Advanced Nursing Practice in Public Health Nursing

Professor Sheila Twinn
The Nethersole School of Nursing, The Chinese University of Hong Kong

Advanced nursing practice in public health nursing is sometimes considered to be less well established than in some of the other clinical settings we will be discussing today. This is partly because examples of clinical practice vary significantly, so I thought it would be helpful to describe advanced nursing practice in public health nursing in two geographical locations which have some common links but are very different in culture and context. These locations are the United Kingdom (UK) and Hong Kong. I have chosen the UK partly because that is where I practiced as a public health nurse so I am familiar with the model of practice but more importantly because there have been strong links between public health nursing in the UK and Hong Kong. These links have led to similarities in the preparation of practitioners and the interpretation and implementation of practice in these two settings despite being 8500 kilometers apart. However, when discussing developments in advanced nursing practice, an important starting point is that of the interpretation and definition of public health nursing.

Public health nursing has been described by a range of terms in different settings and locations. Terms such as community nursing and health visiting provide examples. Although there are differences in these approaches to public health nursing, there are also some very important common characteristics. Stanhope and Lancaster (2000) identify some of these common characteristics in their definition of public health nursing. They describe public health nursing as the 'practice of promoting and protecting the health of populations using knowledge from nursing, social and public health sciences'. An important emphasis in public health nursing is that of promoting wellness rather than 'curing sickness'; so frequently involves working in primary prevention with apparently healthy individuals of all ages. Indeed, one of the major aims of care is the identification of the health needs of a population so the focus of care varies in different communities and from country to country. In some less well developed countries the focus may be on infectious diseases including HIV, whereas in more developed societies, the focus will be on the prevention of chronic diseases resulting from unhealthy life styles which of course includes heart disease, diabetes and cancer; diseases which are major causes of mortality both in the UK and Hong Kong. Such an approach to care highlights the importance of skilled assessment at both a community and individual level.

Another important point to consider when discussing the development of advanced practice in public health nursing is that of the interpretation of advanced practice. As we have seen today there are different definitions and interpretations of the term but for my presentation I have chosen the definition presented by Pearson and Peels (2002). These authors build on the definition by Hamric and her colleagues to develop an international perspective of this approach to care. They describe advanced practice as competence in five areas of practice: clinical skills, research, teaching, consultancy and leadership. Clinical skills in the context of public health nursing include assessment, prevention, education and health protection. The recent outbreak of SARS provides a good illustration of the importance of skills of health protection to the health of the community and individuals.

Different definitions of public health nursing and advanced practice have contributed to a review of nursing practice in primary care carried out by the Department of Health in the UK. The review provides a framework for the development of three core functions in advanced practice in public health nursing (Department of Health, 2002). These core functions demonstrate the range of care provided by public health nurses and include: acute assessment leading to diagnosis, care, treatment and referral; continuing care, particularly in rehabilitation and chronic disease management and finally public health in terms of health protection and promotion to improve the health of the community and reduce inequality amongst individuals in the community. The core functions also demonstrate the opportunity for the development of advanced practice within each of these areas of practice. Indeed, I have used examples from the core functions outlined in the review to illustrate the developments of advanced practice in public health nursing in the UK.

The first example is within the core function of acute assessment and is that of public health nurses making an individual assessment of patients attending for consultations in general practice. As many of you may know general practice is the provision of primary care in the UK and until recently doctors have been the only providers of such care. The development of advanced practice has allowed the implementation of public health nurses working as the first point of contact for patients requiring a 'same day service'. This frequently includes minor illnesses such as upper respiratory tract infections. Using skills in advanced assessment, nurses identify those patients for whom they can diagnose and provide treatment. Those patients who need medical treatment are referred to the general practitioner. Research findings demonstrate no difference in patient outcomes in terms of adherence to treatment and reattendance rates. In addition, findings demonstrate higher levels of satisfaction in patients' perceptions of returning to normal health amongst the nurse practitioner group. In another study of patients requesting 'same day service' findings demonstrated those patients consulting nurse practitioners received significantly more health information than those treated by physicians (Kinnersley, et al., 2000). Importantly, patient satisfaction is consistently identified as a positive outcome in studies of patient consultations with advanced nurse practitioners in primary care (Mundinger, et al., 2000; Schroeder, et al. 2000; Shum, et al., 2000).

Another example of advanced practice in public health nursing is found within the second core function of continuing care. In response to a high incidence of cerebral vascular accidents (CVA) in the UK, initiatives have focused on the development of advanced practice in caring for patients with strokes. Stroke nurse consultant posts have been established in primary care settings to allow nurses to follow patients through the stages of admission, inpatient, rehabilitation and discharge back into the community. This follow-up continues for up to a year after the patient's discharge from hospital to review their progress during rehabilitation. The consultant posts also allow advanced practitioners to provide clinics, order investigations and receive referrals from other practitioners. An important outcome of such developments is the early identification of new problems experienced by patients and the prevention of readmission to hospital.

The final core function of public health and health protection programmes to improve health and reduce inequality provides further examples of advanced practice in public health nursing. An important commonality for advanced practice within this function is that of community assessment and the identification of health needs amongst different population groups. The increase in sexually transmitted infections among young people highlights a growing health need in the UK. Community assessment has led to the setting up of nurse-led genito-urinary medicine clinics where advanced practitioners have responsibility for diagnosing and treating patients. An important outcome of such clinics has been a reduction in the waiting lists for services.

Another example has arisen in response to the epidemiological evidence demonstrating high incidences of unintended pregnancies amongst adolescents. The adolescent pregnancy rate in the UK is the highest in Europe and has led to the development of a government strategy to reduce teenage pregnancy rates. This health need has led to the establishment of nurse-led community contraception clinics where young people receive non-judgmental advice about managing their fertility. The provision of counselling and emergency contraception services for those adolescents who have had unprotected sexual intercourse within the last 72 hours is a particularly important function of these practitioners. The final example is that of the provision of clinic services to young people in residential care. In this setting advanced practitioners have been able to establish clinics to prescribe and give health advice to young people who are often reluctant to seek advice from medical practitioners, thereby protecting a very vulnerable group in the population.

When discussing the development of advanced practice in public health nursing in the UK, it is important to recognise the essential role of nurse prescribing to the success of the three core functions. Amendments to the regulations in the UK took place in 2002 following extensive consultation amongst practitioners and the public. The amendment of the regulations allows appropriately trained nurses to prescribe from a range of specified minor ailments, minor injuries, health promotion activities and palliative care from an extended formulary. Examples of the conditions for which nurses can prescribe include tonsillitis, nausea and vomiting associated with palliative care, preconceptual counselling and emergency contraception. Following the success of the scheme the government is currently working to identify further potential health problems for which nurses might treat and prescribe at the first point of contact of care including the use of antibiotics. Nurses are, however, limited to prescribing from a range of approved medicines and only once they have received the required training and preparation to be an independent nurse prescriber.

Advanced practice in public health nursing in Hong Kong, as in the UK, is influenced by both the definition of advanced nursing practice and the interpretation and organization of practice. As we heard earlier, advanced practice in Hong Kong includes clinical skills, education, research and consultancy (Wong, 2001) and has mainly developed in hospital settings. Public health nursing practice has recently undergone some important structural changes with the Department of Health and Hospital Authority (HA) now both having responsibility for the organization and implementation of care. As in other settings such as the UK, the predominant focus of public health nursing practice is in primary care. The provision of primary care is therefore the joint responsibility of the DOH and the HA, with the DOH mainly responsible for maternal, child and adolescent health as well as health protection and the HA taking responsibility for the provision of general practice and family medicine. General practice is either provided privately by general practitioners or through the General Outpatient Clinics (GOPCs). Because of the cost of care provided by private general practitioners, the GOPC provides an important source of primary care particularly for elderly people. This results in the care in the GOPC focusing mainly on chronic illness and respiratory diseases. The change in policy in the organization of the GOPC led to six pilot GOPCs being established using a model of family medicine. I was part of the research team commissioned by the HA to examine the contribution of nursing and advanced nursing practice to the provision of patient care in the pilot clinics (Twinn, et al., 2003).

The findings of the study identified nursing practice focusing on four major activities in the GOPC setting. These were patient assessment, wound management, health education and post medical consultation counselling. These activities ranged both in the time spent with patients and the complexity of the nursing intervention. An important finding was that of the high levels of patient satisfaction associated with more skilled nursing activities such as wound dressings and minor procedures. Importantly as demonstrated in other international studies, patients repeatedly described nurses as having more time to talk with them and answer their questions. Another important finding was that with exception of group health education, these nursing activities were generally undertaken by both enrolled and registered nurses suggesting that these activities do not necessarily provide examples of advanced nursing practice. It is of course important to acknowledge that each of these practice activities could be undertaken at an advanced level.

Examples of advanced practice were, however, provided by the registered nurses, and nursing offers working in the smoking cessation clinics within each of the GOPCs. These practitioners were observed carrying out comprehensive individual assessments, providing counselling and health education, and importantly, prescribing nicotine replacement therapy. The nurses were also responsible for discharging patients from the smoking cessation clinic. Interestingly, during the semi-structured face-to-face interviews, these nurse described their ability in clinical decision-making, prescribing nicotine replacement therapy and discharging patients as activities contributing to the provision of patient care as well as providing examples of advanced nursing practice. The importance of professional autonomy in determining the effectiveness of advanced nursing practice was also recognized and described by nurses as an important component of their practice. Indeed, the model of nursing practice undertaken by nurses working in the smoking cessation clinics provides a potential model for the future development of advanced nursing practice in public health nursing in Hong Kong.

The findings from the evaluation of the contribution of nursing to the provision of patient care in the GOPCs highlight some important considerations for the future development of advanced practice in public health nursing in Hong Kong. The first of these is the need to assess the effectiveness of advanced practice on patient outcomes and cost effectiveness of care. Evidence suggests that advance nursing practice provides cost effective care in terms of patient outcomes as well as the benefits of advanced nursing practice outweighing any costs of introducing such approaches to practice (Byers & Brunell, 1998; Schroeder, et al., 2000). Further research of advanced nursing practice in public health nursing suggests that although findings consistently demonstrate high levels of patient satisfaction, research needs to be extended to include patient groups with more complex health needs and chronic diseases (Horrocks, et al., 2002). Because of the increasing number of elderly people with chronic health needs, such findings are particularly important for the development of advanced practice in public health nursing in Hong Kong.

Another important issue for future development locally is that of the expansion of the role of the advanced practitioner. Although the role is well developed in the smoking cessation clinics, there are opportunities for expanding the role in the GOPCs, in particular in providing nurse consultants for patients presenting with minor illnesses such as respiratory tract infections. Such a role obviously highlights the importance of advanced skills in assessment and in the diagnosis and management of patients.

Finally, any major developments in advanced nursing practice raises questions about the need for the implementation of nurse prescribing and the extent to which advanced nursing practice can really develop without appropriately trained nurses being able to prescribe from a limited formulary of medications. It is such developments that provide some very exciting challenges and opportunities for public health nursing in Hong Kong.


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