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Chapter 5Community practice and continuity of care

Learning OutCOmes

After completing this chapter, the learner should be able to accomplish the following:

1. Describe the context of person-centred care in terms of community nursing, midwifery and continuity of care

2. Discuss the principles of primary healthcare and apply to practice

3. Describe the roles of a community nurse/midwife and scope of practice

4. Discuss the complexity of holistic person-centred assessment

5. Explain the role of a family carer

6. Describe the role of the nurse and midwife in transfer of care planning

7. Describe the role of the nurse and the midwife in ensuring continuity of care between and among healthcare settings and in the community.

Key terms

This chapter introduces and explains community-based nursing and midwifery and outlines continuity of care. Three essential concepts are continuity of care, person-centred care and community-based care. Planning for and providing care interventions that promote health, prevent illness and support coping with disability is critical in today’s culturally diverse society. It is no longer enough to consider only the person’s needs within the hospital setting; consideration must also be given to how those needs will be met as the person makes the transition from the acute care setting to care at home with support and services from their community.

ESSENTIAL CONCEPTS

Person-centred careA framework that supports the person-centred approach to care is discussed fully in Chapter 1. In this framework

community-based carecommunity nursingcontinuity of caredischarge planninghome nursing

person-centred careprimary healthcaretransfer of carewoman-centred care

the context of healthcare is considered an important pre-requisite. Chapter 4 discusses the many settings in which healthcare may be delivered. This chapter focuses on the particular care environment existing in the community and in the person’s home, as this environment affects the care processes that are important components of person-centred care.

The Australian College of Nursing (ACN, 2014) has iden-tified key principles of person-centred care as a central tenet underpinning the delivery of nursing care and healthcare generally. Person-centred care means:

● Treating each person as an individual ● Protecting a person’s dignity ● Respecting a person’s rights and preferences and ● Developing a therapeutic relationship between the care

provider and care recipient which is built on mutual trust and understanding.

This model of care requires individual, team and organ-isational commitment within a healthcare environment. The person-centred approach sits very comfortably with community nursing and midwifery practice and the assessment process.

Continuity of careContinuity of care is a process by which healthcare pro-viders give appropriate, uninterrupted care and facilitate the person’s transition between different settings and levels of care. Continuity of care ensures a smooth transi-tion from the community to ambulatory or acute-care facilities, and when returning home to receiving home healthcare or other types of healthcare in the commu-nity. Coordination of the care process helps ensure a person-centred and individualised continuum of health-care so that the person may attain maximum recovery and health.

Most people become consumers of healthcare at birth, as most people in developed countries are born in a hos-pital. However, across a life span, health services required by people are delivered in a variety of healthcare settings in the local community as well as in the person’s own home. Although a person’s healthcare may involve many different providers and settings, the nurse or midwife is often the primary person responsible for communicating the person’s needs, teaching self-care and providing the care. As a result, one of the primary responsibilities of the nurse or midwife as caregiver is promoting continuity of care.

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Community practice and continuity of care CHaPter 5 81

Continuity of care is guided by best practice guidelines and is increasing in its importance to the current health-care system. The emphasis on health promotion and the prevention of illness makes teaching individuals of all ages a crucial component of care. To provide continuity of care, nurses and midwives must involve other members of the healthcare team, the person and their family in the plan-ning process in order to meet the physical, psychological, sociocultural and spiritual needs of the person and family in all settings and at all levels of health or illness.

Community-based careCommunity-based care is healthcare provided to people who live within a defined geographical area. That geo-graphical area might be a small neighbourhood in a large urban area or a large area of rural residents. Each commu-nity is unique, and is defined by its people, area, social interactions and common ties.

Community-based care is centred on individual and family healthcare needs. It emphasises the provision of comprehensive, coordinated and continuous services for people with acute or chronic health problems (Stanhope & Lancaster, 2013). Within a framework of community-based care, nurses and midwives help people wherever they are, including where they live, work, play and go to school.

The community-based nurse or midwife considers the continuity of the care the person requires when moving from one level or setting of care to another, providing interventions to promote health, manage acute or chronic illnesses and promote self-care. Community-based care is designed to meet the needs of people as they move into, between and among different healthcare settings.

COmmuNITy NurSINg

Chapter 9 discusses the development of nursing as a disci-pline in Australia and New Zealand. The establishment of community nursing was based on the district nursing concept in the UK and evolved from the care provided by religious organisations in people’s own homes. It further developed as the principles of primary healthcare (PHC) were accepted by governments and became embedded in health policies.

Brief history of community nursing in australiaCalder (1971, cited in Kralik & van Loon, 2011, p. 7) identi-fied that throughout the 1800s, many Christian religious denominations in Australia felt compelled to enact their Christian ethos. They sent out trained and religious women to commence this vocation and work among the sick, poor and needy within the community. By the late 1880s, the idea of nursing people in their homes to free up the over-burdened hospitals was seen as the way of the future, along with more formal home nursing services being developed. The Royal District Nursing Service (RDNS) in Melbourne commenced home nursing services in 1885,

and midwifery, mother and new baby services in the 1890s. The Royal District Nursing Service in South Australia (RDNSSA) was founded in 1894; Sydney Home Nursing Service, 1900; Silver Chain Western Australia, 1905 and Blue Care Queensland in 1953. Funding for these early services was provided through donations, bequests and fundraising.

Requests for donations to fund research, health promo-tion activities, equipment and some direct care can still be found on some health service websites. In Sydney, a home visiting service for mothers and babies was established in 1904 and the first baby health centre in the city opened in 1914.

Community nursing in the mid-1880s was hazardous, given the way nurses were exposed to infectious diseases that resulted from the over-crowded living conditions and poor sanitation and drainage in people’s homes and in the streets. The job of nursing was also physically demanding; nurses were often required to walk or ride bicycles over long distances to get to people’s homes.

Brief history of community nursing in new ZealandDistrict or community nursing was first introduced into New Zealand by Sibylla Emily Maude, who was inspired by the work of the sisters of the Deaconess Institution, pro-viding nursing care for the poor in their own homes. After completing her nursing training in England, Nurse Maude began district nursing in Christchurch in 1896, where she treated minor injuries and illnesses, gave out medicines and distributed clothes to the needy. In 1901, the Nurse Maude District Nursing Association was formed to support her work (Christchurch City Libraries, 2015). The District Nursing Association of New Zealand was established in the early 1900s under the sponsorship of the St John Ambulance Association. Care for the sick inside their homes was further facilitated in 1909 by the Hospital and Charitable Institutions Act, which allowed the development of district nursing schemes. The escalating mortality rate among babies was of concern to Dr Truby King. He founded the Plunket Society in 1907 to scientifically for-mulate advice on child care and nutrition to address the problem. Today, parents of more than 90% of new babies access some aspect of Plunket’s Well Child health service (Royal New Zealand Plunket Society, 2015). The changing population of New Zealand requires meeting not only the cultural needs of many Māori families but also the increas-ing number of families from Pacific Islands.

The unique circumstances of Māori in New Zealand influenced the development of specific community-based services. At the turn of the 20th century, the major threats to health were communicable diseases and malnutrition. The Native Department developed a native health nursing scheme in response to concerns for the future of the Māori race. Māori had reduced immunity to diseases such as tuberculosis, influenza, enteric fever and smallpox.

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82 unit 1 Introduction to nursing, midwifery and health

The first two Māori women nurses were registered in 1909. Nurses’ responsibilities included providing advice on hygiene, food preparation, pregnancy, childbirth and child care and keeping a record of Māori births and deaths.

COmmuNITy mIdwIfEry

Maternity Choices, formerly known as Maternity Coalition, is a national (Australian) consumer advocacy organisation committed to improving the care of women in pregnancy, birth and the postnatal period (Maternity Choices, 2014). A key factor in its program is the recognition that the mid-wife is the most appropriate provider of care for women experiencing normal pregnancies and births. It is widely acknowledged that there is an increasing demand for mid-wifery continuity of care models. These models place women at the centre (woman-centred care) of the com-munity midwifery model and advocate empowering them to assume control and make decisions related to their care in partnership with the midwife. Community midwifery programs emphasise the normality of childbearing and adopting a wellness model rather than a sickness model of care. Woman-centred care includes any person (usually her partner, family or a close friend) the woman identifies as being significant to her (Australian College of Midwives, 2011). The partnership is based on trust and respect for the knowledge and expertise held by both the woman and the midwife. Continuity of care is provided as the mid-wife attends the woman throughout the pregnancy, at labour and in the postnatal period.

Brief history of community midwifery in australia and new ZealandCommunity midwifery is well established in a number of Western countries such as the UK and Canada. In New Zealand, maternity service reform commenced in the early 1980s and by 2002, more than 70% of women had elected to make the midwife their primary maternity carer com-pared with 1% of Australian women. This difference in par-ticipation resulted mainly from limited access for Australian women to such services and a dominance of the medical model of care for women. In response to this situation, mid-wives began campaigning for the introduction of such ser-vices for women. Services now exist in all states; however, these are not widespread and community-based choices for maternity care are still limited.

PrImAry HEALTHCArE

Primary healthcare was defined by the World Health Organization (WHO) (1978, p. 2) as ‘addressing the main health problems in a community, providing promotive, preventive, curative and rehabilitative services’ according to the political and sociocultural characteristics of the country. Primary healthcare has a community-based philosophical base that emphasises consumer involvement,

universal access and affordability of healthcare. These principles underpin the developments in community practice and continuity of care. Programs underpinned by these principles emphasise preventive health and com-munity involvement and are often managed by a commu-nity group that ensures that the program meets the needs of the community.

Primary healthcare in australiaDuring the 1970s, state governments recognised that life expectancy rates had not changed in 50 years (male 70 years and female 75 years) and that many health problems were related to individual’s behaviours and lifestyle choices. Health departments within state and territory governments recognised that health services were far too focused on a curative model of healthcare which was inef-fective and expensive. People had become dependent on quick fixes, medications and medical science, and health professionals were inadequately trained and too poorly resourced to reverse this trend by managing the emo-tional and social issues associated with improving the health of the population.

State governments responded to these issues by forming new and comprehensive community health services with a whole-of-population approach. The Health Commission of New South Wales (1977) commissioned such services in 1972. These state-based services received funding support from the federal government to provide a wider range of access points to health services for people who were not necessarily ill, but who had a problem that could be managed through a more appropriate service and specialised team.

Prevention of illness and large-scale public health edu-cation to raise awareness of poor lifestyle behaviours were features of this new approach. Some strategies to prevent injury and illness put forward by these new services included seatbelts in cars, services devoted to improving Indigenous health, immunisation, sex education, mental health services, drug and alcohol services, and smoking cessation programs. Community health was to focus on population needs; be accessible; be integrated between hospital, community health and general medical practices and include participation of the consumer.

Primary healthcare in new ZealandIn 2000, the New Zealand Public Health and Disability Act gave 21 district health boards (DHBs) overall responsibility for assessing the health and disability needs of their con-stituent populations and managing the resources to best meet the needs. A government strategy paper was pub-lished in 2001 as New Zealand’s Primary Health Care Strat-egy, recognising the importance of a well-functioning primary healthcare system that reduced health inequali-ties. The vision of the document was that:

[p]eople will be part of local primary healthcare ser-vices that improve their health, keep them well, are

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easy to get to and coordinate their ongoing care. Primary healthcare services will focus on better health for a population, and actively work to reduce health inequalities between ethnic groups (King, 2001).

The ethos of the strategy is for health organisations to work with communities to identify their needs and col-laborate to address them. Rather than focusing on indi-viduals who actively seek care, primary health organisations are charged with organising services around enrolled populations. All residents of New Zealand are encouraged to enrol with a local primary health organisation and receive subsidised care as a result. With these factors in mind, PHC has become an integral component of nursing education with strong emphasis on the clinical practice of PHC within nursing degrees (see Research in practice).

nurse’s role in primary healthcareDuring the 1970s, the nurse’s role in Australian primary healthcare was to take on more of a generalist nature, providing a point of entry to the healthcare service, assisting people to define their health problems, refer-ring them to the most appropriate specialist service and case-managing care during the episode. Nurses employed to take on this primary health role also provided individ-ual and group health education and conducted health-screening programs. While nursing service delivery models varied from state to state, over time all nurses providing clinical services to people in the home were undertaking primary healthcare activities as part of their role. However, for nursing services to be truly considered Primary Health Care (PHC), nurses must now ensure that key principles have been addressed effectively in their professional practice (Haley, 2016).

Over the last three decades, community health practices have evolved and changed to suit the needs of popula-tions, respond to the service demands and further meet the health priorities of the nation. The population approach to primary health nursing has been eroded by this change, and the focus of care is now more on the fast, through-put model of healthcare, prompted by both early discharge and day-only admission to hospital. In some services, gen-eralist community nurses have been required to alter their focus away from the population primary prevention role to a more acute/postacute and continuing care model that includes palliative and chronic disease management. How-ever, it is still relevant for community nurses to include health screening and primary prevention in each individual episode of care.

In both Australia and New Zealand, nurses who work in early childhood, mental health teams, adolescent services, chronic care teams, sexual health, HIV services and other specialties such as diabetes education have more of an opportunity to practise a true model of primary healthcare as part of their role. New health service models and mod-els of care must further consolidate community and pri-mary healthcare nurses’ roles as advisors and case managers of people who live with one or several chronic conditions (ACN, 2015).

midwife’s role in primary healthcarePrimary healthcare in the midwifery context relates to the one-to-one care that is provided to the woman throughout the whole pregnancy and postnatal experience. The midwife follows the woman through all phases of the childbearing continuum in a caseload model providing the interface between hospitals and community settings. In addition, the

researCH in PraCtiCe

Primary healthcare implementationThe World Health Organization first recognised that nursing was important to the implementation of PHC strategies. It is timely then that the effectiveness of the clinical experience in primary healthcare nursing is evaluated to ensure further development of the scope of practice required and implementation of programs that aim to promote wellness in communities.

related research

Betony, K., & Yaewood, J. (2013). What exposure do student nurses have to primary health care and community nursing during the New Zealand undergraduate Bachelor of Nursing programme? Nurse Education Today, 33(10), 1136–1142.

This study presents an overview of the findings of a research proj-ect to examine the theoretical and practical exposure student nurses have to PHC and community nursing in their undergradu-ate program, which was undertaken in New Zealand. A mixed-methods approach to capture a ‘snapshot’ of current PHC clinical and theoretical provision was utilised in the study. A survey of

current BN program providers was achieved through the devel-opment of a questionnaire, which consisted of nine questions that included an option to make comments. The questions were designed to capture information relating to placement provision during the BN program, the type of PHC teams BN students were placed with and the exposure BN students had to PHC theoreti-cal principles from the tertiary institution staff. A final ‘question’ requested respondents to enter text responses to identify issues and innovations in their area.

relevance to practice

In nurse education the challenges providing PHC placements are similar to all clinical placements, but with a set of very specific issues such as a variable understanding of what PHC is, a lack of clarity about a team’s role in PHC delivery, and limited capacity to accommodate students. However, despite identified issues, some institutions appear to have found innovative ways of ensuring students gain appropriate PHC experience.

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midwife coordinates the collaboration of all other health professionals who may be involved in the woman’s care. Midwives, as experts in normal healthy childbearing, recog-nise when there are complications and are able to refer the woman to specialist care when this is appropriate.

HOmE NurSINg ANd mIdwIfEry

Home nursing is unique in that the care is provided in a setting that is unfamiliar to the nurse or midwife but famil-iar and comfortable to the person. For most people, the home is a place of safety and security and has meaning and value rooted in ownership, family relationships and memo-ries, and independence. Home healthcare is provided in a setting that is controlled by the individual and their family. Instead of them coming to the nurse or midwife, the health professional goes to them. They or their carers must give permission for the nurse or midwife to enter the practice setting because they are a guest in their home. The nurse or midwife cannot regulate the setting where care is pro-vided, but rather, must adapt to the person’s environment.

Defining characteristics of the nurse and midwifeIt is important to recognise that prior to August 2004, mid-wifery in Australia was considered a nursing specialty but, since the passing of the Nurses and Midwives Act 2004, nursing and midwifery have become two discrete profes-sions (Dietsch & Davies, cited in Haley, 2016, p201). Cur-rently, under the National Registration and Accreditation Scheme for health professionals in Australia (which com-menced in 2010), there is a register of nurses and a sepa-rate register of midwives. Those with dual qualification can register on both. New Zealand had previously recognised midwifery as a profession with an autonomous role in 1990 and since 1992 preregistration midwifery education has been through a 3-year Bachelor of Midwifery program (NZCOM, 2015).

Nurses and midwives choose community practice for various reasons. Many enjoy practising in an autonomous setting where they can use their expertise in an expanded role. Others enjoy managing their time independently and like the satisfaction they derive from the holistic model of care they provide. It is a privilege to be welcomed into a person’s home and life. Networking with other service providers to individualise care is also satisfying.

Community practice provides an opportunity for nurses and midwives to be creative in delivering care. They must possess several key qualities: they must be knowledgeable and skilled in their practice, must be able to make deci-sions independently and they must remain accountable.

Knowledge and skillNurses and midwives who provide care in a person’s home must have the knowledge and skills needed to pro-vide appropriate care and health education. Effective communication is essential (see Fig. 5-1) and advanced

clinical knowledge and skills are crucial. There are many ways to develop the knowledge and skills required for com-munity practice. For instance, there are university and col-lege courses in a wide range of subjects that support community nursing and midwifery practice, as well as uni-versity and college accredited courses conducted by the services themselves. Training opportunities are offered to registered graduates to undertake a placement in commu-nity nursing/midwifery/mental health/drug and alcohol services to gain experience. This training is conducted using a mentor (usually an experienced community nurse or mid-wife) and the support of a clinical educator. Nurses with vast experience in other nursing specialties receive on-the-job training before commencing work as community nurses. All new staff are assessed for competency before undertaking any complex procedures in the community, such as admin-istering intravenous fluids, compression therapy or loading a syringe driver.

The care environment or context determines in part the skills that are required to provide care. Community nursing and midwifery in urban areas is more likely to have imme-diate access to supports such as general practitioners (GPs) and hospital outreach services. However, rural Australia presents specific problems related to distance and difficul-ties in terrain. Organisations such as the Council of Remote Area Nurses of Australia (CRANA) provide a wide range of nurse training opportunities that relate to remote area nurses. Additional skills specific to the context of their practice are included, such as skills in four-wheel driving, changing a tyre on a four-wheel drive and the use of a CB radio.

Figure 5-1 Home healthcare nurses combine effective communication skills with a sound clinical knowledge base when caring for patients and their families.

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Rural community nurses and midwives working in isolated townships collaborate with GPs and specialist doctors who are located in major health districts. These medical officers then co-manage care with the local nurse or midwife by phone. Practice manuals provide risk-factor assessment tools and flow charts that direct the nurse or midwife to the most appropriate profes-sional for an expert opinion. For example, if a person is referred to a community nurse for a health problem and the nurse identifies through assessment that they have drug and alcohol issues, the nurse can consult the man-ual for further assessment instructions, management strategies and appropriate referral options. The issues relating to delivery of healthcare in rural communities are discussed in Chapter 4.

Independence in decision makingCommunity nurses and midwives providing care in the home make independent decisions and assume responsi-bility for decision making. This is especially true in rural and remote nursing in both Australia and New Zealand. When providing care, procedures and policies are in place to support them in the decision-making process. As well, case management meetings with a multidisciplinary team due to the development of technological communication advances. Care decisions that are based on sound practice and knowledge are made independently within the con-text of professional frameworks and workplace policies. However, the GP or other relevant medical practitioner must be consulted regarding medical needs for the per-son. Other team members are consulted for individual advice regarding care. For example, the input of a mental health or child health nurse may be required to address a specific problem. The community nurse and midwife, however, must have a sound theoretical foundation, as well as proficiency in clinical skills and the ability to solve problems creatively, providing the best outcome for the person.

AccountabilityThe responsibility of the community practitioner is always to act in the interests of the person to provide a service that is safe, evidence-based and meets quality and clinical governance standards. Nurses and midwives are account-able for ensuring that all problems identified in an assess-ment are addressed in the care plan along with interventions and outcomes. Documentation of assess-ment, care planning, evaluation of care and outcomes is the strongest evidence you can provide to validate your practice. Standards of practice, guidelines for practice, codes of practice, boundaries of practice, competencies standards and legislation that govern the profession are published by the various professional bodies (see Chapter 12 for further details). Nurses and midwives demonstrate their accountability to the profession by providing an exemplary standard of conduct when on duty.

scope of community practiceSpecialised knowledge and skills plus sophisticated tech-nology allow many people with acute and chronic health-care needs to be treated safely and effectively in the home. Nurses have developed advanced skills and practise as clinical nurse specialists, clinical nurse consultants and, more recently, nurse practitioners. Midwives commonly work in the community without additional education; however, scope exists for those with advanced training to practise as an ‘eligible midwife.’ Having notation as an eli-gible midwife on the register of midwives indicates that the midwife is competent to provide pregnancy, labour, birth and postnatal care to women and their infants; ser-vices and order diagnostic investigations appropriate to the eligible midwife’s scope of practice. An eligible mid-wife may also prescribe scheduled medicines in accord-ance with relevant State or Territory legislation once an endorsement for scheduled medicines under section 94 has been attained (NMBA, 2015). In New Zealand, the Mid-wifery Scope of Practice provides the broad boundaries and competencies of midwifery practice. Minimum com-petency standards have been designed to provide return to the practice guideline for those who have not practised for more than 3 years as a midwife in New Zealand. The Council has established the minimum standard that all midwives are expected to maintain in their ongoing mid-wifery practice (MCNZ, 2015). There are a range of oppor-tunities for nurses and midwives to practise in the community; see Table 5-1.

THE HOmE VISIT

Often on discharge from hospital, home healthcare people feel frightened, in pain, and abandoned, and family mem-bers often feel nervous about their new roles as carers. The community nurse and midwife must keep these concerns and needs in mind when planning and carrying out care. Implementation of healthcare in home visits ranges from teaching and counselling, lobbying and advocating, to hands on care, depending on geographical location and the context of the specific role and healthcare services in the community (Haley, 2016).

Pre-entry phase of the home visitReferrals to community nursing services can be made in writing on a specifically designed referral form, by phone or electronically. The referring agents are mostly public and private hospitals, GPs, private nursing agencies, aged care assessment teams, medical and surgical specialist services, allied health or people themselves. It is reasona-ble for a community nurse to accept a referral from an individual, undertake an assessment and contact the person’s doctor after the assessment is completed.

The referral to the community nurse or midwife con-tains a brief medical or obstetric history, reason for referral, the accurate address and phone number of the person

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taBLe 5-1 examples of community nurse and community midwife servicesarea of service type of service provided

Community nurse Care coordination and management, acute, postacute, rehabilitative, chronic care, palliative care and cancer care nursing, primary healthcare.

Community midwife Provides care across the continuum of pregnancy, birth and postnatal care.

Chronic care nurse Disease state management nurse

Long-term condition management, diagnostic, treatment bundle, self-management, prevention

Acute and postacute care (APAC) or hospital in the home (HITH)

Hospital avoidance programs, acute care (e.g. IV therapy), management of pulmonary embolism in the home.

Adolescent nursing services Counselling, outreach, health education, primary healthcare.

Aboriginal health nursing (Australia) Whānau Ora nursing (New Zealand)

Primary healthcare, advocacy, clinical services.

Alcohol and other drugs nursing Harm minimisation, pharmacotherapy, primary prevention, health education, detox, counselling.

Early childhood nursing (Australia) Plunket nursing or Tamariki Ora nursing (New Zealand)

Family and children’s services for children in 0–5 age range. Developmental screening, home visiting, linking community groups, parenting, immunisation, family support groups, toddler training.

Mental health nursing Prevention and promotion services, acute and non-acute assessment and treatment and ongoing recovery and rehabilitation.

Palliative care nursing Consultant and liaison role, end-of-life care, pain and other symptom management, grief and bereavement counselling.

Rural nursing Primary healthcare, clinical nursing, education and screening, immunisation.

Remote nursing Extended practice, trauma and emergency response, clinics, immunisation, screening, education, clinical nursing.

Specialist nursing: diabetes, dementia, continence, enterostomal therapy, wound management, respiratory, HIV, sexual health

Consultant and liaison role, research, education, individual assessments, physical examination, primary healthcare, education and policy development for colleagues, clinical services.

Nurse practitioners: wound management, Māori health, mental health, drug and alcohol, child and adolescent health, palliative care, remote and rural nursing

Advanced clinical practice, assessment, order diagnostic investigation, prescribe within clinical guidelines, refer to other health professional, approved procedures such as biopsy or sharp debridement.

Eligible midwife Advanced clinical practice, assessment, order diagnostic investigation, prescribe within clinical guidelines, refer to other health professional.

and written orders from a medical officer for any request that requires administration of a drug, injection or invasive procedure. As the community nurse assigned to the case you will review the information and make contact and/or schedule the initial visit. During this conversation, the community nurse determines whether the person’s carer can answer questions related to personal and family needs and can also learn about the person’s cognitive abilities, orientation and carer status. This information is important to plan the first visit.

The first home visit includes documenting a family’s current status as well as an environmental, community and social assessment (Haley, 2016). Safety for the visiting community nurse is an essential element for considera-tion. The person is asked to confirm the address, as well as who will be in the house, the safety of the neighbourhood, whether animals need to be restrained and whether there are any hazards associated with entry to the home. An example would be the need to cross a creek that is subject to flash flooding. A home visit should not be made if there are any potential risks to the nurse. An alternative service

could be offered, such as a clinic visit or meeting at the doctor’s surgery.

On referral and during the initial visit, as much infor-mation as possible is collected about the person’s health problems, surgical experience, socioeconomic status and treatments ordered. It is also understood that this initial contact is the first step in building rapport and making the person feel comfortable and confident about the visit.

In the pre-entry phase, the supplies that will be needed for the first visit, such as wound care products and educa-tional materials, are gathered. The following will need to be organised and taken to the first visit: a comprehensive assessment form, consent to share information form, plan of care form, signature sheet and any other documents relevant to the systems of the area health service. In some areas, nurses carry electronic devices for recording infor-mation. Most community nursing services have a home file that is left in the person’s home during the episode of care. This file contains the progress notes, care plan, path-ways, signature sheet and consent forms. If the person agrees, this file is used by other visiting healthcare providers

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for the purpose of continuity of care. The home file is also a very convenient communication tool for the GP doing the home visit and provides a place for the GP to write in changes to orders. The home file becomes part of the person’s medical record when they are discharged from the service.

entry phase of the home visitThe second phase of the visit is the entry phase. For safety reasons, it is advisable to ensure that home details are made available to someone at the community nurse’s or midwife’s work base before making a home visit. Specifi-cally, a list of names, addresses and phone numbers of people to be visited should be left at the base so that staff can follow-up on a nurse or midwife’s whereabouts if delays occur. Emergency numbers should always be keyed into the nurse’s or midwife’s mobile phone.

In the entry phase, the community nurse or midwife further develops rapport with the person and their family, makes assessments, identifies health issues or problems, establishes desired goals, plans and implements prescribed care, and provides teaching. It must be remembered that community nurses and midwives are guests in the person’s home and are offering services that the individual may accept or reject. Important considerations include negoti-ating frequency of visits, determining who will be attend-ing and giving the person some indication of what time of day the visit may be, for example, in the mornings or after-noons. It is not usually possible to give exact times because of emergencies that may arise.

It is essential to gain the trust of the person and their family and to recognise and respect their values. Accepting the person’s living conditions is necessary even when they differ from the nurse’s or midwife’s own conditions. The community nurse or midwife must ask permission before using the person’s home for activities such as hand-wash-ing. If there is a belief that the furniture in the person’s home or sick room needs to be rearranged to allow for use of equipment, or to remove safety hazards, the person should give permission before any changes are made.

rOLES Of THE COmmuNITy NurSE/mIdwIfE

advocateAdvocacy is the protection and support of another’s rights, and is an important role of the community nurse and midwife. An advocate is one who expresses and defends the cause of another. The nurse must ascertain the person and their family’s views and honour their tra-ditions regarding the locus of decision making (Chater, 2014). If the person or their family are not able to act in their own interest, the community nurse can act on their behalf, with consent to either assist or defend the cause. To advocate on a person’s behalf, the nurse should con-sult with the GP, other health professionals or other com-munity services for the purpose of drawing attention to

an issue or to effect change. In this way the best possible outcome for the person can be assured. This also applies to community-based midwifery. Midwifery places a strong emphasis on a woman’s right to make decisions that affects her care. In hospitals with the emphasis on the medical model, the community-based midwife may need to advocate on the woman’s behalf so that any medical intervention is delivered according to the wom-an’s wishes. Ideally, these wishes would have been nego-tiated in partnership with the midwife prior to admission to the hospital.

educatorIt is an important function of the community nurse or mid-wife to provide education about the disease process, about issues that may arise in the postpartum period and return to normal activities, transition to parenthood and the care of the newborn, nutrition and breastfeeding, elimination, medications and a range of treatments. The nurse or midwife identifies learning needs and then works with the person and their family to mutually develop goals for teaching information necessary to promote health. Family members or other carers may be taught any skill that they are able and willing to perform. The nurse or midwife provides the information necessary to keep the person safe until the next visit, using methods that work best in the home. The goal is to increase the person’s abil-ity to provide self-care. In community nursing where dependent people are more frequently encountered, edu-cation may be directed to ensuring the carer’s ability to care for the family member.

Care manager/coordinatorAs the coordinator of care, the nurse or midwife directs the various services towards a common goal of improving the person’s health and promoting independence. This model of practice is used in community nursing and community midwifery; however, a greater range of healthcare provid-ers may be involved with people cared for by a community nurse.

The community nurse is generally the coordinator of all other healthcare providers visiting the person, including specialist nurses, palliative care, aged care assessment services, chronic care team, enrolled nurses and health service aides. The community nurse is the primary source of communication and coordination of the person’s care and is required to keep the medical professional informed of the person’s progress. The nurse must use effective communication and professional language when convers-ing with health professionals. Remember the GP will be busy when they take a call from the nurse. The nurse needs to be concise with statements, be sure of facts and present them in an articulate professional manner. The nurse’s skill in communicating the seriousness or urgency of a situa-tion to another health professional is paramount in ensur-ing the correct response.

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Community nurses have many skills that are useful in program planning and policy development (Francis et al., 2013, p. 148). The community nurse as care coordinator provides the leadership to coordinate a case conference, inviting all relevant service providers, including the person and their family. The nurse is also required to know about and assist the person with accessing community resources such as support groups, day care centres and aged care services.

referral agentIn community practice, nurses and midwives often iden-tify the need to involve other services in the person’s care. In community midwifery, the wellness model and emphasis on the woman’s right to make informed deci-sions, influences the midwife to encourage the woman to self-refer to other services. However, community midwives may need to make referrals to mental health services, social workers, physiotherapists, lactation consultants or continence advisors. Community nursing and midwifery is based on a primary health model and referral to other services is an expected and frequently exercised part of the role.

As a care manager/care coordinator the community nurse or midwife has a major role in referring people to other services. It is the holistic nature of the comprehen-sive assessment conducted by the community nurse or midwife that puts them in a position to know what ser-vices are required. Some services may require a doctor’s referral and, it may be the community nurse or midwife who approaches the GP for a referral on behalf of the per-son. For example, if the community nurse conducts a wound assessment and on observation decides that the person’s circulation is compromised, and consequently that a vascular consultation is required, the nurse would

advocate for the person by contacting the GP for a referral to a vascular consultant. If, however, the person’s circulation was not compromised but the community nurse required expert opinion from a wound clinical nurse consultant or nurse practitioner regarding treatment, the nurse could make the referral directly.

The Needs Assessment Service Coordination (NASC) agency of New Zealand operates for each of the 21 DHBs and determines the person’s level of need. Hospital and community nurses can refer to this agency to access government-funded support for their clients.

The community nurse in Australia can make direct referrals to all Home and Community Care (HACC) and other state- and federal government-funded services as well as a range of private providers if the person requires assistance in the home (see Table 5-2). See the full range of HACC services on www.commcarelink.health.gov.au. Simi-larly, in New Zealand, the community nurse can access a range of public and private support services in the com-munity (see Table 5-3).

ClinicianThe skills required of the community nurse or midwife are determined by the scope of practice in the area in which they work. Community midwives are required to be experts in recognising deviations from normal pregnan-cies and birth in order to engage specialist care as early as possible. In order to practice as a community midwife, the practitioner must be competent in clinical skills that include speculum examination, perineal suturing, artificial rupturing of membranes and prostaglandin insertion. Midwives, like nurses, also need well-developed skills in grief and bereavement issues and health problems related to harmful behaviours and social issues. Both community midwives and nurses must have skills in cannulation and

taBLe 5-2 examples of home and community care (HaCC) services and other community services in australiaarea of service type of service provided

Home care and Indigenous home care

Personal care, housework, in-home respite, complex personal care needs for bedbound people and people with disabilities.

Community options Case management, brokerage services; for example, extended hours nursing care, personal care, home cleaning, home maintenance, respite and dementia-specific respite.

Home maintenance Home modifications; for example, ramps and bathrooms.

Community transport Transport to medical appointments, shopping, social outings.

Neighbourhood aid Transport, meals, shopping, washing.

Dementia care Daycare centres, respite, nursing management.

Multicultural support Supporting people from culturally and linguistically diverse backgrounds.

Disability network Developing opportunities for people with a disability to access social activities, respite.

Red Cross telecross Providing a daily phone call to people living alone to provide security and check how the person is.

Community aged care packages (CACPs)

Flexible frequent provision of service that best suits the recipient’s needs; for example, 5–7 day services assist with mobility and personal care.

Veteran’s home care Services for gold card veterans only. Basic housekeeping, shopping, personal care, respite care.

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taBLe 5-3 examples of home and community care services in new Zealandarea of service type of service provided

ACC Providing wheelchair, crutches, physiotherapy and transport, home help and income support for New Zealanders who have suffered an accident.

Access Homehealth Providing health support services for people in their homes and includes district nursing, home help and personal care.

CCS Disability Action Providing services and support for all people with disabilities.

Citizens Advice Bureau Providing a free, impartial and confidential service of information, assistance and referral to people in New Zealand communities, about any query or problem.

Age Concern New Zealand Not-for-profit, charitable organisation, dedicated to promoting the quality of life and well-being of older people, advocating positive healthy ageing for people of all ages.

venepuncture and the ability to monitor people’s progress and condition.

The community nurse who may care for individuals across the life span has a varied clinical role and is required to have experience in the application of a range of techni-cal procedures, advanced clinical skills and knowledge to be able to deal competently with health issues in a holistic way. The community nurse (generalist) will encounter people at home requiring care for: end of life; acute medi-cal conditions; chronic medical conditions; or complex wounds. Technically, the nurse requires the skills to man-age: postsurgical drainage devices; orthopaedic devices; vascular access devices; ventilators and other machines such as the vacuum-assisted closure (VAC) wound therapy system. The nurse’s knowledge supports the clinical decision-making process and judgement required to pro-vide expert care. Consider the following scenario and apply what you have read so far about the role of the com-munity nurse.

Hemi Tainui is a widower who lives alone in a Depart-ment of Housing flat located on the first-floor level of a three-storey building. Mr Tainui has just been to see his doctor about an ulcer on his left leg. He has a history of chronic arthritis, hypertension and oedema, and has had a recent left hip replacement. He has been on the waiting list for 18 months for a right hip replacement and is suffer-ing constant hip pain. Mr Tainui is referred by the GP to the community nurse for leg ulcer dressings. The GP requested ‘attend dressings at discretion of community nurse.’ Reflect on the many aspects of the role of the community nurse and consider how best you would meet Mr Tainui’s health needs.

● What are the issues the community nurse considers when assessing how this person will manage at home?

● What would be the major goals of care for Mr Tainui? Are the ‘dressings’ the only thing to consider?

● Is there a case for advocacy on behalf of this person?● Would you consider education regarding his nutrition

important, and, if so, why?● Is there a role for other services in his care? What

role would the community nurse play?

rESPONSIbILITIES Of THE COmmuNITy NurSE/mIdwIfE

assessmentThe ability to assess people and their family carers accu-rately is an important skill for community nurses and mid-wives. Most of the initial assessment takes place during the first home visit, although ongoing focused assessment occurs during subsequent visits. The nurse or midwife must be skilled not only in physical assessment but also in psychological, socioeconomic, environmental, spiritual and cultural assessment. Skilled assessment allows for col-laboration with the person to identify health issues and problems, discuss desired outcomes and plan care.

A good communication technique provides the plat-form for skilled clinical assessment. In order to do this the nurse and patient must develop a trusting relationship that ensure a sense of mutual understanding of the situa-tion and role that each play. A connected relationship is one in which both parties become involved to the degree that they perceive each other as people first, and their roles as secondary (Stein-Parbury, 2013). The role of the nurse or midwife is in a professional capacity, caring for the person via the transfer of knowledge skills and educa-tion. This then assists the person to take a more autono-mous role in the decision-making processes. Besides the basic skills of communication, such as introduction, space, body language, listening, reflection and trust, it is impor-tant for the nurse or midwife to understand that there are other considerations. Indeed, the person who is ill, or in the case of a pregnant woman, worried or facing an unknown situation, may feel powerless and confused about their options.

The initial phase of the assessment is introductory. This is the time for introductions and an explanation of the reason for the interview. Demographic data, including cultural information, contact details, next of kin, address and occupation details, is collected, and mandatory infor-mation regarding Aboriginality, pension or Medicare num-bers are recorded. Asking questions regarding the person’s family support systems such as who they live with, where their nearest family member or supportive friend lives or

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who can assist them with daily living activities if required, their financial situation and transport system will provide some insight into the social situation and the support sys-tem of the client. At this point the history of the presenting problem is sought along with past medical, surgical and family history.

The second phase of the assessment as described ini-tially by Roper and colleagues (2000) suggests a focus on the activities of living (ALs) as a model that enables per-son-centred assessment. The AL framework defines a model based on a dependence–independence continuum across a life span, the dependence pole of the continuum referring to birth and early childhood, moving to total independence in adulthood and changing back to dependence at times of illness or other circumstances.

Holland and colleagues (2008) support Roper’s claim that there are five influencing factors that are used to explore each AL from a person-centred perspective: biologi-cal, psychological, sociocultural, environmental and politico- economic. Questioning the person in regard to each AL from the perspective of the five influencing fac-tors provides an individual collection of data that forms the basis for the person-centred approach to care. This may seem to be a time-consuming exercise; however, with practice and experience you will develop intuitive prob-lem-solving skills and pick up on the cues that will direct questioning. For example, if you are assessing the person’s eating and drinking AL and recognise that they live alone, have poor mobility and do not drive, this would raise questions about how they shop and cook, and whether meals on wheels are available. Similarly, if the person had a low body weight or an empty refrigerator you may be alerted to questioning them regarding their attitude and motivation to eating.

In community midwifery, the primary assessment, known as the antenatal check, may be performed in a clinic environment where the woman presents or in the person’s home. At this point it is imperative that the woman is correctly identified as being suitable for man-agement in a community-based model. In addition to the physical assessment, the woman must be assessed psy-chosocially and any health problems such as depression or social problems such as abusive relationships identified. In the postnatal period, assessment may relate to identifica-tion of breastfeeding problems and involve newborn assessment and tests such as serum bilirubin screening.

Throughout the process of questioning, the commu-nity nurse or midwife begins to understand the needs of the person in terms of their feelings, living situation, cultural needs and economic situation and can structure a collaborative plan of care according to this. Issues that are identified during the initial assessment may lead to further assessment for the purpose of clinical interven-tion. For example, if the person has a wound, then a wound assessment will be required to determine the most appropriate method of management. Similarly, if the person is incontinent, a continence assessment will

be required to establish the cause of the problem and outline the management.

As the assessment process is ongoing, there will be other opportunities to conduct other health screening activities that will be useful in assisting with the manage-ment of the person’s health. For example, the quit- smoking screening tool (Fagerstrom test) can be found at www.quitsa.org.au/aspx/addiction_questionnaire.aspx.

identifying health problemsThe next stage of the person-centred approach to nurs-ing and midwifery care is the identification of actual health needs, issues and problems. This is a collaborative process by the nurse or midwife and person and, when necessary, family carers are included. When actual health problems are identified, interventions are planned in agreement with the person and realistic outcomes are developed. The ability of the nurse or midwife to identify health problems in communities has been enhanced by contemporary education that places PHC at the core of most curriculums.

Planning careWhen developing the plan of care, the nurse or midwife and the person set realistic goals regarding the expected outcomes of care, plan what exactly the care will be and who will be providing that care. It is good practice to include any identified issues, the details regarding the interventions, the expected outcome and an evaluation date on the care plan. This clarifies the expectations of the person and ensures that all other health visitors are clear about their role. It is also a good practice for the person to sign the care plan to certify that the decisions have been made collaboratively and they understand and agree with the plan. It is advisable to make a statement in the nurs-ing/midwifery notes that verifies the collaborative nature of the care planning.

implementing careImplementing care is not always straightforward, as the care provider may be the community registered nurse or midwife, enrolled nurse, health aide or nursing assistant, or any other community worker. Often the care provider is the family carer or even the person themselves. If the enrolled nurse or health aide or other health or commu-nity employees are to provide the care, the community registered nurse or midwife must write the plan of care, discuss it with the relevant worker and provide instruction and guidance regarding care. If the family carers or the person are providing the care or conducting a procedure, the community registered nurse or midwife will be required to provide education and instruction regarding the care and will be required to provide ongoing assis-tance and observation until the carer or person them-selves are proficient in the procedure.

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The registered community nurse or midwife will remain responsible for the person’s care throughout the episode of care and will provide clinical intervention, ongoing assessment and review of care plan and evaluation of care. With the person’s consent, relevant information and feed-back is provided to the GP, medical specialist or other healthcare providers who may be involved. Feedback to other healthcare providers may be in writing through a letter or a copy of a care plan, verbally by telephone or electronically by encoded email if available in the relevant health service. All sharing of information can be done only with the person’s consent.

evaluating careEvaluating care is conducted as an ongoing process as changes in the person’s condition become evident. For instance, if a person fails to respond to an intervention or shows improvement in a condition, the care will be changed accordingly. Even though care is being evaluated progressively, it is advisable to record an evaluation date on a plan of care, as this will prompt reassessment and initiate change. For example, if a person is on a wound pathway and a variance away from the expected normal pathway is noted, the nurse must respond by addressing the change. Failure to achieve the planned outcomes may mean that the outcome was unrealistic and new goals must be set.

Documenting care given in the homeDocumenting care given in the home is mandated by leg-islation and the relevant regulatory authority. The visit may be documented on preprinted forms, checklists or progress notes, or electronically. Progress notes are made to document each visit and must accurately describe the person’s condition, the skilled care provided, the person’s response, their progress towards discharge and an ongo-ing plan for continued care. Other forms of documenta-tion negate the need for writing a progress note on every visit. For example, a clinical pathway dated and signed, with each intervention ticked off and variances recorded or a plan of care with explicitly recorded intervention dated and signed are both acceptable. If using the plan of care or pathway as documentation, the progress note must be updated at least weekly.

fAmILy ANd CArEr NEEdS

Today’s emphasis on home healthcare means that fam-ily carers must carry increased responsibilities. People are being discharged from hospitals ‘quicker and sicker.’ Chronically ill people may need long-term care at home, leaving family members to face the challenges of handling equipment, providing new types of care to loved ones, and dealing with unfamiliar and often ter-rifying sounds, odours and substances. Most carers are

women, and many of them are older than 65 years of age. Older women may themselves have health prob-lems or may not have the physical strength or energy to care for their partner or family member. Even family members who are themselves nurses may find that providing care at home is very different from providing care in the hospital.

Kralick and van Loon (2011) identify that community nursing often involves helping a carer to provide care through an assessment of needs, interdisciplinary com-munication, education and appropriate follow-up sup-port. The nurse also supports family decisions about complex treatments or end-of-life care.

The Australian Department of Veterans’ Affairs (DVA) carer strain index is the tool used by many community nursing agencies to measure carer strain. The tool pro-vides a list of questions and a scoring system that indicates the level of stress a carer is experiencing; there is also an action box to prompt the nurse and carer to discuss pre-ventive strategies. The career strain index can be accessed on the DVA website at www.dva.gov.au.

CONTrOLLINg INfECTION

The use of infection control techniques is important to avoid spreading infection from one person to the next. To prevent the spread of infection, nurses and midwives should use appropriate techniques when handling their equipment bags, including the following:

● Only take what is required into a person’s home and never return products that have been in a person’s home to the general stock supply.

● Perform hand hygiene before touching the person; before reaching into the bag for supplies; before under-taking a procedure and when completing a procedure.

● Clean any equipment removed from the bag before returning it to the bag.

● Place the bag on a liner when setting it down in the person’s home.

Of all the methods used to prevent infection, hand hygiene is the most important, and is necessary before and after treatment. Nurses and midwives use standard precautions during home visits, including wearing gloves and goggles when in contact with blood, body fluids, secretions, excretions and contaminated items. Clean gloves should be put on just before touching areas of bro-ken skin or mucous membranes. See Chapter 33 for a detailed overview of infection control.

Recall Mr Hemi Tainui and add the following reflection to your learning:

● What are the possible sources of hand contamination that may occur when you are undertaking a home visit to Mr Hemi Tainui?

● How would this differ to a hospital-based situation?

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CONTINuITy Of CArE

As discussed at the beginning of this chapter, continuity of care is a primary aim of hospital and community nurses and midwives. Even though continuity of care is multidi-mensional and interdisciplinary, the nurse or midwife is the most constant person involved in the person’s care and therefore takes on a leadership role in planning care. Both hospital-based and community health services use the concept of continuity of care to describe a seamless transition for the person from one health setting to another. Continuity is provided when care is developed by a collaborative interdisciplinary team of health profession-als. This is achieved in a number of ways: communication between interdisciplinary team members; case conferenc-ing; care planning; discharge planning; one health record or an electronic health record; access to databases that contain clinical information such as pathology or x-ray results; good documentation of health problems and liv-ing situation and communication with other service pro-viders, particularly the local GP. The process of achieving continuity of care will be discussed throughout this sec-tion of the chapter.

Continuity of care between community and hospitalIf a person is admitted to a hospital or day surgery centre, the community nurse or midwife is able to provide written or verbal information regarding the person’s current situa-tion at home to assist the inpatient staff plan ongoing care and discharge. Information such as the person’s current health status, current interventions, family carers, the per-son’s functional ability and psychological status, informa-tion regarding the person’s existing community services, and the name and phone number for the person’s commu-nity nurse and HACC case manager will be helpful to the hospital staff. The number of the community nurse or mid-wife is essential for ongoing communication during the episode of care and on discharge. The person’s HACC ser-vice case manager will inform other HACC service providers of their admission to and discharge from hospital, reducing disruption to other community services and ensuring ser-vice commences as soon as the person is discharged. If it is helpful, the person may take the community nursing home records to the hospital or day surgery centre to ensure that the staff have the most up-to-date health information.

It is common for a person to be moved within settings as well as between settings, and the sharing of informa-tion is paramount in achieving good outcomes for care. Examples of transferring within and between settings include the following:

● People are often moved within the hospital, for exam-ple, from the emergency room to a hospital room, from an intensive care unit (ICU) to a hospital room (and vice versa), from one floor to another or from one room to another room on the same floor.

● People are transferred to and from acute care settings and long-term settings.

● People are transferred from acute care settings to their homes.

● People are transferred from ambulatory care settings to acute care settings.

● A woman planning a homebirth may develop complica-tions and be transferred to hospital.

When a transfer occurs, the person must readjust to new surroundings, new roommates, new routines and new people providing care. You may not be responsible for the actual physical move but you are responsible for ensuring that the comfort, safety and teaching needs of the person and their family are met. Although documenta-tion and procedures differ depending on the institution and type of transfer, the person’s needs are always a prior-ity in ensuring a smooth transition and continuity of care.

admission to hospitalChanging demographics (increasing numbers of older adults), increasing chronic illness and the increasing avail-ability of costly medications and treatments have all led to a demand in the improvement of the coordination of care between health facilities and community. Many people cared for by community nurses have chronic health prob-lems and frequently require readmission to hospital. The Australian institute of Health and Welfare’s report, Austral-ian hospital statistics 2011–12, reveals that the number of hospital admissions for people aged 85 and above rose by 9% each year between 2007–08 and 2011–12. This com-pares with an average increase of 4% per year overall for hospital admissions over this period (AIHW, 2013). As well, there are increasing numbers of people having surgery, diagnostic tests and emergency care in purpose-built day hospitals, ambulatory care settings or in hospitals as a one-day-only admission. Improved technologies such as vacuum pumps for intravenous drugs enable many people to receive part of their care at home.

The flow of people between services should be seam-less. Consequently, community nurses may care for people who revolve in and out of hospitals on a frequent basis. Therefore, they must have intimate knowledge of admis-sion and discharge processes within hospitals. This flow can be impacted on when unexpected circumstances occur such as when woman and her family who had cho-sen a community-based model of maternity care but need admission to hospital.

In most hospitals, admission begins with recording the person’s demographic information on an admission sheet which becomes part of their permanent record. Optimally, the same identification number should be applied in the community nurse’s documentation so that the community record becomes part of the person’s health record. The identification number, as well as the person’s name and medical officer’s name (and any other information required by the particular institution), is printed on the identification

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bracelet that is placed on the person’s wrist. This bracelet is an important safety component during the person’s stay because it accurately identifies the individual for procedures and treatments, including medication admin-istration, diagnostic tests and surgery. The bracelet is worn by all patients, and is especially important as a means of identifying those who are irrational, comatose or very young. In some cases, the community nurse is the only person that can supply relevant social and health-related information that can be used for the admission.

transfer of care from hospitalPlanning for continuity of care, which has been more com-monly referred to in hospital-based settings as discharge planning, ensures that personal and family needs are con-sistently met as the person moves from the acute-care set-ting to care at home. The term has now changed to transfer of care, indicating that a person’s care continues beyond hospital as they receive care from another service/facility in the community. The policy directive, care coordination plan-ning from admission to transfer of care in New South Wales (NSW Health, 2011) displays the approach currently taken with the discharge procedures and care for patients from acute settings: www.health.nsw.gov.au/policies/pd/2011/PD2011_015.html. Essential components of planning include: assessing the strengths and limitations of the per-son, their family or support person, and the environment; implementing and coordinating the plan of care; consider-ing individual, family and community resources; and evalu-ating the effectiveness of care. The key to successful planning is an exchange of information between the persons them-selves, the carers and those responsible for care while the person is in the acute-care setting and after they return home. This policy directive applies to clinical staff involved in the care of inpatients. It outlines a five stage process to guide individuals and staff through the hospital stay.

Implementation of this approach will enhance out-comes, safety and experience (NSW Health, 2011). See Box 5-1 for groups of people most requiring complex dis-charge planning.

State Health Departments in Australia and the Ministry of Health in New Zealand have issued strict policy stand-ards regarding discharge planning, and compliance is mandatory. At the time of first contact with the person, a ‘transfer of care risk assessment’ (TCRA) or equivalent should be completed by the clinician. A TCRA is used to identify those people who may have needs that require further assessment and follow-up before they are trans-ferred home or to ongoing care from the acute hospital service (NSW Health, 2011).

Factors to assess in discharge planning include evalua-tion of the person’s ability to carry out activities of daily living (bathing, dressing, toileting, transferring, conti-nence and feeding) and instrumental activities of daily living (using the telephone, shopping, preparing food, doing housekeeping and laundry, taking medications and

accessing transportation). In the case of a new mother, issues such as the availability of social and community supports and her confidence to care for her newborn would be considered.

With earlier hospital discharges, people are often still acutely ill when they go home, and many require compli-cated treatment and care by family members. Family members are expected to change sterile dressings, moni-tor intravenous medications, manage high-technology equipment, give complete physical care and prepare spe-cial diets. Teaching carers how to undertake procedures takes place while the person is still in hospital. This teach-ing is a nursing responsibility that must be documented appropriately. In the maternity context, new mothers may be discharged before they have established breast feed-ing. Well informed family members, as well as community services such as the Australian Breast feeding Association, can support women through the transition to achieve suc-cessful breast feeding.

If the person is sent home without follow-up support and the carer is inadequately prepared, the person will possibly experience an exacerbation of the illness or com-plications that could require readmission or additional treatment. In most major health areas in Australia there are teams such as acute and postacute care (APAC) or HITH as well as community nursing services that can provide acute care in the home and support family carers.

In rural and remote areas, access to postacute service teams may not exist; however, there will usually be a community nurse or a nurse practitioner to provide the ongoing acute care. Distance provides the greatest bar-rier to medical, pharmaceutical and allied health ser-vices in remote and rural areas, and nurses need to be aware of this when discharge planning and make allow-ances. This may mean keeping the person in hospital longer or at least sending home adequate supplies of medications and products that they would not normally have access to.

bOx 5-1 transfer of care standards sensitive to the needs of the following groups of people

● Newborn babies and children who are vulnerable ● Indigenous people ● People with complex healthcare needs, such as:

– a physical disability– dementia– mental illness– a life-limiting illness

● People who:– are socially isolated– have a carer– are old– are veterans– live in supported accommodation

● People from linguistically and culturally diverse backgrounds

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If care required at home is more in terms of chronic disease management, there is a variety of options in differ-ent states of Australia to provide short-term, postdis-charge services. For example, in New South Wales there are short-term (6-week) postacute care packages for aged people or people with dementia who require multiple home services to support discharge. This short-term ser-vice allows more time for other long-term community services to be arranged.

Chronic care teams provide discharge follow-up and ongoing rehabilitation and management strategies. Com-munity nursing services are available to provide clinical nursing care. The provision of medical equipment may vary between health services; however, there are leasing companies that hire out equipment such as beds and hoists.

There is often a waiting list for the more long-term HACC service provision and this is a factor nurses must consider when discharge planning. If there is a HACC ser-vice case manager to assist with planning for services at home in the health area, it is advisable to include this per-son in the discharge planning. People who are frail or aged and young people with a disability are eligible for HACC services.

There are many private community services available for people who are willing to pay for services and some private nursing services that may be covered by medical benefit funds for short-term follow-up. Actually, most people being discharged from hospital are independent in caring and mobility and require no follow-up treatment at home; however, all people leaving hospital must be given a hospital contact number to phone if they experi-ence an adverse event, and most people are given written information regarding ongoing care. In rural and remote areas there is increasing access to telehealth opportuni-ties, which include sending digital photographs by email to a clinical expert, video-conferencing with clinics in metropolitan areas such as diabetes clinics, and other specialist medical services. (See Chapters 7 and 20 for more information on electronic communication.)

There are mandatory ‘must do’ components of the discharge standards for patients (see Box 5-2), the most

important one in terms of continuity of care being the transfer of care risk assessment (TCRA) tool. The tool con-sists of five questions that relate to the person having self-care problems on discharge: whether they live alone; whether they have caring responsibilities for a family member; prior use of community service and whether they usually take three or more medications, including whether their medications have changed in the last 2 weeks. A multidisciplinary team will then work collabo-ratively to ensure that the person’s needs are met through a treatment plan, incorporating the transfer of care risks and the estimated date of discharge (EDD). This is done to alert all staff to the need for transfer of care follow-up and to prevent adverse events. The remaining critical ‘must do’ is to record the EDD and inform the family and person of this date. The EDD is noted by medical staff; however, if the medical staff member is not available, most area health services will have an alternative action plan. One may be to have a list of expected length-of-stay estimates for each diagnostic-related group; this will provide a guide for discharge planning and avoid delays in planning care.

teaching for dischargeImportant teaching topics about self-care at home must be covered before discharge. These topics include medica-tions, procedures and treatments, diet, referrals and infor-mation about changing health status.

The person needs to understand the drug name, dosage, purpose, effects, times to be taken and possi-ble side effects. Information about medications should be given both verbally and in writing. All steps of a procedure (e.g. dressing changes) should be demon-strated, practised and provided in writing. The person or carer should then perform the procedure or treat-ment in the presence of the nurse or midwife to dem-onstrate understanding. The carer should know the purpose of what is being done and how to get supplies. The community nurse or midwife will provide further teaching at home if necessary.

All aspects of the illness or effects of treatment should be clearly described, both verbally and in written materi-als. Many forms of written information are available. They range from printed literature (e.g. from the Heart Founda-tion) to teaching materials developed by the healthcare facility (see Box 5-3 for an example of discharge planning).

transfer of care summary and appointmentsAppointments for the first visit to a GP or allied health professional are often made before discharge. Written verification of the appointment is given to the person by the nurse or midwife. A discharge summary covering the items listed in Box 5-4 is sent, by post or, most com-monly, electronically to the person’s GP in a timely man-ner. Staff must use the transfer of care checklist. The nurse unit manager, or in many cases, a nurse in the

bOx 5-2 mandatory transition of care requirements

Each health service is required to meet the standards outlined in this policy. Admitted people should transition through five stages of care coordination:1. Preadmission/admission2. Multidisciplinary team review3. Estimated date of discharge (EDD)4. Referrals and liaison for transfer of care5. Transfer of care out of the hospital

Source: NSW Health, 2011.

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carer to establish how the person’s daily activities of living will be managed at home. An occupational therapy home visit will be required to assess how the person will access the home from drive-way to inside the house, and to assess how the person will access toilet, shower and bedroom. The occupational therapist (OT) will assess equipment needs such as grab rails, hoists and shower hose and chair, and home modifications such as the requirement for a toilet and shower on the lower level of the house. The person may have to live on the ground floor level of the home initially, as the stairs may be too difficult for him. The OT or physiotherapist will also be required to assess the person’s mobility and teach the person and the carer how to mobilise and use equipment such as hoist, wheelchair and walking frame. The nurse will be required to educate the carer in catheter care, medication administration and other caring procedures. A referral will be made to community nursing for the person’s ongoing health needs. A referral will be made to a community service case manager to arrange services in the home such as transport, personal care assistance and help with housework. The dietician will provide dietary advice; the doc-tor will provide medication prescriptions and a medical discharge summary. Ongoing speech and physiotherapy appointments will be arranged and a social worker will assist with applications for financial assistance.

A discharge summary is prepared by all members of the mul-tidisciplinary team with an electronic copy being sent to the GP within 48 hours of the person being discharged. The person and carer are given support group information for people who have had strokes. Although Mrs Connors still expresses concern about providing care at home, she says she feels more in control now. At the time of discharge, the nurse tells the Connors that someone from the hospital will call them the next day, and gives them a contact number to phone if they have concerns or an emergency.

bOx 5-3 a transfer of care example

Mr Connors is a 55-year-old married man, admitted to the hospital with a diagnosis of stroke. He now has left-side weakness and dif-ficulty communicating verbally. He has had a history of high blood pressure for 10 years. If his blood pressure remains stable, Mr Con-nors is to be discharged from the hospital in 3 days. He will be going home with four new medications and an indwelling urinary catheter. A low-sodium diet is prescribed.

After reviewing the medical record, the nurse interviews Mr and Mrs. Connors. The assessment reveals that Mr Connors has a limited ability to transfer from bed to chair. Both Mr and Mrs Con-nors are fearful of discharge. Mr Connors believes he will be able to return to work as an accountant in 3 weeks and hates the thought of being an invalid at his age, but Mrs Connors thinks he will never work again. They have never faced a life-threatening or disabling illness in the past. They have no strong cultural preferences for diet. They have two adult children who live interstate with their own families. The Connors live in a suburban area in a two-storey home with narrow stairs leading to the second floor’s two baths and three bedrooms. Their doctor’s office is about 1 km away, and a shopping centre is nearby.

Mrs Connors is worried about managing care of the catheter and moving Mr Connors in and out of bed. She needs instruc-tion in the new medications and diet regimen. She is terrified that she may be unable to handle an emergency in the middle of the night. Financially, this two-income family has abruptly become a one-income family. Mr Connors is not 65 years old and thus is not yet eligible for a pension and Mrs Connors may have to take leave from work to care for her husband.

PlanningHow would the nurse coordinate this discharge plan? Conduct a multidisciplinary team case conference including the person and

discharge planning role is responsible for ensuring that these details are checked, completed and agreed to by the person before leaving the hospital. Referrals are posted or hand-delivered by the person to the relevant service. It is most important to record accurate contact details and address.

In meeting the needs of the person being discharged from a healthcare setting, nurses consider that the per-son may be expecting a change from a dependent role to a more independent (self-care) role. People are dis-charged from a healthcare facility when the expected outcomes of care are met and the person or carer has the necessary knowledge and skills to provide care. Although discharge is almost always a welcome event, it also can be stressful.

Leaving the hospital against medical advicePeople sometimes decide to leave the hospital against medical advice (AMA). Although they are legally free to do so, this choice carries a risk of increased illness or compli-cations. A person who decides to leave AMA must sign a form that releases the specialist medical consultant responsible for care and the healthcare facility from any legal responsibility for their health status. The person is informed of any possible risk before signing the form. Their signature must be witnessed and the form becomes part of their record.

bOx 5-4 transfer of care checklist must cover the following information

● Estimated date of transfer ● Destination of transfer ● Notification/transport booked ● Personal items returned ● Referral services booked ● Care plan ● Transfer of care summary provided to person that includes

medication information, community and GP referral information, and follow-up appointments

This should be provided in plain language and explained.

Source: NSW Health, 2011.

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DeveLOPing KnOwLeDge sKiLLs

In this chapter, you have been learning about community-based practice and the roles and responsibilities of the community nurse and midwife.

What have you learnt?

● The principles of primary healthcare and their applica-tion to practice

● The issues relating to person-centred holistic assess-ment in a community setting

● The role and importance of the family carer for commu-nity nurses and midwives delivering care to people in their homes

● To have an understanding of each stage of the home visit including the key procedures and protocols required when visiting people, their carers and families

● The ability to apply infection control in home care to avoid spreading infection

● How to plan for continuity of care as people move from hospital to home care

● How to plan for transfer of care of a person from hospital.

resOurCes

For an extensive range of additional resources to enhance teaching and learning and to facilitate understanding of this chapter, please see the text’s accompanying website located on at http://thepoint.lww.com.

DeveLOPing CritiCaL tHinKing sKiLLs

1. Interview a nurse or midwife employed in a hospital setting and one employed in a community healthcare setting. How are their roles and responsibilities alike? How do they differ?

2. Interview a classmate or family member who has been admitted to a hospital. What were their concerns on admission? How did those concerns differ from those experienced on transfer of care?

3. Compare and contrast the needs of the following peo-ple and their families:a. A 2-year-old who is discharged from ambulatory sur-

gery centre after minor surgeryb. A 34-year-old woman who is discharged home after

treatment for a fractured arm in the emergency roomc. A 78-year-old man who is being transferred from the

hospital to a nursing home.

review QuestiOns

1. In general, how does community-based nursing and midwifery care compare with hospital-based care?a. Care provided in the home is no different from

hospital-based careb. Home care people do not have the same basic needs

as those in the hospital

c. In the home, care must be adapted to the person’s schedules and customs

d. The family or carer’s role is less important in home care

2. Although the community nurse/midwife follows an established plan of care, they are more independent in what role?a. Deciding which doctor’s orders can be followedb. Assuming responsibility for decision makingc. Shifting accountability for care to family carersd. Delegating advanced clinical skills to unlicensed

personnel

3. Although all of the following skills are important, what would be the most important to effective coordination of care and services?a. Physical assessmentb. Knowledge of the lawc. How to use equipmentd. Effective communication

4. Which of the following activities would the nurse/ midwife do in the pre-entry phase of the home visit?a. Call the doctor for a referral orderb. Conduct a health history and physical assessmentc. Collect information and schedule a visitd. Establish mutually acceptable goals for care

5. Before washing their hands, what might a community nurse/midwife ask or say to the person/carer?a. ‘I need to wash my hands. May I use your bath room?’b. ‘I’m going to wash my hands in your bathroom.’c. ‘I will wash my hands after I leave so I don’t bother

you.’d. ‘How often do you wash your hands?’

6. What one activity is most important in preventing infection when providing home care?a. Wearing gloves whenever touching the personb. Following proper procedures for sterile dressing

changesc. Asking the carer to step out of the room during visitsd. Performing hand hygiene before and after care

7. How often must a community nurse document progress notes?a. Once a weekb. At the initial visitc. At each visitd. At the final visit

answers witH ratiOnaLe

1. The correct answer is c. In the hospital, people must conform to established schedules for treatments, medi-cations, meals and visitors. In contrast, in the home it is the person or carer who establishes the schedule and controls the environment.

2. The correct answer is b. The community nurse/midwife is more independent and assumes responsibility for

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decision making. None of the other answers is legally or ethically correct.

3. The correct answer is d. The community nurse/midwife must use effective communication skills with other healthcare providers while coordinating services.

4. The correct answer is c. During the pre-entry phase of the home visit, the nurse/midwife collects information and schedules the first visit.

5. The correct answer is a. The nurse/midwife must ask permission before rearranging furniture or using facili-ties for hand-washing.

6. The correct answer is d. Performing hand hygiene before and after caring for the person is critical in pre-venting infection.

7. The correct answer is c. The community nurse/midwife must document progress notes at each visit.

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weB resOurCes

australiaCommunity programs and guidelinesAcute management of children and infants with asthma policy direc-

tive: www.health.nsw.gov.au/policies/pages/default.aspxCarer Strain Index; Nursing Assessment Form; Community Nursing

Pathways: www.dva.gov.auChronic care standards: www.health.gov.auDischarge standards: www.health.nsw.gov.auDischarge packages South Australia: www.health.sa.gov.au/packagesDischarge from hospital pathway, process and practice: www.dh.gov.

uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/ documents/digitalasset/dh_4116525.pdf

Community servicesCommonwealth Government Carelink Centres: www.commcarelink.

health.gov.auHome and Community Care Program: www.health.gov.au/internet/

main/publishing.nsf/Content/hacc-index.htmNational Directory of Aged Care: www.agedcareonline.com.au

Community nursing and midwifery organisationsAustralian Practice Nurses Association: www.apna.asn.au/scripts/cgiip.

exe/WService=APNA/ccms.rAustralian Faith Community Nurses Association: www.afcna.org.auCongress of Aboriginal and Torres Strait Islander Nurses: http://catsin.

org.auCouncil of Remote Area Nurses of Australia: www.crana.org.auRoyal District Nursing Service: www.rdns.com.au/about-us

new ZealandCollege of Nurses Aotearoa (NZ) Inc.: www.nurse.org.nzMāori Health: www.maorihealth.govt.nzNational Council of Māori Nurses/Te Kaunihera O Nga Neehi Māori O

Aote: www.ngangaru.co.nzNew Zealand College of Midwives: www.midwife.org.nzNew Zealand Family Services: www.familyservices.govt.nzNew Zealand health statistics: www.health.govt.nz/nz-health-statisticsNew Zealand Ministry of Health/Manatu−Haurora: www.health.govt.nzNursing Council of New Zealand/Te Kaunihera Tapuhi o Aotearoa:

www.nursingcouncil.org.nz/index.cfm/1,25,html/HomeMidwifery Council of New Zealand/Te Tatau o te Whare Kahu: www.

midwiferycouncil.health.nz

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