Conceptualising a model to guide nursing and midwifery in the community guided by an evidence review

In high income countries, healthcare systems have been guided by international policies underpinned by principles of public health and primary care. Inherent within this philosophy of care is the need for integration and closer collaboration between primary and secondary services and teams [16, 17]. Integrated care necessitates the inclusion of collaborative links between all sectors of the health service. Such links assist in seamless transitions for people with health issues and ensures the well-being of the entire population [6, 17]. Equally, this constitutes an important factor in guiding community-based nursing and midwifery approaches. The twin concepts of integration and collaboration are key to providing care to patients/clients with complex needs e.g. chronic diseases, as well as delivering preventative care. Papers specific to integration and collaboration referred mainly to home-based care [18‐21], collaborative care [22‐25], and case management [26‐28], with the majority of these interventions led by community-based nurses including practice nurses, nurse practitioners/advanced nurse practitioners, public health nurses, specialist nurses, and multidisciplinary teams.

Directors of public health nursing (DPHN) revealed a number of initiatives to address the challenges relating to fragmented health services both in Ireland [29] (Nally: Response to Email to Director of Public health Nursing (DPHN), unpublished; Burke: Response to Email to Director of Public health Nursing (DPHN), unpublished) and in other jurisdictions [30, 31] with the aim of achieving better integration and collaboration. Examples include Virtual Wards [30] for the integration of health and social care for people with multiple chronic conditions in the community, and Integrated Care Pilots in the UK, yet efficacy and patient service evaluations were often mixed [31]. High quality evidence demonstrates the positive value of nurse-led interventions as an alternative to physician-led care [20, 26, 32‐36]. Martinez-Gonzales et al. [37] in a high quality global systematic review and meta-analysis (n = 30,247) found that nurse-led care for chronic disease management compared favourably with physician-led care when nurses were adequately trained to manage complex conditions with collaboration through minor support and short communication with the physician. Substituting nurse specialist-led interventions for physician-led in primary care is recommended in relation to continence management [33] and diabetes management [34]. Furthermore, Nurse Practitioners (NPs) providing complementary or alternative primary care have equivalent or better patient outcomes than physician-led care and are potentially cost saving. Although consultations were longer, patient satisfaction was higher [36] but as evidence is sparse, more research is needed on economic analysis [18, 22, 33, 35, 36]. In addition, midwife-led models of care for low-risk women have been found to be cost effective, safe, require fewer interventions, and result in greater continuity and satisfaction for women [38‐40].

To enhance clinical practice, administrators and providers of services need to undertake a needs analysis to determine the priorities for action. In enabling such a process, targets need to be clearly defined and person-centered [27, 32, 37, 41]. Access to specialist in-patient services integrated with appropriate community intervention is seen as the most efficient use of resources [19, 20, 25]. Primary and secondary prevention focused on health and wellbeing could be seen as inexpensive interventions that could be included in primary care by a nurse or other members of the multidisciplinary team [42‐45].

Organisation and delivery of nursing and midwifery care in the community is framed within the context of prevention (primary, secondary and tertiary), transitional care, and home-based care. Evidence for primary prevention comes mainly from the domain of maternal and child health. With regard to postnatal maternal and infant care, there appears to be benefits to home visits by trained specialist nurses when providing theoretically underpinned interventions with specific person-centred outcomes [46‐53]. However, evidence is inconclusive due to the high risk of bias in RCTs. A Cochrane review concluded that valid and reliable outcomes for maternal and infant health, specifically educational interventions, are needed to properly establish these benefits [46]. The interventions had at their core a focus on improving maternal agency and self-efficacy [54].

At the secondary prevention level, community based nursing initiatives were found to be effective in relation to immunisations for children [55], community obesity management [56], and cardiac intervention for female CVD prevention [57]. In terms of preventative mental health care, motivational interviewing by community psychiatric nurses was effective for young adults [58]. Community Psychiatric nurses also had positive psychological outcomes in promoting improvements in functional cognitive ability, mental health scores, depressive symptomology, and self-perceived quality of health in older persons with cognitive decline [59, 60]. This high quality evidence suggests that there are opportunities to further develop nursing roles to promote better health among those with mental health risks. The care of individuals with chronic illnesses was found to empower patients to become ‘agents for change’ [61]. However, it was acknowledged to be costly, requiring investment in systems supporting client self-management at home [62].

At the tertiary level, the evidence supports interventions for asthma self-care and symptom reduction [63, 64] and non-pharmacological intervention for Type 2 (T2) Diabetes Mellitus (DM) in youth [65]. There is some evidence of the benefits of school-based RCTs on smoking cessation [66], and healthy diet [67], but this evidence is of a lower quality. Likewise, there is moderate evidence for leg ulcer prevention and management [67], and initiatives to increase condom use skills [68]. When interventions are provided by well-educated specialist nurses, using theoretically driven person-centered interventions, with specific outcomes, the evidence demonstrates that nurses are effective, efficient and satisfying to clients [69, 70]. Recommendations for such interventions include innovation in treatment methods to improve adherence [71], as well as further research into crisis resolution interventions for older people [72]. Therefore, community nurses have a significant positive role to play in primary, secondary and tertiary prevention, improving the wellbeing of certain at-risk groups and improving public health outcomes.

Transitional care refers to a point of nexus between hospital and home and is a vital part of the journey of older people with a chronic illness to either a healthier or palliative state. The evidence review team were acutely aware of the recently completed systematic review on tackling delayed discharge and (re) admission avoidance in relation to acute hospitals [73] commissioned by the Department of Health (DoH). These reviewers recommend an integrated, personalised, and multi-disciplinary approach and an interconnected, comprehensive system that spans all levels and types of care, following the individual through their care continuum. The evidence solely from a community perspective was relatively sparse. Blair et al. [74] examined 17 RCTs to assess effectiveness of home versus hospital cardiac rehabilitation. Overall, for outcomes where nursing input was separately identified, transitional care interventions appears to be largely positive in relation to reduced readmission rates [62, 74‐76], reduced mortality [74], increased patient satisfaction [75, 77] and improving health-related outcomes [74, 78].

Components of interventions associated with positive outcomes appear to be home visiting [62, 74, 76, 77, 79, 80, 81], nurse-led case management or care coordination [61, 76, 78, 82], telehealth [62] and telephone support [74, 78]. The most effective transitional care models were targeted, home-based, and nurse-led in a case-management or coordinated fashion with clear objectives and measurable outcomes. Evidence from a high quality meta-analysis and SRs revealed that transitional care interventions were effective in terms of health-related outcomes, self-efficacy and patient satisfaction in the intermediate and long-term [76, 77]. However, the interventions had to be of high intensity in terms of nursing and other input to achieve short-term outcomes such as reduced re-hospitalisation rates [78, 79]. The effective models needed to have clear and close integration across settings i.e. community to clinic or hospital and could be organised and delivered in either an outreach or community-based way. Furthermore, Coffey et al. [73] advocate for supported communication between primary and secondary care in order to achieve effective transitions.

Home-based nursing is an integral component of the delivery of nursing in the community and the literature revealed it to have a primarily positive influence. Preventive and curative interventions were delivered across the lifespan from birth to old age and most interventions were nurse-led. High quality studies supported home-based primary and secondary care interventions in the context of children and families [58, 60, 83‐89] and children with acute, chronic, complex or palliative care needs. Home-based service models should be carefully planned to align local need with adequate integration with existing services, as described by Rand [31]. Consequently, a strong primary health care system, which is both flexible and responsive, is imperative [90].

A large scale high quality Systematic Review [91] found clear and reliable evidence that home-based palliative care increases the chance of dying at home and reduces symptom burden for patients with cancer in particular. Luckett et al. [92] address the organisation of services for persons with life-limiting illnesses, concluding that future trials must compare the relative efficacy of different models and intensities of specialist palliative care services (SPCSs) providing home nursing. In particular, models need to prioritise the person’s preference for the setting of palliative care delivery, and to address the greater economic cost of homecare as opposed to hospital care, as identified in one Australian study [93].

In terms of chronic illness, some consultation programmes by Advanced Nurse Practitoners can be effective in reducing adverse health outcomes (acute events, falls, and hospitalizations) and were also cost effective [94]. In contrast, outcomes associated with leg ulcer interventions reveal neutral evidence with regards to healing rates or proportion of ulcers healed in the home setting [95, 96]. Nevertheless, the Leg Club initiative was deemed to enhance integration and collaboration of care, resulting in improved care and quality of life for patients [61] and was both cost effective and efficient [67]. However, these initiatives are dependent on patients/clients having the mobility and means to access the services.

Nurses and health visitor-led health promotion programmes for older people improved physical functioning linked with activities of daily living, self-care and management, improved self-efficacy and agency, decreased hospitalisation and readmission rates, and increased opportunity to receive care and remain at home [68, 96]. Whether home-based health promotion interventions offer good value for money remains unclear. Yet, a unilateral focus on cost containment alone has been identified by the Canadian Nurses’ Association [97] as limiting community nursing’s scope. Thus the implementation of a model of care must be underpinned by multiple considerations to enable positive outcomes [98].

The precise effective dose of home-based nursing has not been adequately researched. However, the review did conclude that nurse-led care is more cost-effective than medical care [92, 98]. Enabling components were considered to be the educational, supportive and preventative interventions employed [99] which could optimize population health [100, 101]. In particular, community nursing was considered important for vulnerable [102] or marginalized populations [103]. Moreover, home-based nursing facilitates increased opportunities to observe self-management barriers and creates more viable interventions for client’s own self-management [104]. Although standardised approaches to economic evaluation in cost-effectiveness needs further review, the evidence on interventions has implications for the organisation and delivery of community nursing in terms of ensuring the continuance of care delivery in the home setting [92].

Adjuncts to nursing and midwifery in the community refer to non-licensed personnel and technological supports. Non-licensed personnel are those that work under the direction of a professional - usually a nurse, and who do not have a professional qualification. The interventions relate primarily to maternal and child health [54, 105, 106] and high-risk families with young children [107] where nurse-led interventions with unlicensed personnel had significant positive effects on maternal health. This was particularly related to emotional well-being and depressive symptomology [54, 108, 109]; improved birth outcomes, child physical health [110]; breastfeeding duration and parenting skills [105‐108, 110]; attendance, and preventative child health appointments [105]. Nurse-led interventions with supporting non-licensed personnel included nutritional guidance and screening to support risk reduction in chronic disease management for young adults [111, 112].

In studies with adults with cardiovascular disease, nursing in the community with non-licensed personnel resulted in clinical improvements such as reduced cholesterol level and blood pressure [111, 112] and a reduction in the relative risk of Emergency Department (ED) visits [113]. In the provision of homecare to adults and older people, certified nursing assistants are a core element of the nursing teams and well evaluated by patients [69, 70]. However, the higher ratio of registered nurses to non-professional assistants is considered to be the component of higher levels of satisfaction in comparison with other Dutch healthcare models [69, 70]. This model is of significant international interest due to cost savings (as compared to traditional models), client satisfaction and staff satisfaction [70] and is currently being piloted in areas within the UK, America and Japan.

Tele-healthcare interventions in the community are considered an additional resource for nurses and midwives, with promising potential in supporting care. Interventions vary from nurse-led telephone and/or distance monitoring support using algorithm system from patients’ homes, to email, text messaging and electronic sensors with central reporting [114, 115]. With regard to providing access to healthcare professionals in remote/rural areas, tele-visits/video conferencing can provide a forum for patients to access nursing and midwifery care in a timely manner and reduces costs of travelling for all concerned [116, 117]. For example, in rural Australia, specialist cardiovascular nurses provided additional telephone supports which found a reduction in the number of hospitalisations for patients with heart failure [118].

Community nursing care with the use of technology has been shown to be effective and satisfying to patients, and there is a need for interventions to be underpinned by theory, person-centredness and to have specific patient clinical outcomes. Tele-health, such as telephone health mentoring intervention by community health nurses assists found an increases in self-management [62, 119], improved depression symptoms and general health [116, 120] and heart failure [117] for patients with COPD [116, 117]. Technology is being deployed to expand healthcare delivery beyond traditional hospital and clinic boundaries to the home and community setting. Furthermore, tele-health benefits include providing a support structure which empowers patients to actively participate in their care [53, 61, 121, 122] and enables provision of a person-centred approach [53, 121]. Decisions on the usefulness and effectiveness of small single technology (phone reminders) as well as whole “system” centralized monitoring [115, 120, 122] is difficult due to variability in study interventions, populations, outcome measures and training and level of engagement by nurses.

No single model of community nursing and midwifery emerges from the literature. Both the empirical and grey literature suggest fragmentation and challenges in framing community nursing and midwifery services internationally, thus the lack of a distinct model is not unique to Ireland. Other countries are similarly reviewing the international literature in a quest for the holy grail of a nursing and midwifery model [123]. Debate in the development of models tends to focus on structuralist issues which include a generalist versus specialist approach and geographical versus non-geographical caseloads. For example, the Buurtzorg neighbourhood care model) [69] is primarily focused on district nursing. Similarly, in the UK, the DoH [124] proposed a district nursing model entitled ‘compassion in practice’, underpinned by integration, effectiveness, a quality driven focus, person-centredness, and supported by telehealth, while ensuring that ‘every contact counts’. The service builds on its strong district nursing foundations and continues to have a curative focus but now emphasises the provision of opportunistic public health interventions while promoting self-care of clients.

Unlike Ireland, Canada’s community nursing model is underpinned by nursing theory and integrated with home health and primary health care principles [104]. Even countries that did not necessarily articulate a nursing theoretical model (Netherlands and Australia) did draw on other theories such as those supporting Nurse Family Partnership [87, 125] and Maternal and Child Health Nursing [108]. The evidence from the empirical literature supports the value of theoretical underpinnings, specifying the intervention components which are then matched to appropriate health and social care outcomes. This is very important to match the ambitious goals of policy with the practical ability of the service to meet such goals [97].

Acknowledging this, such a match permits the separation of outcomes at various levels as a means to identify the components necessary to ensure effective, efficient health care outcomes. Despite these benefits, there is a paucity of trials which were theoretically underpinned. This has implications for an Irish model of community nursing and midwifery for the future. Irish models of community nursing [126, 127] have been largely confined to PHN and Community Registered Nurses in the context of primary care teams. Thus they are not universally applicable to the totality of Nursing and Midwifery in the community and there is a danger that they may be discipline-specific rather than a model at a strategic level.

Therefore, a review of nursing and midwifery models requires careful consideration of the totality of community nursing and midwifery development within a lifespan, person-centered approach and systems-based approach, which aligns to parallel health systems in acute care environments. Consequently, this paper identified key competencies for different levels of practice, which were considered in the development of Nursing and Midwifery in the Community Model.

The international literature has similarly examined required competencies for nurses and midwives practicing in a community setting, and this has implications for the development of any model. For example, in the USA, the Council on Linkages between Academia and Public Health Practice (COL) [128] recommended three levels of core competencies for Public Health Professionals. Tier 1 refers to entry level and Tier 3 is at senior managerial level. These have already been adopted in over 50% of state and local health departments and 90% of academic institutions in the USA. Supporting this view in relation to nursing, in Canada there is a requirement for a minimum of two years’ experience with mentoring, leadership and peer support to adequately prepare PHNs for practice [102]. While detail in relation to the expertise of the nurses in the Buurtzorg model [69] is not provided, there is evidence that the competencies required range from generalist to expert depending on the level of specialist care required. From information received from DPHNs, as part of this evidence review, nurses in Ireland in the community are already engaged in continuing professional development education. Some of these include: initiatives to expand scope of practice e.g. chronic disease management, anticoagulation management and ear irrigation. These initiatives demonstrate a community/practice nursing commitment to continuous professional development to enhance service integration and improve the quality of care for clients. In the context of developing a national community nursing and midwifery model, there would need to be standardization in terms of clearly articulating the initial competencies required such as demonstrated in the North American examples above and a clear plan for continuous professional development. This strategic plan would need to be developed in consultation with all stakeholders including the regulatory body Nursing and Midwifery Board of Ireland (NMBI). Implementing this strategic plan requires a national approach supported by effective leadership.

Inherent within any model is the necessity to identify core components which will underpin any effective interventions therein. From this evidence review, those identified are numerous and are frequently context specific. They can be categorised to some extent and include: adopting a care management person-centred approach; led by competent nurses or midwives educated either as specialist or who have received training specific to the interventions; providing targeted home based interventions; supported by tele-health and non-professional support. These components ideally are delivered using a person-centered, team based approach taking cognisance of the determinants of health.