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National Review of Nursing Education
Aspects of Nursing Education: The Types Of Skills And

Knowledge Required To Meet The Changing Needs Of The
Labour Force Involved In Nursing - Literature Review
Report
Submitted by
Victorian Centre for Nursing Practice Research
School of Postgraduate Nursing

The University of Melbourne
Ms. Robyn L. Aitken, Ms. Robyn Faulkner, Dr. Tracey Bucknall, Professor Judith Parker
ISBN 0 642 77241 X (Online version)

DEST No. 6777.HERC01A
Acknowledgements:
The authors wish to acknowledge the following people for their contribution to the report:
Reviewers:
Ms Sue Gold RN Crit Care Cert Alfred BEd LaT GradDip MAppSc
Innovation & Service Management RMIT
Principle Consultant, Sue Gold & Associates
Educator, Education & Staff Development, Cabrini Hospital
Ms Catherine Barrett
Higher Degree Candidate
Ms Mary Carolan
Higher Degree Candidate
Ms Karen Edward
Honorary Fellow
Ms Donna Milne
Research Fellow
Literature Retrieval:
Ms Kitty Wong
Research Assistant (Casual)
Ms Deb Barge
Research Assistant (Casual)
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Executive Summary
In 2001, a research team from the Victorian Centre for Nursing Practice Research, located at the
School of Postgraduate Nursing, University of Melbourne was commissioned on behalf of the
National Review of Nursing Education to undertake a literature review on aspects of Nursing
Education.
The aim of this literature review is to identify recent and predicted changes in health care services
that impact upon nursing and to identify the types of skill and knowledge the nurse has required and
will require when dealing with these changes. Articles were sorted according to major recurring
themes and then according to level of evidence. All articles meeting the NHMRC levels of evidence,
or were descriptive and added to the body of knowledge, were included.
The literature reveals that changes in healthcare services over the past five years are largely
attributed to the concept of healthcare as a commodity. As a commodity, healthcare services are
scarce, with demand exceeding supply. New and innovative ways of maximizing health care funding
to provide health care services to an increasingly dependent aging population are essential. In order
to best manage such valuable resources healthcare services are accordingly in a state of dynamic
organisation and re-organisation.
A significant trend is the move away from institutionalised care and relocating care closer to the
client in his/her home or local community. Emerging from the literature are new ways of delivering
such care. These delivery modes include case management/managed care, patient focused care,
community nurse-led care, integrated hospital and community care, family provided care and care
delivered by unlicensed personnel. While these changes have affected all care modalities, the
literature also reveals specific considerations in the areas of mental health, acute care and
midwifery.
The emergence of the information age and the advent of the technology to support 'remote' care
delivery in the community have also impacted on the way services are delivered. Information is a
critical resource in the health system. It enables the integration across settings, reduces duplication
and errors, and provides timely information. Professionals are increasingly reliant on information at
the "point-of-care" to make decisions crucial to patient outcomes.
At the same time the provision of care has become highly specialised. While client involvement in
care is encouraged and individualisation of care promoted, the concept of population health has also
emerged. Populations may be geographically identified, or may consist of a cohort of client's sharing
the same diagnostic related group. Importantly, the services for each identified population not only
includes disease management, but also disease prevention and health promotion services.
Each of these changes in service has impacted upon the role of service providers. New nursing roles
have emerged in direct response to changes in service. As a consequence, roles have both expanded
to become more generalist and extended to become more specialised. The development of roles
continues to show distinct differences between the setting, locale and focus of practice.
The literature has revealed that both changes in service and changes in role have impacted upon
skills and knowledge required for providing optimal care in the current and future health care
settings. The main themes relating to skills and knowledge of the nurse have arisen both directly
from the literature and through interpretation of the literature by the research team. The skills and
knowledge that have emerged as necessary for all service settings and roles are coordination of
care, patient/client assessment, clinical decision making, patient/client and family teaching, research
consumption and application, and counselling.
It is important to note that the information relating to these themes/trends provided in the body of
the report has largely been based on narrative accounts. To a large extent either clinical or
academic experts have provided this narrative. The research-based data was predominantly
qualitative in nature. This is not uncommon in the field of nursing. As a consequence, the report
contains a low level of evidence in some areas. Where conclusions have been drawn, they have been
based on high level evidence provided in the form of systematic reviews and randomized control
trials and the pertinent details of the research have been included in the text. Appendix D & E
details the breadth of literature reviewed and the corresponding levels of evidence.
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Table of Contents
● Acknowledgements
● Executive Summary
● Table of Contents
● Chapter 1 Introduction
❍ The Purpose of the Report
❍ The Scope of the Literature Review
❍ Methodology
■ Search Strategy
■ Database Searching
■ Internet Searching
● Chapter 2 Literature Review
❍ General Context of Practice
❍ Section 1: The Changes In The Types Of Service Provided Impacting On Nursing
■ Case-Management/Managed Care
■ Patient Focused Care
■ Community Nurse-Led Care
■ Nurse-Led Clinics
■ Family Provided Care
■ Care Delivered By Unlicensed Personnel
■ Mental Health Care
■ Acute Care
■ Midwifery Care
■ Telemedicine/Telehealth
■ Services Provided By Specialist Nurses/Extended And Expanded Roles
■ Effectiveness of Nurse Practitioners
❍ The Current Literature - Satisfaction with the Nurse Practitioner Role
❍ The Current Literature -Nurse Practitioner Contexts/Settings
● Nurse Practitioner and Physician's Assistants
❍ Section 2:Changes in the roles of health professionals which have impacted on nursing
❍ Section 3:Summary of Required Skills and Knowledge
● Chapter 3 Conclusions
● References
● Appendices
❍ Appendix A
■ Definition of terms (Alphabetical Order)
❍ Appendix B
■ Key to in-text abbreviations relating to country of origin:
❍ Appendix C
■ Nurse Practitioner and Clinical Nurse Specialist
❍ Appendix D
■ Abstract sorting by broad category and level of evidence
❍ Appendix E
■ Summary of articles by country of origin

Disclaimer
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Appendices
Appendix A
Definition of terms (Alphabetical Order)
The following are terms used frequently throughout this review.
Assistive or support workers in health care
This category includes workers who are generally not regulated through statutory rulings. "They are
required to act safely and effectively within their sphere of competence...under the direct or indirect
supervision" of a registered nurse (ICN). This includes unlicensed assistants,
Attribute
An attribute "is an inherent characteristic of a person and is used in many cases to distinguish one
individual or group of individuals from another (Merriam-Webster's Collegiate Dictionary, 2000, as
quoted in KPMG).
Enrolled nurses
Enrolled nurses are regulated by government to practice under the supervision of a registered
nurse. Competency standards reflect the standards and scope of practice for which the enrolled
nurse is responsible. (ANCI)
Knowledge
Acquaintance with a fact or facts; a state of being aware or informed; awareness, consciousness.
Intellectual perception of fact or truth; clear and certain understanding or awareness. (New Shorter
Oxford English Dictionary 1993)
Nursing
ICNP® reflects the ICN definition of nursing which follows:Nursing, as an integral part of the health
care system, encompasses the promotion of health, prevention of illness, and care of physically ill,
mentally ill, and disabled people of all ages, in all health care and other community settings. Within
this broad spectrum of health care, the phenomena of particular concern to nurses are individual,
family, and group "responses to actual or potential health problems". These human responses range
broadly from health restoring reactions to an individual episode of illness to the development of
policy in promoting the long-term health of a population (ICN, 1987).
Nursing workforce
"The Australian nursing workforce consists of nurses educationally prepared at two levels", that
being the registered nurse and enrolled nurse (ANCI). The nursing workforce consists of the
employed individuals who are regulated by a statutory body. The workforce reflects a fluctuating
number and skill mix of full time, part time or casual workers.
Registered nurses
Registered nurses are those who are regulated by government, are accountable to the community
and responsible for their own practice. Registration is achieved and maintained through the
attainment of standards of competence that reflect expected behaviours, roles and functions.
Registered nurses have responsibility for the supervision of enrolled nurses (ANCI).
Role
The characteristic or expected function of a person or thing, in a particular setting or environment.

(New Shorter Oxford English Dictionary 1993)
Scope of nursing practice
'Scope of nursing practice' incorporates:
● the settings in which nursing may occur and includes hospitals, primary care services, public
health, child health settings, home environment, schools, prisons and the workplace
● the sectors in which nursing may occur and includes primary, secondary or tertiary centres;
hospitals, hospital in the home, community care, home care, preventative health, health
promotion
● a recognition of specialty and/or generalist nursing practice
● independent or collaborative nursing practice
● clinical practice, consultancy, administration, management, education and research
There is recognition that nursing practice often overlays the practices of other health care
professionals and other health care workers.
The scope on nursing practice will in influenced by length and range of experience, attainment of
competencies and educational preparation.
Service
Assistance or benefit provided to someone by a person or thing (New Shorter Oxford English
Dictionary 1993)
Skills
Skills are "the ability to use knowledge effectively in performing tasks and activities. Skills are not
static, but are learned or developed and thus can be acquired and subsequently refined over
time." (Merriam-Webster's Collegiate Dictionary, 2000 in KPMG)
Appendix B
Key to in-text abbreviations relating to country of origin:
AUS = Australia
CAN = Canada
NETH = Netherlands
SC = Scandanavia
UK = United Kingdom
USA = United States of America
Appendix C
Nurse Practitioner and Clinical Nurse Specialist
While the role of nurse practitioner was developed and became firmly established in both the USA
and Canada approximately thirty years ago, the role has been introduced in the United Kingdom,
Australia and New Zealand in the last five to ten years.
Before going on to outline the nurse practitioner literature it is important to have brief background
information on the title "nurse practitioner", its protection in legislation and the educational
preparation of nurse practitioners since these vary from country to country and between States in
Australia. These differences influence the interpretation of the articles.
Background - the title, Nurse Practitioner, and the legislation
In the United States of America nurse practitioners are one of a number of nurses considered under
the umbrella title, Advanced Practice Nurse (APN). This umbrella title also includes clinical nurse
specialists, nurse midwives and nurse anaesthetists. The title, nurse practitioner or its equivalent
(registered nurse practitioner, etc), is protected in legislation in the individual states' Nurse Practice
Act (or their equivalent). Nurse practitioners are registered nurses who have additional knowledge
and skills in their area of specialty gained through an organised educational program and are
certified by the Board of Nursing (or similar body) to engage in practice as an advanced practice
nurse.
While the title, nurse practitioner, has been in common use in Canada since the 1970's, and nurse
practitioner specific education became available in 1975, the title is not protected in relevant
Canadian Acts. Regulation of advanced nursing practice is seen to be '...within the current scope of
nursing practice and prevailing regulatory approaches.' (Canadian Nurses Association 1999, p 3)
In the United Kingdom educational programs that prepare nurse practitioners for practice began in
1990, however like Canada, the title 'nurse practitioner' is not protected in legislation.
New Zealand is currently discussing protection of title and in a Nursing Council of NZ document, "the
Nurse Practitioner Responding to Health Needs in New Zealand" protection of title is proposed in the
interests of public safety.
Australian states have approached nurse practitioners in a variety of ways. New South Wales,
following an evaluation of the role in a variety of metropolitan and rural settings, amended the
Nurses Act 1991 to provide for nurses to practise as nurse practitioners and the title has been
protected since 1998. At least one emergency nurse practitioner and a community nurse practitioner
have been appointed.
Victoria had pilot nurse practitioner projects in 1999 and currently has further pilots underway. The
title, nurse practitioner, was recently protected in legislation and proclaimed in the Nurses
Amendment Act 2000 in December.
In the Australian Capital Territory four pilot nurse practitioner projects are currently underway
however the title is not currently protected.
South Australia has had extensive consultation about the role through their Department of Human
Services and the Nurses Board is currently seeking comment from key stakeholders on a draft
standards statement for NP practice. These standards include protection of title. Similarly in Western
Australia the Remote Area Nurse Practitioner Report of April 2000 has recommended that the title
nurse practitioner be protected.
Tasmania is also looking at the role but does not appear to have progressed as far as other states.
In Queensland the title is not protected and there appears no move to do this however legislative
changes have already been made to enable isolated practice nurses to administer specific
medications, order x-rays and perform pap smears.
Appendix D
Abstract sorting by broad category and level of evidence
LEVEL OF EVIDENCE
CATEGORY (no. articles in category) I II III IV Qual Ex Oth
Case management/managed care (9) 2 7
Patient focused care (11) 3 8
Community nurse led care (19) 2 7 10
Integrated hospital and community care (7) 5 2
Family provided care (10) 1 1 1 2 3 2
Care delivered by unlicensed personnel (13) 5 7 1
Mental health care (14) 2 3 5 4
Acute care (22) 1 8 13
Midwifery care (28) 1 3 5 2 9 7 1
Telemedicine/telehealth (44) 1 9 4 5 9 13 3
Services provided by specialist nurses/extended and
4 5 1 20 6 2
expanded roles (38)
Roles of other professionals (20) 2 3 3 6 3 3
TOTAL (235) 2 20 20 14 79 84 16
Key
Qual = qualitative study

Ex = expert opinion
Oth = other (literature review, narrative)
Appendix E
Summary of articles by country of origin
COUNTRY
CATEGORY (no. articles in category) Aus UK USA Scan Can Com
Case management/managed care (9) 9
Patient focused care (11) 2 8 1
Community nurse led care (19) 6 11 1 1
Integrated hospital and community care (7) 4 3
Family provided care (10) 2 4 2 2
Care delivered by unlicensed personnel (13) 6 6 1
Mental health care (14) 2 10 2
Acute care (22) 2 6 14
Midwifery care (28) 5 12 10 1
Telemedicine/telehealth (44) 1 15 24 2 1 1
Services provided by specialist nurses/extended and
1 10 26 1
expanded roles (38)
Roles of other professionals (20) 5 15
TOTAL (235) 22 86 115 3 5 4
Key:
Aus = Australia
UK = United Kingdom
USA = United States of America
Scan = Scandinavia
Can = Canada
Com = Combined (USA/Scan, UK/Aus, UK/USA, Aus/USA)
Contents | Previous

Disclaimer

● Chapter 1 Introduction
❍ The Purpose of the Report
❍ The Scope of the Literature Review
❍ Methodology
■ Search Strategy
■ Database Searching
■ Internet Searching
Chapter 1
Introduction
The Purpose of the Report
In April 2001, The Ministers for Education, Training and Youth Affairs, and Health and Aged Care
jointly announced a National Review of Nursing Education to examine the current context of health
services and preparation for nursing practice, and to ensure that nursing education is able to meet
the changing needs of the labour market.
In mid July, the Victorian Centre for Nursing Practice Research, located at the School of
Postgraduate Nursing, University of Melbourne was appointed by the Department of Education,
Training and Youth Affairs, and Department of Health and Aged Care to undertake a literature
review on aspects of Nursing Education.
This interim report outlines the process of review, the evidence gathered and analysed, and a
summary presented.
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The Scope of the Literature Review
The aim of this literature review is to identify recent and predicted changes in health care that
impact upon nursing and to identify the types of skill and knowledge the nurse has required and will
require to deal with these changes.
The specific objectives addressed in this review are

● To describe changes in the types of service provided, including what, where and how those
services are provided, over the past five years which have impacted on nursing
● To describe changes in the roles of health professionals which have impacted on nursing
● To summarise narratively how the above impact on the skills and knowledge required by the
nursing workforce.
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Methodology
Criteria for Considering Studies for this Literature Review
As the overall purpose of this literature review was to identify recent changes in health care which
impact on nursing, studies across a wide variety of topics and methodologies were sought.
Studies were considered appropriate if they
● Had been conducted in Australia, New Zealand, United Kingdom, Canada, United States of
America, Holland or Scandinavia AND
● Documented a change in health care service provision OR a change in the role of a healthcare
provider in the last five years AND
● The change had an actual or potential impact on nursing. This impact may have been
explicitly stated in the text, or alternatively, the reader of the abstract believed there was a
possible impact even though it was not stated.
The type of studies included was initially kept broad. It was acknowledged that information about
changes occurring in health care service provision and providers was likely to be descriptive and the
number of studies that met the criteria for the four National Health and Medical Research Council
(NHMRC) levels of evidence (Table 1) was unknown.
Table 1 Designation of levels of evidence
Level of evidence Study design

Evidence obtained from a systematic review of all relevant randomised
I
controlled trials.
Evidence obtained from at least one properly-designed randomised
II
controlled trial.
Evidence obtained from well-designed pseudorandomised controlled trials
III-1
(alternate allocation or some other method).
Evidence obtained from comparative studies (including systematic
reviews of such studies) with concurrent controls and allocation not
III-2
randomised, cohort studies, case-control studies, or interrupted time
series with a control group.
Evidence obtained from comparative studies with historical control, two or
III-3 more single arm studies, or interrupted time series without parallel
control group.
IV Evidence obtained from case series, either post-test or pretest/post-test.
Source: NHMRC 1999
Search Strategy
The search sought both published journal articles, reports and legislation; and unpublished theses.
In addition, information was gathered from both professional and government Internet sites.
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Database Searching
An extensive search of databases was conducted. This included
A combined search of Journals@Ovid, Cochrane Database, CINAHL, Current Contents and MEDLINE.
The search terms used relate to the objectives of the literature review and were used in the fields:
title, abstract, key word, subject heading and outline headings. Search terms:
(service provision) and (chang$ or new) and nurs$
(health care provision) and (chang$ or new) and nurs$
(health care professional) and role and (chang$ or new)
(model$ of care) and (chang$ or new)
(case manager) and (role adj chang$) or (role adj new)
(coordinated care) and (role adj chang$) or (role adj new)
(shared care) and (role adj chang$) or (role adj new)
telehealth
telemedicine
(hospital in the home) and (role adj chang$) or (role adj new)
(minimally invasive surgery)
(primary care) and (role adj chang$) or (role adj new)
(preventative care) and (role adj chang$) or (role adj new)
nurs$ and (role adj chang$) or (role adj new)
nurs$ and (independent practice)

nurs$ and (scope of practice)
radiology and (role adj chang$) or (role adj new)
(diagnostic studies) and (role adj chang$) or (role adj new)
(organ procurement) and nurs$ and (role adj chang$) or (role adj new)
(transplant coordination) and nurs$ and (role adj chang$) or (role adj new)
angiography and (role adj chang$) or (role adj new)
(telephone triage) and (role adj chang$) or (role adj new)
(protocol adj driven) and nurs$ (role adj chang$) or (role adj new)
leadership (role adj chang$) or (role adj new)
management (role adj chang$) or (role adj new)
(general practitioner) and (role adj chang$) or (role adj new) or role
doctor and (role adj chang$) or (role adj new) or role
midwi$ and (role adj chang$) or (role adj new)
carer and (role adj chang$) or (role adj new)
Note that the truncation symbol used is $, so "nurs$" will locate articles including
nurse, nurses and nursing.
A search of PsycINFO with the terms
nurs
practitioner
midwi
carer
doctor
(changing role)
(new role)
health
hospital
protocol
triage
leader
No truncation symbol however the search term "midwi" locates articles including midwife, midwives
and midwifery.
A search of Australian Digital Theses Program with the terms
nurs? and (chang? role) or (new role)
(medical practitioner) and (chang? role) or (new role)
doctor and (chang? role) or (new role)
midwi?
health sector
Truncation symbol = ?
A search of the abstract field of UMI Proquest Digital Dissertations with the terms
nurs? and (chang? role) or (new role)
(medical practitioner) and (chang? role) or (new role)
doctor and (chang? role) or (new role)
midwi? and role
carer
(general practitioner)
(health sector)
(health care)
Web of Science Proceedings with the terms

(health service provision) and (chang? or new)
(health care provision) and (chang? or new)
(health care professional) and role and (chang? or new)
(model? of care) and (chang? or new)
(telehealth or telemedicine) and ((randomi?ed controlled trial) or (clinical trial))
(hospital in the home) and role
(minimally invasive surgery) and role
(primary care) and ((chang? role) or (new role))
(preventative care) and ((chang? role) or (new role))
nurs$ and ((chang? role) or (new role))
(telephone triage) and ((chang? role) or (new role))
midwi? and ((chang? role) or (new role))
carer and ((chang? role) or (new role))
Searching of all databases was limited to the English language and the years 1996 to 2001 inclusive.
All abstracts, resulting from the literature search of the databases, were examined to identify that
the content related to changes in health care service provision or changes in the roles of health
professionals effecting nursing.
Following the selection of abstracts, the articles were retrieved electronically or by hand. On
identification of appropriate theses' abstracts the electronic databases were searched to identify if
the writer of the thesis had published an article related to the topic of interest. Where the writer had
published, the article was retrieved. Where the writer had not published the work a summary of the
thesis was retrieved. This was read and where appropriate a copy of the full thesis was requested.
Articles were sorted according to major recurring themes and then according to level of evidence. All
articles meeting the NHMRC levels of evidence were included. Where other descriptive information in
articles added to the knowledge this was also included.
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Internet Searching
Internet information and reports published by health and nursing authorities were also sought.
These were particularly useful for information on the role of the nurse practitioner in Australia since
many pilot projects have been or are being conducted and the majority have not been reported in
the published literature.
Sites searched included
ACT Department of Health, Housing and Community Care
Australian Nursing Council Inc.
Canadian Nurses Association
Department of Human Services, Victoria
Health Department of Western Australia
Nurse Directories on: The Nurse Friendly Nurse Practice Acts, Legal and Medical Links
Nursing Board of Tasmania
Nursing Council of New Zealand
Nurses Registration Board New South Wales
Queensland Nursing Council
Royal College of Nursing
South Australian Department of Human Services
Territory Health Services, Northern Territory Government
The Canberra Hospital, Research Centre for Nursing Practice
United Kingdom Central Council for Nursing Midwifery and Health Visiting
Victorian Legislation and Parliamentary Documents Home Page
In addition, the National Health and Medical Research Council Internet site was searched for clinical
practice guidelines. These were then scanned for recommendations that had specific implications for
nursing roles.


Disclaimer

● Chapter 2 Literature Review
❍ General Context of Practice
❍ Section 1: The Changes In The Types Of Service Provided Impacting On Nursing
■ Case-Management/Managed Care
Chapter 2
Literature Review
General Context of Practice
The main objective for the health system in the new millennium is to establish a balance between
social expectations and human rights against decreasing availability of resources.
By 2016 there is a projected increase in aged population to 16% or 3.5 million (AIHW, 1998). Given
that age is the most accurate indicator for health and welfare services (Fuchs, 1984), the
community has to deal with declining mortality rates and a growing disproportion of females to
males. The aging trend also creates a significant increase in multi-system disorders that exacerbate
both physical and mental frailty (Stevens and Onley, 2000).
Increasing consumer involvement requires clinicians to have a broader perspective of client

management that includes an emphasis on the individual's context of health. Consumers expect
safer, more personalised health care, greater involvement in decision making, larger choice and
access to services. They tend to experiment with complimentary therapies and increasingly seek
further information via resources such as the internet (AHMAC, 1996).
Progressively more sophisticated technology has lead to significant improvement in patient

management through accurate diagnosis and treatments. Technology has precipitated new and
innovative healthcare, shortening length of stay in hospitals and improving patient outcomes.
However the high cost of technology and supporting resources has limited its availability to
consumers. There is an emphasis on cost containment and public accountability for health care
decisions surrounding resource usage. Thus, the emergence of evidence based practice has been a
global phenomenon to assist clinicians decision making in the current climate.
New diseases, changing patterns of existing diseases and environmental threats pose further
problems for the community. While technological advances such as minimally invasive surgery,
genetic engineering and cybernetics are revolutionizing health care, a consequence is an increased
demand for specialist professional services to care for these patients. Inadequate numbers of
trained personnel to meet the needs of the health system leads to unsafe work practices, intolerable
workloads and high stress.
To meet the increased demands associated with increasing health care expenditure, economic
rationalization has been employed to ensure greater efficiencies in the system. As a response to the
increased focus on costs and outputs, health care systems have seen the introduction of Diagnostic
Related Groups (DRGs), case mix funding and managed care models, as well as a shift from
predominantly acute care services to community and home care. The primary health care model
ensures linkage between care systems reflecting continuum of care rather than isolated treatments
and experiences. The shift also moves from a curative model to an increasingly preventative model
with a focus on lifestyles to achieve longevity.
In summary, the health system is in a constant state of change in a climate of consumerism, risk
management, accountability, professionalism and managerialism. All of these environmental
variables influence nurses and nursing.
Review of the literature will be divided into three sections. The first section describe the changes in
the types of service provided, including what, where and how those services are provided, over the
past five years which have impacted on nursing and changes in the roles of health professionals,
which have impacted on nursing. The second section describes changes in the roles of health
professionals that have impacted on nursing. The third section summarises narratively how the
above impact on the skills and knowledge required by the nursing workforce. The country of origin is
either explicitly revealed, or noted as an abbreviation with the in-text reference. A key to the
abbreviations is included in Appendix B. The terms patient, client or consumer are used
interchangeably as they appear in the literature reviewed.
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Section 1: The Changes In The Types Of Service Provided Impacting On Nursing
Case-Management/Managed Care
The concept of case management revolves around innovation, resource management and
interagency collaboration. It has developed based on the tenets of primary nursing whereby a key
person is accountable for the care of the patient from admission to discharge. As a health delivery
process it now applies to the coordinated care delivered by a multidisciplinary team. As such, it is
both disciplinary and interdisciplinary. Each participant aims to provide quality health care, decrease
fragmentation of services to enhance the client's quality of life, while at the same time containing
costs. There is an emphasis on problem solving, collaboration, and maximizing efficiency. The
growth of case management is often related to the impact of the aging population and an increasing
requirement for long-term health care planning. In the United States Case Management is
particularly linked to the insurance driven managed care movement that requires accountability
relating to service provision. Accordingly, the tools associated with case management include critical
pathways, protocols and outcome measurements that relate service delivery to cost efficiency,
morbidity and mortality and length of stay (Waterman, Waters, & Awenat, 1996 USA; Coile, &
Matthews, 1999 USA; Reed & Hepburn, 1999 USA; Wayman, 1999 USA; Huber, 2000 USA).
Waterman, Waters, and Awenat (1996, USA) report that Case Managers fall into two different
groups. The first provide both direct care and care coordination. The second deal solely with 'high
risk' patients to monitor and coordinate long term care over repeated hospital visits. The latter case
manager group does not provide direct care. He/she generally manages patients belonging to a
specific diagnostic related group, utilize predetermined plans of care, and act upon any deviation
from the care plan and document by exception. Despite this rather standardised approach to care,
patient involvement is also essential to achieve successful individual outcomes.
While case managers are not necessarily nurses, many health insurers have shifted to nurse case
managers as a more cost-effective way to fund case management and to provide direct services
(Coile & Matthews, 1999 USA). Nurses have the appropriate disciplinary knowledge and skills to act
as case managers. This includes the ability to conduct client/family assessments, formulate a
comprehensive family and client treatment plan, facilitate health service delivery, act as a client
advocate, to individualise needs and goals and to evaluate client/family outcomes (Zink, 2001 USA).
The literature relating to Case Management emanates from the United States and is largely
narrative. There is however, an evidential base relating to the implementation of this model of care,
the changes in service and role that have accompanied its development over the last ten years, and
educational preparation for nurses acting as case managers. This literature falls into three major
categories. These categories are based on the nature of the healthcare practice settings and include:
acute care setting, community care setting, and rural care setting.
Acute care case management was adopted as a model for nursing practice in the late 1980's. It
recognized that nurses are in a key position to manage the care of patients throughout their hospital
stay and avoid the pitfalls of fragmented specialized services. Central to this model is the
recognition that nursing is not a task-based activity, but incorporates knowledge-based professional
practice. An advanced practice nurse role in case management has developed in response to
continuing evolution of the nurse case manager role. The advanced practice case management
nurse (APCMN) may work in either the hospital or outpatient setting and utilises data analyses to
identify a population that would benefit from interdisciplinary management. The APCMN then builds
an interdisciplinary team that create a coordinated service plan that includes a clinical pathway
based on established outcomes, but tailor made to the patient's individual situation. The APCMN
works autonomously as a clinical expert and analyst and adopts a population-focused, leadership
and research-orientated role. Case Management nursing education will need to respond accordingly.
It is anticipated that nurses with bachelor degrees and extensive clinical experience who have high
level skills in communication and collaboration will undertake Masters level preparation to take on
the APCMN roles outlined above (Wayman,1999 USA).
The literature relating to case management in acute care is largely comprised of case studies.A case
study by Waterman, Waters and Awenat (1996 USA) using participant observation and interview
techniques provides research evidence relating to a change of service resulting from the introduction
of an acute care case management model. Conducted in an American rehabilitation ward, the
themes arising from analysis of data identified specific educational needs for nurses assuming the
new role of case managers. Of primary importance was the need to learn new skills and knowledge
relating to patients they otherwise would not care for. Equally important was the need to learn more
about critical pathways. Finally, the nurses required new knowledge to understand accountability
issues.
Novak (1998 USA) reports that nursing has responded to the challenges of shorter hospital lengths-
of-stay and increased patient acuity in the context of an increasing aging and chronically ill
population by adopting a case management model. The literature review in this paper identifies a
paucity of research evidence documenting the essential role attributes of the nurse case manager.
In order to address the situation this study of 15 nurse case managers at a 658 bed regional
medical centre in southeastern United States uses a Delphi technique to obtain expert opinions
about the role from successive rounds of questionnaires. The study also included two focus group
discussions that added reliability to the findings. Results included the following definition of the
nurse case manager: 'coordinator of a multidisciplinary treatment plan which addresses a patient/
family's continuum of care needs while ensuring clinical quality that is cost effective and
organizationally efficient" (p235). Critical skills required to support this role were identified as the
ability to coordinate quality, cost effective care; possessing expert clinical knowledge, clinical
expertise and being able to effectively manage time. Well-developed communication skills, the
ability to provide clear explanations and provide appropriate health education were also identified as
key skills.
A case study by Murray, Broad, & Welnick (1999 USA) describes the introduction of an associate
case manager. A graduate with a Bachelor or Associate Degree in human services, social work or
behavioural science performs this role. The associate does not complete assessments or develop a
plan of care. Instead, he/she complete various delegated aspects once the plan of care is
formulated. The case study on the implementation of this role claimed that the associate made
substantial contributions to the coordinated care teams and enhanced their ability to provide quality
patient care, but did not provide supportive evidence for this claim. The introduction of a role of this
nature however, would require nurse case managers to be prepared with knowledge and skills
relating to supervision of care delivered by non-nursing staff including delegation and evaluation,
and human resource management.
The literature relating to models of case management in the community setting is discussed in the
section entitled: Community Nurse-Led Healthcare Services.
As described by Stanton and Packa (2001 USA), Nurse Case Management in American Rural
Communities has a distinct character created by the unique needs of rural residents and rural
communities. While urban nurse case managers typically coordinate care for clients placed in
disease related groups, there are often too few clients in one group for rural case managers to
implement disease management programs. Instead, rural nurse case managers (RNCM's) are
generalist rather than specialists and require excellent research and administrative skills as they
often work without the traditional support systems that are available to their urban counterparts.
The normal tools of case management such as critical pathways may not be applicable and RNCM's
need to know how to access evidence-based practice guidelines to develop models of care,
databases and outcome measures specific to their individual rural practice settings. Furthermore,
the RNCM not only practices in a setting that has limited healthcare services by virtue of distance,
but they also need to understand the impact of distance and limited financial resources upon their
client's ability to access healthcare services. RNCM's also play a major role in the community's
health and well-being by assuming social and political roles in the community and shaping policy
and healthcare support systems. As such they are involved in designing and implementing a system
of care for the whole community. For example, they may work with public health and school officials
to implement injury prevention and environmental health programs.
Continued on next page...

Disclaimer

● Patient Focused Care
● Community Nurse-Led Care
Patient Focused Care
Patient focused care is a change in service characterised by the re-organisation of health-care

delivery to establish an integrated system of service provision. In turn, this change in service has
lead to an integration and consolidation of service provider roles to eliminate fragmentation,
improve coordination, produce improved outcomes and decrease the cost of providing services. As a
result service partnerships that are oriented around patient care issues rather than the traditional
segmentation of professional groups have been established (Routh & Stafford, 1996 USA; Cormack,
Brady, Porter-O'Grady, 1997 USA; Knox & Irving, 1997 USA).
The literature relating to patient focused care emanating from the United States (USA) is
predominately narrative and relates to the acute hospital sector. Key components include cross-
training staff to provide up to 90% of care, flattened management structures, grouping similar
patient populations together, organizing staff into work teams composed of various care partners,
creating customized critical pathways for the management of care, and documenting by exception
(Vietri, Poskitt, Slaninka, 1997 USA). In such an organisation the traditional physician lead approach
has changed to multi-disciplinary team based 'primary care' (Porter-O'Grady, 1997 USA). The use of
unlicensed staff in patient care situations is common. Caregiver roles have been developed and
tasks identified for each role.
The introduction of the US model of primary care affects the scope and complexity of the role of the
professional nurse. He/she now has a strong focus on management and coordination of activities of
other professionals and supportive staff including supervision and delegation to unlicensed personnel
(Knox & Irving, 1997 USA). In this role the professional nurse has primary accountability for
assessment, planning, patient and family teaching, and evaluation of care. In addition to clinical
skills the professional nurse also requires skills in leadership and cognitive and critical thinking
processes and the ability to clearly define nursing and non-nursing tasks (Ross, Counsell, Gilbert,
1996 USA; Webb & Pontin, 1996 USA; Litwin, Beauchesne & Rabinowitz, 1997 USA; Ingersol, Cook,
Fogel, Applegate & Frank, 1999 USA).
A low level of evidence is present in the literature relating to this model. One qualitative study
reported that the introduction of a primary care model and the subsequent direct accountability for
individual patients improved communication but nurses experienced fluctuations in workload,
shortages of essential resources, and experienced difficulties relating to time pressures and meeting
deadlines (Ingersol, Cook, Fogel, Applegate & Frank, 1999 USA).
The literature relating to patient focused care emanating from the United Kingdom (UK) is
significantly different to that from the USA. In the UK, the patient focused care literature relates not
to the acute sector, but to community based medicine. The role of the General Practitioner (GP) is
central in this literature where primary care is defined as 'first contact care' (WHO, 1987; Meads,
1996 UK) and the aim is to provide a primary health care service as close to the client base as
possible (Hibbs, 1996 UK). This literature is reviewed under section 2 (changes in the roles of health
professionals which have impacted on nursing).
The Australian government has also adopted a population health approach with GP's having a
central role as primary care providers. Once again, the literature relating to this service is reviewed
in Section 2.
Like Australia, and the UK, Primary Health Care in Sweden is a publicly funded community service.
Unlike Australia, Swedish nurses working in general practices do have a significant role in health
promotion. A small purposeful study (n=39) by Bendtsen & Aklerlind (1999 SC) was conducted to
evaluate changes in attitudes and practices among GP's and Nurses after the implementation of an
educational program for early identification and intervention of alcohol related problems. Despite
nurses and physicians completing the same program, nurses' response to training program was
found to be poor. Accordingly, the researchers recommended that nurses require a different form of
education than GP's with regard to alcohol interventions.
top
Community Nurse-Led Care
In the context of an aging population that is increasingly chronically ill and functionally impaired
(Alexy & Elnitsky, 1996 USA; Moneyham & Scott, 1997 USA; Jeglin-Stoddard & DeNatale, 1999
USA; Oberski, Carter, Gray & Ross, 1999 UK; Marek & Rantz, 2000 USA) Community Nurses are
challenged to take on the role of coordinating care in a multidisciplinary environment. In this role
there is again an emphasis on population health and case management. Nurses are increasingly
taking services to the client where they are met with complex situations that require advanced
problem solving skills and the ability to make on-the-spot decisions.
Managed Care insurance plans have changed the face of community care in the United States.
Managed care is primarily concerned with resource utilization and cost-containment to reduce the
financial aspects of care. As a result, care is often fragmented with services that have traditionally
been performed by community nurses being taken over by contracted specialist staff. For example,
infusion and pathology services, rather than nurses, now carry out interventions such as intravenous
administration and venepuncture (Brown & Neal, 1997 USA). In this context, it is increasingly
important for care to be provided in a coordinated fashion.
There is a low level of evidence supporting these claims however, with the literature in this area
being largely narrative. However, a case study by Storfjell, Mitchell and Daly (1997) reports that
after three years of operation a visiting nurse service of New York's Community Nursing
Organisation was able to provide fiscally appropriate care coordination. The visiting nurses in this
project provided direct care services, frequently identified health care problems that required
medical intervention, referred the client to appropriate medical treatment and coordinated care of
patients requiring multiple services problems.
The largely narrative US literature places the community nurse in the ideal position to act as care-
coordinator. Nursing is broad in scope, adopts a holistic perspective of client care, has foundations in
the biological and behavioural sciences and nurses themselves have considerable skills in providing
holistic assessment including actual and potential risks relating to physical, psychological and social
needs of individuals and families (Moneyham & Scott, 1997 USA). There is low level evidence
supporting these claims, with the literature in this area being largely narrative. However, a case
study by Storfjell, Mitchell and Daly (1997 USA) reports that after three years of operation a visiting
nurse service of New York's Community Nursing Organisation was able to provide fiscally
appropriate care coordination. The visiting nurses in this project provided direct care services,
frequently identified health care problems that required medical intervention, referred the client to
appropriate medical treatment and coordinated care of patients requiring multiple services
problems.
An important factor in the success of the New York Visiting Nurse Program was its population health
focus whereby the nurse working with individuals and families in the community as care giver and
care coordinator was able to identify trends and needs of specific community groups. This study
reports that a focus on prevention emerged. The provision of such services is a recurrent theme in
the community literature. It is supported by government policy that moves away from the traditional
"medical" model of disease management toward a nursing model of prevention and early
intervention (Gross & Reed, 1999 USA).
An important factor in the success of the New York Visiting Nurse Program was its population health
focus whereby the nurse working with individuals and families in the community as care giver and
care coordinator was able to identify trends and needs of specific community groups. From this data
a focus on prevention emerged and the participating nurses implemented "wellness plans" that
included education in the areas of stress management, health eating, arthritis, healthy heart,
diabetes management and dance therapy. Blood glucose, blood pressure and cholesterol screenings
were also a component of their case- load. The provision of such services is a recurrent theme in the
community literature. It is supported by government policy that moves away from the traditional
"medical" model of disease management toward a nursing model of prevention and early
intervention (Gross & Reed, 1999 USA).
Another American case-study (Kosidlak, 1999 USA) describes an early intervention/health education
program implemented by community health nurses. Services delivered by the community health
nurses in this instance include the same as those provided by the New York visiting nurses and
additional services including physical examination, breast, prostate and cervical cancer screening,
immunizations, family planning, health education and referrals.
The research by Kosidlak (1999 USA) supports the value of such population based programs. This
researcher reported that public awareness and public education regarding prevention increased
when public health care resources were redirected into preventative programs that service the
community rather than the individual. These findings were not quantified, and the author stated that
not enough time had passed to determine effects on health indicators such as infant mortality,
teenage pregnancies, and mortality related to leading causes of death or the prevalence of risk
factor behaviors. Instead, the benefits were supported by citing specific examples. A new approach
to prenatal care was reported to have decreased fragmentation of services and increased
accessibility and availability. The introduction of an on-line computerised system led to better
coordination of immunisation programs. Collaboration among community coalition members resulted
in the receipt of a grant for a breast and cervical cancer-screening program. Pischke-Win & Minnick
(1996 USA) document a higher level of evidence for the success of such preventative programs in a
quasi-experimental study. Although the sample population was faculty staff at a United States
university and not the broader community, the study found that the introduction of a nurse-led
service increased compliance with self- breast examination but not mammography. It is significant
to note that the preventative intervention adopted changed individual health behaviors, but not
behaviors relating to accessing screening services
It is important to note that any change in practice does not occur without the appropriate
educational preparation. A cross-sectional study by Murray (1998 USA) reported that home
healthcare clinical experiences during basic education were insufficient to prepare nurses for the
extended roles in the community. In order for nurses to function in the role of generalist care-
coordinators the literature recommends knowledge and skills in chronic illness management,
developing clinical practice guidelines, new models of care, change management practices and
health screening methods, epidemiology, health prevention methods and health education. Sound
skills in clinical care delivery, and resource management are deemed essential. Comprehensive
assessment of physical, environmental, social, functional, cognitive/mental, psychological,
economical status, and social and spiritual challenges of older adults is crucial to ensure that
comprehensive care is coordinated, provided and evaluated (Brown & Neal, 1997 USA; Jamison,
1998 USA; Jeglin-Stoddard & DeNatale, 1998 USA). Specialist care coordinators are nurses prepared
at degree level in one or more chronic illness such as multiple sclerosis, diabetes, congestive heart
disease, chronic lung disease, or rheumatoid arthritis (Jamison, 1998 USA).
The 'Aging in place' model of community care in the United States recognises the challenge of the
aging population who will need extensive health care services late in their lives. It offers care
coordination and health care services to older persons residing in their own homes, specially
designed senior apartments, senior private or public congregate housing. Motivated by research
evidence that mental and physical deterioration occurs when frail older persons move from one
setting to another the 'aging in place' model ensures that frail older persons will not have to move
from one level of care delivery to another as their health care needs change. Instead, the type of
care is separated from the place of care and all services a person may eventually need are provided
as required in a single setting (Marek & Rantz, 2000 USA). In this model the care-coordinator
maintains contact with his/her clients through home visits, telephone and electronic
communications. Care coordinators use and develop clinical practice guidelines. Acute crisis are
avoided through collaboration with other health team members to facilitate screenings, access to
services and provides for transitions in care as conditions change. Self-care is promoted through
patient and family education (Jeglin-Stoddard & DeNatale, 1999 USA).
Case study research by Jeglin-Stoddard & DeNatale (1999 USA) investigated the implementation of
a prevention-assessment screening process for community nurses delivering an aging in place
service. The researchers administered a prevention-assessment questionnaire to 32 participants
who had English as their primary language. Using a grounded theory approach, the researchers
analysed the surveys to identify patterns of difficulty and persons in need of assistance prior to
crises. Individual and community interventions based on the survey results were then implemented.
These included individualised treatment such as education relating to dehydration, medication
management, management of respiratory and diabetic equipment, activity and exercise with chronic
disease, self-monitoring and reporting of blood glucose levels, reaching the physician through the
community nurse, counseling for anxiety and end-of life concerns, finding and using support groups
and other resources specific to participant's chronic diseases. More generalised interventions
included initiating regular health promotion sessions and a blood pressure clinic at a senior citizen's
venue. A follow-up questionnaire administered six months later revealed that 64% of participants
had an increased awareness of responsibility for their own health care needs and an improved ability
to access health information. Participants who received individualised care were found to be
empowered to continue their own care with appropriate links to resources or were continuing to
access community service agencies appropriately.
To date there are no results published from a long-term study to identify the ability of the 'aging in
place' model to prevent nursing home admissions. This study will compare aging in place
participants to a control group of clients of similar acuity to evaluate the effectiveness of the model
and examine both the quality of care and the cost of care to determine viability (Marek & Rantz,
2000 USA). There are however recommendations from both the completed (Jeglin-Stoddard &
DeNatale 1999 USA) and incomplete (Marek & Rantz, 2000 USA) qualitative studies reports that
Masters prepared nurses specially trained in case management are responsible for assessing and
reassessing the client's needs, developing and implementing a plan of care, and monitoring the
quality and efficacy of the services delivered. Educational preparation includes knowledge regarding
services provided by professional and nonprofessional staff. Specific skills required for provision of
nursing services are in the areas of medication education and management, nutrition and disease
management, safety, delivery of wound and catheter care and communication with family,
physicians and other health providers.
The literature relating to nurse-led community care coordination has primarily related to the needs
of the urban population. The need to access nursing services to improve and maintain health status
and participate in health promotion activities is especially problematic in rural situations. Similar to
the urban environment, access for rural clients can be improved by taking services as close to the
client as possible. Narrative by Alexy & Elnitsky (1996 USA) describes an alternative model of health
care delivery for a rural area of the USA with limited health resources and care providers. In a
second paper, these same authors report on the large case study (n=222) that evaluates the
implementation of this model in the form of a nurse-led Mobile Rural Health Unit (Alexy & Elnitsky,
1998 USA). The nurse-led Mobile Rural Health Unit provided health care services by visiting a
variety of sites in the rural area (generally senior citizen venues, shopping mall, post offices) three
times per week and initiating home visits on the other two days. Similar to the New York Case
study, services provided included breast and cervical cancer screening, blood glucose and
cholesterol screening, blood pressure monitoring, immunizations, health education and referrals. A
high level evidence (NHMRC Level IV) component of the case study was the utilisation of a pre/post
test to evaluate the service. Selected measures were repeated 12-15 months after the baseline
measurements. Results included an increased utilisation of preventative health resources and
decreased utilization of intervention related resources; increased immunization rates for influenza,
pneumonia and tetanus; decreased utilization of the emergency room and increased participant
knowledge of primary care services available.
New skills and knowledge required by the nurses delivering a nurse-led rural service are similar to
those relating to the introduction of urban services in New York. In addition, the participating nurses
and physicians revealed the necessity for an increased appreciation of health care needs of the rural
elderly. There is also an emphasis on interdisciplinary education, with one of the by-products of the
rural case study being that physicians reported an increased appreciation of skills and competencies
of participating nurses.
The literature emanating from the United Kingdom relating to nurse-led community health care
services is closely linked to the literature relating to primary health care. Once again, emphasis is
upon delivering care closer to the home. NHMRC Level IV evidence from two pertinent studies
details the educational needs of community nurses.
Carr (2001 UK) identifies that context has an important impact on learning needs and explored
whether different learning experiences are required in the community compared to those required
by nursing students learning in the hospital setting. She used a triangulated approach including
focus group discussions collecting retrospective data, non-participant observation and concurrent
interviewing. Themes emerging from the data included the necessity to engage in learning
experiences that exposed the student to the complexity of the community setting. There is a need
particularly for the student to identify that the life details of clients are not easily categorised using a
disease related model and that multiple practice agendas such as acute, chronic and acute care
superimposed on chronic care create diverse care needs. It was deemed essential that students
developed skills in context, repeatedly adjusting existing skills to new situations. Students also
required experiences that would assist them to develop a wider scope of practice than in a hospital
setting, acknowledging the extension of nursing activities and the need to guide informal carers. The
ability to practise in an environment that is not controlled by the nurse was another key theme to
emerge, with nurses needing to develop skills in accepting and accommodating to a wide variety of
care environments. Another important dimension to community nursing care is that practitioners
may need to deal with more than 'essential' health care in the form of the client's dilemmas with
daily life.
The needs analysis conducted by Oberski, Carter, Gray and Ross (1999) recognises the growing
demands placed on community nurses in the United Kingdom by the aging population. This research
found that in contrast to hospital-based nurses caring for elderly patients, the nurse engaged in
community care of older people does not need to specialise in gerontology. Instead, education needs
to assist the nurse to become adaptable to the lifestyles of the elderly, be able to make rapid
decisions concurrently with assessments, practice autonomously and be aware of boundaries with
other professionals.
In this study Houston & Clifton (2001 UK) implemented a corporate model of shared practice, with
health visiting nurses developing multidisciplinary partnerships, and operating in teams. All team
members however, maintained individual accountability. In this model there is an emphasis on
communication skills. The outcome of this model was the introduction of new services resulting from
the collaborative group meetings where active listening allowed development of many new ideas.
New services included a new parents course, a group for post-natally depressed women, a support
group for teenage mothers, parental self-weighing of babies, and standardization of parental
information offered via telephone services at the clinic. The health professionals themselves also
benefited from the change in service. Each participant developed a portfolio to showcase
professional knowledge, shared educational materials with others in the group and experienced a
greater involvement in community development work. The service benefited as use of resources
became more cost effective, a research and development profile was established and it became
recognised as a magnet service with interest expressed by other professionals to develop similar
models.
Narrative literature describes both traditional models of children's community nursing services and
new models that articulate with the GP led primary care services, or are nurse-led in their own right.
The nurses delivering these services may be general nurses, general paediatric nurses or specialist
paediatric nurses. Educational preparation for nurses delivering these services places an emphasis
on both community and paediatric knowledge. Counselling skills, communication/liaison skills and
health education skills are essential pre-requisites for practice (Eaton, 2000 UK).
School nursing services are also a component of paediatric health care in the UK. Narrative literature
(Narracott, Gatehouse & Baird, 1996 UK) identifies that school health services are now nurse-led
and doctors who previously made all decisions are predominately called in for specialist referrals. In
response to this change in leadership of school health services the role of the School Nurse has
changed from the traditional "matron model" to a highly articulate group of nurses with a broad
range of professional skills. These skills include health promotion, health assessment, sex education,
and counseling. The paper by Narracott, Gatehouse & Baird (1996 UK) describes these changes and
includes a testimonial that depicts the School Nurse role as proactive rather than reactive.
Educational preparation focuses on a population model of healthcare delivery with once again, an
emphasis on communication skills, care coordination, "wellness" models, health promotion and
disease prevention.
Evans (2000 UK) discusses issues related to school nurses and sexual health in the United Kingdom.
He indicates that the Department for Education and Employment have stated that school nurses
should be leading a new approach to the 'sexual aspects of life' through education and service
provision to children and adolescents. He identifies the training needs of school health nurses as
incorporating not only a comprehensive understanding of issues relating to sexual health, but also
how this relates to specific client groups. Specific client groups are identified as including
marginalized and socially excluded individuals with special needs, such as those with learning and/or
physical disabilities, those with low self-esteem, those being bullied, peers and school colleagues.
A narrative paper by Canadians Chalmers & Bramadat (1996 Can) describes the shift from individual
community services to community development as an important current and future trend for the
provision of public health. It has been recognized as one of the major underpinnings of the
international health promotion movement and provincial governments in Canada have included it in
their plans to reform and restructure health care services. Community development strategies play a
key role in promoting the health of populations, especially groups at risk and disadvantaged
populations. The purpose of community development is to identify issues and problems affecting
community life (for example, environmental health or adolescent alcohol use) and to develop and
implement plans for change, building community strength, self-sufficiency and well-being. Whilst it
is not specifically designed as health intervention, an improvement in the community's health may
result. A cited example is the Health Cities Movement/Healthy Communities movement launched in
1986 by WHO. The goal is to promote well-being and health of communities by collaborative action
at a local level. Chalmers & Bramadat also cite empirical evidence that public health nurses have a
current and future role in community development services. Knowledge and skills required for
community development nursing include conducting community assessments, analysing
epidemiological and other research data and the ability to organise community action groups without
'taking over'. Knowledge and skills required for community development nursing include conducting
community assessments, analysing epidemiological and other research data and the ability to
organise community action groups without 'taking over'.
Finland's community nursing services are state supported and consist of specialist nurses who
facilitate long-term follow-through with children and families (Duffy, Vehvilainen-Julkunen, Huber &
Varjoranta, 1998 SC/USA). The USA funding system in contrast does not allow long-term
relationship building but instead consists of intermittent care in a complex public and private
system. As a consequence, Finnish practice was found to focus on empowerment and emotional/
informational interventions while US practice focuses on physical elements of health care.
Accordingly, Finnish community nurses are deemed to be in a better position to respond to changing
service needs than their US counterparts. A Scandinavian/US joint research paper using survey and
interview techniques (Duffy, et al. 1998 SC/USA) provides qualitative evidence relating to
community nursing practices in Finland and the USA. Both shared a practice context of increasing
complexity of family care including the challenge of increasing demand for health care services in
the context of rising unemployment. However, the ability to respond to respond to changing service
requirements were found to be markedly different in each country due to the different funding
models employed. Finland's state supported specialist community nurses are able to develop long-
term professional relationships with children and families. The USA community nursing role is
substantially different, consisting of intermittent care in a complex public and private system. The
latter does not allow long-term relationship building. As a consequence, Finish nursing practice was
found to focus on empowerment and emotional/informational interventions while US practice
focuses on physical elements of health care. The researchers concluded that by virtue of their role,
Finnish community nurses were better positioned to respond to changing service needs than their
US counterparts.

Disclaimer

❍ Integrated Hospital and Community Care
● Nurse-Led Clinics
● Family Provided Care
● Care Delivered By Unlicensed Personnel
● Mental Health Care
INTEGRATED HOSPITAL AND COMMUNITY CARE
The literature reports that there is a number hospital outreach services that are designed to
facilitate a smooth transition from acute to community based services.
The US literature relating to integration of hospital and community health care services is largely
contained in the case-management literature. Qualitative research by Forbes (1999 USA) describes
the important shift in the role of the case management nurse as a vital link in the interface between
hospital and community-care. This case study revisits an acute facility where case management is
well established and assesses the impact of managed care on nursing practice. Initially nurse case
managers were advanced practice nurses who were based in specialty units and followed vulnerable
patients in the community. The aim was to improve health outcomes by assisting to stabilize the
client's condition through a collaborative relationship that built on the client's desire for self-
management and the nurses' knowledge of wellness, disease processes and available community
resources. Using a concept mapping approach, the researcher's claimed to discover that the nurse
case-manager role had changed over time. The data presented however, did not support this claim.
Instead, it identified that one of the major roles of the nurse case manager was to 'bridge the gaps'
when client's needs were not met by the health care system. As such, the case manager acted as a
change agent, responded to crises, acted as an advocate and was engaged in trouble-shooting.
A narrative paper by Bailey (1998 USA) again notes that the aging population is growing rapidly and
that integrated health care services are essential in order to avoid complications after acute
hospitalization. Bailey reports on a model of extended care services that includes a nurse care
coordinator, a consultative geriatric assessment clinic, a primary care clinic and the provision of
team-based care to members located in skilled nursing facilities (SNF's). The SNF's provide an
intermediate level of care that 'fills the gap" between the acute hospital setting, nursing home type
care and home care. The role of the nurse care coordinator is to initiate member screening, provide
member orientation, supervise telephonic care coordination and organise a volunteer-based visiting
program.
One Australian model for integration of acute and community services is Hospital in the Home
(HITH). As the name suggests, HITH provides services that are traditionally provided to hospital
patients in their own home environment. Hospital nurses' deliver care in the client's home, rather
than community based nurses. It is a relatively new service and includes activities such as
administration of intravenous therapy, administration of chemotherapy, complex wound care, anti-
coagulation and neonatal services (Montalto & Karabatsos, 1998; McKenzie, 2000 AUS).
McKenzie (2000 AUS) reports that 12 HITH programs in Victoria, Australia administer cytotoxic
drugs outside the controlled environment of the hospital. There is a wide variation of level of
services provided and skills of staff delivering these services. The Victorian Centre for Ambulatory
Care Innovation (VCACI) facilitated an expert committee to develop standards to guide
chemotherapy practices in the community. The paper by McKenzie (2000 AUS) describes the pilot
process initiated to evaluate the standards and criteria that form the measurable components of the
standards. The study was small, consisting of a convenience sample of five HITH services reporting
greater than fifty episodes of chemotherapy care in the previous 12 months. The research
methodology was a written survey followed by structured interviews. The research findings validated
the standards and identified new knowledge and skills required for their implementation. These
findings led to the recommendation that future education programs should be structured to ensure
nurses develop a combination of oncology and community nursing skills, and become familiar with
quality improvement processes to support development of policies specific to their own services.
In 1996 Montalto (AUS) conducted a descriptive survey to examine the patients' and carers'
satisfaction with hospital in the home care in Melbourne, Australia. The HITH service at that time
predominantly provided intravenous antibiotic therapy to selected patients at home. The descriptive
survey revealed that the preference for the convenience and comfort of home was the major reason
for patient's agreeing to enter the HITH unit. Almost all patients and their carers reported that they
would use the service again.
A small telephone administered structured survey (n=14) of Hospital in the Home coordinators/
directors in Melbourne, Australia was conducted by Montalto and Karabatsos (1998 AUS). This
research was prompted by the recognition of a greater emphasis on integration of health services
between hospitals and primary health care providers yet a lack of information about GP involvement
in such services. The research found that there is little GP involvement in these programs, instead
87.5% of services are nurse-led and nurse delivered. GP involvement was limited to management of
intercurrent problems unrelated to the HITH care (21.4%) and even though the HITH coordinator
informed the GP of the patient's admission to the program 42% of coordinators reported that these
GP's had no current active role. The researcher's hypothesised that relationships between GP's and
nurse coordinators may be inhibiting the GP involvement due to the coordinator's hospital
backgrounds. This observation has implications for the knowledge and skills required for nurse-led
hospital in the home programs. Not only do HITH nurses require sound clinical skills and the ability
to work independently, but they also need knowledge of GP services and skills in adopting multi-
disciplinary approaches to health care in a community setting. These findings are consistent with
McKenzie's recommendations that HITH nurses not only require clinical expertise, but that they also
need to develop expertise in community nursing.
The nature of the Australian rural practice context suggests that health care is characterized by a
close relationship between acute and community services. In a narrative paper McMurray (1998
Aus) reports that changes in the Australian Healthcare service have meant an even greater shift
towards community-based services, population health, and multi-disciplinary decision making in
partnership with communities. This is of particular importance to the health of rural and remote
communities where health status and mortality profiles identify there are significant 'at risk'
populations. Underpinning the provision of these services is economic accountability and the need to
demonstrate quantifiable clinical outcomes. Health professionals have responded by developing best
practice protocols and practice guidelines that are transparent to the public and responsive to
community health care needs. These protocols in turn are informed by recent and relevant evidence
of their effectiveness. According to McMurray these changes in service delivery have meant that the
role of rural nurses has become incredibly diverse. Activities undertaken by the rural community
health nurse range from ensuring access to breast screening programs, to interventions dealing with
rising levels of organochlorines in the food chain, and campaigns to reduce road trauma among rural
youth.. In order to adjust to these changes nurses require new skills and knowledge relating to
working in multi-disciplinary research teams, analysing and critiquing research findings,
implementing evidence based research into clinical practice, and gaining proficiency in disseminating
research findings. To support the acquisition of these skills, McMurray recommends the
implementation of research mentorship programs, clinical-university partnerships, interdisciplinary
rural seminars and study days, access to electronic journals and distance education modules.
McMurray's commentary on the changing face of rural health services is supported by qualitative
research by McCarthy, Hegney & Pearson (2000 AUS). Based on data derived from a study of 129
rural health care facilities on 'The role and function of the rural nurse in Australia' McCarthy, Hegney
& Pearson (2000 AUS) quantify the degree of change in reporting that 102 (79%) rural hospitals
had experienced organisational change within the previous year. Significantly, re-structuring in
these services was related to services changing from primarily acute medical services to primary
healthcare or aged care services. Other changes included amalgamation or co-location of services,
closure or downgrading of services and expansion of surgical and midwifery services. The need for
greater accountability for service provision is evidenced by the implementation of case-mix/DRG
related funding and major reform of health care services in preparation for Australian Council of
Health Standards (ACHS) accreditation. The study found that changes to rural health services
resulted in significant changes to the role and function of the rural nurse. They support McMurray's
(1998 AUS) expert opinion and recommend that educational programs be implemented to ensure
that nurses reacted positively to these changes. New knowledge and skills required relate to change
management and the acquisition of strategies to improve interdisciplinary communication, and
community involvement.
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Nurse-Led Clinics
While it is important to highlight that Nurse-led clinics arose from the literature as a theme in their
own right, the description of this change in service and subsequent impact on the role of the nurse
is discussed in other sections of this review for contextual purposes. Accordingly, the literature
relating to this theme is located under the headings Primary Focussed Care, Telemedicine/
Telehealth, and services provided by specialist nurses/extended and expanded roles.
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Family Provided Care
The literature relating to family caregivers includes several studies from the United States, United
Kingdom and one Australian study. Themes emerging from the literature include the level of family
care giver support, patient dependency, needs of family care givers, and the impact of increased
home based care on the role of the community nurse.
Strategies to improve efficiency in health care in the United Kingdom have resulted in an increased
emphasis on home- based care (Kirk and Glendinning, 1998 UK). Home-based care is used to
decrease length of stay, prevent hospital admission and to provide service for people with terminal
or complex care needs (Marks, 1991, 1992 cited in Kirk and Glendinning, 1998 UK). This home care
is often unpaid, informal care, provided by family members (Kirk and Glendinning, 1998 UK). A
substantial number of families are willing to provide home-based services for family members to
keep them at home (Bond, Farrow, Gregson, Bamford, Buck, McNamee & Wright, 1999 UK).
The literature from the United States refers to family practice as treating the patient in the context
of their family and community and confirms that cost cutting in acute care has precipitated a shift of
care from the hospital to the home.. A large USA study by Doeschner, Franks and Saver (1999 USA)
identified that family practice is more cost effective than individual practice. This one-year cross
sectional survey of 35,000 individuals from approximately 14,000 households, found that there was
a 14% reduction in costs when the family practice model was used.
The literature from the US also paints the picture of the chronic and consuming nature of cancer
care-giving. While the narrative literature identifies strategies to assist family members providing
healthcare services, there is little evidence to support the effectiveness of these strategies.
Pasacreta, Barg, Nuamah and McCorkle (2000 USA) conducted a pre test-post test study (NHMRC
level IV) from a convenience sample of 187 cancer care givers attending a 6 hour psychosocial
education program. They found that the education provided to help family members provide cancer-
care had positive effects. Participants reported that they were well informed and confident about
caregiving after the program. They also reported that the program had improved their perceptions
of their own health. However, the study raises the point that not all caregivers are willing or able to
attend support programs and therefore service provision may be affected accordingly.
The literature on the level of family caregiver contribution is primarily narrative. Kirk and
Glendinning (1998 UK) report that the increase in home-based care in the United Kingdom has seen
a shift in family contribution from participation in care decisions to direct care provision. A large
study in England attempted to quantify the level of support being provided by families. Bond,
Farrow, Gregson, Bamford, Buck, McNamee & Wright (1999 UK) surveyed 1444 people aged 65 plus
living at home or in long term care institutions. Of 1127 older people living at home, family
delivered 93% of personal care support on a daily basis. Spouses were the primary providers
(38%), closely followed by daughters (30%). The researchers concluded that there is a substantial
commitment by families to keep the older person at home.
The amount and type of care provided by families has also changed. Patients are being discharged
home with increased levels of technological support and families are providing care that was
previously provided by doctors and nurses. The boundaries between the care provided by family
care givers and nurses are now blurred. In an environment where family carers are delivering
services that in the past have been provided by nurses the literature reports on the supportive role
that nurses have now assumed. A study by Ward-Griffin and McKeever (2000 CAN) who interviewed
23 nurse-family pairs in Canada found that nurses initially provided primary care for the patient and
families provided a support role. However after an adjustment phase nurses expected family
caregivers to learn and take over significant amounts of care. The nurse role at this point was to
monitor caregivers competence and skills. The study identified incompatible role expectations
between the nurses and family caregivers. Family caregivers were not always able to provide the
level of care that was being required of then and often experienced exhaustion, social isolation or
became ill. Nurses are called on to relieve family care giver workload and stress through the
provision of respite and additional home based support in order to ensure caregiver do not become
the 'patient'. Kirk and Glendinning (1998 UK) report that nurses in the UK provide a key role in the
education and supervision of family caregivers. Nurses are also ideally placed to provide information
to potential informal carers to enable them to decide how involved home care they will be.
The literature relating to the needs of family caregivers is supported with evidence from studies in
Canada, US and Australia. Ward-Griffin and McKeever (2000 CAN) interviewed 23 nurse-family pairs
in Canada to identify the nature of the relationships between nurses in the community and family
members caring for elderly relatives. Family caregivers reported exhaustion and social isolation as
result of the burden of care giving and often became 'the patients' themselves. The study found that
nurses initially provided primary care for the patient, and families provided a support role. However,
after an adjustment phase nurses expected family caregivers to learn and take over significant
amounts of care. British literature reports that where voluntary sector support is available this may
decrease family caregiver stress and also reduce costs associated with care (Grant, Goodenough,
Harvey and Hine 2000 UK).
Australian researchers Nankervis, Bloch, Murphy and Herman (1997 AUS) who conducted face to
face and phone interviews with community counselors at 62 Victorian Health and Disability
Organisations, report that little attention has previously been paid to identifying the problems
experienced by family care givers. Yet this information is required to ensure an appropriate match
between services and family care-givers needs. Family caregivers in this study sought help at critical
points: during major changes and during new stages of the life cycle. The problems identified by
family caregivers demonstrate the challenge in looking after their relative and the significant strain
on their health and other relationships. Family caregivers felt socially isolated and reported negative
impacts of their care giving on their marriage, children and other family relationships. Other
challenges identified included having to deal with the stigma of the illness, changes in the patients'
condition and care needs. Carers also reported feeling anger, bewilderment, grief, guilt, anxiety and
helplessness. A lack of information provided about the patient's condition, prognosis and services
was also viewed as a problem. Counsellors are called to be aware of the range of issues faced by
carers and to actively seek to identify and explore these issues with family caregivers. Strategies to
assist family caregivers may include education, advocacy, empowerment, increased resources or
improved problem solving skills.
In Australia Dr Gwen Hartrick from the University of Victoria identifies benefits from a family
approach to community nursing (Hartrick, 1997 AUS). Potentially family nursing enables the nurses
to understand the meaning and experiences of families and illuminate the family's capacity to
transform their experience. However, the current focus on health problems does not acknowledge
the expertise and capacity of families to address their own health and healing needs. While changes
such as improved collaboration and holism have occurred a problem management approach
continues to exist. Hartrick proposes that a transformation of the existing system away from a
health problem approach to an approach that enhances the health and healing capacity of families is
required.
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Care Delivered By Unlicensed Personnel
During the nurse shortages of the 1980's unlicensed staff were employed in the USA to cover the
shortfall (Keepnews, 1997 USA). With increasing financial pressures in health care unlicensed staff
are now being used to reduce costs (Keepnews, 1997 USA; Salmond, 1997 USA; Needham, 1996
UK; Badovinac, Wilson & Woodhouse 1999 USA; Bruser and Whittaker, 1998).
Unlicensed staff is also referred to as unlicensed assistive personnel (UAP), health care assistants,
home health care aides and clinical support workers. Fundamentally all these terms refer to health
care staff who are not nurses but who are employed to perform tasks that were previously
performed by nurses. Evidence relating to unlicensed staff is predominately expert opinions from the
USA and the UK, with very few high level studies. While unlicensed staff are used in Australia,
predominately in aged care, no literature was identified exploring the Australian experience.
There does not appear to be a consensus within the literature regarding the benefits of unlicensed
staff. The UK literature appears to support the introduction of an unlicensed staff role (Needham,
1996 UK; Poole, 1998 UK; Abbott, Johnson & Lewis, 2001 UK). In contrast the literature from the
USA includes concern, (Keepnews, 1997 USA; Salmond, 1997 USA) and in some cases strong
opposition to unlicensed practitioners (Bruser & Whittaker 1998 USA). Salmond (1997 USA) argues
that an RN work force is in fact more cost effective, efficient and improves quality care and through
put of patients compared to the service provided by unlicensed personnel requiring supervision by a
nurse. Bruser and Whittaker (1998 USA) report on a campaign in the American Nurses Association
against the increasing employment of unlicensed staff. Key concepts in the campaign are that 'every
patient deserves a nurse' and nurses are called upon to report unsatisfactory care by unlicensed
staff and promote the capabilities of nurses to policy-makers.
Of particular significance is a cross-sectional survey study (NHMRC level IV) comparing the impacts
of unlicensed staff in the USA and the UK (McLaughlin, Barter, Thomas, Rix, Coulter & Chadderton,
2000 USA/UK). McLaughlin et al (2000) surveyed 342 Registered Nurses (RN) in the UK and USA to
identify differences in the experiences of working with unlicensed staff. Statistically significant
differences were noted with RN's in the UK having higher satisfaction with the ability of unlicensed
staff to perform tasks, communicate pertinent information and provide more time for the RN to
undertake professional activities. The researchers suggest the differences can be attributed to
differences in training levels of the unlicensed staff and ratios of unlicensed staff between the two
countries. The UK has National Vocational Qualification Standards, a set of competencies for
unlicensed staff covering a number of key practices. No comparable national guidelines exist in the
USA. Secondly in the UK the level of RN's is 85-95% compared to 50-55% in the USA. The
researchers conclude there is a need to adopt standardised training requirements in the USA to
ensure the successful implementation of unlicensed staff. Recommendations in relation to the ratios
of unlicensed staff are not discussed.
The impact of unlicensed personnel on the nursing role is a recurrent theme in the narrative
literature. It is suggested that the essence of nursing will be lost (Needham, 1996 UK) as nurses
move away from the bedside to function in more of a supervisory capacity (Salmond, 1997 USA).
This change is speculated to reduce the intrinsic and extrinsic rewards for nurses from direct patient
care (Salmond, 1997 USA). There is also concern that breaking nursing activities into tasks will lead
to a task focus (Needham, 1996 UK).
Another theme emerging is concern regarding the level of function of unlicensed staff. Training is
considered to be inadequate and unlicensed staff are practicing beyond their level of training
(Salmond, 1997 USA; Bruser and Whittaker, 1998 USA). Consequently RN's feel they are unable to
trust or delegate to the unlicensed staff (Salmond, 1997 USA). Role confusion occurs (Salmond,
1997 USA; Bruser and Whittaker, 1998 USA; Needham, 1996 UK) and the quality of patient care is
reduced (Keepnews, 1997 USA). Badovinac, Wilson and Woodhouse (1999 USA) used pre/post tests
(NHMRC level IV) to determine the standard of service delivered by unlicensed personnel. These
researchers surveyed 40 patients, 15 RN's and 9 unlicensed staff as part of a pilot study to examine
the impact of the introduction of unlicensed staff in a short stay medical-surgical unit. Data was
collected on patients' satisfaction and falls before and after implementation of unlicensed staff.
Additionally, RN satisfaction with the unlicensed staff care model was measured after
implementation. An increase in patient satisfaction was noted and there was no significant difference
in the number of falls. RN satisfaction was relatively unchanged. The researchers did not explore
factors that may have impacted on these results
In the UK Waters and Watson (1998 UK) interviewed 16 carers, line managers and nurses to identify
the contribution of untrained staff to health care. Some unlicensed staff believe they do the same
task as nurses with the exception of a few tasks such as medications. Half the managers interviewed
believed the difference between qualification made no difference to quality of care. And half the
managers did not now the differences between some of the roles. Abbott, Johnson and Lewis (2001
UK) who interviewed 99 continuing health care patients and /or their carers in 7 districts of England
found that while community care nurses were valued by patients there was a need for more contact
with nurses. The researchers suggest that given the demands already placed on community nurses,
case managers who do not have health care training may be useful.
A number of narrative papers describe actions required for the successful introduction of unlicensed
staff into health care settings. Authors in both the UK and the USA suggest that unlicensed staff are
here to stay and recommend that nurses need to adapt to survive (Needham, 1996 UK). Health care
institutions are advised not to underestimate the complexity of implementing unlicensed staff
(Salmond, 1997 USA). The attitude of existing staff may add significant complexity to the
implementation process (Treml and Schulman, 1999 USA). Small ward-base committees or
governance groups may be useful forums for addressing these issues (Salmond, 1997 USA). Nurses
are advised to invest their energy in taking charge of the change and developing effective systems
rather than resisting the change (Needham, 1996 UK; Salmond, 1997 USA). Nurses may feel
marginalised and have concerns regarding the impact on patient care (Strachan, 2000 UK) or
experience confusion over the new roles and be unaware of the limits of unlicensed staff (Workman,
1996 UK; Needham, 1996 UK). As identified in the US research, Registered nurses in the UK may
also be concerned that they are expected to supervise, delegate and mentor unlicensed staff without
having had training in these skills (Poole, 1998 UK; Salmond, 1997 USA).
In a small case study Pischke-Winn and Minnick (1996 USA) describe the introduction of unit based
multiskilled environmental workers into 30 patient care units in a medical centre in the USA. The
authors identified a number of key lessons to assist in the successful implementation of such a
program. In particular they are a clear vision, identification and working with resistance, visible
communication, work redesign and publication of the project plan. They identified that another
essential component was to involve nurses and to identify nursing and non-nursing tasks.
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Mental Health Care
The literature reports that political and economic changes in Australia precipitated the process of
deinstutionalization in mental health throughout the 1980's-1990's (Chapman, 1997 AUS). The
narrative by Chapman (1997 AUS) describes the change in services that occurred when asylums
were closed and mental health services were incorporated into mainstream healthcare facilities. This
shift has resulted in a greater emphasis on community care and aims to provide improved
accessibility of services to the general public. For those clients who do require institutionalized care,
length of stay is significantly reduced in the majority of cases so they are returning home with
community mental health follow-up. Community mental health nurses and multidisciplinary mental
health teams provide these services.
Changes to service delivery have consequently dictated the clinical skills required by the healthcare
professional. Nurses need to be reflective in their practice and to hone skills traditionally central in
the clinical practice of other disciplines in the mental health field. Nurses also have a particular role
in liaison with consumers and family who have developed a significant and active role in the
treatment process. The narrative literature reveals that Mental Health nurses are more commonly
being referred to as specialist nurse practitioners. Evidence at the level of case study supports this
commentary. A case study undertaken in the USA looking at the introduction of Advanced Practice
Nurses into specialty-based teams produced a positive result (Tucker, Sandvik, Clark, Sikkink, &
Stears, 1999 USA). Improvements in team function were reported in areas including critical
thinking, accountability, clinical skill development, and communication across the continuum of care,
education and support for staff, an increase in the quality and quantity of research projects and
presentations at conferences.
In the literature emanating from the United Kingdom there is an emphasis on the type of training
made available for the Advanced Nurse Practitioner. Rolfe & Phillips (1996 UK) recommend that this
education should be flexible and ongoing. These authors also report that there still remains some
negative issues with the introduction of Advanced Practice Nurses in established teams and these
are related to fears held by staff about their own job security and role confusion related to the
Advanced Practice Nurse role.
Advanced Nurse Practitioner roles have been developed further in the USA where prescriptive
authority has been made available for psychopharmacologic trained and Masters prepared nurses.
However, due to the difficulty in the process of application for prescriptive authority only 21 % of
nurses have received the authority (Kaas, Dahl, Dehn & Frank, 1998). The role itself is a
collaborative prescribing role with the general practitioner or Psychiatrist but nurses in this role have
experienced a poor acceptance of the role by other healthcare professionals and consumers due to
lack of clarity regarding the role, while other nurses feel uncomfortable with the role itself. Some of
the barriers highlighted by Kaas et al. include poor financial incentives for these Advanced Nurse
Practitioners, a need for more professional development for nurses in the role and further
development of the role within a setting that is conducive to the role.
In the United Kingdom early intervention programs for consumers in mental health require that
mental health nurses have professional skills in lifestyle management, medication management,
symptom management, personal development, stress management and self expression (Lloyd,
Bassett, & Samra, 2000, UK). Mental health nursing has also evolved to the point where there is a
greater emphasis on the acquisition of skills in research based clinical interventions in Advanced
Clinical Nursing. Nurses are increasingly undertaking interventions traditionally undertaken by the
psychiatrist and psychologists (Gournay, Birley & Bennett, 1998, UK: Schneider, Carpenter, &
Brandon, 1999,UK). Counselling is fast becoming a central intervention for the mental health nurse
as opposed to medication management that was once the core skill of the mental health nurse
(Gournay & Gray, 1998,UK). These new skills are a result of new developments in drug treatment
for the seriously mentally ill consumer and the development of evidence that medication and
psychosocial support produce better treatment outcomes for consumers. Mental health nursing is
changing and is diverse and the different perceptions held by community mental health nurses on
the nature and focus of service delivery by community mental health nurses are reflected in the
diverse range of post registration programmes (Barr, 2000, UK).
In the United Kingdom public mental health services provide a range of specialist services that are
largely community based, and that are specifically targeted to people with serious mental illness.
Some key responsibilities of the public mental health system include, assessment, treatment,
support, consultation, transfer of care and communication. Service delivery is increasingly being
provided through a coalition between service providers, where the general practitioner/psychiatrist
and the nurse specialist work together to improve service accessibility through Primary Health Care
Teams (King & Nazareth, 1996, UK). These teams emphasis a holistic approach across the
continuum of care. The growing demand for nurses to work in partnerships in various mental health
settings is supported by literature emanating from the UK, USA and Australia that highlights that
these clinical demands can be generated (Ardern, 1999: Thornton, 1999: White & Brooker, 2001:
Chapman, 1997).
Mental health nurses are key figures in mental health teams, where skills in leadership,
communication, multidisciplinary contribution, advanced clinical skills, health promotion and
prevention of mental illness are required. The 1996 UK National community mental health census of
3421 nurses (reported by White & Brooker, 2001 UK) found there was a 46% increase in the
amount of referrals to community mental health nurses from general practitioners and psychiatrists.
The census also revealed an increase of 22% in counseling as a clinical intervention by community
mental health nurses. White and Brooker noted that the census revealed that levels of clinical
supervision for community mental health nurses had increased. However, they suggested that
additional pre and post registration training to enhance evidenced based clinical skills would help
better equip these nurse specialists for increased case loads and role ambiguity within the service
delivery framework.
Forensic Mental Health is another evolving community service in Australia. Previously service
provision to mentally ill offenders was in either the penal system or a secure unit within an asylum.
Today Forensic Mental Health services are provided by specialist community nurses and in specialty
low security units. Development of the qualifications required to undertake this specialist role is
moving towards more specific forensic nurse training in the undergraduate curriculum and
postgraduate qualifications (Evans & Wells, 2001 AUS). Changes are seen in pre and postgraduate
training, ongoing professional development, support from other professionals in the workplace and
clinical supervision.


Disclaimer

● Acute Care
Acute Care
Narrative papers by Hillman (1999 AUS) and Vincent (1996 USA) provide a background to the
changing nature of acute healthcare services and the subsequent impact on the roles of healthcare
providers. Hillman focuses on the evolution of the Australian public hospital. Until 40 years ago
hospitals were mainly places for bed rest and convalescence. Large public hospitals arose to address
the needs of the poor. A physician visited for several hours each week and surgeons had their own
operating theatre, theatre nurse, ward, ward nursing staff and junior doctors. Healthcare personnel
and healthcare the healthcare workplace was organised in a hierarchical way. Hillman claims that
the legacy of these arrangements is that public health care has grown in a haphazard way, with
scarce resources allocated according to specific initiatives of medical directors and the political
climate at the time.
An explosion of medical knowledge occurred in the 1950's. Whereas previously all hospitals provided
a similar range of options for patients, hospitals became more complex and began to limit their
services to specific medical specialties. Increasingly in-hospital patients had more complex problems
and a greater number of co-morbidities. The explosion of technology in the last twenty years has
added further to the complexity of care delivered in acute hospitals. Buus-Frank (1999 USA) reports
on some of the technological innovations that challenge nurses and encourages nurses to use these
innovations to preserve the human elements of nursing. This expert author states that there is a
blurring of diagnostic testing and clinical monitoring. Devices that have in the past only provided a
singular value are now being placed at the bedside to provide continuous data. Innovations such as
automatic or invasive blood pressure monitoring, pulse oximetry, and continuous electrocardiac, and
electroencephalographic monitoring are now commonplace. Not so commonplace are non-invasive
methods of glucose and arterial blood gas measurement. Cerebral oximetry using infrared
spectroscopy to monitor cerebral blood flow and oxygenation of cerebral microvasculature are also
available in specialized units. Computerized impedance cardiography is a non-invasive method of
monitoring cardiac output, contractility indices and other hemodynamic parameters. On-line
ischemia analysis is another emerging tool that will prove to be valuable in the early diagnosis of
myocardial ischemia and cardiac dysfunction.
While this technology is challenging for the health professionals that use it, it is often overwhelming
for patients, their friends and family. With this in mind, Baby CareLink was developed. Baby
CareLink is a program designed to demystify interventions in a neonatal intensive care unit (NICU)
and provide enhanced medical, informational and emotional support to families of very low birth
weight (VLBW) infants during and after their admission. Baby CareLink itself is a technological
innovation. It is a telemedicine program that is multifaceted, incorporating videoconferencing and
the world wide web (www) that is accessed from the family's home during the infants stay in the
NICU. Videoconferencing facilitates virtual visits and distance learning during the admission period
and provides virtual house calls and remote monitoring after discharge. The www site provides
information relating to issues confronting the family. It may is also used as an electronic interface
for data distribution between health care professionals. A randomized control trial (NHMRC level II)
was conducted by Gray, Safran, Davis, Pompilio-Weitzner, Stewart, Zaccagnini & Pursley (2000
USA) to evaluate the efficacy and benefits of Baby CareLink. The control family group (n=30)
received care as usually practiced in the NICU while a multimedia computer with access to the www
and videoconferencing equipment was installed in the homes of the 26 families randomly allocated
to the intervention group. Outcome measures included family satisfaction scores (using the standard
satisfaction form), infant length of stay, family visits to the NICU and family interactions with their
infant and NICU staff. The researchers found a higher level of satisfaction with care from the Baby
CareLink group, with a lower number of problems being reported compared to the control group
(3% and 13% respectively). The intervention group reported greater satisfaction with the physical
environment of the NICU and visiting policies. Very small infants (< 1000 gms) had shorter lengths
of stay and all Baby CareLink infants were discharged directly to home and not via community
hospitals like 20% of infants in the control group. The researchers concluded that these results
supported the hypothesis that Baby CareLink improves family satisfaction; lowers costs associated
with hospital-to-hospital transfer and facilitates earlier discharge to home for VLBW infants.
Videoconferencing technology has also been implemented in the adult Intensive Care (ICU) setting.
Much of the literature discussed later in the review describes the use of telemedicine to overcome
geographical barriers that separate patient's from the physician in an acute facility. Conversely, this
innovation described by Breslow (2000 USA) and Dorman (2000 USA) overcomes the barrier of
distance between physicians located in a site remote from patients in an acute ICU. In this way, the
specialist physician is not prohibited from leaving the ICU and a single specialist physician can
provide care to patients in multiple ICU's.
Such technological innovations necessity the development of specialised nursing skills. Accordingly,
the role of Clinical Nurse Specialist (CNS) has arisen in acute settings. Lincoln (2000, USA)
distinguishes the role of the Clinical Nurse Specialist from that of the Nurse Practitioner discussed
later in this review. Lincoln used a non experimental, descriptive survey (n=310) to compare the
differences between CNS and NP roles. This was a replication of Williams and Valdivieso's (1992
USA) study to review the current implementation of role activities. The results showed that both
groups performed direct patient care, consultation, education, administration and research. However
it was only in the analysis of time spent in activities and the focus of the activities that differences
presented. CNS were predominantly found in hospital settings, where as the NPs were found mostly
in the ambulatory care area and they performed mostly direct care. CNSs distributed their time
evenly between all roles. Lincoln argued that the CNS role was more vulnerable to the changing
health care system whereas the NP role was far more stable and well defined. These findings are
consistent with other studies comparing roles (Miller, 1995 UK).
Bousfield (1997, UK) also used a qualitative approach to examine the role of the clinical nurse
specialist. She found that CNSs are experienced practitioners who use advanced knowledge,
expertise, and leadership in multidisciplinary environments. The priority for the CNS role is patient
care with additional role components of consultation, education, and research. Bousfield argued that
organizations can be positively influenced by the individual CNS if given sufficient supported and
autonomy. They make a valuable contribution to multidisciplinary team.
In addition, there is a large volume of literature on clinical nurse specialists in the form of opinion
papers. Several of these papers note a transition in the CNS role to more case management
activities. The role of the nurse case manager is discussed in the Case Management section of this
review. Team collaboration and the role of the CNS in facilitating communication in areas such as
discharge planning, pain oncology, cardiovascular, and perioperative areas is also promoted
(Conger, 1996 USA; Wells, 1996 USA; Kee & Borchers, 1998 USA; O'Neal, P., Kozeny, D., Garland,
P., Gaunt, S., & Gordon, S., 1998 USA amongst others).
The perioperative area is particularly rich in technological innovations (Riley & Peters, 2000 AUS).
Virtual reality applications including augmented neurosurgery are being implemented in the
Operating Suite. Precision gloves that would facilitate computer mapping and emulation of precise
movements of the nurses' or physician's hands during technical procedures are also the subject of
laboratory trials. Surgical robotics is a reality as Geis, Kim, Brennan, McAfee and Wang describe in a
1996 publication. These authors conducted a case series (NHMRC level IV) study to identify the
feasibility and efficiency of using robotic arm enhancement in complex minimally invasive surgical
procedures. Their study included the surgeon acting alone (without the need for a surgeon assistant
or scrub nurse to manipulate the equipment) on 24 occasions. There were no incidents or mishaps
during the procedures and all surgical procedures were completed successfully in shorter or
comparable times compared to those performed without the robotic arm. Three additional devices
were tested in combination with the robotic arm. This included head mounted display optics, a 3-D
laparoscope and a harmonic scalpel. This combination significantly enhanced operative times as the
need for de-fogging the laparoscope was reduced. The researchers concluded that implementing
these innovations will reduce costs, and minimize risks if there is a simultaneous educational
investment in team development.
While the above development may reduce the requirements for a scrub nurse, the need for a
Registered Nurse in the Operating Room is the subject of the paper by Christiansen (2000 CAN).
This paper reviews the skills required by the circulating nurse in order to assess whether unlicensed
personnel may perform this role. They conclude that unlicensed personnel are unsuitable for the
circulating nurse role even in an ambulatory short stay setting. Their conclusion is based upon the
necessity for the circulator to be able to engage in a high level of critical thinking, and use or trouble-
shoot highly complex equipment. The circulator is required to anticipate the potential for
complications during surgery and/or anaesthesia, address the same when they arise and function
with a high level of autonomy. Finally, the circulating role requires an ability to respond to varied
availability of resources. They concluded that unlicensed personnel did not have the educational
preparation to undertake such complex functions. These authors also note that the more complex
the environment, the higher the category of caregiver required to provide a comprehensive service
that can address an ever changing environment and a full range of care requirements. They draw
attention to the need for the practitioner to assess changes, re-establish priorities and recognize the
needs for additional resources, as they are required.
The subject of unlicensed personnel is explored elsewhere in this review, however it is appropriate
to mention at this point the driving forces behind the introduction of non-nursing staff in the acute
setting. According to Vincent (1996 USA) work redesign and re-engineering became the 'catch
phrases' of health care in the 1990's. These terms are often used in the context of patient-focused
care, organizational restructuring, and process innovation. Interest arose in the introduction of
unlicensed personnel in the context of decreased resources, the necessity to contain costs, provide
quality care and the notion of multi-skilled health care workers. To achieve redesign it is necessary
to have employees who can function autonomously, are self-directed, are knowledgeable, flexible,
empowered and require little supervision. Conversely, the author claims that the use of unlicensed
personnel (UP) is inappropriate in such a context, as they do not meet these requirements. Instead
UP increase the need for traditional supervision and multiskilling has the potential to create a
reductionistic and mechanistic view of nursing and the pt. She advises that nurses working with UP
should examine the impact of the increased accountability and delegation. Work re-design has
provided a great challenge for nurses. In addition, nurses need to identify how much money using
UP is saving and add the increased costs of supervision and management to consider whether cost
savings are being realized when working with less skilled and knowledgeable staff.
While on the one hand, nurses are considering delegating activities to unlicensed personnel, at the
other end of the scale, nurses in the acute setting are undertaking tasks once performed by junior
doctors (Hopkins, 1996 UK; Carver, 1998 UK). In her narrative paper, Hopkins reports that changes
in the roles of all health care workers in the UK have been precipitated by a considerable changes in
the health care system brought about by government initiatives. These initiatives include the
"National Vocational Qualifications for health-care support workers", "Project 2000", "Scope of
Professional Practice", "NHS and Community Care Act", "Patient's Charter", "Health of a Nation", and
an imperative to reduce junior doctor's hours. In the acute setting, there has been both extension
and expansion of the nurses' role. The literature defines 'extended' roles as performance of
additional tasks that were previously undertaken by other professions, whereas acquisition of
additional skills that fall within the boundaries of nurse education, theory and practice is considered
to be consistent with role expansion (Hopkins, 1996 UK; Carver, 1998 UK; Magennis, 1999 UK).
Accordingly, role expansion appears to indicate nursing roles developing to address unmet needs,
whereas role extension appears to indicate nurses increasingly taking on roles traditionally
performed by medical colleagues. Hopkins warns that where roles are extended there is a danger of
nursing returning to a more task orientated profession. She recommends that role extension only
take place when there are clear indications that patient care may be improved and that the tasks
are incorporated into the work of nursing rather than happening at the expense of the caring role of
the nurse. She highlights the need for appropriate educational programs to support the acquisition
of new skills and those tasks are performed within the Code of Professional Conduct and legal
guidelines in order to safeguard both the nurse and the patient. Finally, Hopkins reports on a
successful venture at the Royal Hallamshire Hospital in Sheffield, UK where the new tasks assumed
by nurses were seen to enhance their roles as well as assisting with the reduction of junior doctor's
hours.
Carver (1998 UK) provides empirical support to Hopkins' opinion paper. Carver undertook a
qualitative study using a phenomenological approach to analyse the impact of reduced junior
doctor's hours on the role of the nurse in an acute regional cardiology centre. Carver conducted four
individual interviews and one focus group interview. Emergent concepts relating to role change
included that role expansion was locally driven and that the influence of the practice environment
was a major factor determining acquisition of specific skills to expand the role of the nurse. She
found that the nurses' scope of practice was determined by increasing competency that arose from
increased knowledge. She also found evidence to reinforce Hopkin's concern that nurses were simply
relieving doctors workload at the expense of their own. From the themes emerging from the
interviews, Carver concluded that nurses were taking on tasks previously assumed by physicians
that did not necessarily complement the role of the nurse and did not directly improve patient care.
However, nurses did experience a degree of freedom from reliance on medical intervention once
these skills were acquired. For example nurses developed skills in intravenous cannulation so they
did not have to call a physician in the middle of the night. In this context, extension of practice
could lead to more holistic patient care.
Another qualitative study conducted by Magennis (1999 UK) examined whether nurses viewed
extension or expansion of their traditional roles in a positive light. This research was prompted by
the Scope of Practice initiative. Magennis used a self-administered survey questionnaire mailed to
40 nurses randomised from a potential sample of 160. This sample was drawn from all registered
nurses in the cardiology unit, intensive care unit and one general medical ward of a general hospital
in one Health and Social Services Trust. Respondents indicated their agreement or disagreement to
17 questions on a five point Likert Scale. T-test analysis revealed that cardiology nurses viewed role
expansion significantly more favourably than general or ICU nurses. This was attributed to greater
emphasis on psychological support, health promotion holistic care in the cardiology setting. 60% of
respondents felt that extended roles were due to doctors unloading what they considered to be
mundane tasks and 72% of respondents saw this as a cost cutting exercise. They were concerned
that these extended activities decreased their ability to expand the scope of their practice in the
nursing domain. This was of significance as expansion of the nursing role was seen in a much more
positive light. Extension of activities was not the only barrier to role expansion, with 78% identifying
that training for expanded roles was inadequate. Significantly, those nurses who had received
further education were more positive towards role expansion. Hopkins opinion relating to the need
for protection against litigation was also confirmed by responses to this study.
Two articles from the United Kingdom consider a nurse-led anticoagulant service. The first (Taylor,
Gray, Cohen, Gaminara, Ramsay, & Miller 1997), a level III-2 study, compares the conduct and
outcomes of a consultant service with a nurse specialist service over two six month periods. Group A
comprised consecutive patients newly referred to the anticoagulant clinic. Group B comprised a
random selection of patients who had been attending the clinic for a period of one year or more.
Specialist staff trained two nurses over a three-month period in specific aspects of anticoagulant
care. Results showed no difference in the primary outcome measure, the time each patient spent
within their INR target range, or the secondary outcome measures, number of general practitioner
consultations and in-patient episodes arising from adverse events related to anticoagulant therapy.
There was no significant difference in the volume and cost of resources used by the patients
between the two services. The authors conclude "... the provision of out-patient anticoagulation by
the nurse specialist service was not a more expensive option than the consultant service despite the
introduction of a domicilliary (sic) service, the training costs of the nurse specialists and longer
anticoagulant clinic hours of the nurse specialist service. ... (it) was as safe as the consultant
service" (p. 827).
In the second study (Hennessey, Vyas, Duncan, & Allard, 2000 UK) a nurse led anticoagulant
service was introduced because of an increase in patient numbers at a clinic in Middlesex. This level
III-3 compared the previous consultant led service with the nurse led service which included a
computerised support system. The nurse initially counselled patients about their warfarin and then
followed them up in clinic until their dosage was stabilised. The nurse also addressed telephone
queries. Results showed that anticoagulant control was not affected by the service change and the
authors concluded that the nurse led service allowed them to accommodate 21% more patients
while improving quality, efficiency and cost-effectiveness of the service and patient care.
Scientific developments in epilepsy management have given rise to specialist neurology units in the
acute care setting. A Cochrane systematic review (Bradley & Lindsay, 2001) of all randomised
controlled and quasi-randomised controlled trials (level 1 evidence) compared specialist epilepsy
nurse interventions with standard or alternative care. While eleven studies were found eight were
excluded mainly on the basis of non-randomised selection. The three trials included were
heterogenous and so results could not be pooled. The intervention described involved multiple
interviews with the specialist epilepsy nurse in addition to standard care. There was some evidence
that newly diagnosed patients whose knowledge about epilepsy was poor may improve their
knowledge scores after nurse intervention. However there was no convincing evidence that specialist
epilepsy nurses improve outcomes for people with epilepsy overall. The authors do say it is plausible
that specialist epilepsy nurses could improve quality of care but further research would be required
before this could be ascertained.
Genetics is an area where a number of controversial ethical issues are arising. However, there is
also promise of great benefits through the application of gene therapy to disease management.
Crosbie, Brewer, Campbell, & MacKay (1998 UK) describe in detail the process and results of their
first experience of breast cancer gene 1 testing in 23 family members in the United Kingdom. They
suggest a unique role within cancer genetics for specialist nurse practitioners in genetic testing and
counseling.
Another theme arising from the acute care literature relating to the impact of service on role
expansion is related to organ procurement. In the setting of an ever increasing need for solid organs
suitable for transplantation, Noah, and Morgan(1999 USA) report that nurses no longer can simply
be involved in supporting families during the experience of procurement without specific training as
a "designated requestor". Roark (2000 USA) reports on an educational program that addresses this
issue by preparing nurses as organ donation requestors. In this program nurses learn about the
steps involved in confirming brain death, issues relating to family acceptance and understanding of
brain death, cultural and ethical issues relating to brain death, bereavement and initiating the
request for donor organs. They also become familiar with family support services.
Finally, clinical practice guidelines on the National Health and Medical Research Council Internet site
(http://www.health.gov.au/nhmrc/publications/pdf/) make some specific recommendations that
have implications for nursing roles in the acute care setting. The clinical practice guideline (1999
AUS), in addition to both the general practitioner (1999 AUS) and the patient family and friends
(2000 AUS) "Guidelines for the prevention, early detection and management of colorectal cancer"
discuss the pre-operative and post-operative role of the stomal therapy nurse in the provision of
information, siting of the stoma and support of the patient.
The "Familial aspects of cancer: a guide to clinical practice (1999 AUS)" suggest that an oncology
nurse with experience in genetics would be one type of professional who could provide counselling in
a familial cancer clinic. Education of the public and health professionals is noted to be vital in cancer
genetics, and both nurses and the Royal College of Nursing are mentioned in relation to this.
While the Australian "Clinical practice guidelines: Management of diabetic retinopathy 1997" do not
include specific references to nurses in the recommendations a quick reference guide for
optometrists, nurses and other health practitioners, "Preserving vision in diabetes" has been
produced indicating a role for the nurse alerting diabetic patients to the need for regular ophthalmic
checks.
It is worth noting however, that Thomas, McColl, Cullum, Rousseau, Soutter & Steen (1998 UK)
conducted a systematic review (NHMRC level I) aimed at identifying evaluations of clinical practice
guidelines in nursing, midwifery and professions allied to medicine. He also examined the
effectiveness and cost effectiveness of guidelines as strategies for promoting improved professional
practice and enhanced patient outcomes. Through this review Thomas et al found that guidelines
containing educational interventions were more beneficial than those using passive approaches and
those incorporating multiple interventions are more likely to bring about behavioral change than
those containing single interventions. The review identified that further research is clearly required
in this area.

Disclaimer

● Midwifery Care
Midwifery Care
The themes that emerge from the midwifery literature are similar in nature to those that have
emerged from the literature in general. The literature acknowledges that nurses' work within multi-
disciplinary teams and research investigates outcomes relating to nurses adopting expanded roles
and coordinating and leading obstetric care.
Traditional models of providing obstetric care involve the participation of multiple caregivers. In the
United Kingdom and Australia there is a high level of evidence supporting a 'continuity of care'
model. In this model care is coordinated throughout the antepartum, intrapartum and postpartum
experience (Hundley, Milne, Glazener & Mollison, 1997 UK; Sandall, 1997 UK; Hodnett, 1999 UK/
AUS; Biro, Waldenstrom & Pannifex, 2000 AUS; Waldenstrom, Brown, McLachan, Forster &
Brennecke, 2000 AUS; Spurgeon, Hicks & Barwell, 2001 UK) by a single caregiver or groups of
caregivers working together. The continuity of care model is examined both as a stand-alone theme
and in the context of the implementation of primary care models. Research also supports the
midwife in a lead role in continuity of care models.
One Cochrane systematic review (NHMRC level I) conducted by Hodnett in 1999 (AUS) searched for
randomised control trials to assess continuity of care from pregnancy through the postnatal period
compared to usual care by multiple care givers. Two trials (Flint, 1989 UK and Rowley, 1995 AUS)
were identified to be of good quality, although it was unclear whether randomization was centrally
controlled. Both trials compared continuity of care by midwives with non-continuity of care by a
combination of midwives and physicians. A total of 1815 women were included with the key findings
being that women who had continuity of care were less likely to be admitted to hospital antenatally
and were more likely to attend antenatal education programs. These women were also less likely to
have drugs for pain relief in labor, less likely to have an episiotomy, but more likely to have a
vaginal or perineal tear. Their newborns were less likely to require resuscitation, but there were no
differences in Apgar scores, birthweight parameters and stillbirth or neonatal death rates.
Three recent good quality studies (NHMRC level II evidence) reported similar findings. Homer, Davis
& Brodie (2000 AUS) sampled 1089 women (550 in the experimental group and 539 in the control
group) using a questionnaire. 775 women responded and those in the group who received
coordinated care from a team of midwives reported greater satisfaction with their care compared to
the control group who received traditional physician led care. In particular they reported shorter
waiting times at appointments, found the clinics/venues more accessible, didn't feel as rushed and
developed an easier rapport with the midwives.
Two Australian studies also examined the differences between team midwifery and traditional
multiple caregiver services in two large public hospitals in Melbourne, Victoria. Biro, Waldenstrom &
Pannifex (2000 AUS) extracted data on interventions and maternal and infant outcomes from
hospital records of 502 women assigned to team midwifery care and 498 women assigned to
standard care (n=1000). The continuity in midwifery care model was associated with a reduction in
medical procedures in labor and a shorter length of stay without compromising maternal or perinatal
care. Waldenstrom, Brown, McLachan, Forster & Brennecke (2000 AUS) used a postal questionnaire
to elicit data from 1000 women, 495 who were randomly allocated to team midwifery care and 505
to standard consultant led care (n=1000). Interestingly, the results from this study differed in that
there was no difference between the intervention and control group with regard to medical
interventions. However, similar findings were noted regarding increased satisfaction with midwifery
team care. In particular this research supported the findings of Homer et al with the greatest
difference in satisfaction relating to the antenatal period.
Two further studies provide additional evidence at the NHMRC level III-1. Spurgeon, Hicks and
Barwell (2001 UK) conducted a randomised controlled trial researching a community-based
continuity of care model. Two pilot groups of 112 and 103 women were randomly drawn from GP
practices in the catchment area of Central England. The first group was allocated to one-to-one
midwifery care and the second group evolved naturally to the care provided by a small group of
midwives. A third group of 118 women were drawn from the Trust's obstetric unit to act as the
control group. A questionnaire was administered six weeks postnatally and found that patient
satisfaction was highest in the midwifery care groups, information and advice received from the
midwifery groups was rated more highly and the women in the intervention groups felt that the
midwives acted as partners in decision making.
In an earlier study, Hundley, Milne, Glazener & Mollison (1997 UK) results were not so conclusive.
These researchers allocated 2844 women to either a midwife unit (continuity of care model) or a
labor ward (traditional model). A 2:1 randomization method in favor of the midwives unit was used
to take into account transfer rates. Hundley et al used a questionnaire to evaluate the outcome
measures of satisfaction, continuity of carer, choice and control. While the responses revealed that
overall experiences did not vary significantly, the midwives group was significantly more likely to
have made their own decisions regarding pain relief.
It is evident from the above literature that midwives at all levels within the profession are involved
in changing service provision that aims to increase continuity of care and carer for the woman.
Within maternity services this has often been interpreted as women-centred care with the need for
the woman (and her partner, if she wishes) being the focus of care (Pope, Graham & Patel, 2001
UK). A research project by Pope, Graham and Patel (2001 UK) was commissioned by the English
National Board for Nursing, Midwifery and Health Visiting. The aim of the study was threefold.
Firstly, it aimed to establish the current role and responsibilities of midwives in a variety of settings
with a range of client groups. The second aim was to identify the changing educational needs of
midwives to fulfil their future widened role and responsibilities within the changing maternity
services. The final aim was to provide information from which to develop an educational package to
assist midwives to respond to the requirements of their changing role and responsibilities. Both
quantitative and qualitative methodologies were employed and included a national survey of
midwives, midwifery supervisors and doctors. The study indicated a strong commitment to women-
centred care on the part of midwives. Similar to the findings by Waldestrom et al (2000 AUS) and
Homer et al (2000 AUS) this was best translated into practice in the antenatal setting. The picture of
hospital care that emerged was less organised. Accordingly, the researchers recommend that the
introduction of more structured frameworks for care would reduce individual variability in care and
afford better monitoring for quality assurance purposes. Continuing education needs for midwives
were identified to include expanded clinical skills such as intravenous cannulation, perineal suturing,
ultrasonography, labor and delivery in water, and interpretation of cardiotocography. There was also
an emphasis on educational preparation regarding research skills, communication, counselling skills
and general issues relating to professional practice such as ethico-legal considerations and
accountability.
A central theme from all of the studies is that the introduction of a continuity of care model has
significant implications for future planning and provision of antenatal, intrapartum and postnatal
services. While it is unclear whether the results from the studies provide a high level of evidence to
support continuity of care or midwife led care it is clear that there exists a potential role for the
midwife to be the primary carer in both community and hospital based obstetric care. Furthermore,
the introduction of this model of care creates the potential for expansion of the midwife's role to
include greater control and autonomy in practice. These latter attributes are particularly important
as the multi-centre case study (NHMRC level IV) by Sandall (1997 UK) reveals that continuity of
carer is not only a key issue related to satisfaction for childbearing women, but that it provides three
key components that can prevent 'burnout' relating to midwifery work. These components include
affording midwifes the opportunity for achieving occupational autonomy, receiving intraprofessional
support and the possibility of developing meaningful professional relationships with women.
As detailed earlier in the review, the establishment of GP led Primary Care Groups (PCG's) to supply
primary care to local communities has been a major new initiative designed to assist modernisation
of the United Kingdom's National Health Service (NHS). The narrative paper by Houston (2000 UK)
reports on how this change in service has impacted on the role of midwives. According to Houston,
midwives in the UK deliver the majority of care to childbearing women at all stages of the
childbearing episode. With the implementation of the GP led Primary Care model of service delivery
they are required to become actively involved in PCG's, contributing to local health improvement
programs and working in partnerships with other professionals delivering primary care services.
In the past such multi-disciplinary teamwork has not always occurred as demonstrated by studies by
Mbwili-Muleya, Gunn & Jenkins (2000 AUS), Pope et al (2001 UK) and Fenwick, Morgan, McKenzie
and Wolfe (1998 UK). The Australian study by Mbwili-Muleya et al reveals difficulties relating to
professional liaison between Maternal and child health nurses during the postnatal period. This
qualitative study used a postal survey to sample 1104 GP's in Victoria. The sample included all listed
female GP's (n=503) and a random selection of male GP's (n=601) to allow for the effects of
gender. Of the 775 GP's who responded, half had no contact with maternal and child health nurses
in the previous month, with 56% of contacts being initiated by maternal and child health nurses.
The researchers recommended that further study was required to identify the benefits of increased
maternal and child health nurse and GP contact on maternal and infant outcomes. In the meantime
however, they suggest that a more systematic approach to the contact between these two providers
of postnatal services would lead to a better coordinated, more cost-effective and efficient use of
services.
The case study component of the research by Pope et al (2001) identified that midwife and GP
partnerships are placed under particular tension when a woman requests a home birth. The
qualitative study by Davies, Hey, Reid and Young (1996 UK) identified that midwives experienced a
lack of support from GP's who were not keen to be involved or present at home confinements. Pope
et al report that this leads to the breakdown of established GP/midwife partnerships as the midwife
would assist a woman to look for another GP if the woman met the criteria for a home birth but her
own GP prevented her from taking up this option. Fenwick, N., Morgan, M., McKenzie, C., & Wolfe,
(1998 UK) also identified reluctance on the part of GP's to fully commit to partnerships with
midwives. In this study postal questionnaires were sent to 58 GPs referring women to midwifery
group practices, a shorter questionnaire was sent to the remaining 67 GPs (non practice group) in
the same postal area. In depth interviews were conducted with 12 GPs. The researchers found that
despite 80% of group practice GPs believing that midwives had the skills to detect deviation from
normal, they did not wholeheartedly embrace working in partnership. While 66% of group practice
GPs would confidently refer women to midwifery care, 50% of group practice GPs felt that midwives
discouraged women from visiting GP's. As a result, 33% of group practice GPs felt they were seeing
group practice women too few times for antenatal checks. It appears that poor communication was
essentially to blame with 64% of group practice GP's identifying that communication with group
practice midwives was poor.
Accordingly, Houston recommends that midwives develop improved leadership, communication and
negotiation skills in addition to enhancing their practice skills. Drawing attention to the Department
of Health document "Making a Difference" (1999 UK) that calls for midwives to expand their role to
include wider responsibilities for women's health, Houston and McFarland (1999 UK) identify a
number of areas in which midwives practice skills can expand. These include further development of
knowledge and skills related to midwifery, women's health, public health, fertility, health promotion
and screening. It is envisaged that primary care, acute care leaders and universities will work
together to develop new educational programs. These programs will aim to address these needs to
ensure that midwives will contribute effectively to the provision of good quality, cost-effective care
that meets the needs of local communities.
An example of an educational program with such a focus is reported in the literature. The paper by
Brittain (1999 UK) provides an account of a course developed by the Department of Midwifery
Studies at the University of Central Lancashire (UCLAN) in response to a request from the North
West Regional Health Authority. UCLAN developed a 3-day program to provide family planning
nurses with specific skills and knowledge to provide emergency hormonal contraception using a
protocol in the absence of a doctor. Brittain explains that this extension of the family planning nurse
role is a particularly significant for public health as one third of live births in the United Kingdom are
unintended. The aim of the educational program was to increase the availability and accessibility of
emergency hormonal contraception in the North West Region while at the same time providing a
clear framework for safe practice.
The need for providing adequate education and the necessary safeguards when expanding the
current role of nurses is also highlighted by a qualitative study by Jowett, Peters, Reynolds and
Wilson-Barnett (2001 UK). This study was commissioned as a part of the larger study by the English
National Board for Nursing, Midwifery and Health Visiting and consisted of a questionnaire examining
three main areas. Firstly, the researchers asked respondents about their awareness of the Scope of
Professional Practice for nurses, midwives and health visitors document that encourages expanded
roles for these professionals. Secondly they asked whether there were any activities/practices that
the respondent would like these professionals to do that were not currently part of their role.
Thirdly, they asked whether the respondent had any concerns about these professionals expanding
what they do. The questionnaire was distributed to medical organizations, professional bodies,
consumer groups, government departments, health authorities, social service departments,
community health councils, private health care providers and centres for nursing and midwifery
education. 212 responses were received. Responses revealed that there was a high degree of
awareness about the Scope document (85%), 25% of respondents described prescribing as a
desirable component of expanded practice, 40% were concerned that staff required adequate
training and 23% identified the need to safeguard patients.
While the literature reviewed so far has focussed on midwifery practice in the UK and Australia, the
literature emanating from the United states identifies similar issues relating to the impact of health
care system developments on midwifery and the roles that midwives play in women's health care. A
narrative paper by Paine, Dower and O'Neil (1999 USA) reports the recommendations of a Taskforce
on Midwifery convened in 1998 by the University of California at San Francisco Center for the Health
Professions. The Taskforce of eight experts from across the country explored the effects of market-
driven changes on midwifery and made fourteen recommendations related to midwifery practice,
regulation, education, research and policy. The recommendations include permitting midwifery care
access to all women requesting that care by ensuring that midwives are placed in a variety of health
care settings. They also recommend that when making decisions about access to midwifery services
policy-makers, regulators, hospitals and health-plan administrators avail themselves of the research
data suggesting that women experience a high level of satisfaction with midwifery care. In times of
economic reform the panel of experts recommended that improved education, expansion of the
midwifery role and integration of midwifery services would result in provision of high quality care at
a reduced cost. Recommendations for educational programs included providing opportunities for
intra-professional education and training experiences and allowing for multiple entry points.
Recommended curricula components include evidence-based health care, cultural competence,
information management, population-based skills (epidemiology, biostatistics, behavioural and
political sciences) and health care policy and financing. Policy recommendations include the
recognition of midwives as independent and collaborative practitioners with rights and
responsibilities relating to scope of practice. Finally, in order to implement the preferred model of
professional practice, the panel recommended that laws relating to entry to practice standards be
passed by State legislatures.
Although conducted two years prior to the paper by Paine, Dower, & O'Neil, (1999 USA) was
published, a national postal survey of 600 midwives (Kraus, 1997 USA) revealed that the scope of
practice of the nurse-midwife has increased over recent years. The questionnaire was mailed on an
nth name basis to members of the American College of Nurse Midwives (ACNM). Responses revealed
that the typical American midwife either practices in a hospital (27%) or in a physician's practice
(24%). The midwives surveyed provide total patient care for an average of 140 client's per month,
chiefly delivering care to childbearing women. While pregnancy related practice was unchanged from
a similar survey in 1993, role expansion has occurred in the area of well-women gynecology,
nutrition, mental wellness, primary care and post-menopausal care. The greatest change identified
was the rise from 51% to 84% of midwives reporting prescribing autonomy and authority.
The literature reviewed did not reveal high-level evidence regarding outcomes relating to the
expanded practice roles referred to by Paine et al (1999 USA) and Kraus (1997 USA). One study of a
high level of evidence (NHMRC III-2) was conducted by Davidson (1999 USA) for a PhD dissertation.
Davidson employed a descriptive one-group design to explore the outcomes of nurse-midwifery care
for high-risk mothers reported positive outcomes. This longitudinal study included a sample of 803
women with one or more high risk factors who were cared for by nurse midwives over a ten-year
period. The researcher found that the high risk women in nurse-midwifery care enjoyed a lower
cesarean section rates than national averages, experienced higher rates of vaginal delivery and
vaginal delivery after cesarean section, and their newborns were less frequently admitted to
neonatal intensive care than the national statistics report. Findings both support the midwifery led
primary care model and suggest that nurse-midwifery care may help to reduce medical
expenditures.
A case study (NHMRC level IV) by Corrarino, Williams, Campbell, Amrhein, LoPiano & Kalachik (2000
USA) used a non-experimental design to evaluate the outcomes of public health nurse visiting to
another high risk group of pregnant women. Although this study does not directly relate to
midwifery care, it does describe nursing interventions relating to a women-centred care model. The
aim of the very limited pilot study was to assist pregnant substance abusers to enter drug
treatment. All ten substances abusing pregnant women had full-term infants, their substance
abusing behaviour improved and 80% retained custody of the child. While this study suggests that
nurses can usefully employ strategies to assist substance-abusing women enter drug treatment,
further studies are needed to assess the assistance and care most likely to result in improved
models of care for substance abusing pregnant women.
A paper by Ecenroad & Zwelling (2000 USA) reported findings from a patient satisfaction survey
following the transition from a traditional maternity unit to a family centred care model. The change
in service was from an 'illness' model to 'wellness' model with care based on evidence rather than
ritual and tradition. The introduction of this model involved significant staff education. A total of 259
women were surveyed with 96% finding their family-centred birth experience to be positive.
The remainder of the literature retrieved from American authors relates to evaluation of different
models of midwifery service delivery in terms of providing quality care at a reduced cost. A
qualitative study by Higgins (1996 USA) as part of a PhD dissertation reviewed 67 private nurse
midwifery practices to assess their relatively profitability and organisational adaptation to
environmental change. She found that only 20 reported successful business performance relative to
the industrial standard and this was not related to organisational adaptation. The remaining articles
fall into the category of expert opinion. For example, Ernst (1996 USA) argues that in collaboration
with physicians, midwifery care and birth centres are well placed to provide quality economically
sustainable services to as many as 85% of childbearing women. In the model presented, nurse-
midwifery care focuses upon wellness. In addition midwives can identify deviations from normal and
implement life-saving interventions through mutually agreed upon protocols. Pence (1997 USA)
reported a shift from total patient care to delegated, shared accountability in a birth centre.
Essentially this is a model of patient focussed care where new parents and their neonates receive
care from cross-trained workers. Its implementation was driven by the managed care agenda and
the author claims that it can be effectively applied to respond to increasing economic pressures.
The final two American articles reviewed relate to advanced practice roles in midwifery and maternal/
child nursing care. Menihan (2000 USA) discusses the use of limited ultrasound in nursing practice
and the issues surrounding this new skill incorporated in midwifery practice. This extension of
perinatal services provides the potential for midwives to gain information relating to fetal wellbeing
to complement the assessment of the fetal heart. Implications for practice include the necessity for
accreditation, as nurses performing this investigation will be accountable for the quality and
accuracy of the reports. The author reports that the Association of Women's Health, Obstetric &
Neonatal Nurses recommends nurses wishing to enhance their role with this new skill undertake an
educational program to gain an understanding of the theoretical and clinical guidelines for limited
sonography.
A narrative paper by Lewis (2000 USA) describes the changes and dramatic growth of maternal and
child health nursing in the past 25 years and the development and importance of advanced practice
nursing. Lewis paints the picture of a healthcare environment characterised by severe nursing
shortages, an aging nursing workforce, in which nurses are increasingly expected to prove their cost-
effectiveness and unique contribution to the health care system. Despite this rather grim picture,
Lewis maintains that there are many new and exciting opportunities for nurses to be employed in
advanced practice roles. Such opportunities arise in the areas where technological advances lead to
expansion of the nursing role. For example increased complexity of care precipitated by the genetics
revolution and reproductive technologies and in the childbearing and paediatric populations where
the numbers of infants and children with complex health care needs have increased. Finally, Lewis
advises that nurses need to remain strongly connected to their nursing identity while at the same
time collaborating rather than competing with other health professionals.

Disclaimer

● Telemedicine/Telehealth
Telemedicine/Telehealth
Telemedicine is an evolving feature of health care service provision in the 21st Century. The
simplest definition of telemedicine is the practice of medicine at a distance (de Lusignan, Meredith,
Wells, Leatham & Johnson, 1999 UK) whereby medical information and consultations are provided
through the use of telecommunication technologies (Mair & Whitten, 2000 UK; Currell, Urquhart,
Wainright & Lewis 2001 UK; Stanberry, 2001 UK). Telemedicine practice generally involves
exchange of information between medical professionals or between the client and medical
professionals. The telemedicine episode may or may not be augmented with additional information
supplied by remote monitoring technologies or visual links such as videoconferencing. "e-health", or
the use of personal computers (PC's), internet (www), and email mediated communication is an
emerging component of telemedicine (Schlachta-Fairchild, 2001 USA). The telemedicine consultation
may be conducted in real time (synchronous), or is time delayed (store-and-forward). The term
"telehealth" refers to the provision of all health care services, from client education to direct health
care delivery via telecommunication technologies (McNeal, 1998).
Telemedicine was introduced in the late 1950's in an effort to increase access and quality of care in
rural and remote areas or in areas where health services were limited (Heterington, 1998 USA). In
the intervening period, there has been a proliferation of technology. Sophisticated innovations in the
form of information distribution, management and analysis systems, videoconferencing, artificial
intelligence and automated decision making systems are now readily available as tools to assist
health care service development (Buus-Frank, 1999 USA). The recent imperative for service delivery
to be patient focussed, community based, accessible and cost effective has led to such technologies
being embraced as alternatives to traditional methods of service delivery beyond the original
application to rural communities (Anastasia & Blevins, 1997 USA). A literature review by Heterington
in 1998 found that radiology (72 articles) was the medical specialty that most utilised telemedicine,
followed by pathology (35 articles) and internal medicine (26 articles). This review, only 5 years
later, identifies a much wider range of applications with only passing references to radiology. While
the use in rural and remote services continues to expand, the literature reveals that telemedicine is
now being used to deliver home-care health services and telephone triage services to urban
populations. The literature reports that services traditionally conducted by acute hospitals on an
outpatient or clinic basis can now be delivered in the community or traditional face-to-face services
may be augmented by telemedicine services. Breslow (2001 USA) provides evidence that
telemedicine applications can also be utilised within acute healthcare services for remote monitoring
by ICU physicians at home. The literature relating to telemedicine describes these specific
applications and reports on research relating to benefits and disadvantages of these applications,
the feasibility and reliability of telemedicine services, and satisfaction with services provided in these
ways. The impact on roles and activities of nurses and other health professionals is also explored.
A Cochrane systematic review (NHMRC level I) by Currell, Urquhart, Wainright & Lewis (2001 UK)
was conducted to assess the effects of telemedicine as an alternative to face-to-face patient care.
Seven well-conducted, randomised control trials were identified. The studies were concerned with
telemedicine in the emergency department and the provision of home care or patient self-
monitoring of chronic disease. The studies collectively involved 800 people, but in most cases
numbers in individual trials were small. On the positive side, none of the studies revealed any
detrimental effects from the use of telemedicine services, the use of telemedicine was proved to be
feasible, technological interventions were found to be largely reliable and were well accepted by
patients. On the negative side, the studies did not show equivocal clinical benefits nor did the
findings constitute evidence of the safety of telemedicine. Despite many claims that telemedicine is
cost effective, the studies provided variable and inconclusive results relating to the cost
effectiveness of telemedicine systems. The authors conclude that policy makers should be cautious
about recommending increased use and investment in unevaluated technologies. They claim that
the trials reviewed prove the feasibility of conducting randomised control studies and draw attention
to the need for further research of this nature.
Mair and Whitten (2000 UK) conducted a systematic literature review of all literature relating to
patient satisfaction with telemedicine (NHMRC level II). They reviewed 32 papers including the same
randomised control relating to telemedicine in the emergency department as included by Currell,
Urquhart, Wainwright, & Lewis (2001 UK). Two trials where participants were randomly selected
were identified and a case-control study was also included. The remaining 28 studies were classified
as providing low levels of evidence. A large proportion of the studies reviewed was concerned with
telemedicine in psychiatry and dermatology. The majority of studies used simple survey instruments
and found that patients were satisfied with telemedicine services. Elements contributing to
satisfaction included: tele-consultations being an acceptable replacement to face-to-face
consultations, that telemedicine increased accessibility to specialist expertise, and that travel and
waiting times were decreased. Findings relating to dissatisfaction included concerns relating to
communicating through a technological medium. Mair and Whitten caution about generalising these
results however, as the results from much of the published research are largely influenced by the
specialised applications of telemedicine practice. Further, they identified a high degree of
methodological deficiency in the published literature. Like Currell, et al these authors consequently
highlight the need for more scientifically robust studies.
While there is much literature on every possible application of telemedicine, this review focuses on
detailing literature where the introduction of a telemedicine service directly impacts on the role of
the nurse.
Literature relating to the use of telemedicine to overcome the challenges of distance for delivery of
healthcare services to citizens of rural and remote communities includes reports on research in the
form of case studies. A case series (NHMRC level II) by Boulanger, Kearney, Ochoa, Tsuei and
Sands (2001 USA) found that there was a high degree of satisfaction with telemedicine-based follow-
up of rural trauma patients discharged to remote areas of Kentucky. These patients attended a Tele-
Trauma Clinic at a regional Medical centre, travelling between 1-80 miles for the consultation rather
than between 100-240 miles to the Level 1 Trauma Centre where follow-up appointments were
previously conducted. A nurse facilitated any necessary radiological studies and recorded the
patient's vital signs prior to the two-way real-time telemedicine link-up. The remote physician
conducted an interview and examined the patient with the assistance of the Clinic Nurse, an
electronic stethoscope and a close-up viewing instrument. The findings were derived from surveying
all consulting physicians and all patients involved in the Tele-Trauma Clinic link-up. Despite the new
skills required and the new role adopted, the Clinic Nurse was not surveyed. Nor was there a
comparison between this service and the usual face-to-face follow-up. The decision to continue and
expand this service was reached through positive responses particularly to the questions: "overall, I
was very satisfied with today's consultation", " telemedicine makes it easier to get medical care" and
negative responses to the question "would you have preferred to see the consultant in person?"
Dimmick, Mustaleski, Burgiss and Welsh (2000 USA) report initial findings from a case study of a
federally funded tele-home care demonstration project in rural Tennessee. The study involved the
use of video camera, video monitor, speakerphone and an electronic interface to the standard home
telephone line. Using this equipment the patient is linked to a home health nurse for one or two
scheduled consultations per week and additional contacts if required. Data was collected over a 12-
month period from the 14 patient participants. All patients had chronic diseases and the types of
services provided included pain control, physical, wound, and vital sign assessment, glucose and
patient controlled analgaesia monitoring and medication management. The data collected set
included 444 telemedicine encounter sheets, monthly satisfaction questionnaires administered by
the nurse over the telemedicine system, telephone interviews by an independent caller and in-depth
interviews by the researcher. Patients reported satisfaction relating to the benefits of easy access to
nursing services, the ability to maintain their own health status at home, a perception of
personalised care and the fact that they didn't have to drive on dangerous rural roads. Participating
patients found the tele-home system user-friendly and as most also received an in-home visit their
claim that the quality was the same or better was valid. Family caregivers were also surveyed and
reported that tele-home care afforded greater confidence in caring for chronically ill relatives at
home by knowing they could easily access help. Providers reported that tele-home health provided a
reliable, low cost, long term patient management system that increased productivity and was a
viable alternative to in-home visits to provide monitoring, management and incremental health
education.
The introduction of a nurse-led telemedicine service to elderly (> 65years) residents of a rural
Scottish village was the subject of a two part report by Macduff, West and Harvey (2001a, 2001b
UK). Using similar equipment to that used in the study reported by Dimmick, Mustaleski, Burgiss, &
Welsh (2000 USA), 20 patients were video-linked from the community nursing clinic to the GP's
rooms. The community nurses' used a referral protocol to determine the need for a video-link GP
consultation, provided the GP with a succinct assessment prior to the consultation. The nurse was
then available to provide support during the consultation at the patient's request and following the
consultation carried out any treatment that the GP advised. The patient questionnaire revealed
satisfaction with the service, particularly relating to convenience and the role of the nurse in
interpreting and explaining points that they had not understood during the GP consultation.
Although a relatively small development in terms of numbers this new service resulted in a
significant expansion of the community nurses' role, both in the provision of technical assistance and
provision of assessment, monitoring, advisory and prescribing services. The numbers of patients
treated solely by the community health nurse increased significantly with only a few patients needed
referral to a face-to-face GP consultation. The participating GP's reported satisfaction with the
service, both in terms of patient outcomes and the decrease in their own workload.
The final study relating to rural telemedicine services is reported in the paper by Harris and
Campbell (2000). This American study evaluated the utilization of computer-based telemedicine in
three rural counties in Missouri. The ten general practice clinics that participated in the study each
received a computer with a network card so that they could connect to the world-wide-web (www),
email, access community specific information and contact a medical librarian. The study revealed
low utilisation of email, but higher utilisation of the www by physicians. With one exception the
study revealed that when compared to the utilisation by nursing staff at the clinics, physician
acceptance of this technology was low. A closer analysis by the researcher revealed that the nurse
often used email at the physician's request. The researcher's concluded that a physician's
willingness to use nurse practitioners in their practices may increase their willingness to use
telemedicine as an extension to their practice. This change in service would therefore have
implications on the role of the nurse practitioner in a GP practice.
The randomized control trial (NHMRC level II) by Brennan, Kealy, Gerardi, Shih, Allegra, Sannipoli
and Lutz (1999 USA) was included in both systematic reviews described earlier. This study
evaluated the use of standard teleconferencing equipment and peripherals (otoscope, stethoscope,
and dermoscope) by emergency physicians to take a medical history and perform a physical
examination on patients in a remote Emergency Department (ED). An ED telemedicine trained nurse
assisted at the remote site. Patients with any of 18 pre-determined minor conditions were
randomised to be seen by either the telemedicine nurse or to conventional physician care at the
remote site. After the local telemedicine nurse and the remote telemedicine physician evaluated 50
patients, the nurse and physician recorded their experiences using a satisfaction scale. Patient
interaction, nurse interaction, video quality, ability to hear and see patients, comfort level in making
diagnoses, audio quality and usefulness of peripherals were rated by remote physicians using a
scale of 1: not very satisfied, to 5: very satisfied. The mean survey responses ranged between 3.7
for usefulness of peripherals to 4.8 for nurse and patient interaction. Nurses rated patient
interaction, physician interaction, video quality, perceived ability of physician to hear and see
patients, perceived comfort level of physician in making diagnoses, audio quality, and ease of use.
Their mean responses ranged from 5.0 for video quality and physician interaction to 3.7 for
perceived ability of physician to hear and see patients. The researchers consequently concluded that
physicians and nurses were satisfied with the use of telemedicine to diagnose and treat selected
groups of ED patients.
Four papers report a longitudinal study (NHMRC level IV) of a telemedicine link between a nurse-led
minor treatment centre in London and an ED in Belfast (Darkins, Dearden, Rocke, Martin, Sibson &
Wootton, 1996 UK; Tachakra, Wiley, Dawood, Sivakumar, Dutton & Hayes, 1998 UK; Tachakra,
Loan & Uche, 2000 UK; and Tachakra, Dutton, Newson, Hayes, Sivakumar, Jaye and Bak, 2000 UK).
Standard videoconferencing equipment was used by the emergency nurse practitioners to access ED
physicians as an alternative to referring patients to a local ED or a local GP. In the first twelve
months of operation, only 0.5% of patients were seen using the telemedicine link. This was fewer
than expected but was deemed to be a cost effective alternative to employing a physician at the
clinic. One could argue that it would be just as cost effective to refer the patients to local physician
services. The 1998 paper revealed that the number had increased to 2.9%, the most common
reason (39%) for the use of telemedicine link being to discuss an X-Ray. The accuracy of the
telemedicine assisted X-ray interpretation was subsequently checked by a review panel and found
that the nurse practitioners working diagnosis was improved with the help of the telemedicine
consultation from a sensitivity of 90% to 97% and a specificity of 96% to 99%. By late 1999, the
number of tele-consultations had increased again to 5.9% of all consultations. When the researchers
examined the hospital records of those who had required admission to determine the reliability of
telemedicine diagnoses, 98% of diagnoses were considered correct. The fourth study conducted four
months later noted that consultation rates increased when a number of local consultant run clinics
were closed and fell when nurse practitioners gained more experience in interpretation of X-Rays.
These studies perhaps illustrate the efficiencies of nurse-led clinics better than those of
telemedicine.
A fifth paper reported in this series reported on the nature of calls to the service. (Tachakra,
Hollingdale & Uche, 2001 UK). This paper reports that two hundred of the 1854 teleconsultations
from mid 1996 to 2000 were with the orthopaedic service. Of these, 193 needed teleradiology with
190 showing an abnormality. The emergency nurse practitioners and orthopaedic registrars
diagnosed all cases correctly. Where patients required hospital admission the emergency nurse
practitioner consulted with the orthopaedic resident telemedically and organised direct ward
admission, thus avoiding the transfer of the patient to a second accident and emergency department
for assessment.
In the UK there is particular recognition of the role of the emergency nurse in determining the level
of first line services required. 'NHS direct' is an UK government initiative to provide a 24-hour
telephone advice line staffed by nurses. It is already established in England and will be operational
in Wales and Scotland by 2000. The function of the telephone consultation is to recommend home
care or referral to appropriate healthcare services through a triage system that identifies the nature
and potential urgency of the clinical problem. Nurses answering the calls are supported by
computerised decision making software, advice and information databases, and electronic
communication links with primary care services, hospital accident and emergency (A&E)
departments, the ambulance service and other agencies. The narrative paper by McLellan (1999 UK)
reports that at the time of writing, 95% of calls were about symptoms, with 45-50% of all calls
being about children. Accordingly, the most frequent users of the call system are parents of young
children. McLellan identifies that the call service has the potential to improve and develop child
health services in the UK, but cautions that this will directly relate to the quality of the advice. He
highlights the need to recruit paediatric nurses to the call service or provide specific paediatric/child
health education to call centre nurses without paediatric qualifications. Additional knowledge
required by call centre nurses includes use of telephone systems and the use of clinical decision
support software. Call centre nurses' also require specific knowledge relating to remote decision
making, eliciting pertinent information from the caller, evidence based practices and knowledge of
local health care service practices and procedures.
Schwartz, Genovese, Devitt & Gottlieb (2000 USA) report that in the USA there are many
commercial telephone call centres and most hospitals have some form of telephone triage system.
These authors showcase a national Veterans Affair telephone care program that is conducted by an
all-RN staff with advanced practice or critical care skills that can work independently and make
critical judgements. The use of computer networks by the service facilitates immediate access to
patient's medical records. This same network facilitates immediate recording of progress notes with
notification to the primary care provider by telephone or e-mail. Continuity of care is ensured
through access to laboratory results so that the telephone triage nurse can determine whether care
at home has been successful or whether the veteran needs to attend a healthcare service.
Telephone triage nurses also make follow-up calls should the patient be referred to a healthcare
service and follow-up veterans following ambulatory surgery. Clinical decision-making support is
afforded through protocols classified by symptom. Other protocols used are specifically for follow-up
of surgical patients. Information provided by the authors identifies that 74% of calls are classified as
clinical (including symptom-related calls, patient education and coordination of care), 10.6% are
administrative calls, and 14.4% are general calls. Patient satisfaction surveys conducted by Veteran
Affairs rated the program as excellent, with patients most appreciating receiving immediate
assistance from a knowledgeable nurse. The authors report that the implications for nursing in the
future are extensive, not the least being that nurses in one state are advising and caring for patients
in another state where they may not be licensed to practice.
The papers outlined so far refer to telemedicine services that primarily aim to provide immediate
access to the health care system and recommend interventions for acute care from a remote site. In
line with the shift of services from hospitals to the community, patients who were hospitalized in the
past may successfully be treated in the comfort of their own homes. The technological advances
associated with telemedicine therefore have great potential for improving delivery of such home
health care (Hepburn-Smith, 1999 USA). Now, virtually any home with a touch-tone phone can
receive interactive visits by health professionals. While standard teleconferencing equipment enables
real time images to be sent over standard phone lines, home telehealth care systems also have the
capacity to capture vital sign information and communicate it to a health professional at a remote
site. Devices include the telestethoscope that transmits heart and lung sounds, pulse oximetry that
transmits oxygen saturation and heart rate readings, ECG that transmits 12 lead ECG recordings,
and automated blood pressure cuffs that transmit temperature pulse and blood pressure readings.
Home telehealth systems also have the capacity to deliver medications through infusion devices with
remote programming capabilities, and transtelephonic defibrillation can restore normal conduction
should a cardiac arrhythmia arise. Portable X-Rays can also be obtained in the home and
electronically transmitted (teleradiology) (McNeal, 1998 USA. A nurse at a central station that is
connected to one or more patient station generally monitors Telehealth systems (Warner, 1996
USA).
The literature relating to telehealth emanates from the United States. Two research articles explore
the feasibility of implementing home telehealth. The first by Shaul (2000) reports on a pilot pseudo-
randomised control trial (NHMRC level II) specifically investigated the feasibility of using telehome
health for elderly patients (( 65 years) with one or more chronic illnesses. Patients who did not meet
these criteria, who were already receiving home health care services, or did not have access to a
telephone, or could not use or have access to anyone, who could use a telephone were excluded
from the trial. Patients who met the inclusion criteria were alternately assigned to either the
intervention or control group. The control group patients received the usual care by visiting the
physician's office, self-care, informal care or a combination of the three. The intervention group
received the telehealth equipment, instruction on its use and 15-20 minute telehealth consultations
two or three times per week by a RN experienced in home care. The telehealth nurse also allocated
additional time each week to coordinating referrals to other providers, obtaining new medication
orders and addressing social support needs. Functional status, frequency and severity of acute
exacerbation of the chronic illness, and quality of life of the two groups were compared through the
completion of questionnaires. A satisfaction survey was also administered to the intervention group.
Preliminary data from the first 8 months revealed that those patients in the intervention group
maintained baseline physical status and incurred fewer hospitalizations compared to those in the
control group. This group of patients rated the quality and satisfaction of the telehealth consultation
as equal to or better than a home visit. Most found the equipment easy to use after instruction
during the set-up visit, although patients with memory problems or impaired cognitive function
required prompting at each telehealth consultation. The telehealth nurse spent an additional 30
minutes per week on coordinating follow-up care.
The case study by Rooney, Studenski, and Roman (1997) specifically focussed on the feasibility of
implementing a home telehealth care program as a lower cost alternative to traditional in-home
care. Patients were selected from multiple referral sources and included in the study if they had two
or more chronic diagnoses, four or more active medications, were under the care of a physician who
approved the program and were willing to consent to participate. Patients with a terminal illness,
severe mental health condition, who were substances abusers, who required daily skilled invasive
nursing procedures, or who were unable to operate the equipment (or have access to a carer who
could) were excluded from the trial. All participating patients received an interactive two-way
televideo with standard computerised assessment tools (including glucose monitoring for diabetic
patients) and access to the telehealth call centre as determined by an individualised care plan. 46
patients participated and received a mean of 4.0 telehealth encounters per week. Telehealth nurses
participated in a mean of 7.3 telehealth consultations per day with a mean duration of 12.25
minutes. 35 patients expressed an overall positive reaction to the system, nine were neutral and
two patients withdrew from the program because they felt the equipment was too intrusive. Few
problems were encountered with the equipment, but those that did arise could be overcome with the
development of a single multifunction device. The researchers reported that the program was cost
effective based on the elimination of travel costs incurred at an average of $7 per visit and lost
productivity of $9 per in-home visit. They concluded that telehome care can provide nursing services
in the home effectively and in a cot-effective way that can complement traditional in-home care.
Higher-level evidence for both the cost-effectiveness and feasibility of telehealth nursing services is
reported in a paper by Johnstone, Wheeler and Deuser (1997 USA). This study (NHMRC level II)
randomised 100 patients to the intervention group and 100 to the control group. The control group
received in-person and telephone visits from the home health nurse, while the intervention group
received in-person and televideo visits. Preliminary findings found high patient satisfaction and cost
savings of 33-50% in the intervention group due to the decreased number of home-visits required.
All three papers raise important considerations relating to the implementation of a home telehealth
nursing service. The researchers noted that in order to cope with the role change precipitated by
this change in service it was essential that nurses already possessed specific skills and knowledge.
They recommended that the telehealth nurse possess excellent assessment and case management
skills, be comfortable in assessing patients from a remote site and be accepting of new service
delivery methods. Kinsella (2000 USA) adds that while it is simple to assume that the routine in-
home visit is easily replicated by a telehealth visit, there are fundamental differences that the nurse
needs to learn how to overcome. These differences include such impediments as time delays, lack of
audio/visual clarity, and the need for repetition. Kinsella also recommends that nurses need to
develop presentation skills appropriate to the telehealth technology and seize the opportunity to
assist in the design and planning of the telehealth tools. The researchers also recommended that
equipment should be chosen carefully. Papers by Douglas (1997 USA) and McNeal (1998 USA)
describe a four-feet tall home-based computerized "nurse" called HANC. Short for home-assisted
nursing care, HANC provides an integrated videoconferencing and monitoring system that would
overcome the problems encountered in the study by Rooney, Studenski, & Roman (1997 USA).
Ades, Pashkow, Fletcher, Pina, Zohman & Nestor (2000 USA) report on a nurse-led home-based
cardiac rehabilitation program evaluated using a controlled trial (NHMRC Level III-2). The study
compared the effectiveness of home-based, telemedicine monitored cardiac rehabilitation with
standard, on-site, supervised cardiac rehabilitation. All patients included in the study had
experienced an acute coronary even within 3 months of entering the program. The intervention
group consisted of patients who were unable to attend the on-site rehabilitation sessions due to
geographical reasons or if work or schedule conflicts precluded their on-site participation. The
control group consisted of patients who were able to attend the on-site sessions without
geographical, work or schedule conflicts. Evaluation criteria consisted of exercise capacity, weight,
quality of life and frequency of adverse effects. Drop-out rates were of no statistical difference
between the control and intervention groups. Both groups demonstrated similar improvements in
exercise capacity and quality of life scores. The weight of the home-based group slightly increased.
There were no exercise-related complications in the home group and there were no exercise-related
deaths, cardiac arrests or myocardial infarctions in either group. These findings support the
introduction of a rehabilitation service for patients who would traditionally be considered of too high
risk for home-based service, but who would not normally have attended on-site rehabilitation due to
geographical, work and schedule factors. With well-established benefits of cardiac rehabilitation after
a coronary event, this use of telemedicine and nursing services may significantly improve public
health.
Another community nurse-led application of telemedicine reported in the literature relates to school
health services. A qualitative study by Whitten, Kingsley, Cook, Swirczynski & Doolitle (2001 USA)
evaluated a telehealth project (Tele-Kid Care) that brought healthcare directly into elementary
schools using interactive video technology and peripheral devices to consult with a physician. The
role of the school nurse was dramatically affected by this project. He/she school nurse was no
longer just responsible for routine record keeping and providing basic vision and hearing screenings.
Instead, the school nurse was responsible for making the telehealth referral, became directly
involved in the interaction between the student and physician and followed up on the home care
being received by the students after the telehealth consultation. Nurses routinely confirmed that
medication was being administered, listened and responded to concerns of parents related to
medications and other healthcare interventions and helped parents connect with other community
resources.
A narrative paper describes the implementation of a multidisciplinary, multi-site telehealth service in

response to an increasing number of children in schools with debilitating medically conditions,
physical or mental disabilities, or complex medical needs (Green, Esperat, Seale, Chalambaga,
Smith, Walker, Ellison, Berg & Robinson, 2000 USA). Initially designed to provide distance education
between academic health science centre, the Nursing Department at University of Texas and school
teachers and nurses, teleconferencing equipment was employed to also provide a telehealth service.
Patients benefited from no longer having to commute long distances to numerous appointments with
single healthcare professionals. As a result of this initiative, teachers and school nurses enjoyed
greater collaboration with healthcare professionals and became more comfortable in providing care
to the participating children.
Telemedicine technologies have also demonstrated effectiveness in Mental health service

applications. A randomised control trial (NHMRC level II) demonstrates a high level of evidence for
the use of telehealth care to augment traditional physician counselling and anti-depressant
medication treatment of depression in the primary care setting (Hunkeler, Meresman, Hargreaves,
Fireman, Berman, Kirsch, Groebe, Hurt, Braden, Getzell, Feigenbaum, Peng & Salzer, 2000 USA). In
this research Hunkeler et al randomly assigned 302 patients to usual care (physician care)
telehealth care (usual care + telehealth provided by trained primary care nurses) and telehealth
care plus peer support (usual care + telehealth + peer support). Telehealth care incorporated
emotional support and focused behavioral interventions for a determined number and duration of
calls. The nurses' providing this service completed a 6 hour training workshop and received ongoing
weekly supervision from the clinical director and a clinical psychologist. Knowledge required included
management and assessment of depression, drug therapies, counseling, behavioral activation,
education skills and provision of emotional support. Peer support incorporated telephone and in-
person supportive contacts. Outcomes were measured using the Hamilton Depression Rating Scale,
Beck Depression inventory, and SF-12 Mental and Physical Composite Scale assessments conducted
at baseline, 6 weeks and 6 months. It is of great significance that the researchers found that the
difference between usual care and care augmented by telehealth nurses is almost as large as that
between drug and placebo trials. Trial results revealed that telehealth patients, with or without peer
support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6
weeks, and 57% at 6 months compared to the control group at 37% and 38% respectively. Mental
function also improved, as did patient satisfaction with treatment. The addition of peer support to
telehealth did not improve these outcomes. Contrary to the researcher's hypothesis, telehealth care
did not improve medication adherence.
The acceptance of nurse provided telemedicine services in mental health is also supported by a
retrospective review of all calls received by a telephone help service for younger people with
dementia, their families and the professionals caring for them (Harvey, Roques, Fox & Rosser, 1998
UK).
Literature describing a randomized controlled trial (NHMRC level II) of child psychiatric assessments
conducted using videoconferencing (Elford, White, Bowering, Ghandi, Maddiggan, St. John, House,
Harnett, West & Battock, 2000 CAN) and a case series (NHMRC level IV) evaluating internet-
mediated, protocol driven treatment of psychological dysfunction (Lange, Van de Ven, Schrieken,
Bredeweg & Emmelkamp, 2000 NETH) were also retrieved. While these studies reported favorable
outcomes, the change in service did not involve nurses.
The above papers have all reported 'real-time' video teleconferencing services. Another mode of
providing services is through a 'store-and-forward' approach. A paper by Lewis, McCann, Hidalgo
and Gorman (1997 USA) reports on the provision of a service that uses a telephone link-up to
communicate and visualise a single still image captured by a digital camera. This technology was
used to facilitate a vascular nursing teleconsultation service for wound assessment. Also present for
the link-up the service replaces an outpatient clinic visit for rural patients who would otherwise have
had to travel significant distances to attend.
A family nurse practitioner from the outreach clinic is also present at the teleconsultation to facilitate
planning for a home-visit and the provision of appropriate wound care. A vascular surgeon is on call
along with other healthcare providers such as a nutritionalist, reconstructive surgeon and
dermatologist. The case study reported demonstrates how this remote method can successfully
evaluate wound healing and plan appropriate home-care interventions. It also demonstrates the
successful implementation of a nurse led clinic and the specialised skills required by nurses who
provide wound management services.
A number of other studies relating to a change to the provision of outpatient/clinic services via
telemedicine appear in the literature. Mease, Whitlock, Brown, Moore, Pavliscsak, Dingbaum,
Lacefield, Buker and Xenakis (2000 USA) conducted a randomised control trial (NHMRC level II)
examining the provision of diabetes control via telemedicine. The intervention group was supplied
with videoconferencing and monitoring equipment and was reviewed by a nurse case manager
(weekly consultations) in partnership with a primary care physician (monthly consultations). Each
week the nurse case manager would review and record assessment data, exercise and nutrition
goals and sense of well being. Based on this data the nurse would recommend nutritional and
exercise alternatives and reinforce medication compliance. The nurse would also participate during
the monthly physician sessions. The control group attended an on-site diabetic clinic for baseline
measurements, was encourage attending diabetic education classes and primary practice clinics and
was reviewed at the end of the three-month trial period. Despite some significant problems with the
equipment the researchers reported better results in the intervention group to the control group in
the outcome measures of reduced HBA1C levels and weight reduction. These parameters are
considered to be the major indicators of diabetic morbidity. This was not a simple comparison of
telemedicine versus traditional on-site clinics however, and any conclusions regarding the efficacy of
treatment must include the contribution of the nursing consultations.
The results from a randomised control trial (NHMRC level II) that directly compared the same
physician consultation service delivered either on-site or through telemedicine were not so
successful. In this study Chua, Craig, Wootton & Patterson (2001 UK/AUS) found that telemedicine
for new neurological outpatients was possible and feasible, but generates more investigations and is
less well accepted than face-to-face examinations. Although a neurology registrar attended the
remote clinic, he/she was not present for the teleconsultation.
More success has been reported from telemedicine services when the healthcare professional is
present with the patient at the remote site. This was the case in the earlier study by Chen &
Patterson (1996 USA) where a clinical nurse practitioner or certified physician assistant assisted in
patient evaluations at the "far end". These researchers found greater acceptance by patients and
were able to detect subtle neurological findings such as abnormal reflexes or retinal abnormalities.
A Finnish study (Haukipuro, Ohinmaa, Winblad, Linden & Vuolio, 2000 SC) also reported success
with remote outpatient consultations when a GP or experienced nurse attended the telemedicine
session. In this randomised control trial (NHMRC level II) postoperative orthopaedic outpatients
were seen either by orthopaedic specialists face-to-face at a central clinic, through telemedicine at
the central clinic, or via a telemedicine link-up in a remote Primary Care Clinic. Although there were
some difficulties in examining the telemedicine patients, telemedicine consultations were deemed
feasible. In addition, both the patients and the specialists participating in the remote intervention
and control group were equally satisfied with the service. These results may lead to cost-savings by
the replacing the usual specialist visits to the regional clinics with teleconsultations. It is unclear how
the on-site intervention group contributed to the results.
Of interest was a pilot cluster-randomised control trial (NHMRC level III-1) comparing telemedicine
at GP clinics to face-to-face specialist surgical outpatient clinics (Harrison, Clayton and Wallace,
1999 UK). In this case satisfaction from remote participants exceeded that of patients participating
in conventional outpatient visits. The greater satisfaction rates for the intervention group suggested
that the time saving nature of teleconsultations is a significant factor in patient satisfaction with
telemedicine services.
Other outpatient applications were the subject of successful telemedicine trials. A case study by
Rosser, Prosst, Roda, Rosser, Murayama & Brem (2000 USA) found in-home post-operative nurse/
intern follow-up for patients undergoing laparoscopic surgical procedures to be both time efficient
and of high clinical accuracy. On average patient's rated their satisfaction with the experience as 4.8
of a maximum of 5. In a small study in the United Kingdom Murdoch, Bainbridge, Taylor, Smith,
Burns, & Rendall (2000 UK) report on telemedicine to support the postoperative evaluation of
patients who have had ophthalmic surgery. A trained ophthalmic nurse captured video slit lamp
images of the patients at an outreach clinic. After some initial equipment difficulties staff were
satisfied in the images received. Only one out of 24 patients found the teleconsultation
unacceptable.
Harrison, Clayton & Wallace (1996 UK) report the results of teleconsultations at six GP practices for
the specialties of dermatology; endocrinology; ear, nose, and throat; gastroenterology;
gynaecology; oncology; orthopaedics; paediatrics; psychiatry; and urology (NHMRC level IV). These
researchers found that 84% of patients would use the service again, 86% felt that the consultant
could understand their problem and that they were able to say what they wanted. Only 8% were
concerned about confidentiality. Of the specialists, all but the dermatologists were satisfied with the
quality of the visual images transmitted during the consultation. These problems can most likely be
resolved by the use of store-and-forward techniques. This technique was found to produce better
results in a literature review that compared live tele-conferencing and store-and-forward methods
(Eedy & Wootton, 2001 UK/AUS). It was also found to lead to correct diagnosis for 90% of patients
in a randomised control trial (NHMRC level II) conducted by Zelickson and Homan (1997 USA).
These researchers compared diagnosis from patient's history alone, to image alone, and image and
history together. The store-and-forward techniques was used as the image component and the
study was used to provide evidence that nursing home teledermatology consults could replace some
on-site consultations. Taylor, Goldsmith, Murray, Harris & Barkley (2001 USA) compared store-and-
forward technology to face-to-face consultations. In this study the patient participated in routine
face-to-face consultations and the clinic nurse took images of their skin lesions. The consultant
dermatologists subsequently reviewed the stored images with a third consultant grading the level of
agreement. From this retrospective analysis (NHMRC level III-3) these authors found that there
were high levels of agreement between the telemedicine diagnosis and the face-to-face
consultations. The recommendations from this study were that instead of a standard consultation,
the nurse could transmit the data and specialists could make a rapid inspection of the transmitted
image to determine the necessity of an urgent follow-up appointment.
As can be seen by the papers reviewed, nurses have a pivotal role in the delivery of telemedicine
services. They may lead the consultation and/or management or be present to assist with the
examination, provide patient education and manipulate/trouble-shoot the telemedicine equipment.
Accordingly, the skills and knowledge directly relate to use of the technology and require varying
degrees of proficiency in patient assessment, management and education.

Disclaimer

❍ Services Provided By Specialist Nurses/Extended And Expanded Roles
❍ Effectiveness of Nurse Practitioners
● The Current Literature - Role of the Nurse Practitioner
❍ The Acute Care Nurse Practitioner
❍ The Nurse Practitioner in General Practice
❍ The Emergency Nurse Practitioner
❍ The Nurse Practitioner Role Generally
❍ Other Nurse Practitioner Roles
Services Provided By Specialist Nurses/Extended And Expanded Roles
While the role of nurse practitioner was developed and became firmly established in both the USA
and Canada approximately thirty years ago, the role has been introduced in the United Kingdom,
Australia and New Zealand in the last five to ten years. The literature retrieved in the search can be
grouped into the following categories: efficiency of the nurse practitioner; satisfaction with the nurse
practitioner role; descriptions or discussions about the role; and the settings in which the nurse
practitioner works.
Before going on to outline the nurse practitioner literature it is important to acknowledge that the
title "nurse practitioner", its protection in legislation and the educational preparation of nurse
practitioners vary from country to country and between States in Australia. As these differences
influence the interpretation of the articles, brief background information regarding the same is
contained in Appendix C
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Effectiveness of Nurse Practitioners
Four recent good quality studies (NHMRC level II evidence) have been reported in the literature.
One trial compared the cost effectiveness of general practitioners and nurse practitioners in primary
care with the main outcome measures including the length of consultation, examinations,
prescriptions, referrals, patient satisfaction, health status and return clinic visits over two weeks.
The trial was undertaken in 20 general practices in England and Wales with patients requesting a
same day appointment being randomly allocated to either the general practitioner (n=665) or nurse
practitioner (n=651). The diagnoses of patients seen included upper respiratory tract infection, viral
illness, minor injuries and eye and ear conditions. Significant results were that nurse practitioner
consultations were longer than those of the general practitioner and that patients were more
satisfied with nurse practitioner consultations. Overall the clinical care and health service cost of the
two groups were similar (Venning, Durie, Roland, Roberts, & Leese, 2000 UK).
A second trial conducted in primary care clinics in New York studied outcomes in patients treated by
nurse practitioners (n=806) and physicians (n=510). (Mundinger, Kane, Lenz, Totten, Tsai, Cleary,
Friedwald, Siu, & Shelanski, M. 2000 USA) The results showed that where "... nurse practitioners
had the same authority, responsibilities, productivity and administrative requirements, and patient
population as primary care physicians, patients' outcomes were comparable." (p 59) In these first
two trials the nurse practitioner undertook a role comparable to the physician.
Another randomised controlled trial in Washington compared a senior center based chronic illness
self-management and disability prevention program led by a geriatric nurse practitioner with a
control group who were shown the facilities of the senior center but had no contact with the geriatric
nurse practitioner. (Leveille, Wagner, Davis, Grothaus, Wallace & LoGerfo, 1998 USA) The geriatric
nurse practitioner role was one in which the nurse practitioner monitored the progress of
participants in their disability prevention and chronic illness self-management. Specific aspects of
the role included education about risk factors, nutrition and medications; encouragement of
participants to select and continue with physical activities/exercises; counselling and support; follow-
up visits and phone calls. Results indicated that the intervention group showed less decline in
function, increased levels of physical activity and spent significantly less time as in-patients during
the study year.
An Australian study (Chang Daly, Hawkins, McGirr, Fielding, Hemmings, O'Donoghue, & Dennis 1999
AUS) investigated whether there was a difference in care provided by medical officers and nurse
practitioners in a specific area of primary health, that of wound management and treatment of blunt
limb trauma. The nurse practitioners were involved in a pilot study prior to legislative change. The
study comprised a four month supervised competency trial and a three and a half-month
unsupervised comparative study. During the study the nurse practitioners followed clearly defined
protocols. While the sample size of the comparative study is small (n=169) the results indicated that
there were no significant differences between the nurse practitioners and medical officers in relation
to client satisfaction. Very positive outcomes of treatment were consistent across both groups. One
benefit was decreased waiting time for treatment. The role of the nurse practitioner in this case was
limited but the authors indicate that the study supports training nurses in specified competencies to
enable them to practice in rural settings.
Six articles were retrieved which met the criteria for level III evidence. Of these, two are controlled
trials (level III-1), one is a cohort study (level III-2) and three are comparative studies (level III-3).
One controlled trial compares nurse practitioner and general practitioner treatment of same day
consultations in primary care across 10 general practices in south Wales and south west England
(Kinnersley, Anderson, Parry, Clement, Archard, Turton, Stainthorpe, Fraser, Butler, & Rogers 2000
UK). The nurse practitioners in this trial had completed the nurse practitioner diploma course at
either the Royal College of Nursing (a precursor to the bachelor program) or the department of
nursing, midwifery and health care, University of Wales. This trial is similar to one already described
in the level II evidence above (Venning et al 2000 USA). Kinnersley's study showed that generally
patients who consulted nurse practitioners were significantly more satisfied with their care. The
numbers of prescriptions, investigations, referrals and reattendances were similar between the
nurse practitioner and general practitioner groups however patients who were managed by nurse
practitioners reported receiving significantly more information about their illness.
In a controlled trial in Ontario, Canada, (Mitchell-DiCenso, Guyatt, Marrin, Goeree, Willan,

Southwell, Hewson, Paes, Rosenabum, Hunsberger, & Baumann, (1996 CAN) the management of
critically ill neonates by clinical nurse specialist/nurse practitioner team in the day and a paediatric-
resident team at night was compared with a paediatric-resident team around the clock. The results
for the outcomes measured (number of neonatal complications; length of stay; quality of care;
parent satisfaction; long term outcomes and costs) indicated that the two teams were similar. The
authors state that the results support the use of clinical nurse specialist/nurse practitioner teams as
an alternative to paediatric-residents. However the results must be interpreted cautiously, firstly
because the neonates cared for by the clinical nurse specialist/nurse practitioner team were cared
for by residents at night, and secondly as both teams were supervised by neonatologists. These
confounders make the results difficult to interpret.
A cohort study of managed primary care of nursing home residents in Southern California
demonstrated that the integration of the efforts of physicians, nurse practitioners and nursing home
staff can lead to low rates of hospital use by nursing home residents. (Joseph and Boult, 1998 USA)
The role of the nurse practitioner in the team was the provision of preventive and chronic care and
other responsibilities in agreement with the physician.
A study to review the impact on geriatric nurse practitioner/physician teams for enrollees residing in
45 long-term care facilities in Massachusetts showed that the use of these teams, when compared
with a physician alone, reduced emergency department and acute care utilisation costs. (Burl,
Bonner, Rao, & Khan, 1998 USA) The nurse practitioner role in this case incorporated taking an
admission history and conducting a physical examination, the development of a comprehensive plan
of care addressing medical, functional and psychosocial issues in collaboration with the physician
and nursing staff. The nurse practitioner also visited the resident regularly and coordinated other
health care. Physicians involved in the study saw the nurse practitioner as a specialist on geriatric
issues and the complex legislative guidelines influencing care.
Dahle, Smith, Ingersoll, & Wilson (1998 USA) describe a comparative study in Tennessee of the
outcomes of patients suffering heart failure prior to and following the introduction of the role of
nurse practitioner specialising in the management of this disease. The NP worked closely with the
medical specialist and followed clearly defined protocols and treatment pathways. The outcomes
compared were limited to length of stay and 30-day readmission rates. Total costs were found to be
significantly lower following the implementation of the NP role, particularly for laboratory costs, ECG
and respiratory therapy. However it is not clear from the 'before and after' study design whether
this cost difference is due to the NP role or the use of clinical management pathways and protocols
which were introduced concurrently.
A second comparative study in a similar group of patients was conducted by Dahl and Penque (2000
USA) in Minnesota. Here the outcomes of a historical control group were compared with the
outcomes of a group of patients attending the in-patient heart failure program. This program was
managed by an adult nurse practitioner and conducted by two second year students, one enrolled in
a clinical nurse specialist program and the other in an adult nurse practitioner program. Length of
stay, in-hospital mortality rates and readmission rates were significantly reduced for program
participants.
The preceding articles, which include research at NHMRC levels of evidence II to III, indicate that
nurse practitioners can provide
● equivalent care to physicians in primary care,

● specific care according to protocols in specialty areas,
● improve outcomes for seniors in self-management and disability prevention and in patients
with heart failure, and
● improved care in collaborative teams with physicians, for residents in nursing homes or long-
term care facilities.
In addition to these articles a number of evaluations not using research methodology related to the
NHMRC levels of evidence have been conducted. These do however support the results provided by
higher quality research.
The EROS (extended roles of staff) project team (Bond, Beck, Derrick, Sargeant, Cunningham,
Healy, Rawes, Holdsworth, & Lawson (1999 UK) conducted a prospective study in Northumberland,
England of the coordinated training and work of four trainee nurse practitioners in general practice
over two years. The objectives were to compare trainee nurse practitioner and general practitioner
decisions in consultations, describe the characteristics of patients attending independent trainee
nurse practitioner training consultations and assess acceptability of the service to patients. The
performances of all trainees were similar. It was not possible to judge the value of attending the
Nurse Practitioner Bachelor of Science course since three out of four trainees were doing this while
the other was not. Over the two years there was increased efficiency with the transfer rate to
general practitioners and the return rate to surgery both lower than that observed elsewhere. Nurse
practitioner efficiency was hindered by their lack of ability to give sick notes, prescriptions and
referrals without these being countersigned by the general practitioner. Overall the general
practitioner mentors judged the diagnostic and treatment decisions of the trainees as good. The
trainees were liked by patients and were classified as a valuable substitute for general practitioners.
An evaluation of the appropriateness of triage decisions in a busy ophthalmic casualty department

and assessment of the diagnostic and management skills of eye-dedicated nurse practitioners was
carried out by Banerjee, Beatty, Tyagi, & Kirkby (1998 UK) in Birmingham over a two week period.
The nurse practitioner saw fifty patients in the least urgent triage category. A supervising doctor
saw all these patients subsequently without knowledge of the nurse practitioner's diagnosis or
proposed management plan. The doctor concurred with diagnosis in all cases and proposed
management in 96% of cases. The discrepancies were minor and would not have resulted in adverse
outcomes. Nurse practitioners in this casualty department undertake a hospital structured training
program of six months and are then assessed by the registrars. If they are successful they are able
to work as nurse practitioners.
Duthie, Drew, Farouk, Hodson, Wedgwood, & Monson (1998 UK) have reported on the development
of a training program for nurse practitioner flexible sigmoidoscopy in the United Kingdom. The
training program required 35 observations and 30 hours of practice on colon models over a three
week period during the observation time, 35 withdrawals and 35 supervised full procedures. The
nurse practitioner's skill is outlined for the first 215 patients independently examined. Ninety-three
percent of the examinations were successful as classified by the depth of insertion or accurate
diagnosis following validation. The others were abandoned due to poor bowel preparation or pain.
Pathology was identified in 51% of patients. There was disparity between the sigmoidoscopy results
and barium enema results in 20 patients however in 17 patients the sigmoidoscopy results were
superior and in the remaining three the barium enema identified moderate diverticular disease not
recognised by the nurse endoscopist.
Another study (pilot) in the United Kingdom (Wan, Taylor, Gul, Taffinder, Gould, & Darzi, 1999 AUS)
evaluated the feasibility of using rigid video-sigmoidoscopes in a community setting with realtime
teleconsultation with a colorectal specialist. No information is included about the education of the
nurse involved. All patients (32) seen in the clinic over a three month period agreed to be in the
study. Two cases had excessive faecal residue but all other cases had good clarity of views. The
study although with limited numbers of patients, showed successful implementation of the role with
both patient and user satisfaction.
Williams, Assassa, Smith, Jagger, Perry, Shaw, Dallosso, McGrother, Clarke, Brittain, Castleden, and
Mayne, (2000 UK) reported on an observational study of the effectiveness of and patient satisfaction
with a service run by five specially trained continence nurse practitioners delivering predefined
evidence-based treatment interventions. The training of the nurses is not described in this article.
The nurse saw all patients over an eight week period with 194 patients completing treatment. The
service was shown to be effective in reducing urinary symptoms and led to high levels of patient
satisfaction. This service is currently being evaluated in a randomised controlled trail.
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The Current Literature - Role of the Nurse Practitioner
A large number of authors outline the role of the nurse practitioner. While the authors do not use
research that fits within the NHMRC levels of evidence the articles can still be separated into two
groups. The first group of articles is where the author has used a systematic process to collect and
analyse information about the role. These include surveys, program evaluations and pilot studies.
The second group is where the author provides a description of the evolution of the role in an
organisation or a discussion about the role from the author's viewpoint. Articles where the author
has used a systematic collection and analysis of data about the role are described individually. These
are grouped according to the context of practice. Any other articles specifically adding to the body of
knowledge about the skills and knowledge required by the nurse practitioner will be addressed
following these.
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The Acute Care Nurse Practitioner
Kleinpell (1997, 1998 USA) and Kleinpell-Nowell (1999 USA) has reported on the predominant role
components of the acute care nurse practitioner following surveys of the nurses undertaking the US
national certification examination for this role which began in 1995. The survey of more than 740
advanced practice nurses (78% response rate from 940 surveys) showed that sixty-one percent of
respondents were practising as acute care nurse practitioners with the majority working in intensive
care and acute care tertiary sites. The major role components included discussing care with the
family members, initiating discharge planning practices and monitoring laboratory and other
diagnostic tests '...to enhance patient care management.' (Kleinpell-Nowell, 1999 p. 12). Time spent
on direct client care was reported to range from 15% to 100% (mean 87%). Forty-three percent of
respondents reported that 100% of their time was spent in direct client care. Other responsibilities
included teaching, research, departmental projects, quality assurance, administrative duties and
program development.
Kleinpell-Nowell (2001 USA) has since published the results of the second year of a five year
longitudinal study exploring the role development of the acute care nurse practitioner which builds
on her previous work. In this study the first six cohorts to take the national certification examination
are sent an annual survey addressing role components, job characteristics, satisfaction with the
acute care nurse practitioner position, plans for employment and demographic data. Each year
additional questions are included to explore a different aspect of the role. Responses from 545 acute
care nurse practitioners two years after national certification showed expansion of the role outside
the traditional teaching hospital setting. Role components highlighted the comprehensive care of
acute care nurse practitioner practice in terms of coordination of care, interactions with family
members, consultation, and discharge planning. An identified area of concern was that some acute
care nurse practitioners were working in staff nurse role to gain clinical experience. Kleinpell-Nowell
comments that minimal clinical practice requirements prior to entry to nurse practitioner programs
vary from no specified clinical experience to five or more years and that since the acute care nurse
practitioner involves mastery of complex concepts that prior clinical experience is important.
Stetler, Effken, Frigon, Tiernan, & Zwingman-Bagley (1998 USA) evaluated the role of the acute
care nurse practitioner in Connecticut. Forty-five role behaviors were evaluated by 106 health key
stakeholders, the 15 acute care nurse practitioners, and 58 patient/family participants. The role
behaviors were grouped into
● medically related role expectations such as prescribing medications, procedures, ordering and
interpreting diagnostic tests, stabilization of patients in crisis;
● nursing related role expectations such as history, assisting staff patients and families in
navigating the health system;
● case management role expectations such as coordination of patient care with multiple health
providers, management of patients with a focus on cost and quality and
● shared medical-nursing role expectations such as participation in interdisciplinary quality of
care improvement, contribution to professional development of peers colleagues and
students and incorporation of patient and family education needs into the plan of care.
Results showed that the performance of the acute care nurse practitioners who had been in the role
for more than six months was rated positively by both clinicians and managers. Providers and
patients and their families viewed the acute care nurse practitioner as an acceptable provider of
care. Noted in the patient and family responses were comments on the emotional and other support
provided which indicated that the nursing component of the role was integral in the blended acute
care nurse practitioner role.
Knaus, Felten, Burton, Fobes, & Davis (1997 USA) documented the introduction of nurse practitioner
role in an acute setting in the University of Missouri Hospital and Clinics, Columbia. The nurse
practitioners, in their first year of practice, collaborated to design a study to investigate their work
activities, the time engaged in activities and the numbers of clients seen within designated time
periods. Two nurse practitioners collected data for four months with the other nurse practitioner
collecting data for five months. The results showed that overall
● 39% of time was spent in direct care (largest amount clinic visits and follow-up activities);
● 31% in indirect care (largest amount in-patient rounds with physicians);
● 13% in administrative activities (protocol and procedure development, product evaluation,
committee meetings, computer time);
● 12% in educational activities (education of medical and nursing students, residents and
professional organisations; materials development; and self-education) and
● 5% in research activities.
In addition physicians indicated that nurse practitioners were good at developing a plan of care,
determining the need for laboratory studies and providing outpatient teaching. Patients were
satisfied with the nurse practitioners bedside manner; teaching and indicated the nurse practitioners
were extremely efficient at procedures and technical aspects of care (Knaus et al 1997 USA).
While the role of the acute care nurse practitioner seems similar in the studies described above it
should be noted that Fox, Schira, & Wadlund (2000 USA) describe a role where the acute care nurse
practitioner is also certified as the first assistant in surgery. In this role the nurse practitioner
provides surgical assistance (suturing, dissection, wound closure) in-patient care, minor procedures,
consultations and office practice.
Two other studies compare the role of the nurse practitioner with the clinical nurse specialist. The
first (Mick & Ackerman, 2000 USA) explored the differences in the role of the acute care nurse
practitioner and the clinical nurse specialist. Eighteen subjects from an academic medical centre
(n=6) and an Internet advanced practice listserv (n=12) completed a questionnaire. Subjects were
asked to rank their expertise in the domains of direct comprehensive care, support of systems,
education, research, and publication and professional leadership. Each domain listed tasks, for
example, support of systems included the tasks: actively contributing to medical centre and school
of nursing recruitment and retention activities; participating in strategic planning; serving as a
mentor; and serving as a spokesperson for nursing and the medical centre when interacting with
other professionals, patients, families and the public. The results showed that although some
individuals believe the two roles, nurse practitioner and clinical nurse specialist, have merged that
they appear to be distinct. Areas of growth identified for the acute care nurse practitioner included
research and publication and professional leadership and to a lesser degree education. It was noted
that these should be incorporated into curricula.
A further study comparing the clinical nurse specialist (n=310) to the nurse practitioner (n=300),
not necessarily in an acute care nurse practitioner, was conducted by Lincoln (2000 USA) and
replicates the work done by Williams and Valdiviesco in 1992. Results showed that clinical nurse
specialists spent significantly less time than nurse practitioners in direct practice. Clinical nurse
specialists spent significantly more time in education, consultation, administration and research.
Both spent the least time in administrative and research roles. The major differences in the roles
between the two studies are that nurse practitioners in the latest study spent more time in providing
direct care and less time in education and administration than in 1992. The clinical nurse specialists
spent more time consulting (18% to 23%) and less time educating (29% to 21%) than in 1992.
The Nurse Practitioner in General Practice
One component of a two-year pilot study in the north west of England (Reveley, 1998 UK) was the
analysis of the role of the triage nurse practitioner in a general medical practice. Doctors at the clinic
supervised the nurse practitioner while she was concurrently undertaking the Bachelor of Science
(Hons.) at the Royal College of Nursing. The aim of this component of the study, eighteen months
after its commencement, was to examine the role of the nurse practitioner compared to the 'second
on call' doctor and elicit patient perceptions of their consultations with the nurse practitioner or
general practitioner. Ten three and a half hour surgeries of both the nurse practitioner and 'second
on call' general practitioner were examined. The results found that the general practitioner saw
more patients than the nurse practitioner, and that patients consulting the nurse practitioner were
younger and more acutely ill. The triage role involved seeing same day patients with undiagnosed
undifferentiated problems who regarded their problem as urgent while general practitioners saw
more patients with ongoing problems. The nurse practitioner was under"... continual pressure to
make decisions and exercise a high degree of skill in diagnosis and management as she has no
previous care plan to follow through."(p. 589) The nurse practitioner role was acceptable to
patients.
The Emergency Nurse Practitioner
A postal survey of senior nurses in all (n=293, response rate=94%) major accident and emergency
departments in the United Kingdom (Tye, Ross & Kerry, 1998 UK) defined the emergency nurse
practitioner as a designated qualified nurse who was '...authorised to independently assess, treat,
and discharge predefined categories of patients'. Tye et al's survey collected information about
emergency nurse practitioner activity which was independent of a medical practitioner. The following
activities were identified: 82 departments authorised nurse practitioners to request X-rays; 35
departments allowed them to interpret the X-rays; 67 departments allowed "over the counter" drug
supplying under local protocol and 52 departments allowed prescription drug supplying from an
agreed list. Tye et al reports that "While the majority of the sample had received some sort of
training, across the United Kingdom as a whole great variations in length, content, and academic
level of courses are evident. ... Given ... (this) ... it is perhaps not surprising that the study also
identified considerable variation in ENP scope of practice."
The Breast care nurse
The "Clinical Practice Guidelines for the Management of Early Breast Cancer Second Stage
Consultation (2000 AUS) Draft" identifies the role of the breast care nurse. It recommends that one
of the strategies to improve recall of information is the provision of a breast care nurse or counsellor
(level II evidence). It also recommends the involvement of a breast care nurse in the treatment
team as it reduces morbidity (level II evidence). The "Clinical Practice Guidelines for the
Management of Advanced Breast Cancer (2001)" indicate that psychosocial interventions can
improve physical, functional and psychological adjustment and should be considered for introduction
into patient care (levels I-IV evidence). Nurses, mentioned in the guidelines, are one of the
providers of such interventions. Specialist breast nurses are also identified in the "Psychosocial
Clinical Practice Guidelines: providing information, support and counselling for women with breast
cancer (1999)". The role is seen as advantageous by providing procedural information along with
other health professionals (level II); enhancing early recognition of social support needs and
decreasing psychological distress (level II); and improving and providing continuity of care
throughout the treatment process (level II).
The Nurse Practitioner Role Generally
A postal survey in the United Kingdom (Hicks & Hennessy, 1999 UK) aimed to identify the role of
the nurse practitioner in both the acute care and community setting. The survey was sent to all
nurses working in an acute unit as clinical specialists (n=50, responses=49) and all practice nurses
working with a general practitioner (n=1940, responses=420). None of the nurses had any from of
nurse practitioner training nor did anyone possess the title of nurse practitioner. Clear areas of
overlap and significant differences were identified in role functions between acute and community
sector nurse practitioner role features. Areas of overlap included examining and diagnosing clinical
problems, making appropriate referrals, designing research/audit reports and critically evaluating
published literature. The differences illustrated the orientations of clinical nursing practice in the two
sectors, for example, primary care nurses perceived that preventive health measures were more
critical in their context than in the acute care sector. Primary care nurses also believed the nurse
practitioner would be more involved with business and management activities. Acute care nurses
placed greater significance on the provision of the total care package suggesting that planning for
every stage of the patient's care is a priority for the acute sector nurse practitioner.
Walsh (1999 UK) surveyed 93 registered nurses taking level 2 or 3 continuing education modules at
the University College of St Martin during summer term 1998 and 108 graduates of or
undergraduates who had completed at least four modules of the Royal College of Nursing bachelor
of science nurse practitioner course. There was a 71% return rate. The tool, the Caring Dimensions
Inventory, has been tested for reliability and validity. There was a strong positive correlation
between the two groups suggesting that nurses and nurse practitioners agree on the relative
importance of many of the items. Nurses rated the following items of more importance than the
nurse practitioners
● reporting a patient's condition to a senior nurse

● being with a patient during a clinical procedure
● assisting a patient with activities of daily living
● keeping relatives informed about a patient and
● being technically competent with a procedure
● Nurse practitioners rated the following items of more importance than the nurses:
● exploring a patient's lifestyle and
● psychosocial aspects
Walsh concludes that there is little difference between nurses and nurse practitioner perceptions of
the relative importance of the aspects of care examined. The fact that nurse practitioners place
more importance on psychosocial care and nurses on technical aspects contradicts the view nurse
practitioners are mini-doctors.
Other Nurse Practitioner Roles
Other nurse practitioner roles are described in the literature including a clinical nurse specialist/
neonatal nurse practitioner and a psychiatric nurse practitioner.
Gibbins, Green, Scott & MacDonell (2000 USA) describes the combined role of clinical nurse
specialist/neonatal nurse practitioner in a breastfeeding clinic who acts as a consultant to Lactation
Consultants in a large breastfeeding clinic. The clinical nurse specialist/neonatal nurse practitioner's
primary role includes elements of advanced practice (critical thinking, assessment and analysis),
leadership, education, consultation (re jaundice, infants with persistent weight loss, suspected
breast infection, etc) and research.
Johnson (1998 USA) describes a role for the psychiatric nurse practitioner similar to that of other
primary care nurse practitioners, with a context-specific focus, including using the psychosocial
interventions of various psychodynamic and biological therapies, advocacy and
psychopharmacology. Typically these NPs perform '...functions that overlap with psychiatrists, such
as diagnosing mental disorders and treating them with various psychodynamic, analytic, or
behavioral therapies' (Johnson, 1998 p. 22).

Disclaimer

■ Summary of the Skills and Knowledge required by Nurse Practitioners
❍ The Current Literature - Satisfaction with the Nurse Practitioner Role
❍ The Current Literature -Nurse Practitioner Contexts/Settings
● Nurse Practitioner and Physician's Assistants
❍ Section 2:Changes in the roles of health professionals which have impacted on nursing
❍ Section 3:Summary of Required Skills and Knowledge
Summary of the Skills and Knowledge required by Nurse Practitioners
A wide variety of descriptions of the functional roles or behaviours of the nurse practitioner have
been found in the literature. Commonalities can be seen in the nurse practitioner role in various
specialty areas and across different countries. A list of nurse practitioner role components included
in the literature is given below under the headings used by Mick and Ackerman (2000): direct
comprehensive care, support of systems, education, research and publication and professional
leadership. Only those activities that have been mentioned frequently in the examined literature are
listed
Direct comprehensive care:
● complete comprehensive physical and psychosocial assessment;

● make differential diagnoses within specialty scope of practice;
● initiate and interpret diagnostic tests;
● use well developed problem solving/clinical decision making skills;
● perform specialty-specific procedures;
● initiate and maintain continuity of care;
● provide advice/counselling;
● coordinate patient care;
● collaborate/consult with other health professionals;
● make referrals to and receive referrals from other health professionals;
● provide preventive care;
● use protocols and guidelines to guide practice;
● empower patients;
● support family/care givers;
● facilitate efficient movement of patient through health care system.
Support of systems:
● write clinical, audit and research reports;

● develop collaborative policies, procedures and guidelines
● participate in committees;
● provide leadership in development, implementation and evaluation of standards of practice;
and
● serve as a mentor.
Education:
● provide health promotion information;

● serve as formal/informal educator and clinical preceptor for nursing and other students;
● provide education for patients and family;
● act as a resource and consultant for staff/others.
Research:
● critically evaluate published literature;

● participate in investigations to monitor and improve care
● collaborate in research projects; and
● implement findings.
A number of authors break down aspects of the role to make explicit, activities such as undertaking
physical examinations, taking a medical history and prescribing medications. In addition Pastorino
(1998 USA) includes another component of the role - participation in health policy. A number of
authors stress the need for negotiation and assertiveness skills (Martin & Hutchinson, 1997 USA and
Lambert & Lambert, 1996 USA), while other discuss the need for nurse practitioners to have
entrepreneurial skills if they are considering independent practice (Blair, 1997 USA and Lambert &
Lambert, 1996 USA).
Regardless of context nurse practitioners require skills and knowledge in advanced physical
assessment, advanced physiology, pathophysiology, health promotion, pharmacology and clinical
decision-making. Other useful skills/knowledge appear to be research, advanced communication,
information about trends in health care, local health policies, funding and legislation. Very specific
skills related to the context or setting where the nurse practitioner is working are also required
however these are dependent on the specific role undertaken. Management, marketing and
entrepreneurial skills may be necessary depending on the role.
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The Current Literature - Satisfaction with the Nurse Practitioner Role
As mentioned in a number of the articles already reviewed patient satisfaction with nurse
practitioner services is good (Venning et al 2000 USA, Chang, Daly, Hawkins, McGirr, Fielding,
Hemmings, O'Donoghue, & Dennis, 1999 AUS; Kinnersley et al 2000 UK; Bond et al 1999 UK; Wan
et al 1999 AUS; Williams et al 2000 UK; Reveley 1998 UK). Mundinger's randomised controlled trial
(2000 USA) found no significant differences in the scores between nurse practitioners and physicians
for any of the satisfaction factors after the first visit, however at six months patients rated
physicians higher on the provider attributes score. This score consisted of the provider's technical
skill, personal manner and time spent with the patient. A study of 149 consumers of nurse
practitioner services demonstrated a high level of acceptance of the role of the nurse practitioner in
a rural community in Nebraska (Schweser 1998 USA).
User satisfaction was also identified in a limited number of studies. Nurse practitioners participating
in the Australian pilot in the emergency department (Chang, Daly, Hawkins, McGirr, Fielding,
Hemmings, O'Donoghue & Dennis 1999 AUS) found their job satisfying and rewarding. The nurse
practitioner and clinician involved in the telesigmoidoscopy evaluation were highly satisfied (Wan et
al 1999 AUS).
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The Current Literature -Nurse Practitioner Contexts/Settings
A summary of the contexts/settings where nurse practitioners work is provided below. The first list
is from the Virginia Board of Nursing/Virginia Board of Medicine Regulations. Unlike many States in
the USA it incorporates nurse anaesthetist and nurse midwife under the heading nurse practitioner.
Most other states list these roles separately under the umbrella term, advanced practice nurse as
mentioned previously.
● adult nurse practitioner;

● family nurse practitioner;
● paediatric nurse practitioner;
● family planning nurse practitioner;
● obstetric/Gynecologic nurse practitioner;
● emergency nurse practitioner;
● geriatric nurse practitioner;
● certified registered nurse anaesthetist;
● certified nurse midwife;
● school nurse practitioner;
● medical nurse practitioner;
● maternal child health nurse practitioner;
● neonatal nurse practitioner;
● women's health nurse practitioner; and
● acute care nurse practitioner.
Other practice areas included in the literature are:
● nurse practitioner sigmoidoscopy / gastroenterology nurse practitioner

● primary care
● nurse practitioner management of heart failure
● nurse practitioner management of least urgent triage categories in an ophthalmic casualty
● nurse practitioner management of urinary continence and
● comprehensive breast clinic nurse practitioner.
In addition to these, pilot projects in Australia have been or are being carried out in the following
areas:
● primary care for 'at risk' youth and sex workers

● primary care for homeless persons
● hospital maternity
● haematology
● wound care
● paediatric eczema
● peri-operative pre-admission
● psychiatric consultation-liaison
● primary care for well women
● sexual health
● military
● diabetes
● stomal therapy/continence/wound care and
● palliative care
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Nurse Practitioner and Physician's Assistants

In addition to nurse practitioners, physician's assistants are also being used in primary care practice
and to an extent in hospitals.
Jacobsen, Parker and Coulter (1999 USA) conducted an exploratory qualitative study to identify the
nurse practitioner and physician's assistants role across nine health maintenance organizations and
multispecialty clinics in which nurse practitioners and physician's assistants had been successfully
integrated, to varying degrees, over an extended period of time. Interviews at each site with several
nurse practitioners, physician's assistants, and physicians, and at least one representative of the
institution's administration. At the sample institutions nurse practitioner and physician's assistants
were treated as interchangeable for the provision of primary care. Both groups reported undertaking
tasks that could be grouped as diagnosis (physical assessments and test ordering), medical
treatment (monitoring diabetes and hypertension), writing prescriptions (although in many
instances these required countersigning by the physician) and providing minor surgical treatment
(biopsies and mole removal). In addition they provided non-hospital acute care (minor trauma) and
well care (Pap smears and breast examinations). Things of interest in scope of practice in this study
were that the physicians generally treated the most complex cases and that nurse practitioner and
physician's assistants were not held accountable in the same way as physicians. The overall
responsibility for medical judgement rested with the physicians.
The American Academy of Pediatrics Committee on Hospital Care (1999 USA) indicates that the role
of the nurse practitioner and physician's assistant in paediatrics has been expanded from the
primary care focus to include the care of hospitalised patients. It recommends that the physician
direct the management of such patients and that written protocols be required. It also suggests
hospitals establish credentialing processes delineating privileges in the same way it is done for
medical staff albeit that nurse practitioners would go through nursing channels and physician's
assistants would through the medical staff process as they work directly under the supervision of a
physician.
A further article indicates that both nurse practitioners and physician's assistants may be used in the
future in intensive care units (ICUs). Lustbader and Fein (2000 USA) reviewed the literature related
to the models of patient care used in ICUs, the role of intensivists, the financial aspects of 24-hour
on-site intensivist coverage and the advent of telemedicine. In their conclusion they surmise that
community hospitals "... may rely on specially trained nurse practitioners or physician assistants to
provide more on-site coverage during off hours."
The final article in the area of physician assistant describes their emerging role in the delivery of
dermatologic health care (Clark, Monroe, Feldman, Fleischer, Hauser & Hinds, 2000 USA). The
number of dermatology physician's assistants has increased from approximately six in 1993 to more
than three hundred, most of whom work with dermatologists in private practice. While the role of
physician's assistant currently does not exist in Australia it should be noted that there is the
potential for nurse practitioners in this field since one of the first nurse practitioner pilot projects in
Victoria involved paediatric eczema.
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Section 2:Changes in the roles of health professionals which have impacted on

nursing
The Primary Care/client focused health care strategy in the UK is operationalised by General
Practitioner's (GP's) commissioning and providing local services based on the needs of local
populations. Commissioning is the strategic response to meeting local health needs through service
developments including developing new services, changing existing services, and downsizing
services where supply exceeds demand. Purchasing refers to negotiation of contracts with local
providers for the provision of these services. While the health authorities still have an overview of
health needs and ensure that appropriate services are provided, it is a major change from health
authorities being the major fund-holder's for services with GP's assistance, to GP's becoming
responsible for allocating funds with health authority assistance (Felvus & Andrews-Evans, 1996
UK). Fund-holding is voluntary and is linked to the number of patients in the GP practice. 53% UK
population is registered with standard fundholders. Most GP's purchase staff, drugs, diagnostic tests
and community health services but not hospital activity. A pilot study increases GP's funding to
purchase all hospital and community health services on behalf of their patients (Hibbs,1996 UK).
New developments arising from this initiative include pre-admission clinics, early pregnancy
assessment units, admission units, consultant outreach clinics, practice-based counseling and
physiotherapy services, community hospital beds, primary care-led minor injury units, team
midwifery services and hospital at home schemes.
Although most of the literature is narrative, of particular significance is the literature relating to the
impact that this change has had upon the provision of primary care services by nurses. The
literature reveals that there is high level evidence in the form of case studies and randomised
control trials (NHMRC level II) for nurses as partners in the provision of patient focused care and for
nurses to expand their roles to assume tasks previously carried out by GP's.
Research includes a qualitative study by Luker, Austin, Hog, Ferguson & Smith (1998 UK) that
reports patient satisfaction and in some case preference over a GP for community nurses and home
visit nurses to prescribe treatment and provide care relating to diabetes, wound management,
asthma and baby care. Preference for the nurse-patient relationship versus the GP-patient
relationship was attributed to lack of social distance and gender issues including the 'caring' capacity
attributed to the female nurse. The practice of home visits was also preferable compared to doctor's
rooms. Such preferences have implications for other GP services that may be assumed by nurses.
For example, a cross-sectional survey of adult victims of violent crime (n=195) revealed that
although assault is a relatively common event in the lives of women who consult their GP, women
rarely disclosed their distressing experiences to the GP (Mezey, King & MacClintock, 1998 UK). The
case study by Goodman, Knight, Ina & Hunt (1997 UK) describes the collaborative relationship
between GP's and district nurses in managing terminal care.
Prior to the introduction of the GP contract, the practice nurse was an emerging occupation in the
UK. The Government predicted that nurses would have a vital role to play (Lipley, 1998 UK) and
indeed following the changes to the primary health service there has been a six-fold increase in
practice nurse numbers (Broadbent, 1998 UK). In addition, there is high level evidence to support
an expanded role for practice nurses in order to meet the demands of the change in primary health
services. A small qualitative study (n= 34 practices) found that practice nurses were carrying out
health promotion activities that were a priority of the new service but that GP's had yet to embrace
(Broadbent, 1998 UK). Positive outcomes when practice nurses engage in health promotion
activities were reported in a large (n=1173) multi-centre trial (NHMRC level IV) in Northeast
Scotland (Campbell, Thain, Deans, Ritchie, Rawles & Squair, 1998 UK). In this study secondary
prevention clinics conducted by practice nurses for patients with a working diagnosis of coronary
heart disease were found to improve patients' health and reduce hospital admissions.
Fall, Walters, Read, Deverill, Lutman, Milner & Rodgers (1997 UK) conducted a prospective
observational cohort study (NHMRC level III-2) comparing health outcomes and resource use for
patients with ear or hearing problems treated by nurses trained in ear care with similar patients
treated by standard practice. Specialized training in the structure and functioning of the ear and
basic audiometry training were given to practice nurses in eight practices in the United Kingdom.
These nurses then practised for six months. A further nine practices where the training had not been
given were chosen and outcomes compared. The authors conclude "nurses trained in ear care
reduce costs, GP workload, and the use of systemic antibiotics, while increasing patient satisfaction
with care." (p 699)
Clients with Psychiatric morbidity constitute a significant proportion of general practice workload.
The findings of a small (n=70) randomised control trial (NHMRC level II) relating to the extension of
nurses skills in the area's of mental health assessment and counseling (Mynors-Wallis, Davies, Gray,
Barbour & Gath, 1996 UK), are reinforced by a large (n=655) rural randomised control trial (NHMRC
level II) by Mann, Blizard, Murray, Smith, Botega, Macdonald & Wilson, (1998 UK). Mann et al that
found training practice nurses to work alongside GP's in assessing patients and providing follow-up
care was associated with outcomes consistent with GP provided care. The necessity for appropriate
training in this area however was highlighted by a large (n=1710) multicentre randomised control
(NHMRC level II) trial by Plummer, Gournay, Ritter & Blizard (2000 UK). This study reported a low
mean detection rate for psychiatric morbidity by practice nurses for patient's whose symptoms were
not severe.
Patients requesting same day appointments for minor illnesses also represent a large proportion of
general practice workload. Evidence for an extension to the practice nurses' role in this area appears
in the literature as a case study and two large multi-centre randomised control trial's. The large
(n=1263) case study Gallagher, Huddart and Henderson (1998 UK) reported that ~50% same-day
requests were handled by the practice nurse either via a telephone or face-to-face consultation. GP
workload fell by 54% with only 7.8% of these patients requiring a GP consultation. The follow-up
patient satisfaction survey (n=325) found that 88% of patients were satisfied with the telephone
advice from the nurse. Two large (n= 1815 & 1716) randomised control trial's (NHMRC LEVEL II)'s
relating to prescribing and provision of minor illness services (Shum, Humphreys, Wheeler,
Cochrane, Skoda & Clement, 2000 UK; Venning, Durie, Roland, Roberts & Leese, 2000 UK) concur
that there are satisfactory outcomes and no significant increases in cost when nurses provide
services in these areas. In these studies, when prescriptions were required they were completed by
the practice nurse and signed by the GP.
Caldow, Bond & Russell (2001 UK) surveyed 433 practice nurses in general practice across Scotland.
The 385 questionnaires suitable for inclusion in the study showed that over 90% of the respondents
applied for the job because working independently and the variety of work involved appealed to
them. Much of their work involves conditions where evidence based advice is the main or only
intervention. In general most practice nurses would be willing to diagnose certain self-referrals and
prescribe within strict protocols, however training in both areas was required.
In all studies new knowledge and skills relating to assessment, clinical decision- making, and
treatment were required to undertake the new roles. These were obtained through varying models
of education ranging from tertiary courses to Mentoring by professional medical colleagues.
With a growing focus on population health and delivery of primary care services, GP's in Australia
are now expected to engage in health promotion activities. A large cross-sectional survey
(n=13,017) revealed that there were discrepancies between patients' expectations of the doctor's
role in promoting healthy life styles and their likelihood of receiving advice (Richmond, Kehoe,
Health, Wodak and Webster, 1996 AUS).
The role of multi-disciplinary health care teams is recognised in the primary health setting (Sims,
Kerse, Naccarella & Long, 2000 AUS). With the de-institutionalisation of Mental Health Care, there
are particularly strong partnerships between GP's and community mental health nurses. A
comparison of the old integrated model and new consultation-liaison model (n=100) for providing
mental health care in general practice in New south Wales revealed that the closer liaison between
GP's and community mental health in the new model had many benefits (Harmon, Carr, & Lewin,
2000 AUS). In order to maximise these outcomes the study recommended that rather than focusing
education solely on educating the GP in mental health, that there is an outstanding need to educate
mental health nurses to enable them to work more effectively in a collaborative team with the GP's.
The literature reveals that role of the practice nurse is not well developed in Australia. Two
qualitative studies shed some light on the current role of the practice nurse and recent role
developments. A questionnaire survey of 452 general medical practices in Victoria conducted by
Bonawit & Watson (1996 AUS) attracted responses from 277 practices, many of which did not
employ nurses. The 93 respondents from 85 practices who were nurses reported that while the
majority of time was spent in clinical procedures, at least 30% of their working week was spent on
clerical tasks. Few were involved in health promotion, educational or advisory work and relied
heavily on the GP for their own continuing education. Twenty four percent of respondents visited
patients at home.
A small qualitative study (n= 8 practices) by Condon, Willis & Litt (2000 AUS) reports minor changes
to the roles recounted in the earlier research. Using purposeful sampling for 4 urban practices,
convenience sampling in 4 rural practices, GP's and practice nurses were interviewed and the
emerging themes analysed. The practice nurse has traditionally carried out a largely receptionist
role in Australia, however this research found that practice nurses are now occupied in largely
nursing work with little time spent on clerical duties. Clerical duties when carried out were most
likely to be directly related to patient care. Nursing duties were largely procedural (venepuncture,
preparing for GP procedures, wound dressings, ECG's, Imunisations, Pulmonary Function tests), with
some triage duties and education/health promotion activities. Unlike their British counterparts, the
relationship between the GP and the practice nurse is rarely collaborative, with the nurse being seen
as a resource to the GP's practice rather than a professional colleague with her own domain of
knowledge and practice. Various innovations were introduced by the physician, but implemented by
nurses. In the majority of cases where practice nurses acted more autonomously, this was seen to
undermine the GP role rather than constitute a valued service. While most practice nurses saw
opportunities to develop the role in terms of gaining more procedural skills, they felt that significant
education was required to expand their role in health promotion and health education. Those GP's
and practice nurses who saw potential to develop the practice nurse role in the areas of heath
promotion and health education were prevented doing so by the current funding structure. This
structure requires the GP to sight the practice nurse's work in order to receive financial
remuneration for the same.
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Section 3:Summary of Required Skills and Knowledge
The main themes relating to skills and knowledge of the nurse across all service settings and roles
are coordination of care, patient/client assessment, clinical decision making, education, research,
counselling and organisational management.
Coordination of quality, cost-effective multidisciplinary care is a skill that recurs across the
literature. Coordination aims to ensure continuity of care between sectors and facilitate health
service delivery. In order to do this, nurses coordinating care require high-level communication and
liaison skills; the ability to delegate to, supervise and evaluate professional and unlicensed staff;
knowledge of professional boundaries of practice; and knowledge of available services, providers
and health funding.
The need to have assessment skills appears frequently but varies somewhat between settings or
roles. Nurses in case management/coordinated care roles require skills and knowledge in
comprehensive assessment of physical, environmental, social, functional, cognitive, psychological
and economic status. Where the nurse is located in the community the assessment skills are
different to those required by the nurse working in the acute care sector. Nurse practitioners and
clinical nurse specialists, regardless of setting, require advanced assessment skills and knowledge
related to the specialty area in which they practice so that they can make differential diagnoses.
Advanced problem solving and clinical decision making skills are also deemed essential in many
roles with the nurse having the ability to adjust their skills to new situations.
The nurses' changing role in education is described in many articles. A larger component of
education given by nurses, particularly in the UK and USA, is related to screening, health promotion
and disease prevention. This includes teaching school children about sexual health and drug issues.
The nurses' role in teaching across disciplines is particularly noted where nurse practitioners are
employed, however the teaching of family care givers is also an important role identified in the
literature. Teaching skills required by nurses include the identification of learning needs, use of
different teaching methodologies and the facilitation of learning. The increase in multimedia use in
education also requires nurses to be competent in this area.
The requirement for research skills is evident in the literature, particularly in relation to evidence
based practice and quality of care. A number of articles indicate that nurses need skills and
knowledge in analyzing and critiquing research findings and implementing evidence based research
into clinical practice. Other articles indicate that nurses should have the ability to monitor the quality
and efficacy of care which requires them to be have skills in the identification of outcome measures,
collection and analysis of data.
The counseling role of the nurse is increasing particularly in the mental health field but also in other
fields of nursing. Nurses need knowledge and skills in this area. A number of support groups
established by nurses both in the community and acute care sector are documented.
The role of nurse executives and middle managers has changed with the move to decentralized
management structures. The role has evolved to one that has non-nursing departments reporting to
it, and the new manager is expected to have knowledge and skills in financial, human resource and
change management; strategic planning; leadership; and mentoring. Nurse practitioners and nurse
midwives in independent practice are also required to have entrepreneurial and business skills in
addition a number of the skills required by managers.

Disclaimer

Chapter 3
Conclusions
In summary, the literature providing information about changes in the health care services and the
roles of nurses and other healthcare workers largely comprises narrative accounts based on expert
opinions. This should not be discounted however, as it provides a useful mapping of the dimension
and scope of nursing practices in this changing practice context. Wherever possible, the themes that
have emerged from this literature have been substantiated with literature providing levels of
evidence classified as high according to the NHMRC guidelines. The areas where the literature
retrieved was of the highest level of evidence were clearly those areas concerned with the most
recent changes in health services, for example, the innovations related to telemedicine and
telehealth and the expanding role of nurse to the level of independent practitioner. Accordingly,
these changes point the way to the requirements for emerging nursing roles and the corresponding
skills and knowledge required to perform those roles and deliver the corresponding health care
services. The literature reveals that nurses require broad based clinical skills that can be extended
and expanded with appropriate training. An ability to work with a burgeoning range of technology
while at the same time providing and overseeing the provision of personalized care to the clients/
patients for whom the technology is servicing is essential. Nurses also need to acquire and process
knowledge rapidly, they need the ability to be sophisticated research consumers, and to be able to
integrate new knowledge with existing knowledge to create new understanding. They need to be self-
directed in their acquisition of knowledge and know how to use resources to access information and
to assist others in gaining skills and knowledge. In this 'information age' nurses require the type of
knowledge that assists them to analyze the risks and benefits of new technologies and to implement
and evaluate new services. Underpinning all of these requirements is the need to be involved in
ongoing learning to develop the capacity to cope with the challenge of practicing an ever changing,
technologically diverse healthcare milieu.

Disclaimer

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National Review of Nursing Education

Aspects of Nursing Education: The Types Of Skills And

School of Postgraduate Nursing

ISBN 0 642 77241 X (Online version)

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Aspects of Nursing Education: The Types Of Skills And

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Aspects of Nursing Education: The Types Of Skills And

Definition of terms (Alphabetical Order)

The following are terms used frequently throughout this review.

Assistive or support workers in health care

The characteristic or expected function of a person or thing, in a particular setting or environment.

Scope of nursing practice

'Scope of nursing practice' incorporates:

USA = United States of America

Background - the title, Nurse Practitioner, and the legislation

Qual = qualitative study

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Aspects of Nursing Education: The Types Of Skills And

The Purpose of the Report

The Scope of the Literature Review

The specific objectives addressed in this review are

Criteria for Considering Studies for this Literature Review

Studies were considered appropriate if they

Table 1 Designation of levels of evidence

Level of evidence Study design

An extensive search of databases was conducted. This included

(service provision) and (chang$ or new) and nurs$

(health care provision) and (chang$ or new) and nurs$

(health care professional) and role and (chang$ or new)

(model$ of care) and (chang$ or new)

(case manager) and (role adj chang$) or (role adj new)

(coordinated care) and (role adj chang$) or (role adj new)

(shared care) and (role adj chang$) or (role adj new)

(minimally invasive surgery)

(primary care) and (role adj chang$) or (role adj new)

(preventative care) and (role adj chang$) or (role adj new)

nurs$ and (role adj chang$) or (role adj new)

nurs$ and (independent practice)

radiology and (role adj chang$) or (role adj new)

(diagnostic studies) and (role adj chang$) or (role adj new)

angiography and (role adj chang$) or (role adj new)

(telephone triage) and (role adj chang$) or (role adj new)

leadership (role adj chang$) or (role adj new)

management (role adj chang$) or (role adj new)

doctor and (role adj chang$) or (role adj new) or role

midwi$ and (role adj chang$) or (role adj new)

carer and (role adj chang$) or (role adj new)

A search of PsycINFO with the terms

A search of Australian Digital Theses Program with the terms

nurs? and (chang? role) or (new role)

(medical practitioner) and (chang? role) or (new role)

doctor and (chang? role) or (new role)

nurs? and (chang? role) or (new role)

(medical practitioner) and (chang? role) or (new role)

doctor and (chang? role) or (new role)