The major nursing and midwifery organizations in Europe have played a large part in this process. Such development bodes well for the future, irrespective of how economies may falter or political directions change. This is an era of mutual recognition and shared development (10).     

Perspective: Leveraging the health care workforce: what do we need and what educational system will get us there?

Shortages of 100,000 physicians and up to one million nurses are projected in the next 10 years. If these statistics are close to true, medical schools would need a 100% increase in graduates over the next 4 years, and nursing schools a 100% increase over the next 13 years. These calculations are instructive in that they demonstrate the absurdity of expecting schools to provide these sorts of increases in that time frame. Other solutions must be considered. For instance, do doctors and nurses need to do everything they are currently called on to do? Could not other members of the health care workforce, such as well-trained lay workers, be leveraged to do some of the more routine work, freeing medical professionals to perform their unique roles? How is such a workforce built, and how shall learners be educated to fill those needs? This article presents a hypothetical model that could be implemented based on carefully researched pilots to meet health care education needs. The model features three essential components: (1) a school for the public in which lay teachers develop curricula with members of the public, for example, about how to incentivize healthy behavior, (2) a college for health as part of a university with interdisciplinary teaching, where patients, faculty members, and students interact in each of the schools and learn together, and (3) the most effective and efficient nursing and medical school curricula, developed together based on evidence of what the student needs to know.     

A course on the transition to adult care of patients with childhood-onset chronic illnesses.

Children with special health care needs born today have a 90% chance of surviving into adulthood, making their transition to adult systems of care an issue that will affect almost all physicians. However, many adult generalists and specialists are not familiar with the management of chronic diseases that begin in childhood. While the public health system has made transition to appropriate adult care a priority, and many specialty organizations have endorsed this concept, there are no published studies addressing how the concept of transition can be taught to medical students or residents. The authors describe a one-week course for medical students, begun in 2001 at their institution, that addresses the transition for youth with special health care needs, emphasizing patient and family-centered care, cultural competence, and decision making in end-of-life issues. Cystic fibrosis, a common genetic disease with increasing life expectancy, is used as the model for the course. Involvement of interdisciplinary faculty, interviews with youth with special health care needs and family caregivers, readings from academic and nonacademic literature, and group discussions are presented as teaching methods. Key insights based on experience with the course are the need to include the voices of patients and families, the use of faculty from various professions and specialties to model interdisciplinary care, and the insight that problems specific to transition offer into contemporary health care financing. Future studies should measure the impact of such courses on students' knowledge of transition issues, and determine essential information required for physicians in practice.     

Relationship Between Nurses and Physicians in Terms of Organizational Culture: Who Is Responsible for Subordination of Nurses?

Aim

To investigate how nurses and physicians perceive organizational culture, their integration into the organizational processes, and relations within a health care team.

Methods

We performed a cross-sectional study that included 106 physicians and 558 nurses from 14 Slovenian hospitals in December 2005. The hospitals were randomly selected. We distributed the questionnaires on the same day to physicians and nurses during a morning shift. The total number of distributed questionnaires represented a 20% of each personnel category at each hospital. The following variables were studied: organizational culture, integration of nurses and physicians in hospital processes, and subordination of nurses to physicians.

Results

Physicians and nurses favored a culture of internal focus, stability, and control. Both groups estimated that they had a low level of personal involvement in their organizations and indicated insufficient involvement in work teams, while nurses also thought that they were subordinated to physicians (mean ± standard deviation, 3.6 ± 0.9 on a scale from 1 to 5) more than physicians thought so (2.7 ± 1.0; P<0.001). Control orientation correlated positively with the subordination of nurses (P<0.005) and negatively with personal integration in an organization (P<0.005).

Conclusion

We found out that subordination of nurses can be explained by market culture, level of personal involvement, and the level of education. Our research showed that the professional growth of nurses was mainly threatened by organizational factors such as hierarchy, control orientation, a lack of cooperation and team building between physicians and nurses, as well as insufficient inclusion of both physicians and nurses into change implementation activities.In Schein''s words: "Organizational culture refers to a shared value system derived over time that guides members as they solve problems, adapt to the external environment, and manage relationships” (1). Many authors agree that Schein''s is the most complete definition of organizational culture (1). Schein defines it as follows: “Organizational culture is the pattern of shared basic assumptions – invented, discovered, or developed by a given group as it learns to cope with its problems of external adaptation and internal integration – that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.”Organizational culture is a factor leading to a successful implementation of changes in health care organizations and fostering learning through work processes (2). The culture should encourage change implementation and at the same time establish work quality as a value. Shortell et al (2) describe different health care subcultures, such as physicians – managers, physicians – nurses, employees – leaders, unit cultures, team cultures, and professional group cultures. Subcultures are one of the major obstacles in achieving the common goals of an organization, because the broad differentiation of work leads to a differentiation of tasks and, consequently, to a differentiation of goals within the various departments/units (2). There is a body of research devoted to the improvement of collaboration between health care workers, with a significant portion of it suggesting shared learning as an important means of increasing collaboration (3). Shortell et al (4) believe that physicians should be aware of the fact that they cannot be the only ones responsible for a patient. They must work in a team and collaborate with all health care professionals and patients. Degeling et al (5) claim that medicine has historically had patronizing relationship toward nursing. Nursing is usually depicted as practical, female, moral, and subsidiary, as compared with the scientific, male, instrumental, and superordinate orientations of medicine. These elements have provided justification for the claimed centrality in the internal organization of nursing, whose operation, in turn, has tended to privilege medicine’s claimed diagnostic and curative role and relegate nursing to that of subservience and support. Degeling et al (5) also claim that conventional models of nursing depict nurses as disciplined, altruistic auxiliaries, who support medicine in applying its knowledge and expertise.The cooperation between nursing and medicine is of strategic importance for high-quality patient care and for creating a positive work environment for both groups of health care professionals. The cooperation should not be created only on a personal level, but also on a professional level, while achieving health care goals.This study focuses on the ways nurses and physicians perceive organizational culture, their integration into the organizational processes, and perception of relations within a health care team.     

'They think they can talk to nurses': practice nurses' views of their roles in caring for mental health problems.

BACKGROUND: Primary care teams have been encouraged to develop the care they provide to patients with mental health problems, and a greater role for practice nurses has been advocated. However, little is known about practice nurses' current level of involvement or their perceived strengths and limitations in caring for patients' mental health problems. AIM: To describe practice nurses' current experiences of caring for patients with mental health problems and to explore their perceptions about enlarging this role. METHOD: Pilot interviews were carried out with a purposeful sample of practice nurses to design a postal questionnaire, which was then sent to 635 practice nurses identified from family health services authority lists in six health authorities in the north-east of England. RESULTS: Completed questionnaires were returned by 445 (70%) practice nurses. Most nurses (83%) reported that they commonly saw patients with a range of mental health problems arising indirectly or directly in consultations. Many practice nurses (52%) lacked any formal mental health training and identified a broad range of training needs. A majority (80%) of responders had concerns about their abilities to address mental health problems effectively, given their existing workloads. However, most (61%) were keen to expand their role in mental health care if appropriate support and training were forthcoming. CONCLUSION: There is considerable potential for practice nurses to realize a greater and more effective role in the care of mental health problems in primary care. Developing practice nurses' contribution will require further training and support.     

Practice nursing in Glasgow after the new general practitioner contract.

Six months after the implementation of the new general practitioner contract in April 1990, practice nurses employed in greater Glasgow were surveyed using a self completed postal questionnaire. Of the 165 practice nurses employed in greater Glasgow 153 (93%) were identified and surveyed. Of these, 131 responded to the questionnaire (86%). The practice nurses were well qualified and experienced. Sixty per cent were under 40 years of age, 68% had been recruited within the previous year and 70% were employed for five sessions or more per week. Many carried out extended nursing duties, including health promotion activities. Many described inadequacies of their employment contract, practice facilities and the functioning of the primary health care team. If service quality is to be assured in practice nursing and practice nurses are to function as key primary health care team workers, then it is important that their role, professional skills, and working facilities are defined, supported and monitored. This should be addressed by general practitioners, practice nurses, and their professional bodies, in collaboration with the health board.     

Health Care Professionals: A Model for Teaching the Components of Society-Culture-Personality in the Delivery of Care

In recent years, the behavioral sciences have contributed tremendously tot he education of future physicians, dentists, nurses, and other health care professionals. With the inclusion of the behavioral sciences component in the National Board Examination (1972), many medical schools have revised their curricula to include sociology in the training of the future physician. However, the tremendous shortage of qualified social scientists made it difficult to meet the needs of medical schools and health programs in the country.     

Educating social workers to meet the challenge of an aging urban population: a promising model.

As Americans live longer, they will require more health and social services to address the onset of acute and chronic conditions. The persistent changes in health care delivery and the increasingly diverse older adult population in urban settings, coupled with the high expectation for families to be responsible for home care needs, challenge social workers, who work alongside physicians, nurses, and other health care professionals, to provide services effectively. Because social workers are becoming more essential, social work education must increase the numbers of social workers with the knowledge and skills necessary for practice in the current U.S. health, mental health, and social service systems, particularly in caring for the aging populations in urban settings. A New York Academy of Medicine study identified the need for increased synergy between the two components of graduate social work education: the field experience and classroom instruction. One educational model, the Practicum Partnership Program, which is designed to better integrate field and classroom, is being tested at six sites. Early results from over 300 graduates are encouraging, with evidence that students' knowledge and skills regarding aging adults have increased, their satisfaction with the experience was very high, and those who were trained reflect the diversity of the population of older adults. The early success of this program suggests that innovative educational models that expose graduate social work students to diverse populations across the continuum of care are possible. Such models will be essential for the nation to be successful in producing a social work labor force qualified to meet the challenge of an aging urban population.     

Enabling technologies promise to revitalize the role of nursing in an era of patient safety

The application of information technology (IT) in health care has the potential to transform the delivery of care, as well as the health care work environment, by streamlining processes, making procedures more accurate and efficient, and reducing the risk of human error. For nurses, a major aspect of this transformation is the refocusing of their work on direct patient care and away from being a conduit of information and communication among departments. Several of the technologies discussed, such as physician order entry and bar code technology, have existed for years as standalone systems. Many others are just being developed and are being integrated into complex clinical information systems (CISs) with clinical decision support at their core. While early evaluation of these systems shows positive outcome measurements, financial, technical, and organizational hurdles to widespread implementation still remain. One major issue is defining the role nurses, themselves, will play in the selection and implementation of these systems as they become more steeped in the knowledge of nursing informatics. Other challenges revolve around issues of job satisfaction and the attraction and retention of nursing staff in the midst of a serious nursing shortage. Despite these concerns, it is expected that, in the long run, the creation of an electronic work environment with systems that integrate all functions of the health care team will positively impact cost-effectiveness, productivity, and patient safety while helping to revitalize nursing practice.     

Twenty-first-century primary care: new partnerships between nurses and doctors.

What role will advanced practice nurses (APNs) play in tomorrow's health care system? The author shares her answer to this question by first looking at the history of APNs and nurse practitioners (APNs whose focus is primary care), explaining what they do, and tracing their increasing success in overcoming long-standing barriers to full acceptance as providers of care. The author emphasizes that while APNs' advancement has usually been based on demonstrating sameness of practice processes and outcomes with those of physicians, in actuality, APNs-whose advanced primary care is delivered with full accountability and is indistinguishable from such care delivered by physicians-offer a different style of practice, which involves caring, nurturing, support, engagement with patients, attention to illness prevention and health promotion, and patient education. It is this difference on which APNs' survival rests. The author then discusses the educational training, economic, marketplace, and other questions that must be answered if APNs and physicians are to achieve a non-competitive, richer future, one in which both work together as partners rather than as members of a hierarchical team. Ultimately, such a future will be possible only when APNs have the same independence, access to patients, and voice in the treatment plan that physicians do.     

The history of written word in Croatian nursing

Today the development of a unique professional language and publishing of professional and scientific publications is the basis of every profession, including the nursing profession. The task of the unique language specific to the nursing profession is to describe the nursing profession (to make it more familiar to the other team members and clients/customers), improve communication between nurses and other team members, help in health care improvement and administration, enable comparison of health care results, improve health care outcomes, as well as facilitate health care documentation and encourage research related to nursing. From the historical point of view, the development of nursing practice in Croatia was not accompanied by professional writings until the end of the 20th century, especially not by professional articles written by nurses themselves. By analyzing old writings and handbooks, the historical development of the written word of nurses is reconstructed for the first time in the region.     

Description and evaluation of a course for practice nurses

There is increasing awareness of the needs of practice nurses for continuing education and both the report of the community nursing review and the government''s white paper Promoting better health have stressed this. A course for practice nurses is described in which the curriculum was based on previous research into their requirements. An evaluation of the course demonstrated changes in the attitude towards the work of the practitioner and an overall increase in confidence of the group. Perceptions of the course and the relevance of the content were also measured. The cost of the course is given and the future direction of training discussed.     

专科护士参与“肿瘤多学科联合会诊”的管理探讨

目的为了更好发挥专科护士在护理领域的咨询、指导作用,保障肿瘤患者护理服务的延续性。方法选取100例患者,采用问卷形式通过健康教育、患者依从性、护士操作、伤口护理,对专科护士满意度进行评价。每周两次参与肿瘤多学科联合会诊,有助于提高专科护士临床护理水平。结果采用问卷形式对MDT进行评估,100份调查问卷中,96%的医生认为专科护士对患者是有益的,78%的患者及家属认为对治疗是较好的。结论患者及医生对专科护士护理操作、伤口护理、健康教育、依从性满意度高于普通护士,存在差异。专科护士积极参与,有效改善专科护理质量,提出护理诊断,完善规章制度、工作职责、工作流程、工作内容、提升了患者家属满意度,不断扩大专科护士的影响力。     

男性科门诊“快速分诊护理流程”应用初探

目的 运用“快速分诊护理流程”以减少男性科门诊患者的就诊时间,提高患者就诊满意度。方法 随机抽取2017年2月~9月来我院就诊的700例患者作为研究对象,其中2017年2月~5月抽取350例患者作为对照组,采用常规分诊护理;2017年6月~9月的抽取350例患者作为研究组,采用快速分诊护理流程,比较两组患者护理满意率、护理质量及门诊量。结果 研究组患者满意率明显上升,分诊护士工作效率也明显提高,相应的护理和医疗质量也随之提高。男性科门诊量也逐步上升,同比增长了41.72%。结论 男性科门诊快速分诊护理流程适应当代门诊护理发展的需要,为患者节约了宝贵的候诊时间,加快了门诊医师就诊速度,满足患者及家属的需求,构建了和谐的护患关系。