Nursing in the Community: A Literature Review
Contents
Review team
Dr Catriona Kennedy
Senior Lecturer
School of Acute and Continuing Care Nursing
Napier University
c.kennedy@napier.ac.uk
Ms Jane Christie
Research Fellow
School of Acute and Continuing Care Nursing
Napier University
j.christie@napier.ac.uk
Ms Ishbel Rutherford
Lecturer
Queen Margaret University College
irutherford@qmuc.ac.uk
Dr Fiona Maxton
Lecturer
School of Community health
Napier University
f.maxton@napier.ac.uk
Ms Dawn Moss
Nurse Consultant/Child Health
NHS Borders/Napier University
d.moss@napier.ac.uk
Ms Jean Harbison
Senior Lecturer
Queen Margaret University College
jharbison@qmuc.ac.uk
Ms Moira Mitchell
Information Services Advisor
Melrose Campus
Napier University
ml.mitchell@napier.ac.uk
Introduction
This literature review is part of the Review of Nursing in the Community in Scotland. The review aims to explore the evidence base for nursing in the community in relation to the key messages within the Kerr Report (Scottish Executive (SE), 2005a) and Delivering for Health (SE, 2005b) .
The remit of the literature review was to conduct a literature search, synthesise the findings and produce a report within a three month period. This timescale has impacted on the scale of work undertaken. To fully evaluate the effectiveness of nursing interventions would have involved carrying out rigorous systematic reviews of each area of nursing in the community. Restricting the review to pooling evidence from systematic reviews would have strengthened the results, conclusions and recommendations drawn. However, systematic reviews of interventions carried out by nurses in the community are limited and this would have severely restricted the coverage of the review and utility of the conclusions.
The review design therefore incorporated methods which would allow thematic analysis and synthesis of evidence from published systematic reviews and primary research. Consequently decisions had to be made about focussing within topic areas and the rationale for this approach will be explained.
Background
This document is written against a background of continuing significant change in the professional, policy and practice context of nursing in the community, related to the modernisation of the NHS in Scotland.
The Nursing and Midwifery Council (NMC) has developed Standards of Proficiency for Specialist Community Public Health Nursing (NMC 2004). These standards only apply to Public Health Nurses, Family Health Nurses and Occupational Health Nurses. They do not apply to the other four specialist practitioner groups currently recognised by NMC - Community Mental Health Nurses, Community Learning Disability Nurses, Community Nursing in the Home - District Nurses and General Practice Nurses.
Changes have been made to the regulation of the initial Nurse Prescribing programme [V100] and all nurses undertaking specialist practice qualifications on a community pathway can now access training to prescribe from the Community Practitioners Formulary where prescribing would benefit the patients for whom they are responsible (NMC 2005).
Partnership for Care (Scottish Executive Health Department (SEHD) 2003) put forward decentralisation of power, and stressed the importance of involving staff, service users and the public in redesign initiatives that will lead to innovation and service improvement. Community Health Partnerships are designed to address health improvement and to reduce health inequalities, highlighting the need for seamless provision of care across professional and organisational boundaries (SE, 2005a). The Kerr Report (SE 2005a) further supported the emphasis on primary care, aiming to ensure safe and sustainable local services, focussing on preventative and anticipatory care. In particular, it is anticipated that priority will be given to supporting patients at home, preventing inappropriate hospital admissions, identifying opportunities for more local diagnosis and treatment, and enabling appropriate discharge and rehabilitation.
Current changes in health care provision and its associated legislation have placed increasing emphasis on caring for people in the community and the importance of primary care services (SE 2005a, 2005b). The demographics of the Scottish population in terms of increasing age and the negative population shift have resulted in a recognition that services need to be realigned in order to meet the needs of patients and clients in the community. The increased focus on long term and enduring conditions alongside increased public awareness and expectation requires further development of integrated health and social care networks to ensure quality provision. Recent policy outlined in Delivering for Health (SE 2005b) reinforces this change.
Following the introduction of the European Working Time Directive, and the General Medical Services Contract (Department of Health (DoH), 2005), NHS Education for Scotland (NES) have been supporting role development in out of hours and unscheduled care and have developed competencies for these new roles (NES 2005). These competencies, which are separate from the standards referred to above, also potentially have an impact on all current community nursing roles, and create opportunities for role development.
One of the key aspects of current policy changes is integrated working between health and social care. This includes multidisciplinary working that along with learning together was confirmed as a priority within government statements and policy documents (SEHD 1998, SE 1999, SEHD 2000, SE 2005a, SE 2005b). Integrated delivery of the service is key to achieving an effective, equitable and efficient health care system and therefore the need for collaboration and partnership remain key issues for all professionals working in the context of community health nursing (Dowling and Glendinning 2003, Peckham and Exworthy 2003).
It is clear that the strong perception of nurses in the community is that the only constant in the current situation is change, and that meeting the needs of their patients within several competing agendas, determined by the multiple drivers outlined above, is becoming significantly more problematic and challenging. This literature review aims to inform the review of nursing in the community in Scotland, providing evidence to inform the delivery of effective and efficient care to meet the health needs of Scotland's people.
Methodology
Aims of the Review
The review took stock of the current contribution nursing in the community makes to the health of people. The evidence within the literature has been critically evaluated in order to determine the:
- Contribution of nurses in the community working within the following areas:
- Anticipatory care
- Managing long term conditions
- Managing hospital admission and discharge
- Supporting unpaid carers
- Reducing health inequalities
- The impact on patient outcomes when nurses use IT
2 In addition the review has addressed the following questions:
- What is the context of nursing in the community?
- What do nurses in the community do?
- Are there core values that are evident?
- What is needed to meet 'Delivering Health' in terms of improving effectiveness and outcomes?
- Is there enough evidence to indicate what developments are required?
- If not, what evidence is needed?
Methods of the Review
This report is based on a literature review of publications on nursing interventions relevant to nursing in the community. This includes interventions carried out by nurses working in the community and those which apply to nursing in the community e.g. the clinical nurse specialist role and hospital outreach. The search strategy included the full range of community nursing roles including health visiting.
Systematic reviewing is "currently the best, least biased, and rational way to organise, cull, evaluate, and integrate the research evidence from among the expanding medical and health care literature" (Moynihan, 2004: 10). Although it was not possible to undertake the processes of the systematic review the methodology of this review was underpinned by that advocated by Cochrane and Scottish Intercollegiate Guidelines Network (SIGN). These methodologies are adapted to reflect the status of knowledge in the field of nursing in the community and the timescale available. However, the essential elements required for a systematic process were met as follows:
- Aims for the review were identified
- Criteria for considering studies in this review were identified
- Literature was identified according to an explicit search strategy
- Studies were selected according to defined inclusion and exclusion criteria
- Literature was evaluated/assessed against defined criteria
- A summary and synthesis of relevant study results is presented
The searches identified there are limited systematic reviews of the effectiveness of interventions carried out by nurses in the community. Therefore in addition to systematic reviews relevant primary research was included.
The Search for Literature
Initially the search focused on systematic reviews and primary research published in the last ten years from an international perspective. This resulted in a large and unmanageable volume of papers; these were subsequently reduced to six years and due to cultural issues focussed on Europe, North America and Australasia.
The main sources of literature were retrieved from extensive searches of the following electronic databases:
- CINAHL (1996 to present),
- EMBASE (1996 to present),
- British Nursing Index (1996 to present)
- MEDLINE (1996 to present)
- Cochrane Controlled Trials Register (1996 - present)
For grey literature, searches of Google Scholar, the NHS Health Technology Assessment Programme site and the Napier University Library catalogue 1996 - 2006 were undertaken.
As the search progressed the decision was made to include the Health Management Information Consortium database. The National Research Register and Index to Theses were also searched but little was found. Hand searching of relevant journals in the field of nursing in the community was undertaken by the reviewers.
Normally a review such as this would include contacting experts in the field; however, the team were not required to do this as a series of workshops were held around Scotland for nurses working in the community. Regular liaison with the project officers ensured the review was focussed and informed by developments in the wider project. Two members of the review team (CK and IR) facilitated workshops at the National Conference held in March 2006. Key issues emerging from the literature review were presented by a member of the review team (CK) at the Consensus Conference in May 2006.
Nursing in the community covers a wide range of specific roles. Initially the searches combined community nursing roles with the key components listed below.
The search strategy for this review used the following key words singly and in combination. An example of one search strategy can be found in Appendix 1. Searches were undertaken for community nursing and -
- admission and discharge
- anticipatory care
- support for carers
- decision making
- health inequalities
- the impact of IT on patient outcomes,
- long term/ chronic conditions,
- models of primary care
- nursing assessment
- nursing interventions
- nursing skills
- person centred care
- risk assessment
- role of the nurse
- therapeutic relationship
Whilst these searches yielded significant numbers of studies many of these were not focussed on nursing interventions in the community. For example papers focussed on medical conditions emerged particularly in chronic illness. Following the initial searches and screening of these titles the searches were refined to focus more closely on district nursing, health visiting and practice nursing roles and interventions. This resulted in a comprehensive review of the databases and the search strategy ensured coverage of essential studies.
The table of search results can be found in
Appendix 2.
Criteria for Considering Studies for this Review
Types of studies
- Meta-analyses and systematic reviews
- Randomised controlled trials
- Primary quantitative studies
- Primary qualitative studies
Types of participants
Nurses who contribute to care of patients and families in the community
Types of interventions
All interventions carried out by nurses aimed to support adults and children in the community in relation to
- Anticipatory care
- Managing long term conditions
- Managing hospital admission and discharge
- Supporting unpaid carers
- Reducing health inequalities
- The impact on patient outcomes when nurses use IT
Types of outcome measures
- Impact of interventions on patient outcomes
- Effectiveness of nursing interventions
To ensure coverage of the range of nursing interventions search terms included assessment, decision making and therapeutic relationships.
Methods of Review and Quality Assurance
Two reviewers (CK JC) independently screened the titles and abstracts for inclusion. Eligibility for inclusion of studies was determined by the criteria identified above. The two reviewers then agreed the studies for inclusion in the next stages of the review.
The included studies were sorted into themes including
- Chronic illness
- Older people
- Children
- District nursing
- Practice nursing
- Health visiting/public health
- Information Technology
- Decision making
- Carers
The included studies were divided amongst the review team according to their area of expertise. Each reviewer had a full text copy of the appropriate eligible studies and was asked to assess the quality of the studies based on agreed criteria (Appendix 3).
Summarising and Synthesising Relevant Study Results
Summarising and synthesising the results was the next step of the review process. A standard format for summarising the outcomes of individual studies was agreed and used as the format for presentation of included studies (Appendix 4), included systematic reviews (Appendix 5) and excluded studies and systematic reviews (Appendix 6).
The reviewers then sought to reach agreement about the consistency, clinical relevance, validity and trustworthiness of the whole body of evidence in order to draw recommendations. The following were considered important:
- Quantity, quality and consistency of findings
- Generalisability of study findings
- Clinical impact
- Implementability for the NHS in Scotland
(Adapted from SIGN 50 http://www.sign.ac.uk/guidelines/fulltext/50/index.html accessed 15/02/06)
This part of the review involved all members of the team to ensure a transparent process. Individual reviewers reported and shared findings with colleagues who scrutinised and challenged the interpretation. Included studies and systematic reviews were synthesised and are reported under the headings from Delivering for Health (SE 2005b) and within the context of nursing in the community.
This review comprises studies and systematic reviews of varying size, methodological approaches and from different contexts. Although carried out systematically this review, due to the limitations of timescale and quality of the relevant studies, could not include rigorous approaches to data synthesis such as meta-analyses. Despite these limitations key themes have consistently emerged from this review and therefore we are confident our analysis and recommendations are valid.
Findings Part 1:
Anticipatory Care
Delivering for Health (SE 2005b) identifies the need to shift the focus of care towards health improvement, self-care and preventative medicine. The emphasis is targeting resources for those most in need and for the proactive delivery of anticipatory care.
Nine qualitative studies, three systematic reviews and eight quantitative studies were reviewed.
There is evidence to indicate that home visiting over a sustained period of time can improve outcomes for vulnerable individuals and families; a mutually trusting relationship needs to be established to act as a foundation for further health improvement activities (Tuttle et al 2000; Elkan et al 2001). Family assessment using a genogram was deemed as useful in collating information about family structure and experiences and the resources utilised within the family (Dunhamel and Talbot, 2004).
Health Needs Assessment Tools were not always viewed as beneficial in identifying individual needs of vulnerable families and identified as superficial and creating a 'tick list' approach to assessment (Cowley and Houston, 2003; Mitcheson and Cowley, 2003). Instead, time spent establishing a relationship between the family and nurse to create trusting supportive environment and to create a picture of the family's life situation was preferred(Jansson et al 2001).
There is evidence to highlight the multifaceted roles of nurses' involvement in anticipatory care including the giving of health information; counselling and supporting; linking clients to community resources; health assessments, risk assessments and detection and prevention of health problems (McNaughton, 2000; Dunhamel and Talbot, 2004; Worobey et al 2004; Arthur et al 2002; Drennan et al 2005; Evans et al 2005; Griffiths et al 2004; Kinn and Clawson 2002; Vass et al 2005). Further evidence identifies support from nurses in the community provided cognitive restructuring and enabled parents to learn problem-solving skills (Groner et al, 2005).
Some of the evidence highlighted the opposite view that multi-faceted home visiting by health visitors and other community nurses did not improve health outcomes for families. A systematic review to evaluate the effectiveness of home visiting programmes on the uptake of childhood immunisation failed to demonstrate a beneficial effect of home visiting on the uptake of immunisation (Kendrick et al, 2000). Wiggins et al (2005) evaluated the effect of postnatal social support for disadvantaged inner city mothers and concluded that offering community support to women does not result in a large enough take up or have a dramatic enough effect on those who use it to change health outcomes of maternal well-being and childhood injury.
To anticipate and prevent health problems nurses in the community need to know their population and community and be properly resourced to carry out health assessments and preventative interventions with the 'healthy' population. Furthermore, evidence needs to identify the relationship between costs and outcomes.
Managing Long Term Conditions
An increasing number of older people who are suffering from chronic conditions, the availability of high technology and high cost medical treatments are impacting on the ways in which chronic illness needs to be managed. Nurses in the community have been identified as fundamental to increasing effectiveness and improving patient satisfaction (SE 2005a, 2005b). Nurses in the community also help parents of children with chronic illness by enabling, facilitating and empowering them to cope at home (Carter, 2000, Olsen & Maslin-Prothero, 2001) and by raising the quality of care for a range of conditions, for example eczema, continence problems and behavioural difficulties, which are currently low profile (Drew et al, 2003).
Seven systematic reviews, three qualitative and five quantitative studies were reviewed. Studies and reviews focussed on a range of nursing roles and interventions and outcomes for adults and children with chronic illness.
There is evidence that the nurses' role encompasses both human qualities and specific clinical skills. Generally, patients value interactions with nurses more, or equally, highly than with physicians and this is due to the humanistic approaches of nurses; information and education provided and the time spent by nurses with older people or children and their carers (Bennett et al, 2005; Caffrey, 2005; Holcomb 2000; Fritch 2003; Worobey et al, 2004). For example a systematic review of interventions to improve the management of diabetes mellitus demonstrated that nurses has as good or better outcomes as physician care (Renders et al 2006). There is some evidence that nursing decision-making and interventions are as effective as physicians (Fritch 2003). Also, families of children with chronic illness valued a 'special relationship' with the community children's nurse (Carter, 2000).
There is evidence that chronic illness such as depression, diabetes, cardiovascular and cerebrovascular disease can be supported in the community by a three pronged approach by ensuring that interventions:
- are delivered over a prolonged period of time supporting self management by patients and their families
- monitor measurable indicators of well-being as well as disease progression
- have strategies for structured recall and patient tracking.
(Renders et al, 2006 Duhamel & Talbot 2004, Fritch 2003, NHS Centre for Reviews and Dissemination 2002).
There is insufficient evidence to demonstrate differences in patient outcomes in relation to reductions in morbidity and mortality, hospital readmissions or cost savings (Hastings & Mitchell, 2005; Loveman et al 2003; Smith et al 2001; Taylor et al 2005). Furthermore, it is not clear what contributions are made to patient outcomes by the different nursing roles i.e. community, specialist or outreach (Taylor et al 2005)
Overall, to manage long term conditions nurses in the community need to develop mutual trusting relationships, tailor care to meet individual needs, liaise effectively with specialist services and ensure interventions are delivered and evaluated over a prolonged period of time.
Managing Hospital Admission and Discharges
Managing hospital admission and discharges better ensures continuity between hospital and home and may reduce the rising trend of unscheduled hospital admissions. One systematic review and three studies using quantitative and qualitative methods were reviewed. These focus on effectiveness and patient and carer satisfaction with hospital at home schemes and reducing risk of hospital admission.
A systematic review of 22 RCTs, including meta analysis, failed to detect a difference in health outcomes for patients in hospital at home compared with acute in-patient care. Evidence from this review suggests that early discharge may increase the overall days of care required by community-based elderly medical patients and there is no compelling evidence of cost savings (Shepperd and Iliffe 2005,).
There is some evidence from this systematic review and the work of Wilson et al (2002) that hospital at home increases patient satisfaction compared with hospital care and it appears this is due to more individualised care received and good communication.
Evidence to date does not support the widespread development of hospital at home services as cheaper substitutes for in-patient care within health services with well developed primary care but nor has it demonstrated that existing schemes should be discontinued. Future research should focus on evaluating the effectiveness of community based admission avoidance schemes and the education needs of staff (Shepherd and Iliffe 2005).
There is some evidence that a proactive approach to discharge planning started at the time of hospital admission by nurses practicing at an advanced level in the community can reduce readmissions (Naylor et al 1999). Similarly, a proactive approach to risk assessment may reduce hospital admission in the over 75's (Jiwa et al 2002).
Nurses in the community need to be proactive in identifying the needs of people who are at risk of being admitted to hospital, those at risk when coming out of hospital and in recognising risks that may lead to readmission. Anticipating care needs and promoting self care would contribute positively to this.
Supporting Informal Carers
Supporting informal carers involves ensuring that they are partners in the provision of care. Thirteen qualitative and two quantitative studies which described the carers' perspective of community nurses and care provision/requirements were reviewed. In the main these were conducted in Australia and Canada, with 2 being UK based. All were published in peer reviewed academic journals.
These studies focused on different areas of care, and disparate issues emerged. The main themes which emerged from these were that of assessment, support, communication and information giving (Perkins and MacFarlane 2001). The need for patient related intervention in the form of information giving was identified in eight studies (Delasega & Zerbe, 2002; McLoughlin 2002, Grimmer et al 2004, King et al 2004, Navaie-Waliser et al 2004; Wilson et al 2002; Woodward et al 2004; Kirk and Glendinning 2002). The type of information required was context dependent but included educating, supporting and counselling (Delasega & Zerbe, 2002), information to prepare the carer for the caring role (Grimmer et al 2004), information on the role of the district nurse (Wilson et al 2002) and other specialist nurses (McLoughlin 2002), information on the services available (Wilson et al 2002, Woodward et al 2004, King et al 2004) and information about asthma in children which increased compliance and self management (Navaie-Waliser et al 2004).
There is some evidence to suggest home care is preferred to institutional care but it can't be assumed that families, particularly women in the home can or will take on a significant caring role (Ward-Griffin 2001). A study by Kirk (2000) identified that parents' of children with complex health care needs have identified that they felt obligated to care for their child at home when the only other option was for their child to remain in hospital. Parent's are often the expert in their child's care and have more knowledge than community based professionals who tend to provide support to their care-giving rather than providing 'hands on' care (Kirk and Glendinning, 2004).
The partnership between carers and professionals was seen to be influenced by the balance between desired and allowed participation (Schoot et al 2005) and the need to understand carers' concepts of caring (Kellet and Mannion 1999). The level of partnership can change over time and can be influenced by the health care system and the services available (Ward-Griffin and McKeever 2000). For example, this latter study, based in Canada, noted the effect of financial impact on service provision.
There is some evidence that nurses in the community offer different interventions for carers. Interactions with carers can be complex and require different interventions for different needs and stages of illness. Nurses are responsive to the needs of those they are caring for and their roles vary between the following:
- Nurse-helper role - nurse takes time to provide and coordinate care with carers in a supportive role
- Manager-worker role - nurse transfers caring role to family, nurse increases supervision and monitoring role, whilst acting as resource and providing emotional support
- Worker-worker role - the nurse tries to co-opt care givers in order to reduce nursing visits but this could result in tension and conflict as carers may feel overwhelmed
- Nurse-patient - demands of caring means carers could become patients
(Ward-Griffin 2001)
However, this is an invisible area of nursing work; hidden, rarely documented and so often unrecognized even by nurses themselves. The tacit nature of work with carers needs to be recognized and recorded.
Nurses in the community need to identify their role and relationship with family carers and evaluate the nursing contribution to supporting lay carers at home
Reducing Health Inequalities
Reducing health inequalities aims to improve the health of the people of Scotland, and to close the gap in life expectancy through encouraging people to take greater control over their own health. It is acknowledged that the debate is no longer concerned with whether inequalities in health exist but what should be done to reduce or alleviate these. Two reviews with meta analysis, a descriptive survey and an RCT were reviewed.
There is some evidence that focused and prolonged interventions can improve health or at least prevent people from getting worse. However this requires substantial investment of resources and there is no systematic evaluation available of the nursing contribution (Fritch 2003).
A meta-analysis of 11 RCTs of interventions to improve childhood immunizations in socio-economically disadvantaged areas failed to demonstrate a change. Although healthcare professionals changed their approach this did not have an impact on outcomes (Kendrick et al 2000).
There is limited evidence of nursing in the community having an impact on health inequalities (Wiggins et al 2005). However, it is difficult to undertake RCTs due to the naturalistic setting. For example, it is difficult to separate health and social needs, perhaps unethical to randomize individuals to intervention and control groups within communities and nursing work is difficult to identify due to its integration into the multi-professional team and communities. Qualitative and participative approaches to data gathering, analysis and research synthesis may help to provide evidence of change and development in this area (Lazenbatt et al 2000).
Evaluating the contribution of nurses in the community to reducing health inequalities is important however alternative ways of collecting and assessing evidence, involving key stakeholders in the community, are necessary.
The Impact on Patient Outcomes when Nurses use IT
There has been a drive toward decision making based on best available evidence, together with a growing emphasis on shared practitioner/client decision making. In tandem with this, the increasing quality and availability of information technology has facilitated the development of knowledge management to support decision making, with initiatives such as the NHS e-library.
Two systematic reviews and eight studies are relevant. These employed various methods: descriptive survey, randomized controlled trials, quasi-experimental and qualitative studies. All of these are small scale, and either UK or USA based. There is insufficient evidence to draw substantive conclusions about the impact on patient outcomes of nurse decision making with or without IT support. There is some evidence, derived from randomized controlled trial, but limited in that no control group was identified, that community nurses can increase participation in health promotion initiatives by incorporating these into community nursing practice (Arthur et al 2002). Nurse led online interventions to provide social support and health education have been found to be useful in reducing isolation of chronically ill, or disadvantaged people, in rural communities in the USA (Hill and Weinert 2004).
There is also some evidence that procedures normally done in hospital, such as anticoagulation monitoring, can be carried out as nurse led interventions in the community using decision support software (de Lusignan et al 2004). However procedures and protocols need to be adapted for use in a community setting and education is essential. The different nature of the community setting has also been identified, via descriptive survey, in that nursing outcomes in the community may be different from those in other settings (Alexander and Kroposki 1999).
Protocols, which are often electronic, for some aspects of care such as wound management and travel vaccinations, can improve care by clarifying roles, consistency and improving confidence and information giving. There are limitations to their use but these can be useful aids to decision making for care and evaluation (Walsh et al 2003).
There is some evidence that telehealth, which can provide information and disease or symptom monitoring, is a useful adjunct to the nursing management of chronic illness. It may reduce hospital admissions, emergency room use and improve morbidity (Duke 2005). New approaches such as automated telephone disease management systems, supported by nursing interventions, show promise but thorough evaluations are required (Piette 2000).
The ethos of collaboration makes it difficult to distinguish the contribution of community nurses to decision making and subsequent interventions (Bliss and While 2003). There is little direct comparative evidence, but one small scale study suggests that there is no substantial difference in decision making processes and achievements between nurse practitioners and GPs (Offredy 2002). Evidence suggests outcomes for community nurses such as increasing patient satisfaction or stopping a condition getting worse may not always be valued as an effective intervention by managers and organizations (Taylor et al 2005).
Urgent need for research evaluating the impact of decision making by nurses in the community, with or without IT support, on patient outcomes.
Findings Part 2:
Nursing in the Community
There were twenty two papers reviewed for this topic, two of these papers used a quantitative methodology, two were systematic reviews and all others used qualitative approaches.
The nature of the community setting means that nursing outcomes may be different from those in other settings (Alexander and Kroposki 1999). Nursing work may be buried in doctor or other health care professionals work making it difficult to identify their contribution (Carnwell and Daly 2003, Carr et al 2001). There is evidence patients are equally or more satisfied with nurse as opposed to doctor interventions (Horrocks et al 2002, Shum et al 2000). There is some evidence to suggest nursing in the community has an important role in multi-agency working (Forester 2004).
The assessment process involves recognising salient issues, seeking information, interpreting the evidence collected, formulating ideas and making judgements to inform decision-making; building the bigger picture through assessment requires knowledge from theoretical and experiential sources (Bryans 2000, Kennedy 2002a 2002b). A typology of knowledge for district nursing assessment practice identifies six dimensions: getting to know the patient in their own setting, getting to know the carer, knowing what needs to be done now, knowing what may happen in the future, knowing/recognising knowledge deficits, and knowing the community resources and services (Kennedy 2004). This typology may have relevance for other areas of nursing in the community. |
Assessment in the form of getting to know and knowing the patient, family and community is a fundamental intervention for nurses in the community (Bryans 2000, Kennedy 2002a, Kennedy 2002b, McGarry 2003, Kennedy 2004, Luker et al 2003, Ohman and Soderberg 2004, Speed and Luker 2004). The development of a close, trusting relationship in getting to know the patient, including children, with a serious chronic illness (and their family) enables the community nurse to assess present and future care needs and act as a foundation for risk prevention and health promotion activities (Ohman and Soderberg 2004, Kennedy 2002b, Luker et al 2000, Carter 2000, Jansson et al 2001, McNaughton 2000, Crisp and Lister 2004).
Tailoring assessment to individual needs and listening to clients cannot be achieved by checklist approach (Cowley and Houston 2003,). Such an approach might result in an insensitive approach to assessment which could not empower patients and families (Mitcheson and Cowley 2003). Joint assessment and sharing knowledge can enhance understanding of the needs of older people (Worth 2001).
There is evidence to suggest that involving patients as partners by encouraging them to be involved in decision making about their care is beneficial to practitioners and may lead to a patient focussed service (Walsh et al 2003).
The tacit nature of nursing interventions in the community is challenging for nursing research (Kennedy 2002b, 2004). The evidence reviewed supports the following key messages:
Context of Nursing in the Community
- The context and power base of nursing in the community is challenging and complex. Nursing work may be buried in doctor or other health care professionals work making it difficult to identify their contribution.
- In order to anticipate health needs, nurses in the community need to know their population and community, its' needs and resources.
- Inequalities in health may not improve as a result of changed interventions by health professionals; they need to work with communities and changes need to be driven by communities themselves.
What Nurses in the Community do
- Holistic assessment, which involves getting to know the patient, family and their community, establishing trusting and reciprocal relationships.
- Anticipate needs and prevent risks through health promotion and early, prolonged, individualised interventions.
- Establish collaborative working relationships with other health and social care providers
Core Values that are Evident:
- Getting to know the patient, family and community
- Building a relationship based on mutual respect, trust and rapport
- Giving patients and families time
- Helping people to achieve the best they can
In conclusion, this review contends that further evidence is needed to improve effectiveness and outcomes. The challenges for nurses in the community lie in the following areas:
- The nature of nursing work in the community and its 'invisibility' is challenging for nursing research.
- There is a need for further research examining the outcomes for patient and carers of interventions carried out by nurses in the community. Service users and carers value the humanistic contribution of nurse to their care consequently patient satisfaction is an important outcome of nursing interventions.
- Exploring the user perspectives of the effectiveness of nurse interventions
- Clarifying the range of roles in nursing in the community
- Becoming more involved and skilled in conducting and leading research using a range of methods
- Designing and leading high-quality clinical trials to establish the efficacy of their interventions.
- Current methodologies such as systematic reviews of randomized controlled trials, considered to be the gold standard for research synthesis and evidence, don't fit especially well with all aspects of nursing work in the community. Alternative, but equally rigorous, ways of collecting and assessing evidence are necessary.
- Nurses in the community should be at the forefront of developing and evaluating emerging health technology
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Scottish Executive (1999) Learning Together: A strategy for education, training and lifelong learning for all staff in the National Health Service in Scotland Edinburgh, Scottish Executive
http://www.scotland.gov.uk/learningtogether/leto-00.htm Accessed 11/07/06
Scottish Executive Health Department (2000) Our National Health - a plan for action, a plan for Change Edinburgh, The Stationery Office
Scottish Intercollegiate Guidelines Network (2001) SIGN 50: A Guideline Developer's Handbook Edinburgh, SIGN
http://www.sign.ac.uk/guidelines/fulltext/50/index.html Accessed 15/02/06
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Appendix 1: Example of search strategy
Medline
1. "district nurs$".af.
2. "health visit$".af.
3. "practice nurs$".af.
4. exp Community Health Nursing/
5. 1 or 2 or 3 or 4
6. exp Patient Admission/
7. exp Patient Discharge/
8. 6 or 7
9. 5 and 8
10. limit 9 to (yr="1999 - 2006" and (clinical trial or clinical trial, phase i or clinical trial, phase ii or clinical trial, phase iii or clinical trial, phase iv or controlled clinical trial or meta analysis or multicenter study or randomized controlled trial or twin study or validation studies))
Medline
1. exp Long-Term Care/
2. exp Chronic Disease/
3. exp Diabetes Mellitus/
4. exp Epilepsy/
5. exp Multiple Sclerosis/
6. exp Osteoporosis/
7. exp Arthritis/
8. exp Coronary Arteriosclerosis/ or exp Coronary Disease/
9. exp Angina Pectoris/ or exp Angina, Unstable/
10. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11. exp Nursing/ or Occupational Health Nursing/ or Maternal-Child Nursing/ or Public Health Nursing/ or Office Nursing/ or Family Nursing/ or Oncologic Nursing/ or Community Health Nursing/ or Home Nursing/ or Rehabilitation Nursing/
12. 10 and 11
13. community.ab. or community.in. or community.kf. or community.kw. or community.nw. or community.ot. or community.ti.
14. 12 and 13
15. limit 12 to (yr="1995 - 2006" and (clinical trial, phase i or clinical trial, phase ii or clinical trial, phase iii or clinical trial, phase iv or clinical trial or controlled clinical trial or evaluation studies or meta analysis or multicenter study or randomized controlled trial or technical report or twin study or validation studies)
Cinahl
1. "district nurs$".af.
2. "health visit$".af.
3. "practice nurs$".af.
4. exp *Community Health Nursing/
5. 1 or 2 or 3 or 4
6. exp *Patient Centered Care/
7. 5 and 6
8. limit 7 to (research and yr="1995 - 2006")
9. limit 8 to english
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Appendix 2: Table of search results
Search terms | Database | Number of hits | Screened & Quality Assessed | Reviewed | Included | Excluded |
Anticipatory care (1) | MEDLINE 1996-2006 Systematic reviews | 34 | 3 | | | |
Anticipatory care (2) | CINAHL 1995-2006 | 42 | 4 | | | |
Anticipatory care/risk assessment (3) | BNI 1996-2006 | 12 | 1 | | | |
Anticipatory care/risk assessment (4) | MEDLINE 1996-2006 | 40 | 3 | | | |
Anticipatory Care | | 128 | 11 | 8 | 6 | 2 |
Long term care/Chronic illness (1) | BNI 1995-2006 | 135 | 10 | | | |
Long term care/Chronic illness (2) | Cochrane Database of Systematic Reviews 2005 | 198 | 4 | | | |
Long term care/Chronic illness (3) | CINAHL 1995- 2005 | 29 | 4 | | | |
Long term care/Chronic illness (4) | EMBASE 1995-2006 Systematic reviews | 50 | 1 | | | |
Long term care/Chronic illness (5) | EMBASE 1995-2006 | 77 | 1 | | | |
Long term care/Chronic illness (6) | CINAHL 1995-2005 | 1083 | 24 | | | |
Long term care/Chronic illness (7) | BNI 1995-2006 Systematic reviews | 3 | 0 | | | |
Long term care/Chronic illness (8) | MEDLINE 1995-2006 | 221 | 12 | | | |
Long Term Care | | 1796 | 57 | 30 | 19 | 11 |
Nursing roles (1) | CINAHL 1995-2006 | 310 | 18 | | | |
Nursing roles (2) | EMBASE 1996-2006 | 2 | 0 | | | |
Nursing roles (3) | EMBASE 1996-2006 | 11 | 0 | | | |
Nursing roles (4) | MEDLINE 1996-2006 | 61 | 0 | | | |
Nursing roles (5) | MEDLINE 1996-2006 | 3 | 2 | | | |
Nursing roles (6) | CINAHL Systematic Review 1995 | 1 | 1 | | | |
Nursing roles (7) | EMBASE 1996-2006 | 4 | 0 | | | |
Nursing roles (8) | CINAHL 1995-2006 | 1 | 0 | | | |
Nursing roles | | 393 | 21 | 14 | 9 | 5 |
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Search terms | Database | Number of hits | Screened & Quality Assessed | Reviewed | Included | Excluded |
Nursing interventions (1) | CINAHL 1995-2006 | 65 | 2 | | | |
Nursing interventions (2) | CINAHL 1995-2006 | 4 | 0 | | | |
Nursing interventions (3) | CINAHL 1995-2006 | 58 | 4 | | | |
Nursing interventions (4) | BNI 1996-2006 | 4 | 0 | | | |
Nursing interventions (5) | MEDLINE 1995-2006 | 38 | 0 | | | |
Nursing interventions (6) | EMBASE 1996 - 2006 | 2 | 0 | | | |
Nursing interventions | | 171 | 5 | 5 | 3 | 2 |
Carers (1) | CINAHL 1996-2006 | 208 | 10 | | | |
Carers (2) | MEDLINE 1996-2006 | 15 | 1 | | | |
Carers (3) | BNI 1999-2006 | 8 | 1 | | | |
Carers (4) | EMBASE 1996-2006 | 28 | 0 | | | |
Carers (5) | CINAHL 1995-2006 | 11 | 0 | | | |
Carers | | 270 | 12 | 12 | 6 | 6 |
Admission and discharge (1) | CINAHL 1995-2006 | 51 | 1 | | | |
Admission and discharge (2) | BNI Systematic Reviews 1995 | 0 | 0 | | | |
Admission and discharge (3) | MEDLINE 1996-2006 | 13 | 1 | | | |
Admission and discharge (4) | BNI 1999-2006 | 12 | 0 | | | |
Admission and discharge (5) | EMBASE Systematic Reviews 1996-2006 | 3 | 0 | | | |
Admission and discharge (6) | EMBASE 1996-2006 | 32 | 1 | | | |
Admission and discharge | | 111 | 3 | 3 | 2 | 1 |
Health inequalities (1) | CINAHL 1994-2006 | 1 | 0 | | | |
Health inequalities (2) | CINAHL 1995-2006 | 12 | 1 | | | |
Health inequalitites (3) | MEDLINE 1999-2006 | 34 | 2 | | | |
Health inequalitites (4) | EMBASE 1996-2006 | 12 | 3 | | | |
Health inequalities (5) | BNI 1999-2006 | 3 | 0 | | | |
Health inequalities | | 62 | 6 | 5 | 3 | 2 |
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Search terms | Database | Number of hits | Screened & Quality Assessed | Reviewed | Included | Excluded |
Using IT (1) | CINAHL 1985-2006 | 1 | 0 | | | |
Using IT (2) | CINAHL 1985-2006 | 19 | 0 | | | |
Using IT (3) | BNI 1999-2006 | 6 | 1 | | | |
Using IT (4) | EMBASE 1999-2006 | 2 | 0 | | | |
Using IT (5) | MEDLINE 1996-2006 | 40 | 0 | | | |
Using IT (6) | BNI 1999-2006 | 3 | 0 | | | |
Using IT (7) | EMBASE 1996-2006 | 15 | 0 | | | |
Using IT | | 86 | 1 | 1 | 0 | 1 |
Models of primary care (1) | EMBASE 1996-2006 | 10 | 0 | | | |
Models of primary care (2) | BNI 1995-2006 | 1 | 0 | | | |
Models of Primary Care | | 11 | 0 | 0 | 0 | 0 |
Meads (1) | BNI 1985-2006 | 1 | 0 | | | |
Meads (2) | CINAHL 1995-2006 | 2 | 0 | | | |
Meads (3) | HNIC Jan 2006 | 8 | 0 | | | |
Meads | | 11 | 0 | 0 | 0 | 0 |
Reilly (1) | MEDLINE 1996 - Feb 2006 | 6 | 0 | | | |
Reilly (2) | EMBASE 1999-2006 | 4 | 0 | | | |
Reilly (3) | BNI 1995-2006 | 4 | 0 | | | |
Reilly | | 14 | 0 | 0 | 0 | 0 |
Therapeutic relationships (1) | EMBASE 1999-2006 | 10 | 1 | | | |
Therapeutic relationships (2) | BNI 1999-2006 | 16 | 4 | | | |
Therapeutic relationships (3) | MEDLINE 1999-2006 | 25 | 2 | | | |
Therapeutic relationships (4) | CINAHL 1999-2006 | 106 | 11 | | | |
Therapeutic relationships (5) | Cochrane Database of Systematic Reviews 2005 | 6 | 1 | | | |
Therapeutic relationships (6) | MEDLINE 1999-2006 | 6 | 0 | | | |
Therapeutic relationships (7) | HMIC Jan 2006 | 7 | 0 | | | |
Therapeutic relationships (8) | BNI 1997-2006 | 8 | 0 | | | |
Therapeutic relationships | | 184 | 19 | 16 | 12 | 4 |
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Search terms | Database | Number of hits | Screened & Quality Assessed | Reviewed | Included | Excluded |
Decision making (1) | CINAHL 1995-2006 | 121 | 0 | | | |
Decision making (2) | BNI 1995-2006 | 17 | 5 | | | |
Decision making (3) | EMBASE 1996-2006 | 24 | 1 | | | |
Decision making (4) | HMIC 2006 | 7 | 0 | | | |
Decision making (5) | MEDLINE 1996-2006 | 7 | 0 | | | |
Decision making | | 176 | 6 | 4 | 4 | 0 |
CHN and assessment (1) | CINAHL 1995-2006 | 28 | 3 | | | |
CHN and assessment (2) | CINAHL 1995-2006 | 62 | 0 | | | |
CHN and assessment (3) | CINAHL 1995-2006 | 10 | 0 | | | |
CHN and assessment (4) | BNI 1995-2006 | 1 | 1 | | | |
CHN and assessment (5) | MEDLINE 1996-2006 | 25 | 3 | | | |
CHN and assessment (6) | MEDLINE 1996-2006 | 94 | 0 | | | |
CHN and assessment (7) | MEDLINE 1996-2006 | 76 | 0 | | | |
CHN and assessment (8) | EMBASE 1996-2006 | 77 | 1 | | | |
CHN and Assessment | | 373 | 9 | 7 | 2 | 5 |
Grey Literature | HTA, Napier Catalogue, 1996-2006 | 7 | 0 | 0 | 0 | 0 |
Subtotal | | 3793 | 150 | 105 | 66 | 39 |
Handsearched | | | 14 | 14 | 7 | 7 |
TOTAL | | 3793 | 164 | 119 | 73 | 46 |
Appendix 3: Criteria for quality review
| Full reference of study or review | | | | | | | |
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| Reviewer |
|
| Initial assessment: | | | | | | | |
| | | | | | | | |
| Does it explore nursing in the community? | | | Yes | | No | | |
| | | | | | | | |
| Is it about delivering health care in the community? | | | Yes | | No | | |
| | | | | | | | |
| Does it fit into nursing in the following areas? | | | Yes | | No | | |
| Anticipatory care Managing long term conditions Managing hospital admission and discharge (including ambulatory care and outreach) Carers Reducing health inequalities Impact on patient outcomes Using IT | | | | | | | |
| Overall Assessment: | | | | | | | |
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| Meta-analyses and systematic reviews | | | | | | | |
| | | | | | | | |
| Primary qualitative research | | | | | | | |
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| Primary quantitative research | | | | | | | |
| | | | | | | | |
| Assessment of quality of primary qualitative studies: | | |
| | | | | | | | |
| Aim of study clear and justified | | | Yes | | No | | |
| | | | | | | | |
| Sampling strategy described and justified | | | Yes | | No | | |
| | | | | | | | |
| Fieldwork well described and appropriately conducted | | | Yes | | No | | |
| | | | | | | | |
| Clearly described/theoretically justified data analysis | | | Yes | | No | | |
| | | | | | | | |
| Good discussion which support conclusions | | | Yes | | No | | |
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| Good: 4 or more of the above | | | | | | | |
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| Average: 2 or more of the above | | | | | | | |
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| Poor: less than 2 of the above | | | | | | | |
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| Comments: | | | | | | | |
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| Assessment of primary quantitative research: | | |
| | | |
| Randomisation method | | | Yes | | No | | Not known |
| | | | | | | | |
| Blinded assessment | | | Yes | | No | | Not known |
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| Attrition rate stated | | | Yes | | No | | Not known |
| | | | | | | | |
| Objective outcome | | | Yes | | No | | Not known |
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| Sample size stated | | | Yes | | No | | |
| | | | | | | | |
| Individual effect size stated | | | Yes | | No | | |
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| Heterogeneity assessed | | | Yes | | No | | |
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| Publication bias | | | Yes | | No | | |
| | | | | | | | |
| Was quality of studies allowed for in the analysis? | | | Yes | | No | | |
| | | | | | | | |
| Was there an attempt to synthesise the findings? | | | Yes | | No | | |
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| Were recommendations made for policy or practice? | | | Yes | | No | | |
| | | | | | | | |
| Was a need for further research identified? | | | Yes | | No | | |
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| Comments: | | | | | | | |
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Assessment of systematic reviews: |
| | | | | | | | |
| Is there a clear question for this review? | |
| | | |
| Well covered | | Not addressed |
| Adequately addressed | | Not reported |
| Poorly addressed | | Not applicable |
| | |
| Are the methods of randomisation reported? | |
| | | |
| Well covered | | Not addressed |
| Adequately addressed | | Not reported |
| Poorly addressed | | Not applicable |
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| Are methods of concealment described? | | | | | | | |
| Well covered | | Not addressed |
| Adequately addressed | | Not reported |
| Poorly addressed | | Not applicable |
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| Are methods of blinding described? | | | | | | | |
| Well covered | | Not addressed |
| Adequately addressed | | Not reported |
| Poorly addressed | | Not applicable |
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| Nature of the intervention |
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| Types of outcomes | | | | | | | |
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| Effectiveness of the intervention: | | | | | | | |
| Harmful | | weak |
| None | | strong |
| | | insufficient evidence |
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| Strength of evidence: | | | | | | | |
| Weak | | insufficient evidence |
| Strong | | | | | | | |
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| Confession box: | | |
| publication bias | | search |
| heterogeneity | | other (specify) |
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| Relevance: | | | Yes | | No | | |
| Similar to occupations in the UK? | | | Yes | | No | | |
| Cultural differences from the UK? | | | Yes | | No | | |
| Health care differences from the UK? | | | Yes | | No | | |
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| Comments: | | | | | | | |
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Appendix 4: Summary of included studies
| Reference | Summary |
1 | Alexander J Kroposki M (1999) Outcomes for community health nursing practice. Journal of Nursing Administration 29 (5) 49-56 | Type of study: Descriptive survey Method: Expert modified Delphi technique. 22 experts: 152 community nurses. Findings: Study generated list of 48 outcomes sensitive to nursing interventions in the community, categorised in 4 domains. Limitations: USA study. Small scale - 48 nurses completed all 3 rounds of questionnaires. Key messages: Recognises that outcomes for community nurses may differ from other settings. These identified outcomes may be used as basis for decision making and research. |
2 | Arthur A Matthews R Jagger C Clarke M Hipkin A Bennison D (2002) Improving uptake of influenza vaccination among older people: a randomized controlled trial. British Journal of General Practice 52 (482) 717-722 | Type of study: Randomised controlled trial. Method: compared 2 forms of approach to maximise uptake of vaccination in over 75s. First - personal letter of invitation to attend surgery, second - invitation issued by practice nurse on home visit health checks. Primary outcome measure - proportion of patients receiving vaccine by end date of study. Findings: offering vaccination as part of nurse health checks has a moderate effect on increasing uptake. Effect more marked for those who do not routinely come forward. Limitations: no control group (intervention free).Other variables may be unaccounted for e.g. contemporaneous national campaign. Confined to one large practice - wide variation in way over 75 health checks carried out, so may not be generalisable. Key messages: participation in health promotion initiatives may be increased by incorporating them into community nursing visits. |
3 | Bennett JA Perrin NA Hanson G Bennett D Gaynor W Flaherty-Robb M Joseph C Butterworth S Potempa K (2005) Healthy aging demonstration project: Nurse coaching for behaviour change in older adults Research in Nursing & Health 28 187-197 | Type of study: Quasi experimental clinical project Aim: To test the feasibility of nurse coaching by telephone and email as a method to help older adults adopt changes in health behaviours and to determine whether the coaching intervention produced measurable changes in health status outcome Method: Community dwelling adults over 60 years with one or more of five chronic conditions were enrolled and then assigned to control and intervention group . Intervention group met with coaches immediately and identified individual behavioural goals followed by telephone or email contact. Control group thanked for time and asked to continue usual care. Both groups were sent quarterly newsletters. Measurement surveys were done on completion of the project. Findings: Coaching was feasible and acceptable. Significant higher health distress and illness intrusiveness in control group. No statistically significant differences between groups on social /role limitations, energy and general health Limitations of study: Different number and duration of contacts by each coach. Different attrition rates in each group. Limited time to achieve outcomes. No measurement of behaviour changes only health outcomes Key messages: Telephone and email are feasible methods to communicate with older adults about their health behaviours. There was less health distress and illness intrusiveness for those who received coaching. More research needed to measure change in behaviours |
4 | Bliss J While A (2003) Decision making in palliative and continuing care in the community: an analysis of the published literature with reference to the context of UK care provision International Journal of Nursing Studies 40 881-888 | Type of study: Literature review, aiming to identify theoretical framework for exploring decision making in palliative and continuing care. Method: exploratory, snowball sampling, selection criteria relevance and ability to inform on decision making. Not true systematic review, but conducted systematically. Findings: demonstrates complexity of community decision making. Identifies model of strategic decision making which would serve as framework for understanding process and outcomes. Limitations: selective exploratory review; may have missed relevant studies Key messages: Ethos of collaboration makes it difficult to distinguish contribution of community nurse to decision making, which is heavily influenced by employing organisations. |
5 | Bryans, A. (2000) District nursing assessment practice: Case study findings British Journal of Community Nursing 5(4) 197-202 | Type of study: Qualitative, exploratory case study Aim: To describe the knowledge and skills involved in initial patient assessment Method: Simulated assessment, structured post-simulation interview and follow up observational visits Findings: Nurses use referral information to glean background knowledge but do not necessarily accept it as accurate before visiting the patient. Interaction flowed naturally and covered a lot with little effort. Nurse was direct, open and explicit. Nurse made a rapid appraisal of patient's potential needs and was able to articulate her perception of these needs. This was informed by her knowledge of condition and psychology. Nurse offered immediate help to patient in coming to terms with her diagnosis and improving her everyday coping. Nurse did not attempt an exhaustive or complete assessment on the first visit Limitations of study: Simulation of 4 case studies, one-shot approach may not reflect the long term contact Key messages: It is important to examine the invisible elements of district nurses knowledge and its effectiveness in practice |
6 | Caffrey RA (2005) Community care gerontological nursing: The independent nurse's role Journal of Gerontological Nursing 31(7) Jul 18-26 | Type of study: Qualitative ethnographic study Aims: To describe the practices of independent community care gerontological non-Advanced Practice Nurse's (APN's).To identify from the client perspective the need for this nursing service, what service was provided and how client evaluated those services. To describe the inter-relationships and communication processes of these nurse with other healthcare providers Method: Interviews were conducted with seven nurses who were providing care on a private-pay basis to the elderly population. The nurses were then observed during home visits with their clients, field notes were recoded. Audio taped interviews were performed at another time with six clients. Interview data was transcribed, analysed and shared with participants. Findings: Activities described by the nurses are: Assessment, documentation, teaching, delegation and assignment, monitoring, advocacy and support. Service valued by the clients included assistance with problem-solving, nurses advocacy role, completing documentation to meet licensing requirements sand the development of close supportive relationships. Limitations of study: Small study based in rural southern and central Oregon Key messages: Services of community based nurses which were valued by older people were: development of the relationship, problem-solving, knowing their community/context, advocacy with physicians, support, and continuity of care |
7 | Carnwell R Daly W (2003) Advanced nursing practitioners in primary care settings: An exploration of the developing roles Journal of Clinical Nursing 12(5) Sept 630-642 | Type of study: Qualitative exploratory, longitudinal study Aim: To explore the current roles of Advanced Nurse Practitioners (ANP's) in Primary Care and how ANPs within three different nursing disciplines developed their role over time Method: Purposive sample of three types of primary care nurses (HV, DN and PN) who had completed Masters in Advanced Clinical Practice were interviewed at one year and then 15 months later; their managers were interviewed once. Content analysis of interview transcripts, thematic analysis and co-researcher check. Findings: Most ANP's returned to a different role. PN's were easily accommodated in clearly defined role. Some were allowed to make referrals and use agreed protocols. They were perceived by managers to be more highly qualified than DN & HV, as role was comparable to GP's, but were restricted in their development because of need to do mundane tasks. DN's ran minor-illness sessions and chronic disease management sessions. HV's raised awareness about public health and changed practice i.e. developing leadership qualities by involving colleagues in training including leadership and working across boundaries. DN's & HV's were often perceived as threat to CNS's who consider themselves leaders of practice, role perceived to be worthwhile but not sure how it fitted into service developments. They had no time for audit, lack of prescribing authority, lack of understanding about skills expertise and role. All wanted to develop a teaching role and saw future in a consultant role but there were no career prospects Limitations of study: Authors did not distinguish between generalist and specialist knowledge.. Lack of clarity re aims of masters programme. Lack of comparison and synthesis of manager and community nurse themes. Lack of synthesis of data so the findings and recommendations are not clear. Key messages: Advanced Nursing Practice is not clearly defined . There is a lack of understanding about the value of master's preparation in practice. Increasing knowledge to Masters level may enable nurses to develop practice but this maybe a threat to others in the team. Frustrations arose from lack of opportunity for career development |
8 | Carr J Bethea J Hancock B (2001) The attitude of GP's towards the Nurse Practitioner role British Journal of Community Nursing 6(9) 444-451 | Type of study: Qualitative investigative study Aim: To investigate the knowledge and attitudes of GP's who do not employ nurse practitioners to find out what prevents them from doing so. Method: Semi-structured interviews were carried out with 10 GPs selected from 75 practices in Nottingham. Data was coded independently by two researchers Findings: Participants were satisfied with practice nurses who carried out a range of activities but had little knowledge of advanced practice and how the role of the nurse practitioner could be integrated into the team. Participants agreed that key skills of the nurse practitioner should included diagnosis and prescribing but there was a lack of awareness regarding the qualifications required to become a nurse practitioners They supported the integration of nurse practitioner in primary healthcare but also identified potential difficulties arising from the blurring of roles Limitations of study: Small study based in Nottingham Key messages: Nurse practitioner role needs to be integrated into primary care. Need to improve understanding of the role, the boundaries and value of collaboration. GP's are not adverse to the role and believe that training is essential. Nurse practitioners need authority to prescribe. Protocols and guidelines should be used |
9 | Carter B (2000) Ways of working: Community Children's Nurses and chronic illness Journal of Child Health Care 4(2) 66-72 | Type of study: Qualitative exploratory (UK) Aim: 1. Explore the role/skills in relation to the physical and psychosocial needs of children and families with chronic illness; 2. examine ways in which these skills are used in decision making in relation to children and families with chronic illness in the community; 3. consider ways that Community Children's Nurses (CCN's) support the processes of adjustment to and coping with challenges of chronic illness in childhood. Methods: A participant enquiry paradigm was used and data were generated using semi-structured interviews (18 CCN's interviewed), supported by field notes. Audiotapes were transcribed and subject to heuristic analysis to identify themes. Findings: All the CCN's described the special relationship with the children and their families, which was characterised by deep understanding of current, and future needs. CCN's emphasised ' ways of working' which involved high degrees of trust, flexibility, support, reflexivity and empowerment. CCN's help families regain, maintain and develop control over their lives. Most useful interventions: Limitations: Small exploratory study. Key messages: Identifies the 'special relationship' developed between the CCN and children and their families, which involved the depth of understanding about the child and family's needs, and depth of providing individualised, family-centred care. Identifies skills of skilled listening, 'ways of working', enabling, facilitating, empowering, planning and teaching. |
10 | Cowley S Houston A (2003). A structured health needs assessment tool: Acceptability and effectiveness for health visiting Journal of Advanced Nursing 43 (1) 82-92 | Type of study: A two-phase qualitative study Aim: to examine acceptability and effectiveness of a structured health needs assessment tool (HNAT) implemented in London Methods: health visitors were interviewed about the HNAT - 30 via telephone interview. 21 assessments were then observed and tape recorded. Stage two consisted of five in-depth case studies of the use of HNAT in practice, each from a different primary care division within the London area. Case study HVs were selected to reflect range of attitudes about the HNAT. These HVs were asked to introduce at least two families each who agree to their interaction with the HV observed and participate in a separate follow up interview. 19 clients were subsequently interviewed. Findings: HNATs generally liked by nurses but often difficult to implement. Assessment tools frequently not used correctly with many using them as a checklist. Clients frequently dislike the tool as HVs tend to ask specific questions, make judgments and are reported to not listen to individual answers. The use of a HNAT does not encourage individualised care. Consistency of service provision does not suit most vulnerable clients who need it tailored to their own needs. Asking the same questions is inequitable for the variety of clients Key Messages: HNATs focus on organisations' agenda and nurses asking routine questions instead of tailoring assessment to individual needs and listening to clients. Many HVs consider the completion of a HNAT form as an additional bureaucratic hoop not beneficial to their practice yet focus on its completion. The use of HNAT is not supported in the literature and is not effective in eliciting clients' needs. |
11 | Crisp B Lister PG (2004). Child protection and public health: Nurses' responsibilities Journal of Advanced Nursing Sep 447(6) 656-663 | Type of study: Qualitative exploratory study Aim: to explore nurses' understanding of their professional responsibilities in relation to child protection and the potential for nurses to be involved in the protection of the children from abuse. Method: purposive, qualitative, interview based design. 99 nurses from an NHS trust in a Scottish city were interviewed - either in groups or individually. Thematic analysis was undertaken Findings: No shared understanding of definition of child protection and what contribution nurses could or should make in relation to child abuse. Main themes identified were: (1) identification, detection and reporting of child abuse (2) monitoring (3) supporting families (4) client education and (5) service development. Lack of agreement as to whether nursing emphasis should be proactive - an emphasis on child abuse or reactive - an emphasis on detection and reporting. Limitations: interviews were not tape recorded and therefore full transcripts not available. Detailed notes only were written down by two experienced researchers. Themes supported by paraphrasing only, rather than verbatim. Once only interviews were conducted over periods of 30-45 mins each potentially limiting scope of findings. Sample was small, may not be fully representative and cannot not be generalised to wider population. Interviews conducted with those who had an interest or involvement in child protection work. Key messages: Lack of consensus about the nurses' role in issue of child protection and abuse. This is particularly with respect to the extent to which nurses should actively seek to detect cases of child abuse. An emphasis on identification and detection was not easily accepted by many nurses and was perceived by some to be a change from their usual role of supporting parents. Detecting and reporting child abuse was also seen to be in conflict with some public health responsibilities. Some nurses believe there is a sharp divide between child protection work and public health interventions. Many child protection roles identified by nurses, however, such as supporting families, parenting education and service development are clearly within the remit of contemporary notions of public health. There is an increasing recognition that other nurses, other than health visitors, can and do also make an important contribution including those who do not work directly with children. |
12 | Delasega CA Zerbe TM (2002) Caregivers of frail rural older adults effects of practice nursing interventions Journal of Gerontological Nursing October 40-49 | Type of study: Randomised Control Trial Aim: To investigate whether Advanced Practice Nurse (APN) intervention would promote more positive and emotional outcomes in caregivers of rural frail older adults recently discharged from hospital Method: Random assignment of participants 65 years and over to treatment and control group with APN implementation in the treatment group only and comparison of the two groups before and after intervention. Treatment group received one in-hospital visit and two home visits at 48 hours and 1-2 weeks post discharge. Instruments used to collect data after discharge were Care giver Burden Inventory (CBI) and Health and Daily Living Form (HDL) Findings: Both groups had similar levels of support from caregivers, similar demographic variables, similar use of healthcare resources and similar self-rated physical health. Significant difference in self-rated emotional health; the control group being worse than the treatment group. Number of disability days was greater in the control group. Through educating, supporting and counselling the APN was able to affect the caregiver's physical and emotional health in a positive way. Limitations of study: Generalisability was limited by ethic background of the sample, small number of caregivers involved and limited region in which patients were recruited Key messages: Advanced Practice Nurse's have a positive impact on caregiver outcomes for those caring for frail older adults in rural communities; they showed fewer physical health symptoms of a psychosomatic nature and fewer disability days, they missed less days of work which resulted in less financial loss. They also had fewer depressive symptoms, emotional responses and care giving stress. Providing support to carers may improve post-discharge outcomes for older adults and families |
13 | de Lusignan S Singleton A Wells S (2004) Lessons from the implementation of a near patient anticoagulant monitoring service in primary care. Informatics in Primary Care 12 27-33 | Type of study: Evaluation of nurse led intervention, removing anticoagulation monitoring from hospital to community, using decision support software Methods: Action research, supported by questionnaires and clinical audit Findings: Monitoring remained satisfactory and safe, while patients appreciated the service as more convenient, more flexible and having quicker feedback. However, problems were experienced as procedures and software developed for hospital proved tricky to implement in community settings. Limitations: Small scale. Started with 18 nurses, finished with 8. Key messages: Moving traditional hospital service to community results in safe systems and better patient satisfaction |
14 | Drennan V Illiffe S Haworth D Tai S Lenihan P Deave T (2005) The feasibility and acceptability of specialist and social care team for the promotion of health and independence in 'at risk' older adults Health and Social Care in the Community 13(2) 136-144 | Type of study: Qualitative evaluation study Aim: To evaluate whether joint health and social review is feasible, , acceptable and effective in solving problems for older individuals Method: Observation at management and team meetings in order to describe and understand the process of team development. Semi structured interviews were conducted with 13 older people, 6 GP's, 9 managers and all team members. Joint health and social care assessment for over 75's deemed at risk, agreeing a goals and then revisiting at 3 months to review agreed actions. Findings: There was commitment to team development but reconciliation of objectives and cultural inclinations was problematic. This was compounded by lack of clarity as to where responsibility for different types of decision-making lay. Joint assessment was used for this study but not perceived to be an efficient way of working; nurses believed they could do this assessment alone. Time was needed to establish a relationship with the older people and using palm-top computers was counter productive to this process. The most frequently unmet need was mobility, Other unmet need were social relationships, clinical depression and problems with cognition. Referrals: 36% GP, 21% OT, 17% housing, 10% social services, 10% optician and 6% community dentist. Using knowledge of eligibility criteria helped financial problems. Older people found this service acceptable and felt it made a difference to their quality of life Limitations of study: Longitudinal effects need further examination. Key messages: Joint health and social review for older people was feasible, acceptable but costly. Initially it was difficult to identify older people with multiple unmet needs, which suggest needs for database of local population. There was a lack of vision, shared operational and local knowledge between GP's HS managers and LA managers along with a lack of expertise in the promotion and management of collaborative working. An optimistic approach to assessment identified risk in third of population. This type of anticipatory care enables early referral and intervention which made a difference to the quality of life for older people. Nurses need to value their contribution. |
15 | Drew J Nathan D Hall D (2003) Role of a paediatric nurse in primary care 2: research findings British Journal of Nursing 12(1) 34-43 | Type of study: Qualitative evaluation (UK) Aim: Not clearly stated, as this is 2nd of 2 articles, 1st article described methodology. Evaluates the role and function of two qualified children's nurses, each working within a different PHCT. Methods: Application of naturalistic inquiry and the use of a formative evaluation strategy. Data collated detailing patient contacts, nurses kept a reflective diary, interviews with members of the PHCT (need more info from 1st article. Findings: Identifies the specific skills of the paediatric nurse as having an acute and maintenance role; also skills as catalyst and facilitator, advanced practice skills, supporting children and families and meeting unmet need. Limitations: Article states that methodology had to be invented and therefore unknown how robust or reliable it was. Also the 2 nurses were highly selected nurses with particular skills, very small sample. Key messages: Identifies the contribution of the children's nurse working in a community setting with the greatest contribution being in raising the overall quality of care of a range of conditions, which are currently of low profile (e.g. eczema and other skin disorders, continence problems, and behavioural difficulties) |
16 | Duhamel F Talbot L (2004) A constructivist evaluation of family systems nursing interventions with families experiencing cardiovascular and cerebrovascular illness Journal of Family Nursing 10(1) 12-32 | Type of study: Participatory research design using Guba and Lincoln's forth generation evaluation approach. Aim: to evaluate family systems nursing interventions (Calgary family assessment and interventions models) Methods: All participants were co researchers and their evaluations of the interventions informed subsequent interventions. Five families participated - 2 families where member had MI and three where member had a stroke. Held preclinical, clinical and research meetings with families on five occasions. Summary report produced at end of each session and synthesis report at end of five sessions. Findings: Humanistic attitude of the nurse - development of a trusting relationship and knowing the nurse. Constructing a genogram - useful to collect information about family structure and experiences of dealing with past and present illness in the family and their resources for doing so. Study revealed this was a useful process for family member rather then just HPs who have traditionally used these. Interventive questioning: stimulated discussion on specific topics. Offering educational information: essential intervention which reassured family members about aspects of illness and reduced stress. Normalization: normalizing consequences of illness was deemed useful. Exploring the illness in the presence of other family members: sharing and venting emotions was useful. Models promote therapeutic relationship between nurse and family. Nurse benefited from being co researchers - reflecting and reconstructing interventions helped them to advance their practice Limitations: Small Canadian exploratory study Key messages: The process allowed the participants to get to know each other and contribute on an equal basis to care planning and decision making. Intense interaction over a prolonged period of time. Identified tacit nature of nursing knowledge and practice |
17 | Duke C (2005) The frail elderly community - based case management project Geriatric Nursing 26(2) 122-127 | Type of study: Qualitative evaluation Study Aim: To investigate the effects of community-based case management for frail elderly and the effect this would have on healthcare utilisation Method: Enrolment of 107 people 65 years or over, implementation of assessment and health care satisfaction survey, establishment of community-based case management programme, telehealth assessments for medically compromised patients and promotion of end of life decision-making and facilitation of monthly carer and family education sessions. Findings: Positive outcomes in all areas that were studied Limitations of study: Based a community in eastern North Carolina, USA Key messages: Community-based geriatric case management for frail elderly using telehealth reduces hospital admissions, emergency room visits, length of stay and total hospital costs. Not clear of the impact on community costs |
18 | Evans C Drennan V Roberts J (2005) Practice Nurses and older people: A case management approach to care Journal of Advanced Nursing 51(4) August 343-352 | Type of study: Qualitative, exploratory study Aim: To explore whether practice nurses use the five cyclical elements of case management approach when caring for people over the age of 75 years and what determines or deters the use of this approach Method: 26-item questionnaire was used to explore practice nurse current management of older people. 45% response rate from 500 practice nurses, 20% of their population were over 75. Was case management used? Findings: Over-75 health check annually, assessment, planning and care giving. Evaluation and referral happened rarely although PN qualified in DN were likely to refer to social services Immunization and cervical screening done as financially remunerated Case management only used in chronic disease and over-75 health check. This maybe due to time pressure of disinterest in older people but there was no evidence. Limitations of study: Self assessment via questionnaire Key messages: Older peopled need proactive care to assess risk and prevent problems developing; case management may be the way forward |
19 | Forester S (2004). Adopting community development approaches, Community Practitioner 77 (4) 140-146 | Type of study: Primary qualitative study Aim: to explore factors that influence adoption of community development approaches within health visiting including skill development. Method: purposive sampling technique to recruit health visitors using community development approaches within mainstream health visiting. Semi structured interviews, drawn from a feminist perspective were conducted with first 3 interviews conducted as a pilot. Subsequent interviews made more specific as a result. 11 participants interviewed from across England. Thematic analysis following Burnard's framework. Transcripts were coded and arranged into themes. Findings: Four main themes identified. (1) Values and skills - participants described a number of ways in which they worked differently from 'traditional health visiting'. (2) Relationships with communities and other agencies (3) Teamwork. Difficulties faced by HVs in relation to lack of organisational support and feelings of isolation when working with clients. Limitations: 11 health visitors interviewed. Discussion focussed mostly on health visitors relationships with other agencies rather than clients. Key messages: Community development requires a more systematic approach incorporating both educational and management support. To develop a public health agenda based on participation and multi-agency working, changes in practice are required in relation to power sharing and risk taking. Practitioners have to be equipped with relevant educational skills but also need to be supported at organisational and policy levels. |
20 | Griffiths R Johnson M Piper M Langdon R. (2004) A nursing intervention for the quality use of medicines by elderly community clients International Journal of Nursing Practice 10(4) Aug 166-176 | Type of study: Qualitative evaluation study Aim: To evaluate the effectiveness of an intervention to improve knowledge, regime and adherence to medication taking in older people Method: A pre and post test design with a cross sectional survey of older people receiving community nursing care was used. A follow up interview was conducted with a subgroup of clients with deficits in knowledge of medications or management ability. Findings: Participants took an average of 10 medications per day. 79.2% were responsible for their own medication administration, 8.3% participants were able to manage their medication successfully. 70.8% needed some form of education about the scheduling and function of medication. Following intervention by community nurse their was a significant improvement in the percentage of medications and schedules correctly named, there was little change in medication regimes Limitations of study: Community nurse were self reporting and not observed. Interviewing may have raised awareness rather than community nurses' interventions Key messages: Overall, there was an improvement in medications named but no significant change in understanding of function of medications. No change in regime or adherence. Study identified that community nurses have an important role in identifying those at risk and to get early action or referral. |
21 | Grimmer K Moss J Falco J (2004) Becoming a carer for an elderly person after discharge from an acute hospital admission The Internet Journal of Allied Health Sciences and Practice 2(4) 13 | Type of Study: Qualitative observational study Aim: To describe the perceptions of people taking on a new or expanded caring role for an elderly patient recently hospitalised with a new or intensified health problem Method: Twenty four primary carers of recently ill, elderly patients were interviewed over a six month period following patient discharge from an acute hospital admission. All interviews were recorded and transcribed for analysis. Qualitative analysis focused on identification of key themes, synthesised from carer interview data. Findings: The physical, financial and emotional costs for the carer were highlighted. Being identified as the primary carer did not necessarily imply that the carer was physically or emotionally prepared to undertake the tasks of caring for their patient. Most carers are constrained by their lack of education about their role and their patient's condition, and by their own health status or other commitments. Carers were insightful about their situation and the services required to meet their needs. Carers have higher levels of anger, anxiety, sadness and depression than non-caregivers. Limitations of Study: Discussion of data analysis limited Sampling strategy not justified. Fieldwork not well described. Only focused on discharges from four acute hospitals Key Messages: It cannot be assumed that someone is willing to take on carer role . If unpaid carers are to continue to be the main source of patient support post-discharge they require to be appropriately resourced to maximise long-term independence in the community. Patients and carers require appropriate community supports, including education for the role |
22 | Groner J French G Ahijevych K Wewers ME (2005) Process evaluation of a nurse-delivered smoking relapse prevention program for new mothers Journal of Community Health Nursing 22(3) 157-167 | Type of study: Quantitative and qualitative (American) Aim: To evaluate the feasibility, recall, and acceptability of an evidence-based intervention using home-health nurses to provide smoking relapse prevention skills to new mothers. Methods: Design of study used process evaluation. Purposive sample of 121 women who had quit smoking between conception and 7 days prior to delivery and had delivered a health baby within 48 hours. Women were screened whether they had smoked a cigarette confirmed by a saliva cotinine test. Findings: The intervention was effective in doubling the rate of remaining smoke free at 3 and 6 months p |