Study of the Implementation of a New Community Health Nurse Role in Scotland

ANNEX C: LITERATURE REVIEW

Literature Review

Aim

To inform the evaluation of the new Community Health Nurse Role, in particular the design and methods.

Methods

The search for literature

A combination of free text and thesaurus terms were entered into the following online

bibliographic databases: British Nursing Index, Cinahl Plus, Medline and Psychinfo. The search strings were tailored according to each database. Details of the online search strategy appear at the end of this report.

The searches were carried out on 29 and 30 June 2010 on full versions of each database. Results were restricted to material published between Jan 2008 and June 2010. The 2008 cut off was chosen because it marked the end of our last literature review which was published in the final report of the community nurse baseline study (Kennedy et al 2009).

We acknowledge that practice nurses were not included in the Scottish Government's policy. However we included them in this review because of the Australian government's policy to expand their role and the possibility of gaining relevant insights to this process via recently published research.

Papers retrieved and number included

Table 1 illustrates the initial results of the search strategy from each of the bibliographic databases. A total of 683 articles were identified. After examining the abstracts 88 (13%) were thought to be relevant. The main reasons for exclusions at this stage were: not relevant to community nursing and not a research based study. All 88 studies were retrieved as full papers and, after further assessment, 33 were included in the review. The main reasons for exclusion at this stage were: a review of research based on narrow selection of the literature (e.g., convenience search), purely theoretical papers or commentaries.

Table 1 number of publications retrieved and included

Database	Total Retrieved by Search Strategy
CINAHL	326
British Nursing Index	87
Medline	79
ASSIA	30
PsycInfo	136
Cochrane Library	25
Total	683

Summarising the findings

Data were extracted from each of the 33 papers and summarised using the following framework. A summary of each paper appears in tabular form in the section titled Summary of Each Study. These are listed by nursing group and country of origin.

Author
Title and source
Nursing group
Country
Aim
Method
Key findings

These summaries were used to form a narrative summary which synthesised the findings arising from the review.

Narrative Summary

Five themes were apparent in the literature:

a) The range of community nurse activities
b) Role expansion and the consequences of that expansion
c) The impact of community nursing on the health of patients
d) Theoretical development of community nursing
e) Research methods
a) The range of community nurse activities

Community nurses engage in activities which reflect the population they serve. For example district nurses who work with the elderly form professional relationships that are founded on key values around longevity, therapy, and family (McGarry 2008). Health visitors respect family routine and have empathy for children and parents (McIntosh and Runciman 2008). School nurses collaborate with teachers, parents, guidance counsellors, and school administrators (Krause-Parello and Samms 2009). Public health nurses engaged in surveillance which involves screening (Megher-Stewart et al 2009). As such community nurses develop experience in working with certain client groups and become relatively skilled in doing so. Indeed the special relationship between nurses and service users is highly valued by service users (McGarry 2008; McIntosh and Runciman 2008; Kennedy et al 2008) sometimes more so compared with other primary care professionals, such as general practitioners (Bonsall and Cheater 2008; Kelcher et al 2009).

Not all nursing activities are so well defined, particularly if the nurse is engaged with complex health problems which are socially determined. An example is public health nurses who provide 'holistic care' (Markham and Carney 2008). These nurses often deal with chronic health conditions which required more complex methods of prevention. Thus in many studies there are references to complexity of health or health care, working across services, and across teams.

b) Role expansion and the consequences of that expansion

Role expansion can happen in two ways a) focussed expansion, or b) diverse expansion. The first was typified by practice nurses in Australia where the government encouraged them to expand their role by taking on more clinical tasks from general practitioners (Jasiak and Passmore 2009). They also helped to co-ordinate services for patients and developed administrative roles (Joyce and Piterman 2009). The second type of expansion was typified by Public Health Nurses in Ireland, Norway, USA and Canada (Philibin et al 2009; Clancy and Svensson 2009; Kaiser and Farris 2009; Meagher-Stewart et al 2009) where roles were more 'holistic' and directed towards families or groups rather than individuals.

There were consequences which were common to both types of expansion. First, was the reaction by their colleagues including doctors and other nurses. This reaction was critical to the success or failure of a new role. For example resistance by other health care professionals acted to limit the role of district nurses in England (King et al 2010), practice nurses in Australia (Halcomb et al 2008; Mills and Fitzgerald 2008; Jasiak and Passmore 2009); school nurses in the USA (Krause-Parello and Samms 2009); and advanced practitioners in England, the USA, Canada and Australia (Aranda and Jones 2008; Bonsal and Cheater 2008). There was however evidence of support for these roles. For example a recent study conducted in England concluded that nurses, doctors and patients support nurses in taking on more work from the general practitioner (Branson and Badger 2008). Support leads to more embedded roles.

The research literature reflects the debate which appears in the wider nursing journals about expanding the role of community nurses. Some commentators argue that 70% of the work of general practitioners could be done by nurses and therefore their role might expand in this direction (Sweeney 2009). However, there are others who see such a move as one which potentially threatens more traditional practices of community nursing which are based on the social aspects of care. They are therefore hesitant to recommend a more individualistic approach to health care which is based on a medical model of intervention (Greenway et al 2008).

One of the more immediate issues facing nurses who take a more comprehensive approach to health care is pinning down the core elements of their work. The role of public health nurses has been difficult to define and is sometimes viewed by other professions as a 'jack of all trades' (Philibin et al 2009; Clancey and Stevensson 2009). The nature of these roles was often shaped by the nature of the given condition. For example nurses often dealt with chronic health conditions which required more complex methods of prevention. Thus there was a clear need for greater flexibility when dealing for instance with families with a diverse range of needs (Yarwood 2008; Fagerstrom 2009).

Training was also seen as either a barrier or facilitator to the expansion of a nurses' role. Post-graduate education was instrumental in helping community nurses in New Zealand to develop constructive relationships with families (Yarwood 2008). Education was also instrumental in developing community and public health nursing in Ireland (Poulton 2009; Markham and Carney 2008), public health nursing in the USA (Hill et al 2010), and practice nursing in Australia (Halcomb et al 2008).

c) The impact of community nurses on the health of patients

Perhaps the greatest test is whether community nurses have a beneficial impact on patients. The most robust evidence for this comes from the published reviews of evidence. Bonsall and Cheater (2008) assessed the impact of community based advanced nurse practitioners and concluded that nurses could provide safe and effective care which was comparable to doctors, however there was little available evidence on their economic benefit and no evidence on whether role maturation lead to greater patient benefit or detriment. Kennedy et al (2008) reviewed the evidence on community nurses which included a wider range of nursing roles and concluded there was little evidence to support the different models of nursing. This was reflected in another review of community nursing conducted by Kelcher (2009) which suggested that patients' knowledge of heath improved, but no evidence the community nurses had a greater impact on mortality, health, hospitalisation or readmission when compared with doctors. Fagerstrom et al (2009) reviewed the evidence on home visiting for elderly people. Studies included nurses and other professionals and the authors concluded that these visits could reduce mortality, improve function and reduce admissions to long term care among the very frail, however the evidence was equivocal.

d) Theoretical development of nursing

There were a few papers which tested the theoretical basis of nursing practice. This resulted in a move beyond the description of nursing practice which was apparent in many academic papers to an empirical and more robust assessment of the evidence. Notable examples include McGarry 2008, McIntosh and Runciman 2008; and Aranda and Jones 2008. McGarry (2008) highlighted the importance of the micro environment in shaping nurse patient relationships and the values which underpinned the therapeutic value of these relationships. They examined the more immediate practice setting i.e., the patient's home. McIntosh and Runciman (2008) assessed partnership working among community paediatric nurses using Bidmead and Cowley's (2005) partnership framework. The authors included the immediate practice setting but also examined partnership working between nurses and other health and social care professionals. Aranda and Jones (2008) used social theories to explain how new nursing roles were socially and politically constructed. They examined how these new roles developed when health care systems changed and thus adopted a more macro view of nursing practice development.

e) Research methods

Nineteen (58%) of the studies used a qualitative methods, nine (27%) used quantitative methods (mainly surveys), and five (15%) were systematic reviews of the literature. Focus groups and interviews formed the basis of most qualitative studies. The findings from most qualitative and quantitative studies were reported using descriptive techniques. However as noted above there were some studies which were theoretically based and this helped them move towards a more sophisticated level of analysis. Some studies also used innovative methods to help provide richer insights either by using novel data gathering techniques or providing the opportunity for comparison within their study design.

For example, King et al (2010) used the Pictor method to elicit in depth data about community nurses practice in palliative care. Pictor is based on a family therapy technique developed by Ross et al (2005) and was used by King et al (2010) to identify and understand the relationships between the patient, their family, friends and professionals. It involves the participant drawing a diagram of the people involved in their case, including themselves and their family. They draw arrows and lines to depict the relationship between each member. The interviewer then asked them to describe these relationships and their impact on their care. Other researchers designed their study to increase the potential of comparison and thus a more insightful analysis. Appleton and Cowley (2008) used a case study which involved a comparison of nurse and patient's views. Mulcahy et al (2008) used nurse patient dyads i.e., a nurse and a patient chosen from their case load. Clancy and Svensson (2009) used purposive sampling to elicit the views of a wide range of professionals. The aim of purposive sampling is to increase the comparative potential of a study. Preset criteria are used to recruit different groups of people who may offer a different perspective on the research topic for example men and women. Arbon et al (2008) interviewed nurses, other professionals, and patients.

Identified knowledge gaps and how the review informed the current evaluation.

Our previous review (Kennedy et al 2009) highlighted the lack of consensus over the role of community nurses and considerable overlap between nursing disciplines. Much of the literature focused on diversity within nursing roles particularly those adopting a more public health approach, although some community nurse roles were more focussed e.g., advanced practitioners. New roles, such as the family health nurse in Scotland co-existed alongside existing roles. However, some research suggested these roles may be become more embedded into community services and more acceptable to other professionals over a longer period.

These findings were supported by more recent research. The tension caused by introducing new roles, or expanding existing roles, remained a dominant theme in the research literature. Many papers illustrated how the new roles were shaped by the reaction of other professionals including medical and nursing colleagues. Education and training were viewed as crucial in helping to define these roles. Some commentators question whether the new roles were desirable and argued these represented a threat to more traditional community nurse practices.

New systematic reviews have appeared in the academic literature which addresses the question of effectiveness including comparisons with other professionals such as doctors. While there is some evidence that community nurses have a beneficial impact on patients health, the evidence for the impact on patients health is either equivocal or patchy.

The aim of the current evaluation is to assess the impact of the new community health nurse in Scotland. Given the comparatively low uptake of the new role across Scotland it was not appropriate to use quantitative methods. Recently researchers have used qualitative techniques to define the core elements of community nurse practice and to assess the impact of these roles on patients. They have employed comparative designs which involve a range of key stakeholders in one study e.g., patients, nurses and other members of the care team. Some have used data gathering and analytical techniques which move beyond description. Others have used theory to help to interrogate their data.

Our study will contribute to this body of research. It uses a case study design which involves patients, nurses and other health professionals and compares nurses who have adopted the new role with those who have not. This will include observations of nurse patient interactions, interviews with nurses and patients, and focus groups with other nurses, doctors and professionals from other services. We will also use emotional touch points to help gather in depth data about the nurse patient experience (Dewar et al 2010). Finally we will use three prominent theories to help inform the interpretation of our data:

a) The co-construction of therapeutic nurse patient relationships
b) Partnership working.
c) The social construction of nursing roles.

Summary of Each Study

District Nurses

1

Author: Wilhelmsson S and Lindberg M (2009)

Title and Source: Health Promotion: Facilitators and barriers perceived by district nurses. International Journal of Nursing Practice 15, 156-163

Nursing Group: District Nurses

Country: Sweden

Aim: Examine the barriers and facilitators to health promotion

Method: Qualitative interviews with purposive sampling n=54

Key findings: District nurses think they should be encouraging health promotion but they feel stuck in chronic disease management (medical oriented tasks) and focus less on health promotion. They also lacked support from management (who were medics) for health promotion e.g., organisational priorities set by the health centre were wrong. The medical rather than the social model of care dominated. Heavy case loads may contribute to this. Nevertheless secondary prevention may prove a pragmatic answer to the dilemma.

2

Author: McGarry J (2008)

Title and Source: Defining roles, relationships, boundaries and participation between elderly people and nurses within the home: an ethnographic study. Health and Social Care in the Community, 17,1,83-91

Nursing Group: Community nurses (District Nurses)

Country: UK (England)

Aim: Examine the impact of the relationship between nurse and patient on care.

Method: Participant Observation of nurse patient interactions and follow-up interviews. Nurses =16 patients= 13.

Key findings: The relationship between nurse and patient is co-constructed and that location, the nature of relationships and the meaning of health an illness are particularly important. These relationships are founded on key values around issues of longevity, therapy, and family and as such these were personal rather than professionally shaped. Nurses also work across health and social care boundaries. The methods used were designed to 'explain and capture the inherent complexity and or qualities of nursing in the home' rather than describe or quantify.

3

Author: King et al (2010)

Title and Source: Community Palliative Care: Role Perception

Nursing Group: District Nurses and Community Matrons

Country: UK (England)

Aim: Examine the relationship between community nursing and palliative care.

Method: Qualitative interviews based on the Pictor method n=15 nurses and n=7 key stakeholders (managers). Pictor is based on family therapy and highlights the people and relationships involved in a recent 'case'.

Key findings: All thought nurses had valuable role to play in palliative care, principally around the coordination of care, providing information and emotional support and providing physical care. There were some doubts around their ability to manage cases due to the volume and complexity and that the role was around specific tasks. New expanded roles may trigger defensive responses from existing professionals. The Pictor method was useful in aiding reflection on the ways nurses worked with patients.

Health Visitors

4

Author: Appleton V and Cowley S (2008)

Title and Source: Health visiting assessment - unpacking critical attributes in health visitor needs assessment practice: A case study. International Journal of Nursing Studies 45, 232-245

Nursing Group: Health Visitors

Country: UK (England)

Aim: Describe the core attributes of health visiting assessment

Method: Case study of 15 health visitors. Each study involved HV and families and comprised of observations, and qualitative interviews.

Key findings: The core attributes are: holistic assessment; multi-factorial and complex assessment; prioritisation; all clients can have unmet needs; influence of personal values and life experience; ongoing nature of assessment; difficult to articulate how they conducted an assessment. Combining observations and interviews were viewed as important in 'unpacking the various elements of health visiting assessment'. However no comparison groups in this study.

5

Author: Hogg R and Hanley J (2008)

Title and Source: Community Development in Primary Care: opportunities and challenges. Community Practitioner 8,1,22-25

Nursing Group: Health Visitors

Country: UK (Scotland)

Aim: Explore HVs views on community development and barriers against and facilitators for.

Method: Semi-structured interviews with 16 nurses

Key findings: Community development is about helping people mobilise their resources to collectively address problems. Most nurses thought they possessed the skills to help people do this. The course they completed did not help them to do this. Some other barriers included target driven systems, low organisational priority, and lack of systems thinking as core in health visiting practice.

6

Author: McIntosh J and Runciman P (2008)

Title and Source: Exploring the role of partnership in the home care of children with special health needs: Qualitative findings from two service evaluations. International Journal of Nursing Studies, 45,714-726.

Nursing Group: Community Paediatric Nurses.

Country: UK (Scotland)

Aim: Empirically conceptualise partnership

Method: In-depth interviews with 17 parents and 20 professionals including medical, nursing, social services, education and the voluntary sector.

Key findings: Two types of partnership were explored. One between nurses and service users (parents) and the second between nurses and other agencies. Bidmead and Cowley (2005) model of partnership was used to analyse the data. Evidence for each existed: Nurses and professionals respected family routine and empathy for the child and parents. Nurses also demonstrated a deep understanding for different styles of adult learning, how to alleviate stress and parental vulnerability to their child's health condition. There was also evidence of extensive partnership across social care boundaries. Partnership is multi-faceted and is knowledge, skill and resource intensive.

Practice Nurses

7

Author: Halcomb et al (2008)

Title and Source: Cardiovascular disease management: time to advance the practice nurse role. Australian Health Review, 32, 1, 44-55

Nursing Group: Practice Nurses

Country: Australia

Aim: Examine the barriers and facilitators to role development

Method: postal self-completion survey n= 284 and qualitative interviews n=10

Key findings: Barriers included legal implications (fear of litigation), lack of space, belief there is no need to change and negative attitudes from GP. Facilitators include collaboration with GP, training, opportunity to deliver care, high job satisfaction and positive consumer feedback. Interdisciplinary collaboration (un this instance between the GP and Practice Nurse was viewed as critical to the success of an expanded role.

8

Author: Senior E (2008)

Title and Source: How general practice nurses view their expanding role. Australian Journal of Advanced Nursing 26,1, 8-15

Nursing Group: Practice Nurses

Country: Australia

Aim: Explore the barriers and enablers to the expanded role of practice nurses

Method: In depth interviews with 22 registered and enrolled practice nurses

Key findings: 86% were happy with the new role. GPs were seen as supportive and this was a crucial enabler. Nurses thought the new role improved care and enhanced job satisfaction.

9

Author: Mills J and Fitzgerald M (2008)

Title and Source: The changing role of practice nurses in Australia: an action research study

Nursing Group: Practice nurses

Country: Australia

Aim: Report on methods used to expand the role (e.g. well women clinics) and barriers and facilitators

Method: Action research

Key findings: GPs were not supportive and this mattered particularly around cervical screening. Team work was also seen as important.

10

Author: Jasiak S and Passmore E (2009)

Title and Source: Enhancing the roles of practice nurses: outcomes of cervical screening education and training in NSW. Australian Journal of Advanced Nursing 27, 2, 40-45.

Nursing Group: Practice nurses

Country: Australia

Aim: Report their role and barriers to that role

Method: Self completed postal survey n=149

Key findings: Most (76%) had expanded their role in providing more clinical services, information and education of women's health. The main barrier to role expansion was lack of support from GPs. 69% wanted more training and education. There is a lack of data on the impact on patients.

11

Author: Joyce C and Piterman (2009)

Title and Source: Farewell to the handmaiden? Profile of nurses in Australian general practice in 2007. Australian Journal of Advanced Nursing 27, 1, 48-58.

Nursing Group: Mixed group of nurses working in general practice (registered and enrolled practice nurses).

Country: Australia

Aim: Describe the working practices of practice nurses.

Method: Self completion cross-sectional survey n=104.

Key findings: All nurses undertook duties related to direct patient care, coordination of care and management of the clinical environment (e.g., 90% undertook practice management or admin tasks). 77% liaised with other health professionals: 66% liaised with social work or community services, 73% coordinated patient services. Thus indications of advanced roles. However not clear how much of a health promotion/prevention role they have. Therefore support required to develop their careers.

12

Author: O'Donnell A et al (2010)

Title and Source: Practice nurses' workload, career intentions and impact of professional isolation: a cross-sectional survey. BMC Nursing, 9, 2.

Nursing Group: Practice nurses.

Country: UK (Scotland)

Aim: Describe practice nurses' role and support for it.

Method: Cross sectional survey n=329

Key findings: Common activities were coronary heart disease management, cervical cytology, diabetes, chronic obstructive pulmonary disease. Most 52% felt isolated in their role, particularly if not part of a larger team e.g., small practices.

Public Health Nurses

13

Author: Meagher-Stewart D et al (2009)

Title and Source: Population Health Surveillance Practice of Public Health Nurses. Public Health Nursing, 26, 6,553-560.

Nursing Group: Public Health Nurses

Country: Canada

Aim: Examine the facilitators and barriers to public health surveillance

Method: Qualitative telephone interviews n=55.

Key findings: Public health surveillance is defined as identifying changing risk profiles and health status patterns and forecasting future disease trends. Part of this is reporting suspicious cases. Most nurses were involved in screening and awareness of the social determinants of health. This made heightened awareness of gaps on service use or health inequalities. Surveillance networks played a key role in surveillance e.g. sharing information and expertise with other professionals, identifying gaps in services, helping inform the local community. This in turn may have helped towards a systems approach and ultimately better health outcomes. Thus more than using epidemiological data called 'ecosocial epidemiology' and less individually based approach to practice.

14

Author: Markham T and Carney (2008)

Title and Source: Public Health Nurses and the delivery of quality nursing care in the community. Journal of Clinical Nursing 17, 1342-1350

Nursing Group: Public Health Nurses

Country: Ireland

Aim: Explore the factors which affect the quality of care

Method: Qualitative interviews with eight public health nurses

Key findings: Nurses provided 'holistic care' i.e., meeting the needs of a diverse population. Effective communication was required to help plan and deliver care and thus poor communication was a barrier to good quality care. Large case loads affected the quality of care and added stress. Education and training were seen as important in helping nurses work more effectively. Resources such as technology and basic infrastructure were lacking.

15

Author: Mulcahy H et al (2008)

Title and Source: Participatory nurse/client relationships: perceptions of public health nurses and mothers of vulnerable families. Applied Nursing Research 21, 169-172.

Nursing Group: Public Health Nurses

Country: Ireland

Aim: To assess the level of mutual participation between public health nurses and vulnerable mothers (where there was cause for concern of harm to the child but no evidence of harm).

Method: Standard and open assessments in the form of an interview with 44 dyads to assess concordance on key aspects of care: needs, satisfaction and response.

Key findings: Findings indicate close levels of participation. They met regularly, and agreed on the required support, information and technology, and decisions. However the clients did not fully agree that the nurse met their needs.

16

Author: Philibin et al (2009)

Title and Source: The role of the public health nurse in a changing society. Journal of Advanced Nursing, 66, 4,743-752.

Nursing Group: Public Health Nurses

Country: Ireland

Aim: To clarify the role of the public health nurse.

Method: Qualitative interviews with 25 nurses

Key findings: Four key findings emerged: the 'jack of all trades' whereby they are seen as a catch all service. Their remit appears very wide in terms of the population they serve, and that nurses are also expected to be very specialist. Prevention takes second place to cure and this represents a tension in the role. In essence the role needs to be limited and better defined. If not overload may result. This comment was made in relation to the new Scottish Role (see discussion). Nevertheless Job satisfaction was high and team work may be a solution.

17

Author: Clancy A and Svensson T (2009)

Title and Source: Perceptions of Public Health Nursing Practice by Municipal health Officials in Norway. Public Health Nursing 26, 5, 412-420.

Nursing Group: Public Health Nurses

Country: Norway

Aim: Assess views on public health nursing

Method: Qualitative interviews with 5 local politicians and 6 senior local authority administrators.

Key findings: All were aware of public health nurses, but thought the focus of their work was to general. They thought PHNs should concentrate on working with families. There was also a lack of collaboration between PHNs and the local authority.

18

Author: Kaiser K and Farris N (2009)

Title and Source: Public and Community Health Nursing Interventions with Vulnerable Primary Care Clients: A Pilot Study. Journal of Community Health Nursing. 26, 87-97.

Nursing Group: Public Community Health Nurses

Country: USA

Aim: Assess the effects of public community health nurse visits on vulnerable patients

Method: Quasi-experimental design on 80 patients (19-93 years) with unmet needs. The 80 were assigned randomly to the intervention or control Intervention = mutual goal setting. Vulnerable defined as: frail elderly, those with poor health literacy, those with unstable chronic conditions, and poor.

Key findings: No significant effects on health behaviour of the 10 week intervention programme but less need identified among participants of that programme over time.

19

Author: Hill et al 2010

Title and Source: Barriers and Facilitators to the Incorporation of Environmental Health into Public Health Nursing Practice. Public Health Nursing 27, 2, 121-130.

Nursing Group: Public Health Nurses

Country: USA

Aim: describe the barriers and facilitators to environmental health among public health nurses.

Method: Cross-sectional self administered survey n=141. training

Key findings: Public health nurses are often asked about environmental health issues e.g. household exposure to risks. However many report lack of time (21%) or interest shown by patients (15%) as barriers to engagement on environmental health. Facilitators are education or resources.

School Nurses

20

Author: Smith F (2009)

Title and Source: School nursing in the UK: Where are we now? British Journal of School Nursing 4, 7.

Nursing Group: School Nurses

Country: UK (whole of the UK)

Aim: Comparison of the 2005 and 2009 survey of school nurses conducted across the UK.

Method: Comparative cross-sectional time series survey conducted by the RCN.

Key findings: Ratio of nurses to schools in 2005 = 1 nurse to 14 schools. 71% felt this was insufficient; 50% said their workload was too heavy; 90% were too busy to provide the service required; 75% wanted to change the balance of their role to include health promotion, pupil counselling and sexual health. Child protection conferences rose to 70% from 50% in 2005. In 2009 nurses were engaged in health promotion and sexual health, obesity and mental health. Lack of time still figures as a barrier to delivering nursing care (64%). Nurse school ratios remain the same although there are variations. There was a 14% decrease in access to training. 82% reported being valued by the school. 54% were satisfied with their job.

21

Author: Krause-Parello C and Samms K (2009)

Title and Source: The US model: The role of school nurses in New Jersey. British Journal of School Nursing. 4, 6, 287-292.

Nursing Group: School Nurses

Country: USA

Aim: Explore the roles and responsibilities of school nurses.

Method: Interviews with 27 nurses

Key findings: Roles are expanding because of the increase of children with chronic conditions e.g. asthma (most common), diabetes, seizures, hepatitis. Duties include administering medications (most common bronchodilators), nursing (first aid, urinary catheterisation, tube feeds, nebuliser), glucose testing) screening, and referrals. Nurse pupil ratio = 1:1300 thus not always possible to administer medications which is the school nurse's responsibility (Policy). Health promotion consisted of counselling, information giving and workshops. School nurses collaborated with teachers, parents, guidance counsellors, and administrators. Few said they were valued by the school.

Specialist Role Nurses including Advanced Practitioners

22

Author: Aranda J and Jones A (2008)

Title and Source: Exploring new advanced practice roles in community nursing: a critique. Nursing Inquiry 15, 1, 3-10.

Nursing Group: Community nurses

Country: International

Aim: A critique of new community nursing roles based on existing evidence.

Method: literature review of 112 papers.

Key findings: The new advanced practitioner roles reflect the changing nature of heath care work and actively challenge and reshape boundaries, identities and social relations in health care. Thus practitioners develop a sense of self and agency. In a sense to nurses take or make these roles. How practitioners do this requires further exploration. Why do some adopt these roles whilst others do not? How nurses view themselves is important e.g., subject to oppression or spearheading change. The tension between caring and curing could be used to examine the change in nursing over time and different ways. Where do the new divisions of labour occur (between medics and nurses)?

23

Author: Bonsall K and Cheater F (2008)

Title and Source: What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review. International Journal of Nursing Studies 45, 1090-1102

Nursing Group: Advanced Primary Care Nursing (any nurse with an advanced nursing practice role in primary care - nurse clinician, nurse practitioner or advanced nurse practitioner)

Country: International

Aim: Assess the impact of advance primary care nursing roles on nurses and patients.

Method: Systematic review. Papers = 88.

Key findings: Many nurses provide safe and effective care and patient satisfaction is high. These nurses deliver care which is comparable to doctors in terms of health status morbidity and mortality and patients' adherence is greater. There is little available evidence on cost effectiveness, efficiency or utility. The introduction of these roles has caused tension between nurses and also other health professionals. Maturation into the role is thought to improve effectiveness, but more studies are required to test this assumption.

24

Author: Murray J et al (2008)

Title and Source: Survey to investigate the role of the community stroke care coordinator. British Journal of Community Nursing. 13,1,31-36

Nursing Group: Community Stroke Co-ordinators (many of whom are nurses)

Country: UK

Aim: Describe how the Community Stroke Co-ordinator posts are implemented.

Method: Survey of 39 post holders

Key findings: The roles and training are poorly defined. There was a wide variation in practice: receiving referrals from a wide range of sources, (community, other hospital wards, A&E, self -referrals). Various assessments were used. Workload was heavy and knowledge of the evidence base was low. Most common source of information was National Clinical Guidelines. There was limited access to key referral services such as transport, psychology and physical therapies. A more robust evidence base may help develop the post.

25

Author: Pontin D and Lewis M (2008)

Title and Source: Maintaining the continuity of care in community children's nursing caseloads in a service for children with life-limiting, life-threatening or chronic health conditions: a qualitative analysis.

Nursing Group: Community Children's Nurse

Country: UK (England)

Aim: Explore factors which influence nurses' case loads

Method: Qualitative interviews with six nurses

Key findings: Nurses display values that are consistent with human centred nursing. Case loads were managed to ensure continuity of care. Care is socially constructed e.g., between the service user and nurse and between the heath care system and the nurse. Support from colleagues was important in helping them to function.

More than one community nurse group

26

Author: Kennedy et al (2008)

Title and Source: Establishing the contribution of nursing in the community to the health of the people of Scotland: Integrative literature review. Journal of Advanced Nursing, 64, 5, 416-439

Nursing Group: Multiple community nursing groups (Review)

Country: International

Aim: Explore the evidence base for community nursing

Method: Systematic review. Papers included = 73

Key findings: Little evidence which supports the effectiveness of different models of community nursing and in particular little evidence that these reduce health inequalities. The effectiveness of nursing depends on trusting relationships between nurses and patients. Nurses are ideally placed to conduct assessments and anticipate and prevent health problems.

27

Author: Fagerstrom L et al (2009)

Title and Source: An integrative research review of preventive home visits among older people - is an individual health resource perspective a vision or a reality? Scandinavian Journal of Caring Sciences, 23, 558-568.

Nursing Group: Multi-professionals but includes district nurses and 'other' nurses.

Country: International

Aim: To assess the practice and effects of home visits

Method: Systematic Review 18 papers.

Key findings: The aim of home visits is to help older people live independent and health lives. Visits usually involve screening, assessment, support and referrals to other services. These visits can reduce mortality, improve function and admissions to long-term care among very frail older people although the evidence is equivocal. The main focus of visits appears to be on narrow heath outcomes rather than more social dimensions of health e.g., social isolation.

28

Author: Kelcher et al (2009)

Title and Source: Systematic Review of the effectiveness of primary care nursing. International Journal of Nursing Practice 15, 16-24.

Nursing Group: Various working in general practice including nurse practitioner, practice nurse, health visitor, and community nurses.

Country: International

Aim: What is the impact of primary and community care nurses on patient health outcomes compared with primary care doctors?

Method: Systematic review 31 studies

Key findings: Nurses provide a diverse range of care such as chronic disease management, illness prevention, and health promotion. Satisfaction with nurse care is better than that given by doctors and a greater impact on quality of life was also evident. The impact on patients' knowledge was also greater. However there is no evidence that nurses have a better impact on mortality, health, hospitalization or readmission.

29

Author: Arbon P et al (2008)

Title and Source: Reporting a research project on the potential of aged care nurse practitioners in the Australian Capital Territory. Journal of Clinical Nursing, 18,255-262.

Nursing Group: Nurse practitioners in the community

Country: Australia

Aim: Investigate the impact of the nurse practitioners on hospital admissions, timely interventions and strengthen multi-disciplinary working.

Method: Mixed methods including routine visit data, interviews with nurses, survey (n=43) and focus groups of professionals in the clinical support teams, survey of clients (n=32).

Key findings: The research did not answer the key questions directly. Instead it assessed the 'potential' impacts of the posts and concluded that the nurse practitioners can play a role in assessment with view to early intervention. Can foster collaboration and access to timely care and brokering within the health service. The impact on patient health and hospital admissions was not assessed.

30

Author: O'Neill M and Cowman S (2008)

Title and Source: Partners in care: investigating community nurses' understanding of an interdisciplinary team-based approach to primary care. Journal of Clinical Nursing 17, 3004-3011.

Nursing Group: Public health nurses, general nurses and practice nurses.

Country: Ireland

Aim: Investigate community nurses' understanding of interdisciplinary team-based approach to primary care

Method: Focus groups with three groups: public health nurses (n=10), general nurses (n=10) and practice nurses (n=7).

Key findings: Nurses thought they contributed to team work and that this in turn lead to enhanced patient care and improved access to services but recognised there were challenges such as: the local availability of a full range of services and team members to suit the local population; resources to help people live at home; the need for supportive team work; poor educational preparation.

31

Author: Poulton B (2009)

Title and Source: Barriers and facilitators to the achievement of community-focused public health nursing practice: a UK perspective. Journal of Nursing Management 17, 74-83

Nursing Group: Community Health Nurses (District Nursing, community staff nurses, school nurses, health visitors, community mental health nurse, practice nurses, community learning disability nurse, midwives, occupational health nurses)

Country: UK (N. Ireland)

Aim: Examine the barriers and facilitators to public health practice

Method: Survey of a random sample of community health nurses n=409

Key findings: Most spent time with families but only 18% spent time on community activity and 9% had conducted a community assessment. Public health nurses (school, health visiting and occupational health) did more community based work. Main facilitator was education and the main barriers lack of managerial support and the need for elaborate routine data recording.

32

Author: Yarwood J. (2008)

Title and Source: Nurses' views of Family Nursing in Community Contexts. Nursing Praxis in New Zealand, 24,2,41-51

Nursing Group: Mixed group of registered nurses working in the community (Public Health Nurses, Practice Nurses, District Nurses, Well Child Nurses, and Rural Health Nurses).

Country: New Zealand

Aim: Explore how community nurses interacted with families

Method: Four focus groups n=18 nurses.

Key findings: Nurses experienced a great deal of satisfaction in working with families. The valued building relationships with families and other professionals. Family nurses saw themselves as good networkers which was necessary to address complex health problems such as violence, building family resilience and fostering collegiate support. Post registration was also valued in helping them develop relationships with the family. They tended to work beyond individuals and more with the family.

33

Author: Branson C and Badger (2008)

Title and Source: Skill mix in general practice: patients', professionals' and managers' perspectives. Primary Care, 18,1, 35-39

Nursing Group: Multi-professionals including GP employed nurses, practice nurses, district nurses and health visitors.

Country: UK (England)

Aim: Contribute to an understanding of skill mix in primary care, but particularly the role of nurses.

Method: Survey of one area in England (n=278 professionals n=241 patients)

Key findings: 68% of patients and 84% of professionals thought nurses could take on more work from GPs. Practice nurses were viewed as important in developing the skill mix. District nurses and health visitors were less visible in the skill mix as viewed by GPs and patients. Over 50% of patients thought routine/repeat prescriptions could be carried out by nurses, but not complex drugs. GPs were less willing to delegate these tasks and others such as demand for immediate care, anti-coagulants, skin complaints, musculo-skeletal problems, mental health or respiratory problems. Over 75% of GPs had already delegated monitoring tasks for chronic conditions such as asthma, diabetes and heart disease. Patients are less willing to see nurses for 'same day issues' or 'heart problems' (which they viewed as life threatening). Continuity of care was seen as important to patients i.e., seeing the same doctor or nurse.

References

Papers included in the literature review

Appleton V and Cowley S (2008) Health visiting assessment - unpacking critical attributes in health visitor needs assessment practice: A case study. International Journal of Nursing Studies 45, 232-245
Aranda J and Jones A (2008) Exploring new advanced practice roles in community nursing: a critique. Nursing Inquiry 15, 1, 3-10.
Arbon P et al (2008) Reporting a research project on the potential of aged care nurse practitioners in the Australian Capital Territory. Journal of Clinical Nursing, 18,255-262.

Bonsall K and Cheater F (2008) What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review. International Journal of Nursing Studies 45, 1090-1102
Branson C and Badger (2008) Skill mix in general practice: patients', professionals' and managers' perspectives. Primary Care, 18, 1, 35-39

Clancy A and Svensson T (2009) Perceptions of Public Health Nursing Practice by Municipal health Officials in Norway. Public Health Nursing 26, 5, 412-420.

Fagerstrom L et al (2009) An integrative research review of preventive home visits among older people - is an individual health resource perspective a vision or a reality? Scandinavian Journal of Caring Sciences, 23, 558-568.

Halcomb et al (2008) Cardiovascular disease management: time to advance the practice nurse role. Australian Health Review, 32, 1, 44-55
Hill et al 2010 Barriers and Facilitators to the Incorporation of Environmental Health into Public Health Nursing Practice. Public Health Nursing 27, 2, 121-130.
Hogg R and Hanley J (2008) Community Development in Primary Care: opportunities and challenges. Community Practitioner 8, 1, 22-25

Jasiak S and Passmore E (2009) Enhancing the roles of practice nurses: outcomes of cervical screening education and training in NSW. Australian Journal of Advanced Nursing 27, 2, 40-45.
Joyce C and Piterman (2009) Farewell to the handmaiden? Profile of nurses in Australian general practice in 2007. Australian Journal of Advanced Nursing 27, 1, 48-58.

Kaiser K and Farris N (2009) Public and Community Health Nursing Interventions with Vulnerable Primary Care Clients: A Pilot Study. Journal of Community Health Nursing. 26, 87-97.
Kelcher et al (2009) Systematic Review of the effectiveness of primary care nursing. International Journal of Nursing Practice 15, 16-24.
King et al (2010) Community Palliative Care: Role Perception. British Journal of Community Nursing, 15, 2, 91-98.
Kennedy et al (2008) Establishing the contribution of nursing in the community to the health of the people of Scotland: Integrative literature review. Journal of Advanced Nursing, 64, 5, 416-439
Krause-Parello C and Samms K (2009) The US model: The role of school nurses in New Jersey. British Journal of School Nursing. 4, 6, 287-292.

Markham T and Carney (2008) Public Health Nurses and the delivery of quality nursing care in the community. Journal of Clinical Nursing 17, 1342-1350
Mulcahy H et al (2008) Participatory nurse/client relationships: perceptions of public health nurses and mothers of vulnerable families. Applied Nursing Research 21, 169-172.
McGarry J (2008) Defining roles, relationships, boundaries and participation between elderly people and nurses within the home: an ethnographic study. Health and Social Care in the Community, 17, 1, 83-91
McIntosh J and Runciman P (2008) Exploring the role of partnership in the home care of children with special health needs: Qualitative findings from two service evaluations. International Journal of Nursing Studies, 45,714-726.
Meagher-Stewart D et al (2009) Population Health Surveillance Practice of Public Health Nurses. Public Health Nursing, 26, 6,553-560.
Mills J and Fitzgerald M (2008) The changing role of practice nurses in Australia: an action research study. Australian Journal of Advanced Nursing, 26, 1, 16-20
Murray J et al (2008) Survey to investigate the role of the community stroke care coordinator. British Journal of Community Nursing. 13, 1, 31-36

O'Donnell A et al (2010) Practice nurses' workload, career intentions and impact of professional isolation: a cross-sectional survey. BMC Nursing, 9, 2.
O'Neill M and Cowman S (2008) Partners in care: investigating community nurses' understanding of an interdisciplinary team-based approach to primary care. Journal of Clinical Nursing 17, 3004-3011.

Philibin et al (2009) The role of the public health nurse in a changing society. Journal of Advanced Nursing, 66, 4,743-752.
Pontin D and Lewis M (2008) Maintaining the continuity of care in community children's nursing caseloads in a service for children with life-limiting, life-threatening or chronic health conditions: a qualitative analysis. Journal of Clinical Nursing,18, 1199-1206.
Poulton B (2009) Barriers and facilitators to the achievement of community-focused public health nursing practice: a UK perspective. Journal of Nursing Management 17, 74-83

Senior E (2008) How general practice nurses view their expanding role. Australian Journal of Advanced Nursing 26, 1, 8-15
Smith F (2009) School nursing in the UK: Where are we now? British Journal of School Nursing 4, 7.

Wilhelmsson S and Lindberg M (2009) Facilitators and barriers perceived by district nurses. International Journal of Nursing Practice 15, 156-163

Yarwood J. (2008) Nurses' views of Family Nursing in Community Contexts. Nursing Praxis in New Zealand, 24, 2, 41-51

Citations in the text

Bidmead C, Cowley S. (2005) A concept analysis of partnership working with clients. Community Practitioner 78, 6, 203-208
Bonsall K and Cheater F (2008) What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review. International Journal of Nursing Studies 45, 1090-1102

Greenway J, Dieppe P, Entwhistle V, Meulen R. (2008) 'Facing the future': the government's real agenda for health visitors. Community Practitioner, 81, 29-32.

Kennedy C, Elliott L, Rush R, Hogg R, Cameron S, Currie M, Hall S, Miller M, Plunkett C, Lauder W. (2009) Review of Nursing in the Community: Baseline Study: http://www.scotland.gov.uk/Publications/2009/04/06105122/15

Ross A, King N, Firth J. (2005) Interprofessional relationships and collaborative working: Encouraging Reflective Practice. Online Journal of issues in Nursing, 10, 3.

Sweeney K (2009) The future of district nursing: the Queen's Nursing Institute debate. British Journal of Community Nursing, 14, 12, 538-543.
Senior E (2008) How general practice nurses view their expanding role. Australian Journal of Advanced Nursing 26, 1, 8-15

Search Strategies

CINAHL (EBSCO)

1 Community Health Nursing (MH)
2 community health nurs*
3 community nurs*
4 health visit*
5 district nurs*
6 public health nur*
7 family health nurs*
8 Schools, Nursing (MH)
9 school nurs*
10 practice nurs*
11 S1 orS 2 orS 3 orS 4 orS 5 orS 6 or S7 orS 8 or S9 or S10
12 Nursing Practice (MH)
13 Nursing Role (MH)
14 Professional Practice (MH)
15 practice development*
16 generic N3 role*
17 Nursing Intervention (MH)
18 (Decision Making or Decision Making, Clinical) (MH)
19 Patient Discharge (MH)
20 "Patient Admission (MH)
21 S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20
22 S11 and S21
23 S11 and S21 - Limiter - Published Date from: 20080101-20100631
24 S11 and S21 - Published Date from: 20080101-20100631; Research Article
25 (MH "cluster sample+") or TX life experiences or TX human science or TX discourse* analysis or TX narrative analysis or TX lived experience* or TX field research or TX field studies or TX field study or TX giorgi* or TX husserl* or TX merleau ponty* or TX van kaam* or TX van manen* or TX spiegelberg* or TX colaizzi* or TX heidegger* or TX participant observ* or TX data saturat* or TX semiotics or TX heuristic or TX hermeneutic* or TX etic or TX emic or TX focus group* or TX purpos* sampl* or TX constant comparison or TX constant comparative or TX grounded research or TX grounded studies or TX grounded study or TX grounded theor* or TX phenomenol* or TX ethnon* or TX qualitative or (MH "ethnological research") or (MH "ethnography") or (MH "phenomenology") or (MH "focus groups") or (MH "discourse analysis") or (MH "theoretical sample") or (MH "field studies") or (MH "constant comparative method") or (MH "thematic analysis") or (MH "content analysis") or (MH "observational method+") or (MH "purposive sample") or (MH "qualitative validity+") or (MH "grounded theory") or (MH "ethnonursing research") or (MH "phenomenological research") or (MH "ethnographic research") or (MH "qualitative studies")(MH "cluster sample+") or TX life experiences or TX human science or TX discourse* analysis or TX narrative analysis or TX lived experience* or TX field research or TX field studies or TX field study or TX giorgi* or TX husserl* or TX merleau ponty* or TX van kaam* or TX van manen* or TX spiegelberg* or TX colaizzi* or TX heidegger* or TX participant observ* or TX data saturat* or TX semiotics or TX heuristic or TX hermeneutic* or TX etic or TX emic or TX focus group* or TX purpos* sampl* or TX
26 S23 and S25
27 S24 or S26

Medline (EBSCO)

1 Community Health Nursing (MH)
2 community health nurs*
3 community nurs*
4 Public Health Nursing (MH)
5 public health nurs*
6 health visit*
7 district nurs*
8 family health nurs*
9 Schools, Nursing (MH)
10 school nurs*
11 practice nurs*
12 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11
13 Professional Practice (MH)
14 nursing practice
15 practice development*
16 generic N3 role*
17 Nurse's Role (MH)
18 S13 or S14 or S15 or S16 or S17
19 S12 and S18
20 S12 and S18
21 S12 and S18 -Limiter - Date of Publication from: 20080101-20100631; Clinical Queries: Qualitative - High Specificity

ASSIA (CSA)

1. Community nursing (DE)
2. Health visiting" or "health visitor client relationships" or "health (DE)
3. Public health nursing" or "public health nurses (DE)
4. #1 or #2 or #3
5. Limit 4 to publication year = 2008-2010

PsycInfo (EBSCO)

1 Nurses or Nursing (DE)
2 community health nurs*
3 Community Services (DE)
4 Primary Health Care (DE
5 Public Health Service Nurse (DE)
6 public health nurs* (KW)
7 health visit* (KW)
8 district nurs* (KW)
9 school nurs* (KW)
10 practice nurs* (KW)
11 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10
12 professional practice* (KW)
13 nursing practice* (KW)
14 practice development* (KW)
15 generic N3 role*
16 nurse* role* (KW)
17 S12 or S13 or S14 or S15 or S16
18 S11 and S17
19 S11 and S17 - Limiters - Publication Year from: 2008-2010
20 S11 and S17 - Limiters - Publication Year from: 2008-2010; Methodology empirical study, field study, interview, -focus Group, literature review, -Systematic Review, -Qualitative Study, -Quantitative Study