General Community Nurses Research Articles

Working with carer grief in community palliative care nursing.

Community nurses (CN), both generalist and palliative care-specific, are key to supporting the carer with their experience of grief. To identify the grief-related needs of carers and the capacity of CNs to provide for those needs. A convergent parallel mixed-methods study which employed i) a needs questionnaire among carers of palliative care patients who had recently died; ii) a qualitative interview study among carers and iii) a questionnaire among CNs which canvassed their confidence and skills in working with carer grief. In the carer survey, just one-third of carers reported engagement with CNs regarding prolonged and anticipatory grief. In the CN survey, low confidence and skill regarding supporting carers with their grief was reported. CNs with palliative care training were more confident and knowledgeable than generalist CNs. Despite offering high ratings for CN compassion and overall quality of support during the dying process, grief support was reported by carers to be missing from their experience of CN care. The role of CNs in providing for the grief-related needs of carers is yet to be established.

Barriers and facilitators to multidimensional symptom management in palliative care: A focus group study among patient representatives and clinicians.

It is widely acknowledged that co-occurring symptoms in patients with a psychosocial and spiritual aspects should also be considered. However, this multidimensional approach is difficult to integrate into daily practice, especially for generalist clinicians not specialized in palliative care. We aimed to identify the barriers and facilitators to multidimensional symptom management. Focus group meetings were conducted with the following stakeholders: (1) patient representatives, (2) generalist community nurses, (3) generalist hospital nurses, (4) general practitioners, (5) generalist hospital physicians, and (6) palliative care specialists. Audiotapes were transcribed verbatim and thematically analyzed. Fifty-one participants (6-12 per group) reported barriers and facilitators with 3 main themes: multidimensional symptom assessment, initiating management of nonphysical problems, and multidisciplinary collaboration. As barriers, generalist clinicians and palliative care specialists reported that generalist clinicians often lack the communication skills to address nonphysical problems and are unaware of available resources for multidimensional symptom management. Palliative care specialists felt that generalist clinicians may be unaware that assessing nonphysical problems is important and focus on pharmacological interventions. Generalist nurses and palliative care specialists indicated that hierarchical difficulties between them and generalist physicians are barriers to multidisciplinary collaboration. Reported facilitators included using symptom assessment scales and standardized questions on nonphysical problems. Generalist clinicians can be supported by improving their communication skills, increasing their awareness of available resources for multidimensional symptom management, and by using a standardized approach to assess all 4 dimensions of palliative care.

Chronic wound care delivery in wound clinics, community nursing and residential aged care settings: A qualitative analysis using Levine’s Conservation Model

To explore patient experience of chronic wound care across diverse models of outpatient wound care delivery. Chronic wounds represent a significant personal, family and healthcare system burden. Evidence suggests specialist wound clinics are more effective and less expensive, however, most outpatient wound care is delivered by general community nurses. There is little understanding of how patients experience diverse models of wound care delivery and the subsequent impact on their capacity to adapt to imbalances in their internal/external environment. Descriptive, qualitative study. Eighteen patients with chronic wounds from three wound services were engaged in semi-structured interviews. Initial inductive analysis was refined deductively using Levine's Conservation Model. Chronic wounds lead to imbalances and subsequent adaptions in energy conservation and personal, social and structural integrity. Nursing process and wound care system responses suggest specialist wound clinics provide access to the right person and care at the right time, with less care variation. The community nursing model is most effective with a small team of nurses and a documented care plan, with specialist wound nurse oversight. Residential aged care facilities emerged as important sites for wound care delivery revealing higher variance in care and less specialist wound oversight. The application of Levine's conservation model provides a theoretical understanding and important insights into the patient experience of nurse and system elements across diverse models of wound care delivery. Specialist oversight by expert wound nurses with the capacity for medical specialist referral is the cornerstone of good wound care. A frequently reviewed wound care plan and skill development for nurses in primary, aged care and community settings are vital. Shared care between specialist and primary care should include evidence-based pain assessment, clear referral pathways, collaborative relationships, telehealth capacity, patient-held wound plans and upskilling of frontline clinicians.

Generalist Palliative Care Delivered by Community Nurses

Background: Little is known about general nurses providing palliative care in the community. This case outlines the care delivered to a gentleman living at home with COPD by a Community Intervention Team (CIT) working in collaboration with allied health professionals. Case presentation: The care of a gentleman who has expressed a wish to be cared for at home is outlined. His care is managed by a range of professionals to include the GP, public health nurse (PHN), pharmacist and CIT. Outcome and follow up: The CIT deliver physical and psychological care, both of which are indicative of palliative care. The service supports GPs and PHNs and is demonstrated as being a key service that supports the delivery of palliative care in the community. The CIT work as a service to ensure that the gentleman and his family access both primary and specialist services in a co-ordinated and efficient manner. Conclusion: General community nurses provide a palliative approach to care. This case displays that communication and collaboration among team members working in the community are key to the delivery of palliative care. More research is needed to clarify the role of general nurses delivering palliative care in the community.

A comparison of the management of venous leg ulceration by specialist and generalist community nurses: A judgement analysis

BackgroundVenous leg ulcer management in the UK varies significantly. Judgements made by nurses contribute to this variability and it is often assumed that specialist nurses make better judgements than non-specialist nurses. This paper compares the judgements of community tissue viability specialist nurses and community generalist nurses; specifically, the ways they use clinical information and their levels of accuracy. ObjectivesTo compare specialist and non-specialist UK community nurses’ clinical information use when managing venous leg ulceration and their levels of accuracy when making diagnoses and judging the need for treatment. DesignJudgement analysis. SettingUK community and primary care nursing services. Participants18 community generalist nurses working in district (home) nursing teams and general practitioner services and 18 community tissue viability specialist nurses. MethodsData were collected in 2011 and 2012. 18 community generalist nurses and 18 community tissue viability specialist nurses made diagnostic and treatment judgements on 110 clinical scenarios and indicated their confidence in each of their judgements. Scenarios were generated from real patient cases and presented online using text and photographs. An expert panel made judgements, and reached consensus on the same scenarios. These judgements were used as a standard against which to compare the participants. Logistic regression models and correlational statistics were used to generate various indices of judgement “performance”: accuracy, consistency, confidence calibration and information use. Differences between groups of nurses with different levels of characteristics linked to expertise were explored using analysis of variance. ResultsSpecialist nurses had similar cue usage to the generalist nurses but were more accurate when making diagnostic and treatment judgements. ConclusionIt is not obvious why the tissue viability specialist nurses were more accurate. One possible reason might be the greater opportunities for ‘deliberate practice’ afforded to specialists. However, restricting aspects of practice only to specialist nurses is likely to hinder the judgement performance of generalists.

The impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial).

BackgroundThe risk factors for chronic disease, smoking, poor nutrition, hazardous alcohol consumption, physical inactivity and weight (SNAPW) are common in primary health care (PHC) affording opportunity for preventive interventions. Community nurses are an important component of PHC in Australia. However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice. This study aimed to address this gap in our knowledge.MethodsThe study was a quasi-experimental trial involving four generalist community nursing (CN) services in New South Wales, Australia. Two services were randomly allocated to an ‘early intervention’ and two to a ‘late intervention’ group. Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients. Those in the late intervention group provided usual care for the first 6 months and then received training. Clients aged 30–80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected. Data on their SNAPW risk factors, readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline, 3 and 6 months. Analysis compared changes using univariate and multilevel regression techniques.Results804 participants were recruited from 2361 (34.1%) eligible clients. The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group (from 12.9 to 23.3% and 12.3 to 19.1% respectively) as did the proportion who recalled being referred for dietary or physical activity interventions (from 9.5 to 15.6% and 5.8 to 21.0% respectively). There was no change in the late intervention group. There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group. Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months.ConclusionThe study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity, this did not translate into significant changes in lifestyle behaviours or weight. This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses.Trial registrationACTRN12609001081202

Is there scope for community health nurses to address lifestyle risk factors? the community nursing SNAP trial

BackgroundThis paper examines the opportunity and need for lifestyle interventions for patients attending generalist community nursing services in Australia. This will help determine the scope for risk factor management within community health care by generalist community nurses (GCNs).MethodsThis was a quasi-experimental study conducted in four generalist community nursing services in NSW, Australia. Prior to service contacts, clients were offered a computer-assisted telephone interview to collect baseline data on socio-demographics, health conditions, smoking status, physical activity levels, alcohol consumption, height and weight, fruit and vegetable intake and 'readiness-to-change' for lifestyle risk factors.Results804 clients participated (a response rate of 34.1%). Participants had higher rates of obesity (40.5% vs 32.1%) and higher prevalence of multiple risk factors (40.4% vs 29.5%) than in the general population. Few with a SNAPW (Smoking-Nutrition-Alcohol-Physical-Activity-Weight) risk factor had received advice or referral in the previous 3 months. The proportion of clients identified as at risk and who were open to change (i.e. contemplative, in preparation or in action phase) were 65.0% for obese/overweight; 73.8% for smokers; 48.2% for individuals with high alcohol intake; 83.5% for the physically inactive and 59.0% for those with poor nutrition.ConclusionsThere was high prevalence of lifestyle risk factors. Although most were ready to change, few clients recalled having received any recent lifestyle advice. This suggests that there is considerable scope for intervention by GCNs. The results of this trial will shed light on how best to implement the lifestyle risk factor management in routine practice.

How useful is the expert practitioner role of the clinical nurse consultant to the generalist community nurse?

Objective: The objective was to draw attention to the clinical component of the clinical nurse consultants’ (CNC) role in the community. Design: Quasi‑experimental research design that used descriptive statistics for data analysis. Setting: An urban community nursing organisation comprising six community nursing Centres within the northern part of a major Australian city. Subjects: A self selected sample of nine generalist community nurses (GCN) for a focus group. Information gained from this group informed the development of a questionnaire, which was sent to a convenience sample (n=125) of GCNs. Participation was voluntary and participants were not identified. Seventy‑eight questionnaires were returned within the specified time frame, providing a return rate of 62.4%. Results: Three main themes emerged: enabling the community nurses’ role; accessing clinical knowledge\expert practitioner; and valuable resource. The main reasons community nurses accessed CNCs were for clinical knowledge (73%) and problem solving (70%); the majority (82.9%) indicated visiting patient’ homes with the CNCs was most useful. Conclusion: As the complexity of patients’ needs at home increase, CNCs have taken on an integral clinical role within the organisation. The positive working relationship between the CNCs and GCNs presumably had enhanced patient outcomes and improved patient health status. A significant strength of the survey was the consistent responses in favour of CNCs working in the community with the GCNs. A limitation is that the response rate was small (n=78) and results cannot be generalised. Results of this survey could serve to inform future work force planning.

An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial).

BackgroundLifestyle risk factors, in particular smoking, nutrition, alcohol consumption and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care (PHC) has been shown to be an effective setting to address lifestyle risk factors at the individual level. However much of the focus of research to date has been in general practice. Relatively little attention has been paid to the role of nurses working in the PHC setting. Community health nurses are well placed to provide lifestyle intervention as they often see clients in their own homes over an extended period of time, providing the opportunity to offer intervention and enhance motivation through repeated contacts. The overall aim of this study is to evaluate the impact of a brief lifestyle intervention delivered by community nurses in routine practice on changes in clients' SNAP risk factors.Methods/DesignThe trial uses a quasi-experimental design involving four generalist community nursing services in NSW Australia. Services have been randomly allocated to an 'early intervention' group or 'late intervention' (comparison) group. 'Early intervention' sites are provided with training and support for nurses in identifying and offering brief lifestyle intervention for clients during routine consultations. 'Late intervention site' provide usual care and will be offered the study intervention following the final data collection point. A total of 720 generalist community nursing clients will be recruited at the time of referral from participating sites. Data collection consists of 1) telephone surveys with clients at baseline, three months and six months to examine change in SNAP risk factors and readiness to change 2) nurse survey at baseline, six and 12 months to examine changes in nurse confidence, attitudes and practices in the assessment and management of SNAP risk factors 3) semi-structured interviews/focus with nurses, managers and clients in 'early intervention' sites to explore the feasibility, acceptability and sustainability of the intervention.DiscussionThe study will provide evidence about the effectiveness and feasibility of brief lifestyle interventions delivered by generalist community nurses as part of routine practice. This will inform future community nursing practice and PHC policy.Trial RegistrationACTRN12609001081202

Exploration of interaction and shared care arrangements of generalist community nurses and external nursing teams in a rural health setting

Objective: The purpose of this pilot study was to determine the understanding of nurses within a shared care model and the degree of interaction evident in their practice in the shared care nursing environment in a rural caresetting. Sharing of care between different nursing teams can allow for the improved use of minimal resources available in rural communities. The objectives of the research were firstly, to identify the interactions of nursing teams in a shared care model and secondly, to determine how shared care is evident in their practice. The final objective was to draw attention to the importance of shared care models in rural health settings and to develop recommendationsto support shared care models. Design: A qualitative, non experimental, grounded theory descriptive study was used in this research. Setting: Primary care. Subjects: The sample comprised the generalist community health team, which consisted of registered nurses with more than 5 years post registration experience in community health nursing and two external nursing teams, comprised of a palliative care team and an aged care team. Main Outcome Measures: Identification of the nursing interactions and shared care practices in order to develop recommendations to foster and support shared care models in changing health structures. Results: The study generated four themes: a lack of understanding of each teams’ roles; difficulties in communication of information; the importance of setting shared goals in care planning; and the need for collaboration to ensure clarity in case coordination. Conclusion: Results suggest that confusion around role, skills, communication, care planning and coordination of care within a shared care model are creating barriers to effective sharing of care. Co‑location of services should enhance sharing of care. These results should facilitate the development of care approaches that maximise health outcomes and contribute to a better understanding of collaborative processes that can assist in the provision of health care in rural settings.

Non-medical perspectives within primary care.

Through time, starting in the Victorian era, primary care has been responsible for the majority of health care delivery and it will continue to do so with the imminent reconfiguration of services in light of Ara Darzi's recommendations for London.1 Indeed, the recent recommendations could be seen as re-emphasizing the role of primary care and challenging the dominance of the hospital in British health care. Further, despite the many advances in therapeutics the reality remains that patients all too frequently do not adhere to their prescribed therapies2 emphasising the gap between the laboratory of medical advances and the real life patient and therefore the importance of understanding patients within the context of their lives in London. The traditional skills of generalist community and practice nurses and pharmacists are being augmented by the development of specialist interests around chronic disease management, public health and the management of minor illness. Thus we are seeing the emergence of a range of practitioners to both supplement and substitute for general practitioners in the delivery of primary care services. Horrocks et al's systematic review3 confirmed that nurse practitioners were able to deliver equivalent care to that of general practitioners despite the relative professional immaturity of the nurse practitioners compared to the doctor samples. Disappointingly there are few trials comparing pharmacist delivered or nurse delivered services with normal doctor led primary care. Nonetheless, pharmacists, nurses and other non-medical practitioners are increasingly delivering innovative services to meet current health needs in primary care. Thus nurses and pharmacists are at the forefront of public health initiatives offering alcohol screening, emergency contraception, Chlamydia screening and plans for pandemic vaccination. Similarly nurses and pharmacists are working together on various chronic disease management initiatives around diabetes, COPD and heart disease with a special emphasis upon effective medicine management and minimization of avoidable hospital admissions. This new journal can make a useful contribution to the dissemination of an evidence base for these emerging areas of practice as well as being a vehicle for debate around issues relating to integrated care and team working across an increasingly diverse group of practitioners delivering primary care to Londoners.

Enhancing Emotional Well-being Through Self-care

This article discusses the importance of self-care in enhancing the emotional well-being of generalist community nurses providing palliative care. This research undertaken in Australia explored the relationship between emotional well-being and professional practice. The results demonstrated the importance of self-care, aspects of palliative care that impacted on nurses' well-being, and strategies utilized by nurses to care holistically for themselves to continue providing holistic palliative care.

Implementing Family Health Nursing in Tajikistan: From policy to practice in primary health care reform

The health systems of former Soviet Union countries are undergoing reform away from the highly centralised, resource-intensive, specialised and hierarchical Soviet system, towards a more generalist, efficient health service with greater focus on primary health care. Family Health Nursing is a new model designed by WHO Europe in which skilled generalist community nurses deliver primary health care to local communities. This paper presents a qualitative evaluation of the implementation of Family Health Nursing in Tajikistan. Using Stufflebeam's ‘Context, Input, Process, and Product’ model, the paper aims to evaluate the progress of this reform, and to understand the factors that help or hinder its implementation. A four-phase research design investigates the development of the Family Health Nurse role over time. In 5 rural areas, 6 focus groups and 18 interviews with Family Health Nurses, 4 observations of their practice, 7 interviews with families and 9 interviews with physicians were carried out. Data were analysed according to the components of Stufflebeam's model. Although the legacy of the Soviet health system did not set a precedent for a nurse who is capable of decision-making and who works in partnership with the physician, Family Health Nurses were successfully implementing new practices. Crucial to their ability to do so were the co-operation of physicians and families. Physicians were impressed by the nurses’ development of knowledge, and families were impressed that the nurses could offer real solutions to their problems. However, failure to pay the nurses regular salaries had led to serious attrition of the workforce. We conclude that the success of the Family Health Nurse role in other countries will depend upon its position in relation to the historical health care system.

A sense of security for cancer patients at home: the role of community nurses

The present paper reports on a qualitative research project designed to expose the presently unrecognised minutiae of community nurses' work with cancer patients at home, and to identify the ways in which these, combined to form comprehensive care episodes, contribute to physical and psychosocial well-being. The project was conducted in two locations in New South Wales, Australia, one metropolitan and one rural. The research model focused on particular nurse-patient encounters, and involved pre- and post-encounter interviews with nurses, post-encounter interviews with patients and carers, and observation of the encounters themselves. Participants included generalist community nurses, cancer patients being cared for at home, and their primary carers where appropriate. This research demonstrates that regular contact with generalist community nurses is associated with a strong sense of security about the immediate situation for home-based cancer patients and their primary carers. This sense of security is a significant component of patient and carer physical and psychosocial well-being, and may have implications for health services utilisation. In the present paper, the authors outline the factors underpinning this sense of security, and argue that these findings contribute important new knowledge that is vital for contemporary debates about role responsibilities and continuity of care for cancer patients.

Mental health and physical illness in older people

Older people are acknowledged as being high users of health care and social services. Older people with physical health problems are more than twice as likely as people who are physically healthy to suffer a depressive illness. Nevertheless, most elderly people do not suffer from depression and it is not an inevitable consequence of being old and physically disabled or ill. Depression at any age whether in the presence of other illness or not is a highly treatable illness; treating it effectively will improve the level of functioning and the quality of life for both patients and carers. Community nurses provide a good deal of what may be termed supportive care for people with mental health problems, however, they may be ill prepared by their training to provide this care in the best possible way. This article examines the facts about mental ill-health in older people and points to some of the ways in which generalist community nurses, practice nurses, health visitors and district nurses may be able to improve their practice with this important and potentially vulnerable group.

Community Nursing in a Climate of Economic Rationalism: The Need to Value an Ethic of Care

For almost 25 years generalist community nurses have provided professional services and developed many innovative programs in response to the needs of Victorian communities. They have established a Primary Health Care role in the co-ordination and management of preventative and therapeutic programs, as well as undertaking their more traditional duties of support and nursing care. At the present time there is unprecedented change occurring in both the structure and practice of community nursing, due, in large part, to measures aimed at achieving economic goals and reducing the high cost of illness care. These changes are creating ethical dilemmas for generalist community nurses who believe that the social costs of economic management might, in the long term, outweigh the gains. At a time of growing socio-dislocation when the community is exhibiting symptoms of alienation, experienced generalist community nurses are needed more than ever to provide a voice for those whose needs are not being met. The dilemma for nurses is how to provide the services that the community needs, cope with increasing and more complex caseloads, meet the demands of the bureaucracy, and become involved in the politics of decision making to influence health policy. The ethical stance of generalist community nurses and the rational stance of politico-economic decision makers are explored, and it is suggested that it is vital for nurses to value their professional ethics and to reaffirm their role if they are to survive the next 25 years.

Back to Bikes

The 'Back to Bikes' health promotion initiative was planned and implemented by the Generalist Community Nurses working in the Health Centres of Wallerawang and Portland New South Wales.

Ethical Problems Encountered by Mental Health Nurses

This descriptive study examines ethical conflicts reported by psychiatric-mental health nurses in community and inpatient settings. Generalist community nurses were included for comparison. The analysis of cases included reviewing general descriptions of the cases and identifying decision maker, principles involved, and type of moral conflicts. Fifty-seven case situations were collected: 20 cases from a psychiatric hospital, 18 cases from community mental health programs, and 19 cases from a general public health program. Fifty-one of the 57 cases reflected ethical problems. Using Jameton's (1984) categories, 30 of the 57 cases were rated as a dilemma, 18 were rated as moral uncertainty, and 3 were rated as examples of distress. The mental health nurses indicated that they believed they were the decision maker in the majority of cases. The general community nurses were more likely to believe the client was the decision maker. The identified principles, based on Veatch and Fry (1987), were doing good, or beneficence (26); confidentiality (10); autonomy (9); avoiding deception (4); and preventing killing (2). In the remaining 6 cases no principles were identified. Staff conflict was present in 13 of 20 inpatient cases, as compared with only 3 cases in each of the community settings (p less than .005).