Community Health Nursing Report

The role and scope of practice of Community Health Nurses in Victoria

Phase 1 of

The role and scope of practice of Community Health Nurses in Victoria, and their

capacity to promote health and wellbeing

Carmel Condon Project officer, CHN SIG Pat Nesbitt Deakin University Scott Salzman Deakin University

Date: May 2008

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This work is copyright. No part of this report may be reproduced by any means without prior written permission. All enquiries about this report should be directed to: Olive Aumann President Community Health Nurses Special Interest Group, Victoria Telephone: 8843 2233 Email: oaumann@wchs.org.au Acknowledgements The project was commissioned and funded by the CHN SIG and the Australian Nursing Foundation (ANF). Specifically two thirds of the funding came from the CHN SIG, however the remaining third of the funding came from the ANF (Vic. Branch), through the 2006 Elizabeth Hulme Grant SIGs.

The authors greatly appreciate the contribution of all the community health nurses involved in this study and the work of the steering committee, particularly Olive Aumann, Jenny McLean and Giancarlo Di Stefano from the Community Health Nurses Special Interest Group (CHN SIG) executive and the ANF for their assistance, particularly Vanessa Standfield.

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TABLE OF CONTENTS Executive summary......................................................................6

Introduction...................................................................................9 Background and rationale for the study ...................................................................9 The study .................................................................................................................9 Steering Committee ...............................................................................................10 Project objectives ...................................................................................................10 Structure of the Report...........................................................................................10

Literature review.........................................................................11

Methodology ...............................................................................14 Design and methods of investigation .....................................................................14 Definition of community health nursing ..................................................................15 Population ..............................................................................................................15 Data collection instrument......................................................................................15 Procedure for data collection .................................................................................15 Ethical considerations ............................................................................................16 Statistical Analysis: ................................................................................................16

Results ........................................................................................17 Victorian community health nurse characteristics ..................................................17 Professional qualifications of community health nurses.........................................21 Community health nursing practice........................................................................25 Community health nursing competencies ..............................................................28 Nursing knowledge.................................................................................................28 Allocation of community heath nursing resources..................................................29 Allocation of community heath nursing resources..................................................29 Community health nursing specialties....................................................................31

Discussion ..................................................................................35

Conclusion and recommendations...........................................39

Appendices .................................................................................45 Appendix A: Steering Committee Terms of Reference ..........................................45 Appendix B Questionnaire .....................................................................................47 Appendix C Information for Participants.................................................................58 Appendix D Summary of nursing theories................Error! Bookmark not defined.

Glossary ......................................................................................61

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List of Tables Table 1 Average years worked in community health - males and females ..................... 18 Table 2 Average years experience in the community health sector compared with

average years experience in current community health position ............................ 19 Table 3 Percentage of community health nurses regularly undertaking professional

development................................................................................................................... 24 Table 4 Community health nursing practice considered necessary or

essential/community health nursing practice undertaken often or regularly ......... 25 Table 5 Numerical summaries for significant differences identified in the scores for

practice considered essential or necessary, and practice undertaken often or regularly.......................................................................................................................... 26

Table 6 Proportion of CHNs providing key elements of practice/proportion who advocate this element of community health nursing practice ................................. 26

Table 7 Estimated percentage of time allocated to key elements of practice compared with estimated percentage of time needed to be allocated....................................... 27

Table 8 Numerical summaries for significant differences identified in the scores for time allocated to key elements of practice and time needed to be allocated ......... 27

Table 9 Nursing competencies considered necessary or essential to CHN practice and used often or regularly.................................................................................................. 28

Table 10 Nursing knowledge considered essential or necessary for practice and utilised often or regularly in community health nursing ........................................... 29

Table 11 Numerical summaries for significant differences identified in the scores for nursing knowledge considered essential or necessary for practice and nursing knowledge used often or regularly .............................................................................. 29

Table 12 Distribution of community health nursing resources by client age group...... 30 Table 13 High-risk groups allocated 50-100% of community health nursing time ......... 30 Table 14 Estimated time allocated to high-risk groups compared with estimated time

considered appropriate to be allocated ...................................................................... 31 Table 15 Numerical summaries for significant differences identified in the scores for

estimates of time spent with at-risk groups and time considered appropriate to spend with each group.................................................................................................. 31

Table 16 Areas of community health nursing practiced often or regularly: comparisons between generalist CHNs and other CHN specialties................................................ 32

Table 17 Competencies for community health nursing used often or regularly: comparisons between generalist CHNs and other CHN specialties ........................ 33

Table 18 Nursing knowledge utilised in community health nursing: comparisons between generalist CHNs and other CHN specialties................................................ 34

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List of Figures Figure 1 Geographic location of community health nurses work setting ....................... 17 Figure 2 Age distribution of community health nurses..................................................... 18 Figure 3 Years worked in community health as a function of sex ................................... 19 Figure 4 Percentage of community health nurses as a function of the years of

experience in the community health sector and years working in current community health position........................................................................................... 20

Figure 5 Sector in which Community health nurses worked prior to working in community health .......................................................................................................... 20

Figure 6 Proportion of Community health nurses working full time and part time........ 21 Figure 7 Percentage of community health nurses with one or more postgraduate (PG)

qualifications.................................................................................................................. 22 Figure 8 Number of community health nurses with or without postgraduate (PG)

qualifications as a function of age group ................................................................... 22 Figure 9 Highest level of postgraduate qualification held by community health nurses

......................................................................................................................................... 23 Figure 10 Highest levels of postgraduate qualifications by geographical location ....... 23 Figure 11 Number of community health nurses with specialty postgraduate (PG)

qualifications.................................................................................................................. 24 Figure 12 A model of nursing advocacy ............................................................................. 37

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Executive summary Health care spending consumes about 10% of the Gross National Product (GNP) in Australia and health spending is increasing, with health being one of the fastest growing employment sectors. Therefore, it is imperative to identify good health management practices as a key to providing appropriate cost effective care to the broader community. Nurses have long been recognised as appropriate community care providers, particularly in the Australian health care system that purports to be based on the principles of primary health care. However, this ‘place’ for community health nurses (CHNs) is not obvious in Australian health care funding arrangements. Furthermore, lack of policy emphasis on community health nursing compromises the nursing profession’s ability to provide appropriately prepared nurses for the community health sector. CHNs believe that they play a significant role in the provision of community health care; they also believe that their role is misunderstood and at risk of destabilisation, and consequently, may be lost to the community. In order for the nursing profession to maintain its relevance in serving local communities, nurses and those who represent them must understand and be able to articulate the types of community health nursing services and the value of these services to local communities. CHNs’ directed this research with the support of the Australian Nursing Federation (ANF) Victorian Branch, as they seek to clarify and consolidate their role(s) within the community health sector.

Purpose This project involves two phases. The purpose of Phase 1 is to:

1. Explore and describe the role of community health nurses who work within community health centres in Victoria

2. Identify common characteristics of health care delivery provided by community health nurses

Method Phase 1 involved a comprehensive self-administered questionnaire, which all CHNs working in Victorian community health centres were invited to complete. The questions were based on national competency standards for registered nurses. Following analysis of the questionnaire responses and subject to funding, phase 2 will involve focus group discussions involving CHNs who volunteer to participate in these discussions.

Results Key findings from analysis of the data revealed that:

• Demographic data for the nurses in this study were similar to published nursing labour force data on nurses working in community health. The average age of community health nurses was 46.5 years. Most were female (93.9%), most were in part-time employment (65.4%) and most were located in major cities (61.3%), followed by inner regional (23.4%) and outer regional (15.3%) areas.

• Over half (51.3%) the nurses had been working in community health for 10 or more years, while over a quarter (27.4%) had been working in their current position for less than 5 years.

• Almost two-thirds (65.8%) of nurses reported holding one or more postgraduate qualifications; 88.2% reported undertaking professional

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development activities considered essential or necessary to their practice equivalent to at least one week per year and 85.5% reported holding membership of at least one professional association.

• Almost 90% of the nurses worked with older people (65+ years) and most (82.6%) worked with people with chronic illness. Just under half worked with indigenous groups and homeless people and less than 40% worked with refugee groups and people affected by HIV/AIDS

• The major areas of community health nursing practiced often or regularly by the majority of community health nurses included advocacy (83.0%), needs assessment of individuals and families (75.5%), health education/health counselling (75.0%) and monitoring health status of individuals or families (72.5%).

• Competencies used often or regularly by the majority of community health nurses related to referral to other services (88.5%), collecting data on clients’ functional status (83.0%), contributing to multi-disciplinary services (81.4%) and providing health education (79.6%).

• Nursing knowledge used often or regularly by the majority of community health nurses included anatomy and physiology (87.6%), knowledge pertaining to a social model of health (82.3%), primary health care (81.3%), social determinants of health (81.3%) and comprehensive assessment (79.5%).

• Statistical analyses indicate that CHNs are calling for a stronger role in advancing comprehensive primary health care as advocated by the International Council of Nurses

Discussion Overall, analyses suggest that community health nursing functions complement Victorian community health policy and priorities that address primary care. Community health nursing does this through comprehensive nursing assessment, monitoring of progress towards health goals, early intervention through appropriate referral to health, and social support services, together with health education. Community health nursing clearly embraces a social model of health, with particular emphasis on advocacy to promote self-reliance among people with, or at risk of dependence on the broader health system, older people and those with low incomes, to be independent wherever possible, within their local communities. Their combination of biophysical, psychosocial and cultural knowledge as well as their experience of the acute health system strengthens their capacity to assess functional status, their capacity as health educators and their capacity to contribute to multi-disciplinary primary care.

However, CHNs are well prepared, often at postgraduate level, to contribute to the broader aspects of comprehensive primary health care rather than primary care and consider themselves as underutilised by the community health sector.

Conclusion and recommendations The results of this study add to the body of knowledge already available in the literature relating to community health nursing and they will contribute to the clarification of the role of CHNs in Victoria. The authors conclude that community health nursing brings to community health a combination of biomedical, psychosocial and cultural knowledge, together with an understanding of the broader health sector, which renders them ideal providers of primary care. However, their knowledge and expertise extend to the broader aspects of comprehensive primary health care, which if utilised to its capacity could strengthen the primary health care movement to

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accommodate and influence the growing demands of the health care system in Victoria. The authors recommend:

1. That further research be conducted to highlight the benefits of community health nursing interventions on the health and well-being of the groups and communities with whom they work

2. That evaluation of existing models of community health nursing occurs to determine their appropriateness for best practice in community health nursing within current policy frameworks, Australia–wide.

3. That a concerted campaign is undertaken to promote models of best practice within the profession and amongst policy makers and funding bodies that includes CHNs role in comprehensive primary health care

4. The expertise of community health nurses be acknowledged and recognised through the establishment of a formal process for CHNs to have regular dialogue with policy makers that contributes to the development of community health policy in Victoria

5. That the CHN SIG be supported to have an annual conference/workshop in which the membership submit recommendations for collective action to nursing associations, the Department of Health and Community Services and those community health interest groups with a policy remit.

6. That CHNs be encouraged and supported to contribute to comprehensive primary health care using best practice models

7. That a series of focus groups or workshops involving CHNs be held to identify models of best practice for community health nursing currently in use, to agree on indicators to be used in evaluating outcomes of CHN interventions and to develop strategies for establishing strategic alliances for accessing policy makers.

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Introduction Health care spending consumes about 10% of the Gross National Product (GNP) in Australia and health spending is increasing, with health being one of the fastest growing employment sectors. Consequently, since the early 1990’s managers of health care agencies throughout Victoria have contended with enormous change, requiring them to rethink their models of practice and mix of services as a key to providing appropriate cost effective care to the broader community. Although economically driven, the changes were in recognition of communities being better served through the adoption of primary health care principles in the delivery of health for all (Baum, 2002b; Keleher, 2004; McMurray, 2007). These changes not only affect management, but also the professional disciplines that prepare the health workforce and the individuals who provide the services. In order for the nursing profession to maintain its relevance in serving local communities, nurses and those who represent them must understand and be able to articulate the types of community health nursing services required and their value to local communities.

Background and rationale for the study Fourteen years ago, Clarke & Cody (1994) predicted that by the year 2010, 70% of health care would be provided in the community. Moreover, nurses were identified as the most appropriate community care providers (McEwan, 1998; Smith, 2000) in partnership with communities under what is now termed the Charter for People’s Health (Gottschalk & Scoville-Baker, 2004). However, this ‘place’ for community health nurses is not obvious in funding arrangements such as Medicare, Home and Community Care (HACC) and Community Aged Care Packages (CACPs), which are central to the functioning of health care systems in the community (Harding, 2004; McMurray, 2003). Furthermore, lack of policy emphasis on community health nursing may be associated with reduced emphasis of community health nursing in the Nurses Board of Victoria’s standards for undergraduate course accreditation. This lack of emphasis compromises the nursing profession’s ability to provide appropriately prepared nurses for the community health sector as a great deal of nursing education and practical application in Australia, is what (Keleher, 2007a) has coined ‘hospital-centric’ therefore influencing the direction and scope of the care that nurses provide.

In Victoria, the Community Health Nurses Special Interest Group (CHN SIG), a subgroup of the Australian Nursing Federation represents community health nurses. Competition for finite health resources evidenced by the introduction of community health workers and merging of health services has raised concern amongst the CHN SIG membership. They sense that the CHN’s unique contribution to multidisciplinary community health is misunderstood and is being eroded. To ensure emphasis on community health nursing, it is fundamental that policy makers and funding bodies understand what community health nurses contribute to preventative health and health maintenance in local communities.

The study The CHN SIG executive commissioned this study in response to a direct request from the SIG membership to review the role of community health nursing in Victoria. In late 2006, the CHN SIG undertook to consult with CHNs across Victoria regarding community health nursing activities currently undertaken in Victorian community health services and their relevance within the current health system. The results of this project will help to clarify the work presently undertaken by CHNs in Victoria and highlight any need to redirect or reorient their services in order to remain relevant and responsive to their communities. These results will also assist the CHN SIG to

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represent accurately the direction community health nursing needs to take to maintain its relevance.

There are two phases to this project. Phase 1 involved a comprehensive self-administered questionnaire that every community health nurse working in Victorian community health centres was invited to complete. Following analysis of the questionnaire responses and subject to funding, phase 2 will involve focus group discussions involving community health nurses who volunteer to participate in these discussions. In this report, the authors summarise the characteristics, competencies, knowledge and activities of CHNs identified by 114 CHNs throughout Victoria.

Steering Committee The steering committee that supported the project comprised:

Olive Aumann CHN SIG president Jenny McLean CHN SIG treasurer Giancarlo Di Stefano CHN SIG secretary Carmel Condon Project Officer Helen Keleher Nurse Academic, LaTrobe University Meredith Kefford DHS Primary Health Care Branch Pat Nesbitt Nurse Academic, Deakin University

Mark Staaf Professional Officer, ANF (Vic. Branch) The terms of reference for the Steering Committee are listed in Appendix A

Project objectives The objectives of the overall project are to:

1. To explore and describe the role of community health nurses (CHNs) who work within community health centres in Victoria

2. To identify common characteristics of health care delivery provided by community health nurses

3. To determine the factors influencing the capacity of CHNs to deliver health services for older people and people with chronic health problems

4. To determine the factors influencing the capacity of CHNs to contribute to best practice development for risk assessment and community well-being in general and more specifically for the elderly and people with chronic health problems

5. To identify the need for and recommend changes in policy and resource allocation to support CHNS’ contribution to research activities addressing health promotion and maintenance of older people and people with chronic illness

This report of phase 1 of the study addresses objectives 1 and 2 and makes recommendations for further research required in phase 2.

Structure of the Report There are five sections to this report:

• Background and rationale for the study • Methodology • Results • Discussion • Conclusion and Recommendations

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Literature review We cannot divorce ourselves from the milieu of our times; however, our past should inform the present. Our current public health movement had its beginnings in Europe during the late 19th century in response to adverse living and working conditions that resulted in appalling death tolls from poverty and disease. This public health movement, according to Edgecombe (2001, p.1), has three distinct phases called: the age of environment (1875 - 1930), the age of medicine (1930 - 1950) and the age of lifestyle (1950 - 1990). It is this later phase that set the stage for the primary health care movement and sustainable health development programs, indicating a shift in thinking to what has been called the new public health movement (McMurray, 2007). The new public health movement gained momentum through the endorsement of primary health care by the World Health Organisation in their declaration of Alma Ata of 1978. While over the past 30 years the primary health care movement has met with mixed success, it has served to encourage health care providers and policy makers to consider health care in a more holistic manner recognising the social and environmental as well as biological determinants of health (Kendall, 2008).

The concepts embedded within primary health care were not foreign to the profession (Nutbeam & Harris, 2005), as even Nightingale in the 1860s was only too aware that the external conditions in which a person resided affected the capacity of a person to remain healthy (Plymat, 1998). In England, district nurses were established with the support of Florence Nightingale and were regarded as the first public health nurses (Edgecombe, 2001 p.3). American nurse Lillian Wald, in the late 19th and early 20th centuries considered herself to be a public health nurse. Wald set the tone for collaborative care based upon a sound assessment of both individual patients and their environments (Edgecombe, 2001 p.3). In Australia, prior to 1973 nursing practice in the community was defined by practice settings, in schools and infant welfare centres for example. However, with the inception of the new public health movement, community health nurses quickly adopted a social model of health or a holistic perspective of health, health education, health promotion and disease prevention grounded in the principles of primary health care (Koch, 2000; St John, 1999; World Health Organisation, 1974)

There is a great deal of confusion that surrounds the nomenclature and role of the community health or public health nurse (Allender & Spradley, 2005; Brookes, Daly, Davidson, & Hancock, 2004; St John & Keleher, 2007). The term community health nurse did not appear in Australia until the 1970s (Keleher, 2007a). In North America the community health nurse was known as the public health nurse (Allender & Spradley, 2005 p.18) for the first 70 years of the 20th century. The current literature uses the terms community health nurse (CHN) and community nurse (CN) interchangeably (St John & Keleher, 2007). The term ‘community-based nursing’ has also appeared in the literature (St John & Keleher, 2007). Without doubt, inconsistent terminology affects the recognition of community health nursing as a nursing specialty by the public and policy makers alike. Nevertheless, while public health nurses have enjoyed a rich history associated with the application of principles similar to those identified in primary health care to nursing care in the community, their valuable contributions to community health are continually subverted by a world that values a ‘quick fix’ technological approach to health and the allocation of health resources.

As patterns of health and illness changed, a shift occurred in policy responses from previously accepted institutionalised settings to broader community based services (Cioffi, Wilkes, Warne, Harrison, & Vonu-Boriceanu, 2007; Kemp, Harris, & Comino, 2005). Many clients or patients require continual acute treatment, often carried out by nurses in the community, who have defined specialties. Examples of community-

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based services involving nursing include hospital in the home programs dealing with acute and complex chronic conditions, mental health nursing, and oncology and palliative care nursing. In addition, health care funding has been provided to general medical practitioners to support new roles for nurses such as the practice nurse in general medical practitioners’ (GP) offices (Halcomb, Patterson, & Davidson, 2006). In short, there has been an expansion of the CHNs role in the community in a variety of roles.

CHNs are well placed to provide health services to the broader community. However, there is a gap in the literature confirming that this is indeed the case. In addition, it could be argued that there is confusion amongst mangers, policy makers and the general public about the actual ‘work’ of CHNs, which inhibits their capacity to perform to their potential (Brookes et al., 2004). Smith (2000) argues that by working in the community over a period, CHNs have developed an affinity with individuals, families, and groups, which is qualitatively different and more profound than that usually experienced by the nurse who works in an acute care environment. These relationships are not episodic, but can span many years and may embrace several generations. Thus, it could be stated that CHNs focus on developing an understanding of the cultural values and discourse of the communities with whom they work (Smith, 2000, 2002). Therefore, CHNs use this social as well as biophysical parameters when planning care and respond in a way that is not always available to nurses working in acute settings. In this way, the nature of CHNs’ work is unique and these differences set it apart from other nursing specialties.

Moyer & Wittmann-Price (2008 pp. 56 - 57) support the comments made by Buresh & Gordon (2000) that while public opinion of nursing remains high, the general public does not have a clear understanding of nursing work. While some community-based nurses have expanded their practice roles in the community, it does not mean that they address public health issues. The nurses in these roles interact with individuals and their families, whereas CHNs, as specialists, bring to their practice expertise in public health and skills that address the needs of the community in addition to their foundation knowledge of nursing (Allender & Spradley, 2005 p.16; St. John & Keleher, 2007, p. 6). To place this statement in perspective, Buresh & Gordon (2006) indicated that nurses have done themselves a disservice by remaining relatively silent about what they do. Brookes et al (2004) refer to Koch’s earlier work in 2000 where they noted that limited research and publications by community health nurses themselves has led to a decline in their influence. Research and publications were not considered part of the job description in the 1970s - 80s (Brookes et al., 2004). Buresh & Gordon (2000) suggest that if administrators really understood nursing work and recognised the expertise of their nursing staff, they would not make some of the decisions they do that ultimately impact upon patient or client mortality and morbidity.

It has been argued that a high proportion of registered nursing staff is a key factor in improved patient care leading to better outcomes (Duffield et al., 2007). Other studies concur (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Brooten & Youngblut, 2006) and add that education, expertise and experience contribute to improved health outcomes for clients. Aiken et al (2003, p.1621) state the hospitals that employ nurses with a bachelor or higher degrees are associated with better client outcomes. Brooten & Youngblut (2006, p.97) indicate that advanced practice nurses (APNs) provide consistently improved health outcomes if they are prepared at masters level with specialty focus that matches their client care requirements.

While the studies mentioned generally relate to institutional settings, the significant role of high quality primary and community care providers who assist their clients to live independently within their communities has been highlighted (Hurst, 2006),

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emphasising that if the transition from hospital to community is going to succeed the calibre of staff must be high.

Considering the outcomes of these studies, it could be hypothesised that as community health nurses work frequently as independent sole nurses in increasingly multifaceted environments with increasingly complex needs, they must be very skilled to meet individual client and community demands effectively. Community health nurses are responsible not only for individual care but they develop and run new services within their communities. Unlike the practice nurse, who operates from the general practitioner’s office for example, the community health nurse functions independently in multiple complex environments emphasising the need for community health nursing to also access evidenced based research and to establish professional accountability systems.

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Methodology Community health nursing is a recognised specialty within the discipline of nursing that is grounded in a unique body of knowledge based upon concepts of care explicated by notable theorists from Nightingale in the 1860s through to Boykin & Schoenhofer from 1993-2001 (Bush, 1992; Craven & Hirnle, 1996; Melieis, 1991; Moyer & Wittmann-Price, 2008). While the approach to theory development and the advancement of conceptual models has varied, nurse theorists have given voice to the accepted meta paradigm that expounds the relationship between person, health, environment/situation and nursing1. The work of theorists has served to guide the development of the discipline throughout the world and has led the profession to continually examine the relevance of nursing practices (Craven & Hirnle, 1996). The current trend of evidence based practice has evolved from this process of inquiry as the profession seeks answers to questions that will not only guide acceptable, safe nursing practice but build on the growing body of knowledge that will help shape future educational programs and health policy development (Edgecombe & Chater, 2008; White, 2005)

Community health nurses (CHNs) engage in diverse nursing practices embedded in accepted conceptual frameworks or models. Models of community health nursing2 extend the relationship between person, health, environment and nursing to include such concepts as community, community health problem, demography, epidemiology, community assessment, community based nursing, community health nursing (Hood & Leddy, 2005) and community development. Together these concepts characterise CHN’s concerns with the health of their communities and define community health nursing domains of practice as:

• population-based assessment; • partnerships with community members and stakeholders (community

development), • emphasis on health promotion and primary prevention, • creating environmental, social and economic conditions for health, • a focus on high risk groups or populations, • primary concern for group as a whole and • judicious management and allocation of resources (Anderson & McFarlane,

2006; Hood & Leddy, 2005).

As CHNs take the discipline of nursing to their practice they must clearly demonstrate nursing competencies in their roles. Nursing competencies are outlined in the national competency standards for registered nurses (Australian Nursing and Midwifery Council, 2006) are divided into four domains: Professional Practice; Critical Thinking and Analysis; Provision and Coordination of Care; and Collaborative and Therapeutic Practice. This study sought to identify the nursing competencies, nursing knowledge and nursing activities fundamental to community health nursing in Victoria.

Design and methods of investigation Phase 1 of this study involved analysis of data relating to community health nursing activities undertaken in Victorian community health services during 2006.

1 Examples of nursing theories are listed in Appendix D 2 Examples of models of community health nursing include Community as partner model; Dimension’s model; Epidemiological model; Family development model; Health promotion model; Lundy-Barton’s general system’s model for community and population assessment and intervention; Systems model of geopolitical and phenomenological communities; PRECEDE-PROCEED model.

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Definition of community health nursing For the purpose of the study, community health nursing was defined as nursing that maintains a population focus on community needs in addition to providing direct primary care nursing for individuals and families from high-risk groups and vulnerable communities. The focus of community health nursing is on health promotion and prevention of disease and involves:

• lifestyle and behavioural approaches (health education, empowerment and skill development) and

• sociological approaches (community development and engagement, policy and organisational change and community action) as well as

• health development and health promotion including political advocacy to secure resources for population groups, community development projects, community action, policy development.

• community assessment and community health research as well as • primary care services to individuals and groups including case management

for individuals and groups and service coordination for groups of individuals (St John, 2007)

Additional terms and definitions influencing this study are included in the Glossary as the end of this report.

Population sample Initially the sample was to be derived from registered nurses with at least twelve months community health experience who were working in community health services in any of the 78 municipalities across Victoria in late 2006 and who voluntarily agreed to be part of the study. Four CHNs with less than twelve months community health experience also completed the questionnaire. These data were included in the analysis as the CHNs, by making the effort to complete the questionnaire, indicated that they wished to contribute to the consultation.

Data collection instrument A structured questionnaire (Appendix B) developed in conjunction with the CHN SIG executive and steering committee was prepared specifically for the study and was designed to be self-administered. The questionnaire had six sections relating to demography, nursing competencies3 nursing practice, nursing knowledge, work allocation and job satisfaction. These sections were designed to obtain data on the characteristics of CHNs, their role and scope of practice, and the knowledge and skills utilised in community health nursing. The questionnaire incorporated a variety of descriptors for some community health activities, knowledge and competencies familiar to CHNs in an effort to obtain a comprehensive picture of the characteristics of community health nursing practice (Polit & Beck 2006).

Procedure for data collection Access to participants occurred through the Australian Nursing Federation (ANF) (Vic. Branch). A package which included a copy of the questionnaire and covering letter (Appendix C) outlining the objectives of the project and an addressed reply paid envelope was mailed to 512 ANF Victorian members registered as currently working as CHNs. The 73 members of the CHN SIG were mailed a separate copy of the package so these CHNs were mailed duplicate copies. An invitation to participate in a focus group and attached consent form together with a separate reply paid

3 Questions regarding nursing competencies were based on the four domains identified in the national competency standards for registered nurses (reference?)

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envelope was also included. In order to provide all CHNs with the opportunity to contribute to the study, the ANF also mailed multiple copies of the questionnaire, covering letter and reply paid envelope to the managers or nurse coordinators of all state funded community health services with a request that they pass the documentation on to CHNs in their organisation. CHN SIG members received a reminder email approximately two weeks before the return date on the questionnaire. In total, the ANF mailed 742 copies of questionnaires and accompanying documentation in an attempt to reach 525 nurses estimated to be working in community health in Victoria, in 2004 (Australian Institute of Health and Welfare, 2006)4.

Ethical considerations Every effort was taken to ensure confidentiality and anonymity for participants. Responsibility for distributing questionnaires was undertaken by ANF administration directly, not through the researchers or the CHN SIG executive. CHNs were given contact details of the president of the CHN SIG should they have any questions or concerns arising from the questionnaire. Participation in the study was voluntary.

Statistical Analysis: All statistical analysis was conducted in XL Statistics 5.0 (Carr, 2002) and SPSS 14.0 (SPSS Inc., 2005). Analyses involved both parametric and nonparametric statistical methods. For instance, the corresponding non-parametric equivalent methods were used where data did not conform to the stringent assumptions associated with the application of parametric statistical methodologies.

4 AIHW data on nurses working in community health in 2005 was not available.

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Results Of the 742 questionnaires posted to ANF, CHN SIG members and community health services employing community health nurses (CHNs), 114 returned completed questionnaires. The return rate represented 21.7% of the 525 nurses estimated to be working in community health in 2004 (Australian Institute of Health and Welfare, 2006) or 22.3% of the 512 ANF members who were mailed questionnaires directly.

Victorian community health nurse characteristics Demographic data collected included postcode of workplace, age, sex, years spent working in community health, sector of previous employment prior to working in community health and postgraduate qualifications.

The workplace postcode provided an estimate of geographical location. In this study, 111 CHNs (97.4%) provided the postcode or postcodes of their place of work. The data revealed 84 postcodes. These postcodes were aligned, as closely as possible, to the Australian Standard Geographical Classification (ASGC) of major city, inner regional and outer regional areas (Australian Bureau of Statistics, 2006). However, postcodes are not an ASGC; consequently, geographic location reported in Figure 1 is an estimate only. Figure 1 Geographic location of community health nurses work setting

Inner regional (n = 26)23.4%

Outer regional (n = 17)15.3%

Major city (n = 68)61.3%

After remote and very remote ASGC areas were excluded5 from national workforce data, the distribution of CHNs by geographical location (major cities: n = 68, 61.3%; inner regional: n = 26, 23.4% and outer regional: n = 17, 15.3%) was similar to national6 data on nurses working in community health centres in Australia (Australian Institute of Health and Welfare, 2008).

Of the 114 CHNs who responded, 107 (93.9%) were female and 7 (6.1%) were male. The proportion of males was similar to the proportion of males (6.6%) estimated to be

5 According to ASGC definitions only one Victorian postcode is associated with a remote area and no Victorian postcodes are associated with very remote areas, therefore comparisons with the national data were based on metropolitan, outer regional and inner regional areas only. 6 Separate Victorian data were not available for comparison

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working the community health in Victoria in 2004 (Australian Institute of Health and Welfare, 2006) and in publicly funded community health centres (6.0%) in 2006 (Australian Institute of Health and Welfare, 2008). Comparative analyses based on sex were not conducted because there were too few males for the diversity of groups involved. However, some descriptive statistics report sex to indicate the demographic profile of males in this study.

All males and 102 (95.3%) females indicated their age at 30 June 2005. The age range for females was between 21 and 64 years (males: 25 - 50 years). The average age of CHns was 46.5 years (SD: 8.6); (males: 40.6 years, SD 10.2; females: 46.9 years, SD 8.5). The average age of CHNs in this study was consistent with the average age (44.9 years) of Victorian registered nurses working in community health in 2004 (Australian Institute of Health and Welfare, 2006) and the average age (48.8 years) of nurses working in publicly funded community health centres in 2005 (Australian Institute of Health and Welfare, 2008).

Figure 2 illustrates the age and sex distributions by five-year age groups. The majority (n = 67; 61.5%) of CHNs were in the 40 to 54 years age groups (40 - 44 years: n = 16, 14.7%; 45- 49 years: n = 28, 25.7%; 50 - 54 years: n = 23, 21.1%). There was no significant difference in the age of nurses working in major cities, inner regional or outer regional areas (F 1.16, p = 0.331). Figure 2 Age distribution of community health nurses

0.0

5.0

10.0

15.0

20.0

25.0

30.0

20 -

24 y

rs

25 -

29 y

rs

30 -

34 y

rs

35 -

39 y

rs

40 -

44 y

rs

45 -

49 y

rs

50 -

54 y

rs

55+

yrs

5 year age groups

Per

cent

age

of n

urse

s (n

= 1

09)

MalesFemales

The proportion of nurses 55 years and over (n = 17, 15.6%) was similar to Victorian registered nurses working in community health (17.7%) in 2004 (Australian Institute of Health and Welfare, 2006), but lower than that reported for nurses working in publicly funded community health centres (26.5%) in 2006 (Australian Institute of Health and Welfare, 2008).

Descriptive statistics for years worked in community health are reported by sex in Table 1. Experience in community health nursing ranged from less than one year for Table 1 Average years worked in community health - males and females

Descriptive statistics Reported in years

All n = 113

Males n = 7

Females n = 106

Mean (SD) 10.6 (7.5) 7.1 (9.4) 10.8 (7.3) Median (Range in years) 10 (<1 - 35) 4 (1 - 28) 10 (<1 - 35)

- 19 -

four nurses to 35 years experience for one nurse with an average of 10.8 years experience for females and 7.1 years for males.

Years of experience in community health is reported in five year groupings by sex in Figure 3. Just over a half (51.3%, n = 58) of the CHNs had been working in community health for 10 or more years, while over a quarter (27.4%, n = 31) had less than 5 years community health experience. Figure 3 Years worked in community health as a function of sex

0.0

5.0

10.0

15.0

20.0

25.0

30.0<1

-<5

yrs

5-<1

0 yr

s

10-<

15 y

rs

15-<

20 y

rs

20-<

25 y

rs

25+

yrs

% o

f com

mun

ity h

ealth

nur

ses

(n =

113

)

MalesFemales

Descriptive statistics for number of years worked in the CHN’s current community health position compared with the number of years worked in the community health sector overall is reported in Table 2. The median number of years worked in community health was 10 years, almost twice the median number of years (5.5 years) community health nurses had worked in their current position. Table 2 Average years experience in the community health sector compared with average years experience in current community health position

Descriptive Statistics Reported in years

Years in current position n = 114

Total years in community health n = 113

Mean (SD) 7.0 (6.1) 10.6 (7.5) Median (Range) 5.5 (<1 - 25) 10.0 (<1 - 35)

Years of experience in community health overall is compared with years of experience in current community health position in Figure 4. While the majority (n = 91; 72.6%) of CHNs had been working in the community health sector for 5 or more years, less than half (43.0%; n = 48) had been working in their current community health position for less than 5 years and almost half (47.9%; n = 23) of this group had been in their position for less than two years. This suggests that experienced CHNs have the capacity to contribute to the development of the community health sector.

- 20 -

Figure 4 Percentage of community health nurses as a function of the years of experience in the community health sector and years working in current community health position

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

<5 y

rs

5-<1

0 yr

s

10-<

15 y

rs

15-<

20 y

rs

20-<

25 y

rs

25+

yrs

Per

cent

age

of c

omm

unity

hea

lth n

urse

s Community health (n = 113)Current position (n = 114)

The sector in which the CHNs worked prior to their current position was identified in 88.6% (n = 101) questionnaires. Figure 5 indicates the proportion of CHNs working in each sector prior to their employment in the community health sector. Almost two-thirds of these nurses (65.3%, n = 66) held positions in a hospital prior to taking up their current position. Examples of other sectors of employment included aged care and disability, education, local government, occupational health and safety, rehabilitation, residential care, prison, state government and not-for-profit organisations such as Diabetes Victoria and the Diabetes Institute. Figure 5 Sector in which Community health nurses worked prior to working in community health

Community based nursing

(n =17)16.8%

Other (n = 18)17.8%

Hospital (n = 66)65.4%

- 21 -

The majority (n = 109; 95.6%) of CHNs were in permanent employment. The five CHNs not permanently employed had been working in their current position for 1 - 2 years. The proportion of CHNs employed part-time and full time is reported in Figure 6. The majority of the 101 (88.6%) CHNs who provided details of employment status indicated that they were employed part-time (n = 66; 65.3%), with the highest proportion of nurses overall (n = 55; 54.5%) working between .05 - .09 effective full-time equivalent (EFT). The proportion of CHNs in part-time employment was similar to Victorian labour force data on registered nurses working in community health (59.8%) in 2004 (Australian Institute of Health and Welfare, 2006) and in publicly funded community health centres (58.2%) in 2006 (Australian Institute of Health and Welfare, 2008) Figure 6 Proportion of Community health nurses working full time and part time

Full time(n = 35)34.7%

0.5-0.9 EFT* (n = 55)54.5%

<0.5 EFT* (n = 11)10.9% * Equivalent full-time

The majority of community health nursing positions were attached to multidisciplinary teams. Of the 112 CHNs who responded to this question, 106 (94.6%) indicated that they worked in a multidisciplinary team. Moreover, 110 nurses named the position of their immediate supervisor. Of these nurses, 59 (53.6%) identified their immediate supervisor as a director, manager or coordinator of a team or specific program and 24 (21.8%) identified their immediate supervisor as a nurse manager or coordinator. The remaining 27 (24.5%) nurses indicated that they reported to a manager or person from another discipline.

Professional qualifications of community health nurses All but one of the CHNs in this study held registration with the Victorian Nurses Board as a Registered Nurse Division 1. The other nurse held registration as a Registered Nurse Division 2. The percentage of CHNs with one or more postgraduate qualifications is reported in Figure 7. Almost two-thirds (n = 75; 65.8%) of the 114 community health nurses in this study reported holding postgraduate qualifications; 36.8% (n = 44) with at least one postgraduate qualification and 27.2% (n = 31) with two or more postgraduate qualifications.

- 22 -

Figure 7 Percentage of community health nurses with one or more postgraduate (PG) qualifications

34.2% 38.6%

No PG qualification (n = 39)

1 PG qualification(n = 44)

2 or more PG qualifications (n = 31)

27.2%

The distribution of CHNs with postgraduate qualifications is reported by age in Figure 8. These results suggest that there is no correlation in the proportions of community health nurses, either with or without postgraduate qualifications, as a function of their age group. Similarly, there was no significant difference in the proportion of CHNs with postgraduate qualifications in major cities, inner regional or outer regional areas (H 1.92, p = 0.383). Figure 8 Number of community health nurses with or without postgraduate (PG) qualifications as a function of age group

0

5

10

15

20

25

30

35

20 -

24 y

rs

25 -

29 y

rs

30 -

34 y

rs

35 -

39 y

rs

40 -

44 y

rs

45 -

49 y

rs

50 -

54 y

rs

55 -

59 y

rs

60 +

yrs

Num

ber o

f com

mun

ity h

ealth

nur

ses PG qualifications (n = 69) No PG qualifications (n = 40)

- 23 -

The highest levels of postgraduate qualifications reported in this study are illustrated in Figure 9. The highest postgraduate qualification held by the majority (n = 52; 69.3%) of the 75 community health nurses that reported postgraduate qualifications was at graduate diploma level. Figure 9 Highest level of postgraduate qualification held by community health nurses

Gradraduate Diploma (n = 52)69.3%

Graduate Certificate

(n = 11)14.7%

PhD/Honours (n = 2)2.7%

Masters (n = 10)13.3%

The level of postgraduate qualifications held by CHNs in each of the major geographical areas is presented in Figure 10. Postgraduate qualifications at graduate diploma level were most common across all geographical areas (major city: n = 30, 65.2%; inner regional: n = 11, 68.8%; outer regional: n = 10, 83.3%). There was no significant difference in either the proportion of CHNs with graduate diplomas between the three geographical areas or in the proportion of CHNs with graduate certificates between major cities and inner regional areas (H 0.293, p = 0.864). Figure 10 Highest levels of postgraduate qualifications by geographical location

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Major city Inner regional Outer regional

Per

cent

age

of c

omm

unity

hea

lth n

urse

s Graduate Certificate Graduate DiplomaMasters Other (PhD/Honours)

(n = 46) (n = 16) (n = 12)

- 24 -

The major areas of postgraduate qualifications held by CHNs are reported in Figure 11. Postgraduate qualifications specifically in community or public health were held by 41 (36.0%) of the 114 CHNs in this study, which is over half (54.7%) of the 75 nurses who reported postgraduate qualifications. Figure 11 Number of community health nurses with specialty postgraduate (PG) qualifications

10

16

4

5

6

7

9

41

11

0 10 20 30 40 50

Other than nursing^

Other nursing*

Management/SocialPolicy

Cancer related

HealthPromotion/Education

Womens/Sexual Health

Diabetes education

Family/Child/Adolescent

Community/PublicHealth

Number of PG qualifications (n = 109) .

* Other nursing qualifications include Aged care; Anaesthetics & recovery; Cardiothoracic; Continence; Critical/intensive care; MCH Nursing, Nursing ethics, Remote area nursing. ^ Other than nursing qualifications include Arts; Disability; Ethnic studies; Counselling; Recreation; Rural social welfare; Vocational education & training

Although not requested in the questionnaire, over one-third (n = 43; 37.7%) of the CHNs provided additional descriptive data about other qualifications they held. These included pre-registration or further education at certificate, advanced certificate, diploma or advanced diploma levels in community health, health promotion, health education, midwifery, sexual and reproductive health, mental and social health, infectious diseases, women’s health, continence management and education, family, child and adolescent health, and undergraduate degrees in arts, community health, health science, midwifery and nutrition.

The proportion of CHNs who regularly undertook professional development (PD) is reported in Table 3. Of the 110 (96.5%) nurses who responded to this question, 97 (88.2%) reported undertaking PD activities equivalent to at last one week per year and all reported that they considered these activities essential or necessary to their practice. Table 3 Percentage of community health nurses regularly undertaking professional development Professional development activities Response

n = 110 (%)

Considered essential/necessary for community health nursing

n = 86 (%) Access to continuing education and training at least one week/year 97 (88.2) 86 (100.0)

Membership of professional association 95 (85.5) 77 (89.6)

Of the thirteen CHNs who reported not undertaking PD activities equivalent to one week per year, ten reported that they considered PD necessary or essential to their practice. Overall, there was a significant difference in the proportion of time CHNs

- 25 -

estimated they spent on PD and what they thought was appropriate to spend (Z -3.397; p = 0.001) with CHNs reporting they require greater access to PD.

Of the 95 (85.5%) CHNs who reported holding membership of a professional nursing association, 77 (89.6%) considered their memberships essential or necessary to their practice. Only one of the thirteen nurses who did not hold membership of a professional nursing association considered this type of membership necessary to their community health practice and none considered membership of a professional association essential to their practice.

Community health nursing practice CHNs indicated the practices they considered necessary or essential for CHNs to undertake and those they undertook often or regularly. Results of analysis of responses to these questions are reported in Table 4. Advocacy was considered both essential or necessary (n = 99, 89.2%) for CHNs to practice and practiced often or regularly (n = 93; 83.0%) by the majority of CHNs in this study. Significant Table 4 Community health nursing practice considered necessary or essential/community health nursing practice undertaken often or regularly

Nursing practice

Num

ber

prov

idin

g pr

actic

e Number (%)

who consider practice

necessary or essential for

CHNs Num

ber o

f re

spon

ses Number (%)

who undertake practice often or regularly

Advocacy 112 99 (89.2) 111 93 (83.0) Needs assessment family/individual 110 92 (84.4) 109 83 (75.5) Health counselling 112 93 (83.8) 111 84 (75.0) Monitoring health status of individuals 109 86 (81.1) 106 79 (72.5) Community assessment* 111 87 (79.8) 109 65 (58.6) Medication education/management* 108 82 (77.4) 106 66 (61.1) National/state health promotion strategies* 108 75 (70.8) 106 61 (56.5) Health screening 112 76 (68.5) 111 62 (55.4) Diabetes management/education* 112 71 (65.7) 108 45 (40.2) Sexual and reproductive health* 109 66 (62.9) 105 48 (44.0) Cancer prevention* 109 67 (62.0) 108 46 (42.2) Accident prevention* 110 67 (61.5) 109 46 (41.8) Case management/coordination 112 68 (61.3) 111 59 (52.7) Mental health assessment* 109 63 (58.9) 107 37 (33.9) Cardiovascular health/rehabilitation* 111 62 (55.9) 111 50 (45.0) Infection control 110 59 (54.6) 108 52 (47.3) Arthritis education* 112 59 (54.6) 108 26 (23.2) Continence management/education* 110 56 (51.9) 108 32 (29.1) Respiratory management/education* 110 51 (48.1) 106 31 (28.2) Wound care/management* 100 47 (47.0) 100 30 (30.0) Alcohol and drug education/management* 111 50 (46.3) 108 32 (28.8) Discharge planning* 108 45 (42.9) 105 30 (27.8) Parenting education* 108 42 (40.0) 105 27 (25.0) Immunisation* 111 42 (38.5) 109 21 (18.9) Triage and First aid* 110 40 (37.7) 106 23 (20.9) Ante natal care* 112 39 (35.5) 110 15 (13.4) Venipuncture* 110 34 (33.3) 102 25 (22.7) Urinalysis* 110 29 (28.2) 103 16 (14.5) Needle & syringe exchange coordination* 109 26 (24.5) 106 18 (16.5) ECG monitoring* 111 20 (19.2) 104 10 (9.0) * Numerical summaries for significant differences identified in the scores for practice considered essential or necessary and practice undertaken often or regularly are reported in Table 5

- 26 -

differences were detected in the scores for practices considered essential or necessary for CHNs to undertake and those undertaken often or regularly for 22 of the 30 items reported. For each practice, more CHNs indicated that the practice was essential or necessary for CHNs to undertake than CHNs who reported they undertook the practice often or regularly. Numerical summaries for scores where significant differences were detected are presented in Table 5. Table 5 Numerical summaries for significant differences identified in the scores for practice considered essential or necessary, and practice undertaken often or regularly

Community health nursing practices Z p-value Community assessment of health needs and priorities -2.82 0.005 Medication education/management -2.33 0.020 Local implementation of national/state health promotion -2.02 0.044 Diabetes management/education -2.73 0.006 Sexual and reproductive health -2.15 0.032 Cancer prevention -2.65 0.008 Accident prevention -2.63 0.008 Mental health assessment -3.84 0.000 Cardiovascular health/rehabilitation -2.16 0.031 Arthritis education -3.62 0.000 Continence management/education -2.92 0.004 Respiratory health management/education -3.19 0.001 Wound care/management -3.12 0.002 Alcohol and drug education/management -2.31 0.021 Discharge planning -2.74 0.006 Parenting education -2.58 0.010 Immunisation -3.73 0.000 Triage and first aid -2.86 0.004 Ante natal care -3.39 0.001 Venipuncture -2.70 0.007 Urinalysis -2.66 0.008 Needle and syringe exchange coordination -3.04 0.002 ECG monitoring -2.66 0.008

Key elements of community health nursing practice are reported in Table 6. One or more of these elements may make up any single episode of service. Most CHNs estimated how much time they allocated to each element of their practice; fewer estimated how much they thought was appropriate however. Table 6 Proportion of CHNs providing key elements of practice/proportion who advocate this element of community health nursing practice

Key elements of practice

Num

ber o

f re

spon

ses

Number (%) providing

key element of practice N

umbe

r of

resp

onse

s Number (%) advocating key element of practice

Health education 108 106 (98.1) 63 63 (100.0)Health assessment 107 102 (95.3) 68 63 ( 92.6)Secondary consultation 103 96 (93.2) 57 56 ( 98.2)Professional Networking 107 97 (90.7) 57 56 ( 98.2)Monitoring health status of individuals or groups 107 95 (88.8) 58 58 (100.0)Care coordination 105 91 (86.7) 62 59 ( 95.2)Community development 108 91 (84.3) 83 80 ( 96.4)Community consultation 108 85 (78.7) 70 69 ( 98.6)Policy development and review 104 80 (76.9) 60 59 ( 98.3)Directing services to local health priorities 106 81 (76.4) 77 75 ( 97.4)Health screening 103 78 (75.5) 62 60 ( 96.8)Developing leadership skills in the community 104 58 (55.8) 68 65 ( 95.6)Advocating for change 107 57 (53.3) 88 78 ( 88.6)Informing community groups of research results 107 54 (50.5) 75 68 ( 90.7)

- 27 -

Nevertheless, the responses from the CHNs who did respond to this question suggest that CHNs consider that each of the elements of practice identified is central to community health nursing. Notably, a greater number of CHNs advocated allocating community health nursing resources to developing leadership skills in the community (appropriate: n = 68; current: n = 58), advocating for change (appropriate: n = 88; current: n = 57), and informing community groups of research results (appropriate: n = 75; current: n = 54) than the number who reported that they were currently allocating time to these elements of practice.

The proportion of time allocated to key elements of nursing practice is compared with the time CHNs considered appropriate to allocate is reported in Table 7. Table 7 Estimated percentage of time allocated to key elements of practice compared with estimated percentage of time needed to be allocated

Key elements of practice

Num

ber

of

resp

onse

s

Estimated percentage

of time allocated

Mean (SD) Num

ber

of

resp

onse

s

Estimated percentage

of time needed to

be allocated Mean (SD)

Health education 108 42.1 (29.3) 92 49.5 (30.5)Health assessment 107 40.3 (28.1) 92 44.7 (30.8)Secondary consultation 103 32.2 (29.3) 89 36.5 (31.8) Monitoring health status of individuals/groups 107 34.2 (31.9) 93 38.7 (32.6)Care coordination 105 33.9 (30.3) 94 39.5 (30.2)Health screening 103 26.4 (28.0) 90 33.9 (31.4)Directing services to local health priorities* 106 25.9 (27.1) 90 37.2 (30.8)Community development* 108 22.7 (22.3) 93 33.9 (28.2)Professional Networking* 107 19.5 (17.2) 92 26.5 (20.5)Community consultation* 108 18.8 (21.3) 92 34.1 (29.4)Policy development and review* 104 15.8 (15.6) 95 22.8 (22.6)Developing leadership skills in community* 104 14.3 (21.6) 90 29.4 (29.1)Advocating for change* 107 11.1 (17.4) 88 27.3 (25.8)Informing community of research results* 107 9.9 (15.6) 90 22.3 (23.4)* Numerical summaries for significant differences identified in the scores for estimated time spent on key elements of practice and time considered appropriate to spend are reported in Table 8

As with nursing practice, where there was a significant difference between the scores for estimated time allocated to key elements of practice and the scores for estimated time considered appropriate to allocate, CHNs indicated that they considered they should spend more time on these key elements of their practice than they estimate they spend currently. Where significant differences in these responses were detected, numerical summaries are reported in Table 8. Table 8 Numerical summaries for significant differences identified in the scores for time allocated to key elements of practice and time needed to be allocated

Key elements of community health nursing Z p value Directing services to locally defined health priorities -2.797 0.005 Community development -3.028 0.002 Professional networking -2.728 0.006 Community consultation -4.218 0.000 Policy development and review -2.050 0.040 Developing leadership skills within the community -4.457 0.000 Advocating for change -5.817 0.000 Informing community groups of research results -4.935 0.000

- 28 -

Community health nursing competencies Nursing competencies utilised often or regularly and considered necessary or essential to CHNs practice are reported in Table 9. Over 70% of the CHNs who provided data on each nursing competency considered that all nursing competencies were essential or necessary to community health nursing practice. However, over 90% indicated that assessing the need to recommend other services (n = 102/112; 91.1%), providing health education (n = 102/113; 90.3%) and providing formal referral for services (101/112; 90.2%) were necessary or essential competencies for community health nursing. Around 80% indicated that they often or regularly used competencies required for assessing the need to recommend other services (n = 100/113; 88.5%), collecting data on functional status (n = 93/112; 83.0%), contributing to multi-disciplinary services (n = 92/113; 81.4%) and providing health education (n = 90/113; 79.6%). Table 9 Nursing competencies considered necessary or essential to CHN practice and used often or regularly

Nursing competencies

Num

ber

resp

onse

s

Number (%)

who consider

competency necessary

or essential Num

ber u

sing

co

mpe

tenc

y Number (%) who use

competency often or regularly

Recommend other services 112 102 (91.1) 113 100 (88.5) Provide health education 113 102 (90.3) 113 90 (79.6) Refer through formal process 112 101 (90.2) 113 90 (79.6) Evaluate progress towards health goals 112 99 (88.4) 113 87 (77.0) Comprehensive nursing assessment 112 99 (88.4) 113 85 (75.2) Assess progress towards health goals 112 98 (87.5) 113 81 (71.7) Contribute to multi-disciplinary services 112 97 (86.6) 113 92 (81.4) Implement planned health care 113 97 (85.8) 113 86 (76.1) Develop health plan 111 94 (84.7) 111 77 (69.4) Collect data on functional status 113 94 (83.2) 112 93 (83.0) Involve other disciplines in assessment 111 92 (82.9) 107 79 (73.8) Nursing consultancy to other disciplines 111 82 (82.9) 112 72 (64.3) Coordinate services 112 81 (72.3) 112 70 (62.5) Analyse data on functional status 112 81 (70.5) 113 66 (58.4)

Nursing knowledge Nursing knowledge considered essential or necessary for community health nursing and utilised often or regularly is reported in Table 10. Knowledge of anatomy and physiology was considered necessary or essential for practice (n = 101, 90.2%) and used often or regularly (n = 99, 87.6%). Similarly, over 80% of CHNs considered knowledge of primary health care, social determinants of health, and a social model of health necessary or essential for practice and also used this knowledge often or regularly.

- 29 -

Table 10 Nursing knowledge considered essential or necessary for practice and utilised often or regularly in community health nursing

Nursing knowledge

Num

ber o

f re

spon

ses Number (%)

who considered knowledge essential or

necessary for practice

Num

ber

who

use

d kn

owle

dge Number (%)

who used knowledge

often or regularly

Anatomy and physiology 112 101 (90.2) 113 99 (87.6) Comprehensive assessment 110 96 (87.3) 112 89 (79.5) Pharmacology* 111 96 (86.5) 113 80 (70.8) Primary health care 110 94 (85.5) 112 91 (81.3) Bio-physical determinants of health 111 94 (84.7) 112 86 (76.8) Management of the disease process 109 92 (84.4) 112 87 (77.7) Ethical principles relating to health 111 93 (83.8) 113 89 (78.8) Social determinants of health 110 91 (82.7) 112 91 (81.3) Mental health* 110 91 (82.7) 112 79 (70.5) Social model of health 109 90 (82.6) 113 93 (82.3) Pathophysiology* 110 90 (81.8) 113 74 (65.5) Health systems and processes* 108 87 (80.6) 109 65 (59.6) Health promotion theory 112 89 (79.5) 113 85 (75.2) Health education theory 109 85 (78.0) 112 81 (72.3) Health legislation and common law* 111 84 (75.7) 113 67 (59.3) Mental illness* 107 79 (73.8) 110 59 (53.6) Public health policy* 110 81 (73.6) 113 66 (58.4) Epidemiology* 111 75 (67.6) 111 69 (62.2) Nursing theory* 109 66 (60.6) 112 49 (43.8) * Numerical summaries for significant differences identified in the scores for knowledge considered essential or necessary for community health nursing practice and scores for knowledge used often or regularly are reported in Table 11

Significant differences were identified between some scores for knowledge considered necessary or essential for practice and scores for knowledge used often or regularly, with more CHNs indicating knowledge as essential or necessary than used often or regularly, which may suggest that CHNs’ knowledge may be underutilised. Where significant differences occurred, numerical summaries are reported in Table 11. Table 11 Numerical summaries for significant differences identified in the scores for nursing knowledge considered essential or necessary for practice and nursing knowledge used often or regularly

Nursing knowledge Z p value Pharmacology -3.12 0.002 Mental health -2.72 0.007 Pathophysiology -2.82 0.005 Health systems and processes -2.11 0.035 Health legislation and common law -2.60 0.009 Mental illness -3.26 0.001 Public Health Policy -2.70 0.006 Epidemiology -2.86 0.004 Nursing theory -2.43 0.015

Allocation of community heath nursing resources The distribution of community health nursing resources across age groups is reported in Table 12. The majority (n = 90; 89.1%) of 101 CHNs who responded, indicated that they worked with older people (65+ years), and over half of these CHNs (n = 53; 58.9%) reported that at least half their time was directed to working with this age group.

- 30 -

Table 12 Distribution of community health nursing resources by client age group

Age groups

Number of Responses

(a)

Number working with

age group

Number working ≥50% of

time/age group

Number working 100% of their

time/age group n (%) n (% of a) n (% of b) n (% of b)

0-12 years 89 (78.1) 52 (58.4) 10 (19.2) 3 (5.8) 13-26 years 97 (85.1) 78 (80.4) 15 (19.2) 4 (5.1) 27-64 years 105 (92.1) 101 (96.2) 39 (38.6) 2 (2.0)

65+ years 101 (88.6) 90 (89.1) 53 (58.9) 5 (5.6)

There was a significant difference in the estimated time spent and that considered appropriate for CHNs to allocate to 13 to 26 year olds (Z - 0.498, p = 0.010), with these CHNs indicating that greater allocation of community health nursing recourses to this age group is required. There was no significant difference in the estimated time spent and time considered appropriate for CHNs to spend with the other age groups.

The distribution of CHNs working with high risk groups is reported in Table 13. Of the CHNs who responded the majority of CHNs directed their services to people with low incomes (n = 106, 99.1%); people living with chronic illness (n = 90, 82.6%); people with mental illness (n = 88, 84.6%); carers (n = 87, 80.6%); people from cultural and linguistically diverse backgrounds (n = 81, 79.4%) and co morbidity (n = 81, 77.1%). Just over half (n = 56; 52.3%) of the 106 CHNs who reported working with people with low incomes spent at least 50% of their time with this high-risk group and 44% (n = 48) of the 109 CHNs who gave an indication, spent at least half their time addressing chronic illness. The majority of CHNs estimated that they directed less than 20% of their time to indigenous (86.8%, n = 92); refugee (83.2%, n = 84) and homeless groups (83.0%; n = 83). Table 13 High-risk groups allocated 50-100% of community health nursing time

At risk groups

Num

ber

of

Res

pons

es Number

(%) working with ‘at

risk’ groups

Number (%) directing

≥50% of their time to high risk groups

Number (%) directing 100% of

their time to high risk groups

Low Income 107 106 (99.1) 56 (52.3) 12 (11.2) Chronic Illness 109 90 (82.6) 48 (44.0) 12 (11.0) Mental Illness 104 88 (84.6) 22 (21.2) 1 (1.0) Carers 108 87 (80.6) 17 (15.7) 1 (0.9) Cultural and linguistic diversity 102 81 (79.4) 22 (21.6) 3 (2.9) Co morbidity 105 81 (77.1) 34 (32.4) 4 (3.8) Disability (including dementia) 106 65 (61.3) 17 (16.0) 4 (2.8) Young families 102 63 (61.8) 16 (15.7) 3 (3.9) Domestic violence/sexual assault 100 57 (57.0) 7 (7.0) 0 (0.0) Indigenous people 106 52 (49.1) 6 (5.7) 1 (0.9) Homeless 100 41 (41.0) 10 (10.0) 4 (4.0) Refugees 101 32 (31.7) 9 (8.9) 3 (3.0) HIV/AIDS 100 17 (17.0) 3 (3.0) 1 (1.0)

Estimates of time allocated to high-risk groups and time considered appropriate to be allocated are reported in Table 14.

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Table 14 Estimated time allocated to high-risk groups compared with estimated time considered appropriate to be allocated

At risk groups Num

ber

of

Res

pons

es

Estimated percentage

of time spent

Mean (SD)

Num

ber

of

Res

pons

es

Estimated percentage

of time considered appropriate

to spend Mean (SD)

p value

Low Income 107 51.3 (30.3) 92 58.3 (30.6) 0.111Chronic Illness 109 42.6 (34.9) 92 48.8 (35.8) 0.209Co morbidity* 105 31.3 (30.3) 89 41.3 (33.1) 0.028Cultural and linguistic diversity* 102 25.6 (27.1) 89 33.6 (28.8) 0.021Mental Illness* 104 25.5 (25.9) 91 32.7 (27.7) 0.028Carers* 108 21.9 (21.7) 94 29.1 (25.6) 0.030Disability (including dementia)* 106 20.5 (26.2) 90 29.9 (30.7) 0.029Young families* 102 18.3 (25.1) 90 25.2 (28.3) 0.025Domestic violence/sexual assault* 100 13.7 (16.8) 85 21.2 (23.0) 0.028Homeless* 101 13.3 (25.8) 85 23.2 (31.6) 0.001Refugees* 101 10.4 (22.9) 85 17.8 (28.2) 0.007Indigenous people* 106 9.2 (20.4) 88 22.2 (28.5) 0.000HIV/AIDS* 100 4.7 (15.2) 81 12.3 (21.3) 0.000*Numerical summaries for significant differences identified in the scores for estimated time CHNs spent with high-risk groups and time they considered appropriate to spend with these groups are reported in Table 15

There was no significant difference in the time allocated to people with low incomes and people with chronic illness and that considered appropriate to allocate to these groups. However, a significant difference was found between the estimates of time spent working with all the other high-risk groups listed in Table 13 and what CHNs considered appropriate to allocate to these groups. Again, in each instance, CHNs indicated that more community health nursing resources are required for these groups. Numerical summaries for at-risk groups where a significant difference was identified between estimates of time spent and time considered appropriate to spend are reported in Table 15. Table 15 Numerical summaries for significant differences identified in the scores for estimates of time spent with at-risk groups and time considered appropriate to spend with each group

At risk Group Z p value Co morbidity/dual diagnosis -2.196 0.028 Cultural and linguistic diversity -2.314 0.021 Mental Illness -2.199 0.028 Carers -2.174 0.030 Disability (including dementia) -2.188 0.029 Young families -2.243 0.025 Domestic violence/sexual assault -2.200 0.028 Homeless -3.227 0.001 Refugees -2.716 0.007 Indigenous people -3.769 0.000 HIV/AIDS -3.721 0.000

Community health nursing specialties Qualitative data collected through an open-ended question suggested that Victorian CHNs have developed specialty areas of practice. Some CHNs reported more than one specialty. However, five main specialities emerged. Considerable expertise has been developed in the area of chronicity. Skills CHNs associated with chronicity were case management, coordination, rehabilitation and education relating to chronic disease or chronic health problems such as diabetes, heart disease and respiratory

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disease (including asthma) as well as aged care and wound care management. Other specialties included women and families, the ‘generalist specialist’ and to some extent, adolescent health and health promotion/community development. Other areas of expertise named included continence nursing; disability; drug & alcohol; health assessment; homelessness; hospital admission risk program (HARP); infectious diseases; marginalised communities; men’s health; mental health/dual diagnosis; palliative care; pharmacotherapy; physical activity; primary care; refugee health; rural nursing and wound care/management.

The responses of CHNs who identified themselves as generalists were analysed separately and compared with all other responses to determine differences in the scope of practice, competencies and knowledge utilised by generalists compared with other CHNs. Comparisons of nursing practices are reported in Table 16. In the main, there was very little difference between the nursing practice of generalists and other CHNs. For example, advocacy, assessment, monitoring health status and health education/counselling were the four most commonly reported practices by both generalists and other CHNs. Table 16 Areas of community health nursing practiced often or regularly: comparisons between generalist CHNs and other CHN specialties

Generalist CHNs Other CHN specialties

Nursing practice

Number (%) who practice

often or regularly

Number (%) who practice

often or regularly

Num

ber

resp

onse

s

n % Mean score

Num

ber

resp

onse

s

n % Mean score

Monitoring health status of individuals 24 18 (75.0) 3.1 85 61 (71.8) 3.0Advocacy* 24 17 (70.8) 3.0 88 76 (86.4) 3.5Health counselling 25 17 (68.0) 2.9 87 67 (77.0) 3.2Assessment individual/family needs 24 16 (66.7) 3.0 86 67 (77.9) 3.2Cardiovascular health/rehabilitation* 25 16 (64.0) 2.8 86 26 (30.2) 1.6Community assessment 25 15 (60.0) 2.8 86 50 (58.1) 2.6Medication education/management 24 14 (58.3) 2.5 84 52 (61.9) 2.7Health promotion strategies 24 14 (58.3) 2.9 84 47 (56.0) 2.5Diabetes management/education* 25 14 (56.0) 2.7 87 31 (35.6) 1.9Case management/coordination 25 13 (52.0) 2.4 87 46 (52.9) 2.5Cancer prevention 25 12 (48.0) 2.4 84 34 (40.5) 2.1Health screening 25 12 (48.0) 2.8 87 50 (57.5) 2.5Triage and First aid* 24 11 (45.8) 1.8 86 12 (14.0) 0.9Arthritis education* 25 10 (40.0) 2.1 87 16 (18.4) 1.1Accident prevention 25 10 (40.0) 2.3 85 36 (42.4) 2.5Venipuncture 24 9 (37.5) 1.5 86 16 (18.6) 0.9Infection control 25 9 (37.5) 1.8 86 43 (50.0) 2.1Wound care/management 24 9 (37.5) 1.8 86 21 (24.4) 1.3Continence management/education 25 8 (32.0) 1.8 85 24 (28.2) 1.6Sexual and reproductive health 24 8 (33.3) 1.8 85 38 (44.7) 2.0Respiratory health 24 7 (29.2) 1.8 86 24 (27.9) 1.4Urinalysis 24 6 (25.0) 1.3 86 10 (11.6) 0.9Mental health assessment 24 6 (25.0) 1.8 85 31 (36.5) 1.9ECG monitoring* 25 6 (24.0) 0.9 86 4 (4.7) 0.3Immunisation 25 6 (24.0) 1.1 86 15 (17.4) 0.8Alcohol and drug education/management^ 24 5 (20.8) 1.7 87 27 (31.0) 1.9Discharge planning^ 24 4 (16.7) 1.1 84 25 (29.8) 1.3Parenting education^ 24 4 (16.7) 1.2 84 23 (27.4) 1.4Needle & syringe exchange coordination^ 24 3 (12.5) 0.8 85 15 (17.6) 1.0Ante natal care^ 25 2 (8.0) 0.9 87 13 (14.9) 0.9*Significant differences identified between CHN generalists and other CHN specialties are reported below ^Insufficient numbers in generalist groupings to test for significance

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Where significant differences were detected, generalists were more likely to report cardiovascular health/rehabilitation (Z 3.328, p =.001), diabetes management/education (Z 2.28, p =.023) triage and first aid (Z 2.002, p = .045), arthritis education (Z 3.347, p = .001) and ECG monitoring (z 2.259, p = .024) as a regular part of their practice. Although 70% of generalists reported advocacy as a common part of their practice, there was a significant difference between the responses of both groups with generalists less likely to report advocacy (Z -2.295, p = 0.022) as a regular part of their practice.

Comparisons between the competencies used by generalists and other CHNs are reported in Table 17. Once again, generalists and CHNs reported employing very similar competencies in their practice. Table 17 Competencies for community health nursing used often or regularly: comparisons between generalist CHNs and other CHN specialties

Generalist CHNs Other CHN specialties

Competencies

Number (%) Used often or

regularly

Number (%) Used often or

regularly

Res

pons

es

n (%) Mean Res

pons

es

n (%) MeanRecommend services from other disciplines 25 22 (88.0) 3.6 88 78 (88.6) 3.6 Provide educational activities 25 21 (84.0) 3.4 88 69 (78.4) 3.4 Assist other health disciplines 25 19 (76.0) 3.0 88 73 (83.0) 3.3 Refer through formal referral process 25 19 (76.0) 3.3 88 71 (80.7) 3.4 Involve other disciplines in assessment 24 17 (70.8) 3.0 87 62 (71.3) 3.0 Evaluate progress towards health goals* 25 16 (64.0) 2.8 88 71 (80.7) 3.3 Implement planned health care 25 16 (64.0) 2.9 88 70 (79.5) 3.3 Nursing consultancy to other disciplines 24 15 (62.5) 2.8 88 57 (64.8) 2.9 Coordinate services 24 15 (62.5) 2.8 88 55 (62.5) 2.7 Collect data on functional status* 25 15 (60.0) 2.8 88 78 (88.6) 3.5 Assess progress towards health goals 25 15 (60.0) 2.9 88 66 (75.0) 3.1 Develop health plan 25 15 (60.0) 2.8 86 62 (72.1) 3.1 Comprehensive nursing assessment 25 14 (56.0) 2.8 88 71 (80.7) 3.3 Analyse data on functional status 25 12 (48.0) 2.6 88 54 (61.4) 2.8 Receive reports from other disciplines 24 11 (45.8) 2.5 87 40 (46.0) 2.3 *Significant differences identified between CHN generalists and other CHN specialities are reported below

The only significant differences detected were that generalists were less likely to report that they collect data on functional status (Z -2.846, p = 020) or evaluate progress towards health goals (z -2.846, p = 0.004) although over 60% of CHNs used these competencies often or regularly. However, over 60% of generalists reported employing these competencies often or regularly.

Knowledge used by generalists and other CHNs in their practice is compared in Table 18. The majority of generalists and other CHNs used similar nursing knowledge often or regularly. Significant differences in the responses for knowledge of anatomy and physiology (Z - 2.96, p = 0.003), health systems and processes (Z -2.419, p = 0.016), legislation and common law affecting health (Z -2.359, p = 0.018), social determinants of health (Z -2.124, p = 034) and social model of health (Z -1.987, 0.047) were detected. Generalists were less likely to report using these aspects of nursing knowledge than other CHNs.

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Table 18 Nursing knowledge utilised in community health nursing: comparisons between generalist CHNs and other CHN specialties Generalists Other specialties

Nursing knowledge

Number (%) Used often or regularly

Number (%) Used often or regularly

Res

pons

es

n (%) Mea

n

Res

pons

es

n (%) Mea

n

Management of the disease process 25 20 (80.0) 3.2 87 67 (77.0) 3.1 Health education theory 25 20 (80.0) 3.0 87 61 (70.1) 2.9 Anatomy and physiology* 25 19 (76.0) 3.2 88 80 (90.9) 3.6 Primary health care 25 19 (76.0) 3.2 87 72 (82.8) 3.3 Bio-physical determinants of health 25 19 (76.0) 3.0 87 67 (77.0) 3.1 Health promotion theory 25 19 (76.0) 3.0 88 66 (75.0) 3.0 Social determinants of health* 25 18 (72.0) 3.0 87 73 (83.9) 3.4 Comprehensive assessment 25 18 (72.0) 3.0 87 71 (81.6) 3.3 Social model of health* 25 17 (68.0) 3.1 88 76 (86.4) 3.4 Ethical principles relating to health 25 17 (68.0) 2.9 88 72 (81.8) 3.2 Pharmacology 25 16 (64.0) 2.8 88 64 (72.7) 3.1 Mental health 25 15 (60.0) 2.6 87 64 (73.6) 3.0 Pathophysiology 25 13 (52.0) 2.6 88 61 (69.3) 2.7 Health systems and processes* 24 12 (50.0) 2.3 85 54 (63.5) 2.9 Mental illness 24 10 (41.7) 2.6 86 49 (57.0) 2.7 Health legislation and common law* 25 10 (40.0) 2.2 88 57 (64.8) 2.8 Public health policy 25 10 (40.0) 2.4 88 46 (52.3) 2.8 Epidemiology 24 9 (37.5) 2.3 87 40 (46.0) 2.4 Nursing theory 24 9 (37.5) 2.2 88 40 (45.5) 2.4 * Significant difference in scores for generalist CHNs and other CHN specialties are reported above

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Discussion The similarity between the demographics of the nurses in this study and published Victorian nursing labour force data on nurses working in community health suggests that the study sample is representative of Victorian community health nurses. Therefore, the conclusions from this study should be applicable to the general population of community health nurses in Victoria. The results of this study support the literature that states that CHNs provide a wide range of primary care services while maintaining a public health focus on the health of communities and sociological approaches to population health (Keleher, 2003; Kemp et al., 2005; Smith, 2000; van Loon, 2008). However, there are some features of the study that place community health nursing within a comprehensive approach to primary health care that are notable when considered in relation to community health policy.

The Victorian government’s community health policy is arguably the major influence on the role and scope of practice of publicly funded community health nurses and an appropriate context in which to discuss the future of community health nursing. This policy dictates that community health services should improve and maintain the health and wellbeing of individuals, families and communities; addressing the social determinants of health by enhancing the power of individuals, families and communities to be self-reliant in managing, maintaining and enhancing their health and wellbeing. More specifically, these services should be community-based, ‘physically accessible and linguistically appropriate’ and provide an avenue to a full continuum of primary health care and support services, including health promotion, disease prevention, treatment, rehabilitation, support and advocacy, chronic disease management and links to secondary and tertiary services. There are qualifications however. Services are required to respond to the greatest existing or potential health risks within a population health and wellbeing model while giving priority to people with the poorest health status and the greatest economic and social need. The state government’s vision for community health services is to build a stronger evidence base for a primary health care approach and primary health care interventions. These interventions involve integrated health promotion, prevention and early intervention strategies for people with ambulatory care sensitive conditions (ACSC), mental health problems, children and families, and people with complex social and health problems as well as ambulatory care previously provided in hospital settings (Department of Human Services, 2004).

The results of this study sample portray CHNs as a body of experienced nurses, largely prepared at postgraduate level for independent community health nursing working within multidisciplinary health services. The findings suggest that when nurses enter the community health sector, they bring with them experience of the broader health sector, particularly the acute health system, its practices and processes. There is also some suggestion that CHNs transfer their skills within the sector despite holding permanent positions. CHNs’ experience, supplemented by relevant post-graduate studies regardless of age or geographical location, suggests acknowledgment by the sector of the requirement for advanced nursing competency in critical thinking and analysis, provision and coordination of care and collaborative and therapeutic practice to provide community health nursing.

Less than 20% of the CHNs in the study identified themselves as generalists. However, this phase of the study (Phase 1) was not able to identify clearly what was meant by the term ‘generalist’. Those CHNs that identified themselves as ‘generalists’ tended to provide similar services, use the same competencies, and draw upon the same nursing knowledge as other CHNs who reported working as a specialist, although not always called upon to provide the same services, utilise

- 36 -

specific competencies or draw upon specific nursing knowledge as often or regularly, which is consistent with providing a more generalist service. The results do suggest however, that generalist CHNs require a comprehensive suite of knowledge and skills in order to work across a broad range of programs and services. As generalist CHNs may not focus on any specific health priority, they may be in a position to identify emerging health problems not being addressed on a population basis, therefore should be contributing to policy development.

There was no evidence to suggest that generalist CHNs are working at a beginner level as described in acute care settings (Fairweather & Gardner, 2000). Rather, all CHN profiles confirmed that community health nursing is a specialty (Grehan, 2008). There was a tendency overall to specialise in areas of chronicity, which is consistent with the allocation of a high proportion of resources to older people and people on low incomes, which may help to explain the attention given to co morbidity and reflect health policies directing resources towards complex health problems. There is some suggestion that other risk areas requiring community health nursing resources may be emerging, mental illness and cultural and linguistically diverse groups for example. These results also suggest that community health nurses direct their practice towards health priorities set in government policy. However over 80% of the CHNs estimated that they directed less than 20% of their time to indigenous, refugee, and homeless groups. Barriers to proving community health nursing amongst these groups could be explored in Phase 2.

A key element of community health nursing practice identified was comprehensive assessment. Whether working with individuals, families, groups or local communities, these results suggest that comprehensive nursing assessment involves collecting and analysing data on physical and social health status in association with other disciplines. Assessment involves decision making about the environmental, psychosocial and cultural factors that may influence the potential to achieve or maintain independence and the changes clients could make to achieve their desired goals. Assessment also involves the nurse working in partnership with the client to determine the clients’ understanding of their circumstances, their physical and psycho-social responses to physical and social health determinants, how these responses will affect them now and in the future and the extent to which their community is able to meet their needs. Assessment includes identifying with the client what they need or desire to know and understand to be able to decide what actions they will take to achieve optimal independence and the services or supports that may assist them achieve wellbeing. Comprehensive assessment occurs over time and can involve setting health goals with the client and other disciplines, contributing to and implementing planned health care, evaluating progress towards health goals, referral to other disciplines and social support services, coordinating care, monitoring health progress and evaluating interventions in conjunction with the client and multidisciplinary team.

The emphasis on advocacy in the data suggests that advocacy is fundamental to community health nursing. Advocacy has been described as an integral part of the community health nurses role and the cornerstone of primary health care (Downie, 2007) and is, therefore, consistent with Victorian community health policy. The goals of nursing advocacy are client autonomy and self-determination leading to optimal independence and agency. Agency refers to the ability either individually or collectively to act to influence change (Germov, 2002b) and recognises people as responsible individuals who can choose to act in one way or another (Buresh & Gordon, 2006). The nurse advocate places priority on the rights of the individual, group or community as client.

Advocacy is also integral to the ethical principles of health care essential to all nursing practice (Baker, 2006). In an advocacy model, health education, provided

- 37 -

hand in hand with assessment complements the assessment process. The nurse as advocate acts as an enabler and communicator, explaining, interpreting, motivating and offering options throughout the assessment process to enable the client to make choices about how to work towards optimal independence. Health education is also integral to professional practice for community health nurses, part of the therapeutic process of community health nursing. Other terms community health nurses used when referring to this key element of their work included health counselling, health coaching, and secondary consultation. Comprehensive nursing assessment therefore, is complex. There is no way to simplify the process. It requires competency in the nursing domains: critical thinking and analysis, provision and coordination of care and collaborative and therapeutic practice, that is, the competencies tested in this questionnaire. To attempt to simplify assessment would compromise professional practice and could lead to unethical practices.

The key elements of community health nursing identified in this study, and summarised in Figure 12, are integral to nursing advocacy whether applied with individuals, families, groups or communities. To ignore CHNs’ expertise in this area is to associate nursing with the dominant medical paradigm, when in reality nursing, from the time of Nightingale, has been aligned with health knowledge (Besner, 2004 p.352) and has continued to be so in subsequent theoretical models of nursing (see Appendix D). Figure 12 A model of nursing advocacy

The results of this study confirm that CHNs utilise a combination of biophysical and psycho-socio and cultural knowledge in their practice. When applied within an advocacy model, CHNs can be accessible and approachable sources of knowledge relating to anatomy and physiology, pathophysiology, pharmacology, the disease

Key elements of health promotion

Community assessment Community consultation

Community development Health screening

Directing services to locally defined health priorities Informing community groups of research results

Developing leadership skills in the community National/state health promotion strategies

Key elements of health protection Health assessment Secondary consultation Health education Monitoring health status Care coordination

Nursing competencies Comprehensive nursing assessment

within a multi-disciplinary process Evaluating progress towards health goals

Providing health education Recommending other services

Referral through a formal process Care coordination

Nursing knowledge Anatomy and physiology

Comprehensive assessment Ethical principles r elating to health

Management of the disease process Biophysical determinants of health

Pharmacology Mental health

Pathophysiology

Social model of health Primary health care Social determinants of health Health promotion theory Health education theory Health legislation and common Health systems and processes Public health policy

Clients’ rights as priority

Key elements of nursing advocacy

- 38 -

process, mental health and the psychosocial and cultural influences on health. In addition, they are able to familiarise their clients with health systems and processes and broader social support systems and processes. The combination of biophysical and psychosocial knowledge together with knowledge of the broader health system renders community health nurses ideal enablers of client self-reliance in managing, maintaining and enhancing their health status, all features of Victorian community health policy. Further consideration and testing of this advocacy model and other nursing models appropriate to community health nursing are required when developing models of best practice for community health nursing.

Arguably, the most critical findings of this study is the CHNs’ call for more community health nursing resources to be directed to comprehensive primary health care practice. The community health nursing skills, knowledge and approach to health care provision identified in this study suggest that CHNs are a fundamental component of a comprehensive primary health care system.

Limitations to this study The questionnaire was self-administered and while this technique assured anonymity of CHNs, a self-administered mailed questionnaire can affect response rates and therefore limit the correlation between the data collected and the reality of CHN practice. The questionnaire was lengthy, in an attempt to gather as much data in ‘one hit’, and consequently may have deterred some CHNs from completing it. From the study, the researchers were able to determine the scope of CHN practice; however, the results do not generate information related to client outcomes, which would assist in determining the effectiveness of CHN practice.

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Conclusion and recommendations This study involved analyses of data from a self-administered questionnaire posted to nurses registered with the ANF as working as a community health nurse. The study sought to explore and describe the role of community health nurses (CHNs) in Victoria and identify common characteristics of health care delivery provided by these nurses. The results of this study add to the body of knowledge already available in the literature and they will contribute to the clarification of the role of community health nursing in Victoria. Analyses of the data suggest that community health nursing resources directly address priorities identified in Victorian community health policy, particularly older people on low incomes with chronic disease. Major components of community health nursing include comprehensive nursing assessment incorporating health education provided within an advocacy model of health, which encourages self-reliance in managing, maintaining and enhancing health and wellbeing. However, the CHNs’ have demonstrated a strong interest in being part of a comprehensive primary health care program and have indicated that they have the knowledge and skills to work within a social model of health and would therefore be ideal contributors to the health and social reforms required for equity in health for all Victorians.

The authors conclude that community health nursing brings a level of biomedical, psychosocial and cultural knowledge to primary health care that, together with CHNs’ understanding of the broader health sector, strengthens the primary health care system’s ability to address growing demands on the overall health system. However, the need for professional recognition and support of CHNs’ role in comprehensive primary health care is as strong today as it was in the first five years of this century (Besner, 2004; Keleher, 2000). Community health nursing is a nursing speciality therefore a helpful approach to articulating the CHN’s role may be to express the combination of specialist clinical and population-based skills and knowledge that underpin CHNs’ ability to make the link between health and its social determinants. To do this successfully, CHNs will need to take a stronger role in promoting best practice, by developing best practice indicators and evaluating and reporting on the social reforms and health outcomes of primary health care nursing interventions such as the recent economic evaluation of a sustainable farm families program (Boymal, Rogers, Brumby, & Willder, 2007). When CHNs are able to speak out and articulate what they do, and how effectively they do it, they will have a greater chance of convincing

The authors recommend:

1. That further research be conducted to highlight the benefits of community health nursing interventions on the health and well-being of the groups and communities with whom they work

2. That evaluation of existing models of community health nursing is undertaken to determine their appropriateness for best practice in community health nursing within current policy frameworks, Australia-wide

3. That a concerted campaign is undertaken to promote models of best practice within the profession and amongst policy makers and funding bodies that includes CHNs’ role in comprehensive primary health care

4. The expertise of community health nurses be acknowledged and recognised through the establishment of a formal process for CHNs to have regular dialogue with policy makers that contributes to the development of community health policy in Victoria

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5. That the CHN SIG be supported to have an annual conference/workshop in which the membership submit recommendations for collective action to nursing associations, the Department of Health and Community Services and those community health interest groups with a policy remit.

6. That CHNs be encouraged and supported to contribute to comprehensive primary health care using best practice models

7. That a series of focus groups or workshops involving CHNs be held to identify models of best practice for community health nursing currently in use, to agree on indicators to be used in evaluating outcomes of CHN interventions and to develop strategies for establishing strategic alliances for accessing policy makers.

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Appendices

Appendix A: Steering Committee Terms of Reference

Community Health Nurses Special Interest Group

RESEARCH PROJECT STEERING GROUP TERMS OF REFERENCE

PROJECT TITLE “The role and scope of practice of Community Health Nurses in Victoria and their capacity to promote health and wellbeing.”

PREAMBLE

The Community Health Nurses Special Interest Group is undertaking a research project to identify factors that influence the capacity of Community Health Nurses in Victoria to contribute to the health and wellbeing of individuals and communities. The project is the culmination of work undertaken by the Community Health Nurses Special Interest Group over the previous 3 years, exploring the role of Community Health Nurses in Victoria within the current political, funding and policy context. The study will be divided into two phases, involving both quantitative and qualitative approaches, and pursue triangulation in data analysis for a comprehensive understanding of the role of Community Health Nurses, and their capacity to promote health and well being. Phase one will identify the role and scope of practice of community health nurses. Phase two will identify the capacity of community health nurse’s to promote health and wellbeing.

PURPOSE A Project Steering Group will be convened to steer and monitor the project implementation and methodology.

OBJECTIVES AND FUNCTIONS The objectives of the Project Steering Group are:

• To provide input into the research focus and methodology; • To provide information and feedback on the progress of the project

implementation; • To provide input into the project report and dissemination of findings

MEMBERSHIP Community Health Nurses SIG executive committee ANF Representative DHS PHC Branch representative 2 Nursing Academic representatives Project Officer

At times and for particular purposes, other members may be co-opted onto the Project Steering Group.

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MEETINGS Meetings will be convened bi-monthly with the flexibility of meetings more frequently as needed. These meetings will be convened and minuted by the CHNSIG Chair & Secretary. Meetings may be conducted via teleconferencing or other media as required.

REPORTING AND DELEGATION

The Project Officer will report on implementation, progress and issues to the Steering Group each meeting. The CHNSIG executive will provide monthly updates to the membership at the monthly SIG meetings.

A final report, presenting the findings that detail both the role and the capacity of Community Health Nurses, in Victoria, to meet the needs of their communities will be provided by the Project Officer to the Project Steering Committee at the completion of the Project.

Appendix B Questionnaire

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Appendix C Information for Participants Dear Community Health Nurse

The Victorian Community Health Nurses Special Interest Group (CHN SIG), which represents the professional interests of Victorian community health nurses, is seeking your assistance with the above research project. The project aims to consult with community health nurses across Victoria about the types of community health nursing activities currently being undertaken in Victorian community health services, the relevance of their services within the current health system and the need to redirect or reorient these services in order to remain relevant and responsive to their communities. The SIG operates under the auspice of the Australian Nurses Federation and provides a voice for Victorian community health nurses to contribute to and comment on policy development relating to Victoria’s community health program.

The results of this project will: • Inform community health nurses of the overall role, scope and relevance of

their sector so that they can effectively promote their professional role and scope of practice amongst their colleagues and their communities

• Enable the CHN SIG to accurately represent your professional interests both within the ANF and the Department of Human Services (DHS), particularly in relation to the direction the sector needs to take to remain responsive and relevant to individual clients, client groups and communities

• Provide a professional voice for community health nurses to effectively contribute to Victorian community health policy.

The project is being conducted in two phases. Phase 1 involves a comprehensive self-administered questionnaire that every community health nurse working in Victorian community health services is invited to complete. Subject to additional funding, phase 2, will be undertaken following analysis of the questionnaire responses, and will engage community health nurses, who volunteer to participate, in focus group discussions about their capacity to promote health and wellbeing

The CHN SIG has established a Steering Group to oversee this project. Its membership includes the executive of the CHN SIG, two nursing academics, an ANF representative, a DHS representative and the project officer. As a community health nurse you are invited to contribute to this project by completing the enclosed questionnaire and returning it to the address provided on the questionnaire form by 15 December 2006. Your participation is entirely voluntary and confidentiality will be maintained at all times. No identifying information will be collected on the questionnaire. Only people employed in this project will have access to the questionnaire responses for analysis. Data from these questionnaires will remain the property of the CHN SIG. The results of this study will only be used in reporting the findings to the CHN SIG and in journal articles approved by the CHN SIG.

If you know any community health nurses who did not receive this questionnaire, please encourage them to contact me (details below) to request a questionnaire to be sent to them. Thank you for your interest and participation in this project.

Ms Olive Aumann Chair ANF Community Health Nurses SIG 29 November 2006

Appendix D Summary of nursing theories Theorist Goal of Nursing Framework for practice

Nightingale (1860)

To facilitate "the body's reparative processes’ by manipulating client's environment (Torres, 1986)

Client's environment is manipulated to include appropriate noise, nutrition, hygiene, light, comfort, socialisation and hope

Peplau (1952)

To develop interaction between nurse and client (Peplau, 1952)

Nursing is a significant, therapeutic, interpersonal process (Peplau, 1952). Nurses participate in 'structuring health care systems to facilitate natural ongoing tendency of humans to develop interpersonal relationships (Marriner-Tomey and Alligood, 1998)

Henderson (1955)

To work independently with other health care workers (Marriner-Tomey and Alligood, 1998), assisting client to gain independence as quickly as possible (Henderson, 1966); to help client gain lacking strength (Torres, 1986)

Nurses help client to perform Henderson's 14 basic needs (Henderson, 1966)

Abdellah (1960)

To provide service to individuals, families, society; to be kind, caring intelligent, competent and technically well prepared to provide this service (Marriner-Tomey and Alligood, 1998)

This theory involves Abdellah's 21 nursing problems (Abdellah and others, 1960)

Orlando (1961)

To respond to client's behaviour in terms of immediate needs; to interact with client to meet immediate needs by identifying client's behaviour, reaction of nurse, and nursing action to be taken (Torres, 1986; Chinn and Kramer, 1999)

Three elements - client behaviour, nurse reaction and nurse action comprise nursing situation (Orlando, 1961)

Hall (1962)

To provide care and comfort to client during disease process (Torres, 1986)

The client is composed of the following overlapping parts: person (core), pathological state and treatment (cure) and body (care). Nurse is caregiver (Marriner-Tomey and Alligood, 1998; Chinn and Kramer, 1999)

Wiedenbach (1964)

To assist individuals in overcoming obstacles that interfere with the ability to meet demands or needs brought about by condition, environment, situation or time (Torres, 1986)

To assist individuals in overcoming obstacles that interfere with the ability to meet demands or needs brought about by condition, environment, situation or time (Torres, 1986)

Levine (1966)

To use conversation activities aimed at optimal use of client's resources

An adaptation model of human as integral whole based on 'four conversation principles of nursing' (Levine, 1973)

Johnson (1968)

To reduce stress so that client can move more easily through recovery process

This theory of basic needs focuses on seven categories of behaviour. Individual's goal is to achieve behavioural balance and steady state by adjustment and adaptation to certain forces (Johnson, 1980; Torres, 1986)

Rogers

(1970)

To maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through 'humanistic science of nursing' (Rogers, 1970)

'Unitary man' evolves along life process. Client continuously changes and coexists with environment

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Theorist Goal of Nursing Framework for practice Orem (1971)

To care for and help client attain total self-care A self-care deficit theory, nursing care becomes necessary when client is unable to fulfil biological, psychological, developmental or social needs (Orem, 1991)

King (1971)

To use communication to help client re-establish positive adaptation to environment

Nursing process is defined as dynamic interpersonal process between nurse, client and health care system. Interpersonal process is viewed as human-to-human

Travelbee (1971)

To assist individual or family in preventing or coping with illness, regaining health, finding meaning in illness or maintaining maximal degree of health (Marriner-Tomey and Alligood, 1998)

Interpersonal process is viewed as human-to-human relationship formed during illness and "experience of suffering'

Neuman (1972)

To assist individuals, families and groups in attaining and maintaining maximal level of total wellness by purposeful interventions

Stress reduction is goal of systems model of nursing practice (Torres, 1986). Nursing actions are in primary, secondary or tertiary level of prevention

Patterson and Zderad (1976)

To respond to human needs and build humanistic nursing science Patterson and Zderad, 1976; Chinn and Kramer, 1999)

Humanistic nursing requires participants to be aware of their ‘uniqueness’ and ‘commonality’ with others (Chinn and Kramer, 1999)

Leininger (1978)

To provide care consistent with nursing's emerging science and knowledge, with caring as central focus (Chinn and Kramer, 1999)

With this transcultural care theory, caring is the central and unifying domain for nursing knowledge and practice

Roy (1979)

To identify types of demands placed on client, assess adaptation to demands and help client adapt

This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes (Roy, 1980)

Watson (1979)

To promote health, restore client to health, and prevent illness (Marriner-Tomey and Alligood, 1998)

This theory involves philosophy and science of caring; caring is interpersonal process comprising interventions that result in meeting human needs (Torres, 1986)

Parse (1981)

To focus on human being as living unity and individual's qualitative participation with health experience (Parse, 1990; Marriner-Tomey and Alligood, 1998)

The individual continually interacts with environment and participates in maintenance of health Marriner-Tomey and Alligood, 1998). Health is continual, open process rather than state of wellbeing or absence of disease (Parse, 1990; Marriner-Tomey and Alligood, 1998; Chinn and Kramer, 1999)

Benner and Wrubel (1989)

To focus on client's need for caring as a means of coping with stressors of illness (Chinn and Kramer, 1999)

Caring is central to the essence of nursing. Caring creates the possibilities for coping and enables possibilities for connecting with and concern for others (Benner and Wrubel, 1989)

Boykin and Schoenhofer (2001

Built upon the knowledge of other nursing scholars who have developed theories of caring, this work invites all nurses to develop nursing knowledge and to theorise from within the nursing situation in sharing both the content and context of nursing experiences as they are lived in meaning patterns

Draws on Mayeroff’s caring components: knowing, trust, humility, hope and courage

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Glossary Term Definition/explanation Source

Advocacy Mediation in which a third party attempts to provide assistance to those who may be experiencing conflict in what they desire. The goal is to assist parties to understand each other on many levels so that agreement upon an action is possible.

Stanhope and Lancaster (1992) p.682

Understanding the worldview, life circumstances, and priorities of those requesting or receiving care and exploring the possible options with them in light of their preferences.

Gadow, S in Anderson & McFarlane (2004) p.86

Appropriate advocacy is based on the ability to understand the popular sector’s realities and to translate and negotiate between the system’s sectors with the goal of reducing barriers to culturally sensitive care.

Chrisman (1997) in Anderson & McFarlane (2004) p.124

Advocacy in nursing

The nurse advocate places the client’s rights as priority. The goal of nursing advocacy is to promote client autonomy and self-determination to bring about an optimal degree of independence in decision-making.

Stanhope and Lancaster (1992) p.682

The ability of people, individually and collectively, to influence their own lives and the society in which they live.

(Germov, 2002b) p.20 Agency

The capacity for acting or the condition of acting or exerting power to bring about change. Agency recognises people as responsible persons who can choose to act one way or another

(Buresh & Gordon, 2006) p.28

Agency in nursing Nursing actions that involve teaching; listening, reading; assessing; monitoring and interpreting; evaluating; negotiating; advocating; observing, deciding and acting… because or so that…

(Buresh & Gordon, 2006) p.29

Agent A person (McMurray, 2003) who is instrumental, through whom power is exerted; someone who acts and brings about change, and whose achievements can be judged in terms of his or her own {professional} values and objectives

(Buresh & Gordon, 2006) p.28

Biomedical/ medical model

Disease is a physiologic and psychological abnormality A disease -oriented, illness and organ focussed approach to patients with an emphasis on pathology

(Anderson & McFarlane, 2006) p.122

Bio-psychosocial model

A model of illness that focuses on the individual patient for diagnosis, explanation and treatment but takes into account the biological, psychological, and social factors implicated in a patient's condition.

(Germov, 2002b) p. 14

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Term Definition/explanation Source Community based nursing

'… focuses on promoting and maintaining the health of individuals and families, preventing and minimizing the progression of disease, and improving quality of life’

(Ayers et al. 1999; Hunt, 2005 cited in St. John & Keleher 2007, p. 5.)

Community development:

Acting to affirm and strengthen the community's ability to grow and care for itself by teaching basic health measures

(Anderson & McFarlane, 2006) p.335

Community assessment

The process of identifying positive and negative factors that impinge on people in order to develop strategies to bring about change and empowerment

(Anderson & McFarlane, 2006) p.169

Community empowerment

Developing the capacity of a community, or an individual in a community to identify, respond and resolve their problems. Community empowerment places little emphasis on professional expertise and focuses on community participation in decision-making and community -based advocacy.

O'Connor -Fleming & Parker (2001) p.22

Community Health Promotion

Facilitation of a community-driven health agenda in a negotiated mutual partnership between community and health promoter (community development health promotion), rather than the traditional method of presenting and identified agenda of health problems to the community (community-based health promotion)

O'Connor-Fleming & Parker (2001) p.23

Population-based nursing practised in a variety of community settings (Anderson & McFarlane, 2006) p.317

‘a specialty that, in addition to providing care for individuals and families, also focuses on groups, communities and populations.' Community health nursing is 'not defined by the setting but rather by a fosus upon high-risk or vulnerable populations and the whole community

(St John & Keleher 2007, p. 6).

Community health nurses identify and challenge barriers to wellness and empower people to change the agents that affect their health adversely. Community health nursing practice is built upon the foundation of nursing science. Community health nursing acts to promote optimum health of individuals and the community by promoting the right to informed choice, advocacy and self-determination by working in partnership with clients, groups and their communities and recognising their actual and potential strengths.

Berwick CHS http://www.chnwa.org.au/index.php?option=com_content&task=view&id=13&Itemid=27 retrieved 3 November 2006

Community health nursing

Community Health Nursing is a synthesis of nursing practice, Public Health practice, Health Promotion and Primary Health Care. The practice of community health nursing expands into the areas of disease prevention, health enhancement, empowerment, advocacy, community development and research.

http://www.southernhealth.org.au/chnurse.htm

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Term Definition/explanation Source Community nursing

Nursing that takes place outside a hospital or institutional setting and includes both community based nursing and community health nursing

St John, in St John and Keleher 2007, p4

Enabling To take action in partnership with individual groups, families or communities to empower them. It fosters sustainability of health promotion in the community.

(World Health Organisation, 1998)

Equity in health People’s needs guide the distribution of opportunities for well-being (World Health Organisation, 1998)

Evidence based medicine

An approach to medicine arguing that all clinical practice should be based on evidence from randomised control trials (RCTs) to ensure the effectiveness and efficacy of treatments.

(Ezzy, 2002) p. 52

Evidence based practice

Practice-orientated research activities to improve the effectiveness of practice and health care outcomes

http://www.health.adelaide.edu.au/nursing/ebp/ retrieved

The provision of learning experiences that facilitate voluntary adaptations of behaviour conducive to health

O'Connor-Fleming & Parker (2001) p.22

Health education

A process comprising of consciously constructed opportunities for learning and communication designed to improve health information, health literacy, health knowledge and developing life skills which are conducive to the promotion of an individual and community’s health including that of the environment.

(World Health Organisation, 1998)

Health equity (Keleher, 2007b) p. 21 Health literacy The cognitive and social skills which determine the motivation and ability of individuals

to gain access to, understand and use information in ways which promote and maintain good health.

(World Health Organisation, 1998)

Health protection Enforced regulation of human behaviour to protect individual and community health eg. OH&S, road safety

O'Connor -Fleming & Parker (2001) p.22

Any combination of health education, legislation, community development and advocacy related to organisational, economic, and political interventions designed to promote behavioural and environmental changes conducive to good health.

(Richmond, 2002) p.197 Health promotion

‘the process of enabling people to increase control over and improve their health’ (World Health Organisation, 1998)

Healthy public policy

Creation of a social, economic and physical environment that assists and encourages people to make healthy choices. Responsibility for change lies predominantly with the

O'Connor-Fleming & Parker (2001) p.23

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Term Definition/explanation Source system rather than the individual.

Men's health A movement that recognises that certain aspects of masculine identity and behaviour can be hazardous to health.

New public health A model of health that links public health concerns which focus on physical aspects of the environment (clean air and water, safe food, occupational health through legislation), with the behavioural, social and economic factors that affect people's health. Emphasis is on primary prevention, participation and primary health care.

(Germov, 2002b) p.14

Nurse practitioner The title given to nurses endorsed by their State Nurses Board to practice in an advanced and extended role, such as the ability to prescribe certain drugs, and undertake specific procedures without direct supervision from a medical officer.

Both the point of first contact with the health care system and a philosophy for delivery of that care

(Baum, 2002a) p. 367 Primary Health Care

Socially appropriate, universally accessible, scientifically sound first level care provided by a suitably trained workforce supported by integrated referral systems and in a way that gives priority to those most in need, maximises community and individual self-reliance and participation and involves collaboration with other sectors. It includes:

• health promotion • illness prevention • care of the sick • advocacy • community development.

Australian Primary Health Care Research Institute (APHCRI). http://www.anu.edu.au/aphcri/ retrieved 3/11/2006

Public policies and infrastructure (buildings, installations, and equipment necessary to ensure healthy living conditions for communities and populations) to prevent the onset and transmission of disease among the population, with a particular focus on sanitation and hygiene such as clean air, water, and food and immunisation.

(Germov, 2002b) p. 5 Public health

All organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole.

(World Health Organisation, 1998)

Randomised controlled trials

A biomedical research procedure used to evaluate the effectiveness of particular medications and therapeutic interventions. 'Random' refers to the equal chance of participants being in the experimental (in receipt of the intervention) or control (not receiving the intervention and used for comparison) group. 'Trial' refers to the experimental nature of the method.

(Ezzy, 2002) p. 50

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Term Definition/explanation Source Risk factors Conditions that are thought to increase an individual's susceptibility to illness or

disease such as abuse of alcohol or smoking. (Germov, 2002b) p. 13

Social Responsibility for Health

The decisions and actions of the decision-makers in both public and private sector to pursue policies and practices which promote and protect health. Social responsibilities for health is lacking when policies and practices pursued by the private and public sectors are of the kind that harm the individuals, families, communities and the environment.

(World Health Organisation, 1998)

Secondary consultation

The provision of professional guidance and support to health professionals, community service providers and clients at their request to ensure that clients are able to access and understand health information and care within their own communities.

Social action Attempting to achieve a shift in power relations and in resources (Baum, 2000b) p.370 Social capital Social relations, networks, norms, trust, and reciprocity between individuals that

facilitate cooperation for mutual benefit. (Germov, 2002a) p. 85

A focus on the social determinants (social production, distribution and construction) of health and illness, and the social organisation of health care. Attention is given to the prevention of illness through community participation and social reforms that address living and working conditions

(Germov, 2002b) p. 14

Consideration of the structural, environmental conditions within which behaviours occur

(McMurray, 2003) p. 81

Social health involves changing those aspects of the environment that promote ill health rather than continue to simply deal with illness after it appears, or continue to exhort individuals to change their attitudes and lifestyle when, in fact, the environment in which they live and work gives them little choice or support for making such changes.

South Australian Health Commission (1988), p.3 cited in (Baum, 2002b) p. 533

Understanding that health is contingent upon, and emerges from, a range of socio-cultural and environmental conditions.

(Keleher, 2007b) p.20

Social model of health

A conceptual framework for improving health and wellbeing by addressing the social and environmental determinants of health in tandem with biological and medical factors

(Department of Human Services, 2004) p.41

Social justice A belief system that gives high priority to the least advantaged (Germov, 2002a) p.84

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Term Definition/explanation Source Social structure The recurring patterns of social interaction through which people are related to each

other, such as social institutions and social groups (Germov, 2002b) p. 19

Social support The support provided to an individual by being part of a network of kin, friends, or colleagues.

(Richmond, 2002) p. 210

Statistical terms used in the report

F: The analysis of variance (ANOVA) test statistic H: The Kruscal-Wallis test statistic Mean: The arithmetic average n: number of observations p value: the probability (%) of getting the observed results just by chance Significant difference: The likelihood that the study results are not due to chance SD: (Standard deviation) can be thought of as an estimate of the average distance that data values differ from the mean Z: a unit to express how far and in what direction that item deviates from its distribution’s mean (average). The Z score is derived by standardising the data

Polit, D and Beck, C (2006)

Women's health movement

Attempts to address sexism in medicine by highlighting the importance of gender in health research and treatment.

(Germov, 2002c) p.41

Anderson, E. T., & McFarlane, J. (2006). Community as Partner Theory and Practice in Nursing (5th ed.). Philadelphia: Lippincott Williams & Wilkins.

Baum, F. (2002a). Community Health Services in Australia. In J. Germov (Ed.), Second Opinion An Introduction to Health Sociology (2nd ed., pp. 365 - 388). South Melbourne Victoria: Oxford University Press.

Baum, F. (2002b). The New Public Health. Melbourne: Oxford University Press.

Buresh, B., & Gordon, S. (2006). From silence to voice: what nurses know and must communicate to the public (2nd ed.). Ithaca, NY: Cornell University Press.

Department of Human Services. (2004). Community Health Services - creating a healthier Victoria (Policy). Melbourne Victoria: Primary and Community Health Branch Victorian Government Department of Human services.

Ezzy, D. (2002). Researching health. In J. Germov (Ed.), Second Opinion An Introduction to Health Sociology (2nd ed., pp. 49-64). South Melbourne Victoria: Oxford University Press.

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Germov, J. (2002a). Class, Health Inequality, and Social Justice. In J. Germov (Ed.), Second Opinion An Introduction to Health Sociology (2nd ed., pp. 67 - 94). South Melbourne Victoria: Oxford University Press.

Germov, J. (2002b). Imagining Health Problems as Social Issues. In J. Germov (Ed.), Second Opinion An Introduction to Health Sociology (2nd ed., pp. 3-27). South Melbourne Victoria: Oxford University Press.

Germov, J. (2002c). Theorising Health. In J. Germov (Ed.), Second Opinion An Introduction to Health Sociology (2nd ed., pp. 28 - 48). South Melbourne Victoria: Oxford University Press.

Keleher, H. (2007). Social perspectives on health. In W. St. John & H. Keleher (Eds.), Community Nursing Practice: Theory, Skills and Issues (pp. 18-38). Crows Nest: Allen & Unwin.

McMurray, A. (2003). Community Health and Wellness: a Socioecological Approach (2nd ed.). Sydney: Harcourt/Mosby.

Polit, D. And Beck, C (2006) Essentials of Nursing Research Methods, Appraisal and Utilization (6th ed). Sydney: Lippincott Williams and Wilkins

Richmond, K. (2002). Health Promotion Dilemmas. In J. Germov (Ed.), Second Opinion An Introduction to Health Sociology (pp. 195 - 214). South Melbourne Victoria: Oxford University Press.

St John, W. (2007). Context and Roles in Community Nursing Practice. In W. St John & H. Kelleher (Eds.), Community Nursing Practice Theory, Skills and Issues (pp. 6). Crows Nest, NSW: Allen & Unwin.

World Health Organisation. (1998) Health Promotion Glossary. Geneva: WHO