Inr. J. Nun-. Slud., Vol. 28, No. I, pp. 27-37, Printed in Great Britain.
1991. 0
002s7489/91 s3.00+0.00 1991 Pergamon Press plc
Nursing outside hospitals: the working experience of community nurses.. job characteristics D. R. DUNT, M.B., B.S., PhD., M.F.C.M.* M. J. TEMPLE-SMITH, B.Sc., Dip.App.Ch.Psych., M.A.Ps.S K. A. JOHNSON, S.R.N., S.C.M., B.A., F.C.N.A. Department ofCommunity Medicine, The University of Melbourne, 243 Grattan Street, Carlton, Victoria 3053, Australia
Abstract-The Community Nursing Project reports the results of a mailed questionnaire survey of the working and educational experience of 689 nurses employed outside hospitals and nursing homes in Victoria in 1985. This paper reports that part of the study relevant to their practice settings, job titles, job content and working conditions. Confusion about titles for community nurses was evident given that subjects offered 281 separate job titles. A title with the general form ‘Community Nurse-specialist designation’ was acceptable to 88% of nurses. Eighteen (of 57) job activities were identified that were performed at least weekly by four of the six principal practice areas. Therefore while the concept of the generic community nurse is a meaningful one, it is only so when the differences in job content across practice areas are acknowledged. Medical clinic nurses however do not conform to this general pattern. Seventy-nine per cent of the nurses currently had a job description. However, only 45% had a statement of job conditions, 26% had a formal job orientation, 24% worked overtime unrewarded by payment or time in lieu and only 59% could reschedule their work times. These figures varied greatly between practice areas. It is suggested that the concept of the community nurse-specialist designation be promoted. Specifically this could be done by the adoption of this title and the development of appropriate post-basic educational courses. While these conclusions have most relevance for Australia, they will also be of interest to nurses of other countries where an increasing emphasis on primary health care has resulted in an expansion of community nursing practice. *Author
to whom
correspondence
should
be addressed.
21
28
D. R. DUNT et al.
Introduction
This is the second of two papers reporting the results of the Community Nursing Practice Research Project. This project, initiated by the Royal Australian Nursing Federation (RANF) Victorian Branch, was conducted by the Department of Community Medicine, University of Melbourne in collaboration with a Steering Committee, which included representatives from some community nursing practice areas, special interest groups and the RANF. The broad objective of this study was to describe in some detail the characteristics of community nurses in Victoria, Australia, in particular their educational characteristics, career structure and work experience. The impetus for such a study was a desire to promote professional practice in an area of nursing that, as a result of the growth of community health practice overall, has been rapidly growing. In these circumstances the relevant professional association became aware of the lack of information about current practice and was concerned that this practice was being shaped more by outside events than by appropriate consideration and planning. A particular concern was the fragmentation and proliferation of areas of community nursing practice. The possibilities of reversing this process to create a generic community nurse (working in different practice settings) was to be particularly explored. The specific aims of this paper are to identify and classify the range of practice settings of nurses providing care outside the hospital and nursing home settings; to identify the confusion in terminology and titles for nurses working in community settings and to make recommendations for clarifying this situation; to document the professional role of each area of community nursing practice as currently being practised; and finally from this documentation to identify areas of commonality and areas of uniqueness with respect to skills and knowledge required. Other data concerning educational and job entry characteristics, as well as perceptions about educational preparation, current employment and future career options are reported in a companion paper (Temple-Smith et al., 1989). Changing roles in community nursing practice areas have been documented in a number of countries, including China (Ying et al., 1985), Botswana (Naconaco, 1986) and the U.S.A. (Cross et al., 1983; Keating, 1985). The job content of the community health nurse is largely determined, however, by the specific needs of the community served. While such overseas studies provided a useful framework for this study, the expansion of community health nursing practice in Australia is due to a particular combination of factors. These include a change in Government policy to establish community health centres, followed by an increase in hospital outreach programmes, the hospice movement and an increased trend of de-institutionalization. Technological advances have also enabled domiciliary management of procedures formerly only available in a hospital setting. Only a few studies relevant to this study have been conducted in Australia. In one of these, nurses in five community practice areas were studied in regard to their present tasks, functions and perceptions of changes in their own practice area (Katz et al., 1976). Nurses noted the growing importance of coordination of patient needs and family support, as well as health promotion. They perceived their role as becoming more autonomous but requiring more specific skills, especially in counselling. Nurses were also asked whether they were performing or believed they could perform six broad categories of job tasks of varying skill, ranging from taking patient histories to providing counselling. Some nurses were currently performing all tasks listed and a greater percentage believed they were capable
NURSING
OUTSIDE HOSPITALS
29
of performing all of the tasks in the future. However, the results of this study did not discriminate between practice areas. Responses of nurses using a ‘do-it-yourself’ group research kit formed the basis of a discussion paper concerning the role and organization of nurses in community-based child and family health care (Wadsworth, 1980). Many community nurses’ roles were defined by the expectations-often misplaced-of others, including other nurses. This was confusing for the patient and created mistrust between health professionals. Nurses agreed that community nursing needed to be ‘characterized by high levels of communication, cooperation and collaboration’, most efficiently achieved locally with a small number of nurses performing a wide variety of tasks. The role of the community health nurse was examined in 1984 through the perceptions of 65 community health team members (Round and Sellick, 1984). Doctors, social workers and managers as well as nurses from 10 community health centres in Melbourne were asked to rate the relevance of a set of tasks attributed to the generalist role of a community health nurse. Nurses differed significantly from the other groups in the perception of their role in eight of 22 tasks, with the greatest disparity (involving five tasks) occurring between doctors and nurses, (e.g. community liaison, coordination within the community health team, and decision-making) and managers and nurses (e.g. team leadership, research functions, and community liaison, thought by community nurses to be part of their role). Methodology
For the purposes of this study, a community nurse is defined as a nurse working outside a hospital, nursing home or nursing education centre. The sample frame consisted of a listing of community nurses between 1975 and 1985, drawn from the Victorian Nursing Council (VNC), the statutory body with the responsibility of issuing annual practising certificates. The VNC included with the certificates a voluntary questionnaire enquiring about type of practice areas. It is estimated that the VNC listing of community nurses in 1984 (3575 nurses) represents 86 per cent of all registered community nurses practising in Victoria. This listing excluded 353 district and visiting nurses who were listed as ‘hospitalbased or directed’ and 174 nurses with psychiatric and/or mental retardation qualifications only, both groups being subsequently added. During a pilot study, it became clear that the necessary data to be collected required a questionnaire of such length that it affected the response rate. Consequently data in this pilot questionnaire was split in two-though retaining some common items-to create two study questionnaires, the first being delivered to one sample drawn from the sampling frame and the second to a second such sample. The study population thus consisted of two 10 per cent stratified random samples taken with a constant sampling fraction from each major community practice area from the sampling frame. Data reported here includes some data common to both samples, as well as some from only the first or second sample. Initial questions common to both questionnaires sought information about current practice area, the appropriateness of the classification provided and an acceptable overall title for community nurses. Other information relevant to this study included the title of present position as well as sociodemographic data. Questions restricted to Sample I included those on job conditions, for example, the presence of job description, existence of a job orientation programme and full/part-time employment status. Questions restricted to Sample II included a detailed analysis of the job tasks and activities performed-including
30
D. R. DUNT et al.
their frequency-by community nurses as part of their role. These were developed by a sub-committee of the steering committee and are as follows (numbers in parentheses indicate number of questions relevant to this topic): prevention (3); health promotion (4); assessment (5); direct client/patient care (9); advocacy (4); administration (17); research/evaluation (4); supervision (4); travel (1); case-sharing (3). Specific activities are listed in Table 1. These job content questions were coded as being performed daily, weekly, monthly, quarterly or ‘not at all’. Questionnaires, with a covering letter, were mailed to subjects. Reminders were made by follow-up letter, telephone call or certified letter, 695 of 825 questionnaires were returned. Six of these were discarded because of inadequate completion, leaving 689 questionnaires for analysis; 351 (of 415) from the first questionnaire and 338 (of 410) from the second. This gave a response rate of 84 per cent. Data analysis
Data was analysed using the Statistical Package for the Social Sciences. Given the study aims, practice area was the main independent variable by which other variables were analysed. Statistical comparisons between practice areas were limited, however, by the size of some areas. Eleven major practice areas, each containing more than 18 nurses, were identified and included in analysis of the data common to both Sample I and II (n = 607). Six major practice areas were similarly identified for analysis involving Sample I (n = 252) of Sample II (n = 251) only. These were community health centre (CHCN); maternal and child health (MCHN); community-based district and visiting (CDVN); hospital-based district and visiting (HDVN); occupational health (OHN) and medical clinic (MCN). Other practice areas included in the analysis of both samples combined included public health (PubH); community psychiatric (CoPsy); school medical (ScMed); nursing in school, college or university (S/C/U); and diagnostic, pathology and blood bank nursing (D/P). Statistical comparison of I and II showed no significant differences in any of the following characteristics: gender, marital status, children, education level and nursing qualifications. Due to the large number of statistical tests performed, a stringent level of significance was adopted (P c 0.001). Magnitude of differences (and that of 95010confidence intervals) were not calculated, as comparison to one community nursing reference group is inappropriate.
Results
Practice areas
Seventy per cent of community nurses worked in six practice areas: medical clinic, community-based district and visiting, maternal and child health, occupational health, community health centre, and hospital-based district and visiting (in order of decreasing frequency). Table 2 outlines the data for the total study population. Titles and terminology
Confusion regarding job titles within community nursing was reflected in the very large number of job titles (281) listed by respondents (total study population data, n = 689). The most common are listed in Table 3. While in some instances these 281 titles indicated a level of seniority, designation of employment and/or specialization, many suggested a lack of conformity in terminology. For example, 97 maternal and child health nurses listed 30 titles. These included: Infant Welfare Nurse; Infant Welfare Sister; Maternal and Child
NURSING
Table
1. Activities
OUTSIDE
31
HOSPITALS
of the ‘Generic’
Community
Nurse
PREVENTION
ADVOCACY
Screening-regular, routine -of special groups (e.g. diabetes, t.b.)
INTERPRETATION TO PATIENTS/CLIENTS OF INSTRUCTIONS/REQUIREMENTS OF OTHER HEALTH PROFESSIONALS/AGENCIES/AUTHORITIES
MAINTENANCE PROMOTION HEALTH
OF SAFE ENVIRONMENT
ADVOCACY -INDIVIDUAL -agency -community
OF HEALTH
TEACHING-INDIVIDUALS -FAMILIES -Groups
Preparation of health material/programs.
ADMINISTRATION
promotion
MAINTAINING RECORDS -PATIENT/CLIENT CARE -OTHER AGENCY RECORDS
ASSESSMENT INDIVIDUAL-HEALTH STATUS (PHYSICAL, PSYCHOSOCIAL, ENVIRONMENT) -FOR HEALTH NEEDS -for placement Family Community DIRECT
(e.g. community
profile)
CLIENT/PATIENT
Emergency
CARE (e.g. DRESSINGS, ETC.)
treatment
COUNSELLING-INDIVIDUALS -FAMILIES -Groups Socialization
WRITING Writing
REPORTS
submissions
Attending meetings -within agency/organisations -with other local agencies -professional organisations
LIAISON WITH -OTHER NURSES -OTHER HEALTH PROFESSIONALS -management -Board of Management -Government Local State Federal -Unions/Professional organisations
Participation in studies (e.g. collecting data)
Crisis intervention Rehabilitation
Designing studies
CO-ORDINATION
and implementing
Of staff within own agency -Nursing -Other health professionals -Others-specify ....... ...... .... .............. .. ...
Long term planning
Of activities
(as part of your normal
health
agencies/services
SUPERVISION
Interpretation
of health
research/evaluation
statistics/research
for community
CASE
work)
SHARING
nurses
in Agency/Unit/Centre
With nursing
Other
health
professionals
With other health professionals own organisation/agency
in Agency/Unit/Centre
nurses
Registered Nurses/other observation/field visits
Activities
forming
health
professionals
part of the community
on
nurses
health
TRAVEL
Other Student
region
RESEARCH/EVALUATION
activities
of other
within
Development of policy -within agency -with other agencies
CARE
MAINTENANCE OF ACTIVITIES OF DAILY LIVING (e.g. HYGIENE, DRESSING, NUTRITION, ETC.) TECHNICAL INJECTIONS,
ON BEHALF OF CLIENT/PATIENT
personnel
With health professionals agency/organisation
role in capitals;
others
not part,
in
not in own
in lower case.
D. R. DUNT et al. Table 2. VNC listing and total population by practice area Practice area
Public/community health Maternal and child health Child care District/visiting (not hospital-based) Psychiatric Mental retardation Physically handicapped (not geriatric) Specialty Occupational health Private School medical (Health Commission) School/college/university Medical clinic Dental clinic Other (inc. post basic nursing courses) Sub-total District/visiting (hospital-based) Psychiatric (basic qual. only) Mental retardation (basic qual. only) Total
VNC listing
Number of responders (070of total in area)
433 584 78 625 78 5 32 13 312 66 106 88 762 16 376
82 (19%) 98 (17%) 15 (19%) 105 (17%) 15 (17%) 2 (40%) 4 (13%) 2 (15%) 57 (18%) 14 (21%) 16 (18%) 17 (19%) 132 (17%) 3 (19%) 59 (16%)
3,575
621 (17%)
353 140 34
49 (14%) 17 (12%) 2 (6%)
4,102
689 (17%)
Table 3. Ten most commonly reported titles of a total of 281 different titles offered by respondents Job title District Nurse Occupational Health Nurse Infant Welfare Sister Community Health Nurse Infant Welfare Nurse Maternal and Child Health Nurse Clinic Sister Nurse/Receptionist Sister In Charge Sister
Number reporting title 39 33 25 17 16 12 11 10 10 10
Health Nurse; Maternal and Child Health Sister; Infant Welfare Nurse and Family Planning; Sister in Charge-Infant Welfare Centre; Relieving Sister-Maternal and Child Health; Infant Welfare Advisor. Preference for title Six hundred and four nurses (88%) considered as appropriate the general title of ‘Community Nurse’ with a sub-title indicating practice area, for example ‘Community Nurse-Maternal and Child Health’. Forty-seven nurses made the following alternative suggestions: specialty title only (22); prefix ‘Community’ then specialty (e.g. Community-
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OUTSIDE
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33
District Nurse) (6); Community Nursing Sister (4); Community Sister (4); Nurse Practitioner (3); State Registered Nurse (2); Community Health Worker (2); Primary Contact Nurse (1); Registered Nurse-sub-title Community Health (1); Two categories-Health Resource Nurse and Visiting Health Nurse (1). Those who preferred to have a specific specialty title only stated that the title ‘Community Nurse’ was too general. Job conditions Part-time employment levels (total study population). In total, 288 (43%) nurses were employed part-time. Significant differences occurred in part-time employment between the 11 major practice areas (x’,,,= 85.6; P < 0.001). The highest levels of part-time work existed for public health nurses (70%) and the lowest levels for school medical nurses (6Yo). There was, predictably, a significantly higher proportion (x 22= 114.1; P < 0.001) of parttime nurses compared to full-time nurses who stated that dependant children affected their choice of employment. Employment status differed significantly by age group (x2s = 16.0; P < O.OOl), nurses in the 20-30 years age group having the highest rates (71 To) of full-time work. Job descriptions (Sample I). A high proportion of nurses (78%) reported having a job description, either at their appointment (63070),or subsequently (15%). Nursing staff had been involved in the drafting of 74% of job descriptions in those situations where they existed. Eighty-nine per cent of those nurses with a job description felt that it accurately reflected their responsibilities. Thirty-four per cent of those with a job description were able to state that it had been reviewed during the previous two year period. In these circumstances significant differences did occur between practice areas (x 2 I o = 38.9; P < 0.001); highest levels of review (50%) existing for HDVNs and lowest levels (20%) for MCNs. Seventy-nine per cent of respondents believed an adequate job description to be of high or very high importance. State of conditions of employment (total study population). Respondents were asked if they had had access to a formal statement of conditions of employment when they began their present job. Two hundred and ninety-seven (45%) had such a statement; 371 (56%) did not or did not know. There was a significant difference (x21o= 50.5; PC 0.001) between major practice areas in terms of which groups did have such access, highest levels existing for school medical nurses (71%), and lowest levels for MCNs (24%). Those employed full-time (57%) were significantly more likely to have a statement of employment conditions than those working part-time (43%) (x2, = 16.3; PC 0.001). Initial orientation to job (Sample Z). Respondents were asked whether there had been a formal (classroom) orientation programme on starting their present position. Informal orientation was more frequent than formal orientation, with 73% of nurses in all having had someone to ‘introduce them’ when they started their present job. Rescheduling work hours and overtime (Sample I). Nurses are required to work outside normal working hours in a number of community practice areas. In these circumstances only 50% of nurses were able to reschedule their work or adjust their hours accordingly. Forty-five per cent of nurses were paid for overtime, 31% were given time in lieu, and 24% received neither overtime pay nor time in lieu. Significant differences existed between practice areas (x2ro=69.1; P < 0.001) with OHNS (76%) most often paid for overtime and MCHNs (3%) least often. Sixty-one per cent of MCHNs stated that they neither received overtime payment nor time in lieu. Time off in lieu (57%) rather than overtime payment (43%) was preferred by nurses overall. However, there were significant differences
34
D. R. DUNT
et al.
(x25 = 23.3; P < 0.001) between practice areas with MCHNs preferring this option most and MCNs least.
Job content (Sample II) Activities listed in the job content question are shown in Table 1. The activities of the community nurses in the six main practice areas (from Sample II) that were performed frequently (by more than 50% of a practice area at least weekly) are summarized in Table 4. Eighteen of 57 activities were so identified. All but four of these 57 activities, however, were identified as being part of the nurse’s role in at least four of the six practice areas. The four activities which were not part of a community nurse’s role are liaison with State and Federal Governments, co-ordination of other staff in an agency and supervision of other health professionals in agency. Prevention and health promotion. Of the three prevention activities considered, only maintenance of a safe environment was performed frequently by nurses of four of the six practice areas. Otherwise routine screening was frequently performed at least weekly by the MCHNs (72%) and OHNs (65%) only. Screening of special groups was not frequently performed by any group. In the area of health promotion, health teaching to individuals and families was performed frequently by five and four practice areas respectively. Health teaching to groups was frequently performed at least weekly by the CHCNs and MCHNs only. Assessment. Assessment of both health status and health needs of the individual was frequently performed by all six practice areas. Assessment for individual placement was performed at least weekly by only the OHNs, family assessment in this way by only the MCHNs and CDVNs. Direct patient/client care. Maintenance of activities of daily living, provision of technical care (e.g. dressings) and counselling of individuals and families were frequently performed Table 4 (a). Nurses performing selected job activities by practice areas (per cent) CHCN
MCHN
CDVN
HDVN
OHN
MCN
Prevention Maintenance of a safe environment
39
88
78
60
78
28
Health promotion Health teaching individuals families
13 70
96 69
82 76
71 57
91 0
49 13
Assessment Individual health status Individual health needs
68 72
94 89
86 82
71 64
86 73
29 19
52 53
79 6
86 84
91 91
39 83
33 70
73 65
92 61
72 72
67 55
96 5
33 14
Direct client/patient care Maintenance of activities of daily living Technical care Counselling individuals families
CHCN, Community Health Centre Nurse; MCHN, Maternal and Child Health Nurse; CDVN, Community-based District & Visiting Nurse; HDVN, Hospital-based District & Visiting Nurse; OHN, Occupational Health Nurse; MCN, Medical Clinic Nurse.
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HOSPITALS
Table 4 (b). Nurses performing selected job activities by practice areas (per cent) CHCN
MCHN
CDVN
HDVN
OHN
MCN
66 66
74 43
12 65
71 60
91 59
54 29
91 55 67
98 SO 25
92 48 13
91 50 91
96 76 61
97 43 31
61
60
82
76
57
51
Travel
61
92
92
96
96
35
Case-sharing other health professionals
19
20
51
13
57
29
Advocacy Interpretation of care requirements to clients Advocacy on behalf of clients Administration Maintenance of records client other agency Writing reports Liaison with other nurses other health professionals
by four, five, five and four practice areas respectively. By contrast, emergency treatment was frequently performed only by the OHNs and the MCNs. Rehabilitation was frequently performed by only the CDVNs, HDVNs and OHNs. Advocacy. Interpretation of care requirements to patients and advocacy on behalf of individuals were frequently performed (six and four areas respectively). Advocacy on behalf of an agency or the community similarly was performed only by the CHCNs. Adminisiration. Maintaining records of patient care and other agency records, writing reports, liaison with other nurses and other health professionals were frequently performed by most practice areas (six, four, four, six and five areas respectively). Attending meetings within agencies was only frequently performed by the CDCN and CDVN, liaison with management only by the CHCN, HDVN and OHN. Research/evaluation. Research activities were not performed frequently by nurses of any of the practice areas. Co-ordination and supervision. Co-ordination of nurses within the agency was performed frequently by the CHCN only; co-ordination of other health professionals by the OHN only. Supervision. Supervision activity was not frequently performed by any of the six practice areas. Travelling. Travel to visit clients as part of normal work was frequently performed by nurses of all six practice areas except MCNs. Case-sharing. Case-sharing with other health professionals within the agency was frequently performed by all practice areas. Case-sharing with other nurses only was frequently performed by the CHCN and both groups of visiting nurses. Discussion
It is clear from these results that working conditions in community nursing in Victoria, Australia, were good in a number of aspects but not uniformly so. A positive aspect was that almost four-fifths (78%) of nurses currently had a job description. However, negative features were that less than half (45%) had a statement of conditions of employment; only
36
D. R. DUNT et al.
about a quarter (26Oro)had had a formal orientation programme for their job, about a quarter (24Yo) worked overtime not rewarded by payment or time in lieu and only about three-fifths (59%) could re-schedule their work times. (Perceptions about income levels and job classifications as they existed during the study period were not sought.) In addition, these different measures of working conditions varied between practice areas in many instances. This variability in conditions across and between practice areas justifies concerns about the implication of the recent rapid growth in community nursing for its future direction. The study results are particularly relevant to the issues relating to the diversity of community nursing practice, in other words the proliferation of practice areas and possible fragmentation of the work experience and job content of community nurses. While the results do indicate considerable diversity of experience they nonetheless demonstrate bounds to this diversity. Firstly, despite the proliferation of practice areas (22) nominated by nurses, a large majority (70%) worked in only six practice areas (75% if public health and community health are merged). Thus, the fragmentation of community nursing, in an overall numerical context, is not as great as might be otherwise considered. Secondly, while 281 job titles were identified, amply confirming suspicions about confusion in terminology and titles, almost 90% of nurses agreed that the ‘Community Nurse-specialist designation’ e.g. ‘Community Nurse-Maternal and Child Health’ would be an acceptable title. It should be noted that, while this title was specifically proposed to the nurses rather than being the response to an open-ended question, it was done so on the basis of the pilot survey in which the nurses’ own suggestions were sought. Thirdly, while considerable diversity existed in the job contents of the six practice areas (see below) there was a core of activities that were frequently and widely performed by community nurses. (Eighteen of 57 job activities were so identified and with all but four of the 57 being regarded as part of the community nurse’s role.) Some qualifications nevertheless are required in interpreting these job content results. While the same activity (e.g. assessing an individual’s health status) may be performed by nurses in different practice areas, the precise nature of this activity may still vary between practice areas, and indeed between nurses in the same practice area. In addition, some practice areas have job contents more in common than others while one (MCN) is very different to the others. Thus CDVNs and HDVNs were the only areas to frequently perform rehabilitation activities and OHNs and MCHNs were the only groups to perform routine screenings. MCNs, who constitute the largest community nursing practice area, shared very few job activities with the other five large practice areas. Most MCNs work alongside and under the direction of general practitioners, a fact which determines their job activities. This is also true for diagnostic and pathology nurses and other medical clinic nurses working closely with medical specialists. In brief, the different practice areas of community nursing (with the exception of medical clinic nurses) share a sufficiently large number of job activities to make the concept of the generic community nurse a meaningful one. Nevertheless there is clearly a sufficient diversity of activities between practice areas for the concept of separate practice areas to remain meaningful. The educational consequences of this are that postgraduate courses in community nursing should contain compulsory core units relevant to community nursing but also include elective units relevant to particular practice areas. (In Melbourne, this occurs currently in courses such as those offered at La trobe University, Phillip Institute of Technology and the Royal District Nursing Service). There is a strong
NURSING
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37
indication however that the group of nurses classified by the Victorian Nursing Council as MCNs (which includes diagnostic and pathology nurses) should be categorized differently to other groups of community nurses and received a different post-basic educational experience.
Conclusion
Community nursing, at least in Victoria, Australia currently consists of a large number of dispersed and relatively isolated groups which nevertheless share many common features in their job activities. A more appropriate model (and set of working conditions) for nurses practising in a community setting depends upon the promotion of the concept, and title, of the community nurse-specialist designation, which recognizes both the common and separate features of the different practice areas. While these conclusions are based on the study of community nursing in one Australian State, they are of relevance for community nursing in other parts of Australia and other countries. Acknowledgements-We acknowledge the helpful advice and direction of the Steering Committee to the study, in particular Miss N. Bryan, Dr M. Bennett and Miss B. Carson. In addition, Dr Bennett gave considerable guidance in regard to developments in post-graduate nursing education. We would like to thank Professor R. Webster and the Department of Community Medicine for their generous financial and secretarial support, Dr E. Khatib for computing advice, Dr S. Wales for editorial assistance and MS L. Pearce for typing. We thank the large number of individuals and special interest groups, for their time and assistance when consulted during the study design stage. Finally, we acknowledge the many community nurses who gave so freely of their time to answer our questions. The study was funded by the Royal Australian Nursing Federation (Victorian Branch).
References Cross, J., Northrop, C. and Strasser, J. (1983). How community nurses spend their time. Nurs. Hlth Cure June. 314-317. Katz, F. M., Mathews, K., Pepe, T. and White, R. H. (1976). Stepping Out. New South Wales University Press. Keatings, S. and Nevin, V. (1985). New directions in primary health care nursing. Nurs. Educ. 10(5), 19-23. Naconaco, V. N. and Stark, R. D. (1986). The development of a family nurse practitioner program in Botswana. Int. Nurs. Rev. 33(21), 9-14. Round, R. and Sellick, K. (1984). How community health team members perceive the role of the community health nurse. Aust. J. Adv. Nurs. l(3), 37-44. Temple-Smith, M. J., Johnson, K. A. and Dunt, D. R. (1989). Nursing outside hospitals: the working experience of community nurses. I. Educational characteristics and job perceptions. Community Health Studies, 13,306-3 15. Wadsworth, Y. (1980). Let’s Communicate. Royal Australian Nursing Federation. Ying, L. J., Davis, A. J., and Janforum, I. (1985). Health care and nursing in the Peoples Republic of China. J. Adv. Nurs. 10, 279-284. (Received 4 July 1990)
1991. 0
002s7489/91 s3.00+0.00 1991 Pergamon Press plc
Nursing outside hospitals: the working experience of community nurses.. job characteristics D. R. DUNT, M.B., B.S., PhD., M.F.C.M.* M. J. TEMPLE-SMITH, B.Sc., Dip.App.Ch.Psych., M.A.Ps.S K. A. JOHNSON, S.R.N., S.C.M., B.A., F.C.N.A. Department ofCommunity Medicine, The University of Melbourne, 243 Grattan Street, Carlton, Victoria 3053, Australia
Abstract-The Community Nursing Project reports the results of a mailed questionnaire survey of the working and educational experience of 689 nurses employed outside hospitals and nursing homes in Victoria in 1985. This paper reports that part of the study relevant to their practice settings, job titles, job content and working conditions. Confusion about titles for community nurses was evident given that subjects offered 281 separate job titles. A title with the general form ‘Community Nurse-specialist designation’ was acceptable to 88% of nurses. Eighteen (of 57) job activities were identified that were performed at least weekly by four of the six principal practice areas. Therefore while the concept of the generic community nurse is a meaningful one, it is only so when the differences in job content across practice areas are acknowledged. Medical clinic nurses however do not conform to this general pattern. Seventy-nine per cent of the nurses currently had a job description. However, only 45% had a statement of job conditions, 26% had a formal job orientation, 24% worked overtime unrewarded by payment or time in lieu and only 59% could reschedule their work times. These figures varied greatly between practice areas. It is suggested that the concept of the community nurse-specialist designation be promoted. Specifically this could be done by the adoption of this title and the development of appropriate post-basic educational courses. While these conclusions have most relevance for Australia, they will also be of interest to nurses of other countries where an increasing emphasis on primary health care has resulted in an expansion of community nursing practice. *Author
to whom
correspondence
should
be addressed.
21
28
D. R. DUNT et al.
Introduction
This is the second of two papers reporting the results of the Community Nursing Practice Research Project. This project, initiated by the Royal Australian Nursing Federation (RANF) Victorian Branch, was conducted by the Department of Community Medicine, University of Melbourne in collaboration with a Steering Committee, which included representatives from some community nursing practice areas, special interest groups and the RANF. The broad objective of this study was to describe in some detail the characteristics of community nurses in Victoria, Australia, in particular their educational characteristics, career structure and work experience. The impetus for such a study was a desire to promote professional practice in an area of nursing that, as a result of the growth of community health practice overall, has been rapidly growing. In these circumstances the relevant professional association became aware of the lack of information about current practice and was concerned that this practice was being shaped more by outside events than by appropriate consideration and planning. A particular concern was the fragmentation and proliferation of areas of community nursing practice. The possibilities of reversing this process to create a generic community nurse (working in different practice settings) was to be particularly explored. The specific aims of this paper are to identify and classify the range of practice settings of nurses providing care outside the hospital and nursing home settings; to identify the confusion in terminology and titles for nurses working in community settings and to make recommendations for clarifying this situation; to document the professional role of each area of community nursing practice as currently being practised; and finally from this documentation to identify areas of commonality and areas of uniqueness with respect to skills and knowledge required. Other data concerning educational and job entry characteristics, as well as perceptions about educational preparation, current employment and future career options are reported in a companion paper (Temple-Smith et al., 1989). Changing roles in community nursing practice areas have been documented in a number of countries, including China (Ying et al., 1985), Botswana (Naconaco, 1986) and the U.S.A. (Cross et al., 1983; Keating, 1985). The job content of the community health nurse is largely determined, however, by the specific needs of the community served. While such overseas studies provided a useful framework for this study, the expansion of community health nursing practice in Australia is due to a particular combination of factors. These include a change in Government policy to establish community health centres, followed by an increase in hospital outreach programmes, the hospice movement and an increased trend of de-institutionalization. Technological advances have also enabled domiciliary management of procedures formerly only available in a hospital setting. Only a few studies relevant to this study have been conducted in Australia. In one of these, nurses in five community practice areas were studied in regard to their present tasks, functions and perceptions of changes in their own practice area (Katz et al., 1976). Nurses noted the growing importance of coordination of patient needs and family support, as well as health promotion. They perceived their role as becoming more autonomous but requiring more specific skills, especially in counselling. Nurses were also asked whether they were performing or believed they could perform six broad categories of job tasks of varying skill, ranging from taking patient histories to providing counselling. Some nurses were currently performing all tasks listed and a greater percentage believed they were capable
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of performing all of the tasks in the future. However, the results of this study did not discriminate between practice areas. Responses of nurses using a ‘do-it-yourself’ group research kit formed the basis of a discussion paper concerning the role and organization of nurses in community-based child and family health care (Wadsworth, 1980). Many community nurses’ roles were defined by the expectations-often misplaced-of others, including other nurses. This was confusing for the patient and created mistrust between health professionals. Nurses agreed that community nursing needed to be ‘characterized by high levels of communication, cooperation and collaboration’, most efficiently achieved locally with a small number of nurses performing a wide variety of tasks. The role of the community health nurse was examined in 1984 through the perceptions of 65 community health team members (Round and Sellick, 1984). Doctors, social workers and managers as well as nurses from 10 community health centres in Melbourne were asked to rate the relevance of a set of tasks attributed to the generalist role of a community health nurse. Nurses differed significantly from the other groups in the perception of their role in eight of 22 tasks, with the greatest disparity (involving five tasks) occurring between doctors and nurses, (e.g. community liaison, coordination within the community health team, and decision-making) and managers and nurses (e.g. team leadership, research functions, and community liaison, thought by community nurses to be part of their role). Methodology
For the purposes of this study, a community nurse is defined as a nurse working outside a hospital, nursing home or nursing education centre. The sample frame consisted of a listing of community nurses between 1975 and 1985, drawn from the Victorian Nursing Council (VNC), the statutory body with the responsibility of issuing annual practising certificates. The VNC included with the certificates a voluntary questionnaire enquiring about type of practice areas. It is estimated that the VNC listing of community nurses in 1984 (3575 nurses) represents 86 per cent of all registered community nurses practising in Victoria. This listing excluded 353 district and visiting nurses who were listed as ‘hospitalbased or directed’ and 174 nurses with psychiatric and/or mental retardation qualifications only, both groups being subsequently added. During a pilot study, it became clear that the necessary data to be collected required a questionnaire of such length that it affected the response rate. Consequently data in this pilot questionnaire was split in two-though retaining some common items-to create two study questionnaires, the first being delivered to one sample drawn from the sampling frame and the second to a second such sample. The study population thus consisted of two 10 per cent stratified random samples taken with a constant sampling fraction from each major community practice area from the sampling frame. Data reported here includes some data common to both samples, as well as some from only the first or second sample. Initial questions common to both questionnaires sought information about current practice area, the appropriateness of the classification provided and an acceptable overall title for community nurses. Other information relevant to this study included the title of present position as well as sociodemographic data. Questions restricted to Sample I included those on job conditions, for example, the presence of job description, existence of a job orientation programme and full/part-time employment status. Questions restricted to Sample II included a detailed analysis of the job tasks and activities performed-including
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D. R. DUNT et al.
their frequency-by community nurses as part of their role. These were developed by a sub-committee of the steering committee and are as follows (numbers in parentheses indicate number of questions relevant to this topic): prevention (3); health promotion (4); assessment (5); direct client/patient care (9); advocacy (4); administration (17); research/evaluation (4); supervision (4); travel (1); case-sharing (3). Specific activities are listed in Table 1. These job content questions were coded as being performed daily, weekly, monthly, quarterly or ‘not at all’. Questionnaires, with a covering letter, were mailed to subjects. Reminders were made by follow-up letter, telephone call or certified letter, 695 of 825 questionnaires were returned. Six of these were discarded because of inadequate completion, leaving 689 questionnaires for analysis; 351 (of 415) from the first questionnaire and 338 (of 410) from the second. This gave a response rate of 84 per cent. Data analysis
Data was analysed using the Statistical Package for the Social Sciences. Given the study aims, practice area was the main independent variable by which other variables were analysed. Statistical comparisons between practice areas were limited, however, by the size of some areas. Eleven major practice areas, each containing more than 18 nurses, were identified and included in analysis of the data common to both Sample I and II (n = 607). Six major practice areas were similarly identified for analysis involving Sample I (n = 252) of Sample II (n = 251) only. These were community health centre (CHCN); maternal and child health (MCHN); community-based district and visiting (CDVN); hospital-based district and visiting (HDVN); occupational health (OHN) and medical clinic (MCN). Other practice areas included in the analysis of both samples combined included public health (PubH); community psychiatric (CoPsy); school medical (ScMed); nursing in school, college or university (S/C/U); and diagnostic, pathology and blood bank nursing (D/P). Statistical comparison of I and II showed no significant differences in any of the following characteristics: gender, marital status, children, education level and nursing qualifications. Due to the large number of statistical tests performed, a stringent level of significance was adopted (P c 0.001). Magnitude of differences (and that of 95010confidence intervals) were not calculated, as comparison to one community nursing reference group is inappropriate.
Results
Practice areas
Seventy per cent of community nurses worked in six practice areas: medical clinic, community-based district and visiting, maternal and child health, occupational health, community health centre, and hospital-based district and visiting (in order of decreasing frequency). Table 2 outlines the data for the total study population. Titles and terminology
Confusion regarding job titles within community nursing was reflected in the very large number of job titles (281) listed by respondents (total study population data, n = 689). The most common are listed in Table 3. While in some instances these 281 titles indicated a level of seniority, designation of employment and/or specialization, many suggested a lack of conformity in terminology. For example, 97 maternal and child health nurses listed 30 titles. These included: Infant Welfare Nurse; Infant Welfare Sister; Maternal and Child
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Table
1. Activities
OUTSIDE
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HOSPITALS
of the ‘Generic’
Community
Nurse
PREVENTION
ADVOCACY
Screening-regular, routine -of special groups (e.g. diabetes, t.b.)
INTERPRETATION TO PATIENTS/CLIENTS OF INSTRUCTIONS/REQUIREMENTS OF OTHER HEALTH PROFESSIONALS/AGENCIES/AUTHORITIES
MAINTENANCE PROMOTION HEALTH
OF SAFE ENVIRONMENT
ADVOCACY -INDIVIDUAL -agency -community
OF HEALTH
TEACHING-INDIVIDUALS -FAMILIES -Groups
Preparation of health material/programs.
ADMINISTRATION
promotion
MAINTAINING RECORDS -PATIENT/CLIENT CARE -OTHER AGENCY RECORDS
ASSESSMENT INDIVIDUAL-HEALTH STATUS (PHYSICAL, PSYCHOSOCIAL, ENVIRONMENT) -FOR HEALTH NEEDS -for placement Family Community DIRECT
(e.g. community
profile)
CLIENT/PATIENT
Emergency
CARE (e.g. DRESSINGS, ETC.)
treatment
COUNSELLING-INDIVIDUALS -FAMILIES -Groups Socialization
WRITING Writing
REPORTS
submissions
Attending meetings -within agency/organisations -with other local agencies -professional organisations
LIAISON WITH -OTHER NURSES -OTHER HEALTH PROFESSIONALS -management -Board of Management -Government Local State Federal -Unions/Professional organisations
Participation in studies (e.g. collecting data)
Crisis intervention Rehabilitation
Designing studies
CO-ORDINATION
and implementing
Of staff within own agency -Nursing -Other health professionals -Others-specify ....... ...... .... .............. .. ...
Long term planning
Of activities
(as part of your normal
health
agencies/services
SUPERVISION
Interpretation
of health
research/evaluation
statistics/research
for community
CASE
work)
SHARING
nurses
in Agency/Unit/Centre
With nursing
Other
health
professionals
With other health professionals own organisation/agency
in Agency/Unit/Centre
nurses
Registered Nurses/other observation/field visits
Activities
forming
health
professionals
part of the community
on
nurses
health
TRAVEL
Other Student
region
RESEARCH/EVALUATION
activities
of other
within
Development of policy -within agency -with other agencies
CARE
MAINTENANCE OF ACTIVITIES OF DAILY LIVING (e.g. HYGIENE, DRESSING, NUTRITION, ETC.) TECHNICAL INJECTIONS,
ON BEHALF OF CLIENT/PATIENT
personnel
With health professionals agency/organisation
role in capitals;
others
not part,
in
not in own
in lower case.
D. R. DUNT et al. Table 2. VNC listing and total population by practice area Practice area
Public/community health Maternal and child health Child care District/visiting (not hospital-based) Psychiatric Mental retardation Physically handicapped (not geriatric) Specialty Occupational health Private School medical (Health Commission) School/college/university Medical clinic Dental clinic Other (inc. post basic nursing courses) Sub-total District/visiting (hospital-based) Psychiatric (basic qual. only) Mental retardation (basic qual. only) Total
VNC listing
Number of responders (070of total in area)
433 584 78 625 78 5 32 13 312 66 106 88 762 16 376
82 (19%) 98 (17%) 15 (19%) 105 (17%) 15 (17%) 2 (40%) 4 (13%) 2 (15%) 57 (18%) 14 (21%) 16 (18%) 17 (19%) 132 (17%) 3 (19%) 59 (16%)
3,575
621 (17%)
353 140 34
49 (14%) 17 (12%) 2 (6%)
4,102
689 (17%)
Table 3. Ten most commonly reported titles of a total of 281 different titles offered by respondents Job title District Nurse Occupational Health Nurse Infant Welfare Sister Community Health Nurse Infant Welfare Nurse Maternal and Child Health Nurse Clinic Sister Nurse/Receptionist Sister In Charge Sister
Number reporting title 39 33 25 17 16 12 11 10 10 10
Health Nurse; Maternal and Child Health Sister; Infant Welfare Nurse and Family Planning; Sister in Charge-Infant Welfare Centre; Relieving Sister-Maternal and Child Health; Infant Welfare Advisor. Preference for title Six hundred and four nurses (88%) considered as appropriate the general title of ‘Community Nurse’ with a sub-title indicating practice area, for example ‘Community Nurse-Maternal and Child Health’. Forty-seven nurses made the following alternative suggestions: specialty title only (22); prefix ‘Community’ then specialty (e.g. Community-
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District Nurse) (6); Community Nursing Sister (4); Community Sister (4); Nurse Practitioner (3); State Registered Nurse (2); Community Health Worker (2); Primary Contact Nurse (1); Registered Nurse-sub-title Community Health (1); Two categories-Health Resource Nurse and Visiting Health Nurse (1). Those who preferred to have a specific specialty title only stated that the title ‘Community Nurse’ was too general. Job conditions Part-time employment levels (total study population). In total, 288 (43%) nurses were employed part-time. Significant differences occurred in part-time employment between the 11 major practice areas (x’,,,= 85.6; P < 0.001). The highest levels of part-time work existed for public health nurses (70%) and the lowest levels for school medical nurses (6Yo). There was, predictably, a significantly higher proportion (x 22= 114.1; P < 0.001) of parttime nurses compared to full-time nurses who stated that dependant children affected their choice of employment. Employment status differed significantly by age group (x2s = 16.0; P < O.OOl), nurses in the 20-30 years age group having the highest rates (71 To) of full-time work. Job descriptions (Sample I). A high proportion of nurses (78%) reported having a job description, either at their appointment (63070),or subsequently (15%). Nursing staff had been involved in the drafting of 74% of job descriptions in those situations where they existed. Eighty-nine per cent of those nurses with a job description felt that it accurately reflected their responsibilities. Thirty-four per cent of those with a job description were able to state that it had been reviewed during the previous two year period. In these circumstances significant differences did occur between practice areas (x 2 I o = 38.9; P < 0.001); highest levels of review (50%) existing for HDVNs and lowest levels (20%) for MCNs. Seventy-nine per cent of respondents believed an adequate job description to be of high or very high importance. State of conditions of employment (total study population). Respondents were asked if they had had access to a formal statement of conditions of employment when they began their present job. Two hundred and ninety-seven (45%) had such a statement; 371 (56%) did not or did not know. There was a significant difference (x21o= 50.5; PC 0.001) between major practice areas in terms of which groups did have such access, highest levels existing for school medical nurses (71%), and lowest levels for MCNs (24%). Those employed full-time (57%) were significantly more likely to have a statement of employment conditions than those working part-time (43%) (x2, = 16.3; PC 0.001). Initial orientation to job (Sample Z). Respondents were asked whether there had been a formal (classroom) orientation programme on starting their present position. Informal orientation was more frequent than formal orientation, with 73% of nurses in all having had someone to ‘introduce them’ when they started their present job. Rescheduling work hours and overtime (Sample I). Nurses are required to work outside normal working hours in a number of community practice areas. In these circumstances only 50% of nurses were able to reschedule their work or adjust their hours accordingly. Forty-five per cent of nurses were paid for overtime, 31% were given time in lieu, and 24% received neither overtime pay nor time in lieu. Significant differences existed between practice areas (x2ro=69.1; P < 0.001) with OHNS (76%) most often paid for overtime and MCHNs (3%) least often. Sixty-one per cent of MCHNs stated that they neither received overtime payment nor time in lieu. Time off in lieu (57%) rather than overtime payment (43%) was preferred by nurses overall. However, there were significant differences
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et al.
(x25 = 23.3; P < 0.001) between practice areas with MCHNs preferring this option most and MCNs least.
Job content (Sample II) Activities listed in the job content question are shown in Table 1. The activities of the community nurses in the six main practice areas (from Sample II) that were performed frequently (by more than 50% of a practice area at least weekly) are summarized in Table 4. Eighteen of 57 activities were so identified. All but four of these 57 activities, however, were identified as being part of the nurse’s role in at least four of the six practice areas. The four activities which were not part of a community nurse’s role are liaison with State and Federal Governments, co-ordination of other staff in an agency and supervision of other health professionals in agency. Prevention and health promotion. Of the three prevention activities considered, only maintenance of a safe environment was performed frequently by nurses of four of the six practice areas. Otherwise routine screening was frequently performed at least weekly by the MCHNs (72%) and OHNs (65%) only. Screening of special groups was not frequently performed by any group. In the area of health promotion, health teaching to individuals and families was performed frequently by five and four practice areas respectively. Health teaching to groups was frequently performed at least weekly by the CHCNs and MCHNs only. Assessment. Assessment of both health status and health needs of the individual was frequently performed by all six practice areas. Assessment for individual placement was performed at least weekly by only the OHNs, family assessment in this way by only the MCHNs and CDVNs. Direct patient/client care. Maintenance of activities of daily living, provision of technical care (e.g. dressings) and counselling of individuals and families were frequently performed Table 4 (a). Nurses performing selected job activities by practice areas (per cent) CHCN
MCHN
CDVN
HDVN
OHN
MCN
Prevention Maintenance of a safe environment
39
88
78
60
78
28
Health promotion Health teaching individuals families
13 70
96 69
82 76
71 57
91 0
49 13
Assessment Individual health status Individual health needs
68 72
94 89
86 82
71 64
86 73
29 19
52 53
79 6
86 84
91 91
39 83
33 70
73 65
92 61
72 72
67 55
96 5
33 14
Direct client/patient care Maintenance of activities of daily living Technical care Counselling individuals families
CHCN, Community Health Centre Nurse; MCHN, Maternal and Child Health Nurse; CDVN, Community-based District & Visiting Nurse; HDVN, Hospital-based District & Visiting Nurse; OHN, Occupational Health Nurse; MCN, Medical Clinic Nurse.
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Table 4 (b). Nurses performing selected job activities by practice areas (per cent) CHCN
MCHN
CDVN
HDVN
OHN
MCN
66 66
74 43
12 65
71 60
91 59
54 29
91 55 67
98 SO 25
92 48 13
91 50 91
96 76 61
97 43 31
61
60
82
76
57
51
Travel
61
92
92
96
96
35
Case-sharing other health professionals
19
20
51
13
57
29
Advocacy Interpretation of care requirements to clients Advocacy on behalf of clients Administration Maintenance of records client other agency Writing reports Liaison with other nurses other health professionals
by four, five, five and four practice areas respectively. By contrast, emergency treatment was frequently performed only by the OHNs and the MCNs. Rehabilitation was frequently performed by only the CDVNs, HDVNs and OHNs. Advocacy. Interpretation of care requirements to patients and advocacy on behalf of individuals were frequently performed (six and four areas respectively). Advocacy on behalf of an agency or the community similarly was performed only by the CHCNs. Adminisiration. Maintaining records of patient care and other agency records, writing reports, liaison with other nurses and other health professionals were frequently performed by most practice areas (six, four, four, six and five areas respectively). Attending meetings within agencies was only frequently performed by the CDCN and CDVN, liaison with management only by the CHCN, HDVN and OHN. Research/evaluation. Research activities were not performed frequently by nurses of any of the practice areas. Co-ordination and supervision. Co-ordination of nurses within the agency was performed frequently by the CHCN only; co-ordination of other health professionals by the OHN only. Supervision. Supervision activity was not frequently performed by any of the six practice areas. Travelling. Travel to visit clients as part of normal work was frequently performed by nurses of all six practice areas except MCNs. Case-sharing. Case-sharing with other health professionals within the agency was frequently performed by all practice areas. Case-sharing with other nurses only was frequently performed by the CHCN and both groups of visiting nurses. Discussion
It is clear from these results that working conditions in community nursing in Victoria, Australia, were good in a number of aspects but not uniformly so. A positive aspect was that almost four-fifths (78%) of nurses currently had a job description. However, negative features were that less than half (45%) had a statement of conditions of employment; only
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D. R. DUNT et al.
about a quarter (26Oro)had had a formal orientation programme for their job, about a quarter (24Yo) worked overtime not rewarded by payment or time in lieu and only about three-fifths (59%) could re-schedule their work times. (Perceptions about income levels and job classifications as they existed during the study period were not sought.) In addition, these different measures of working conditions varied between practice areas in many instances. This variability in conditions across and between practice areas justifies concerns about the implication of the recent rapid growth in community nursing for its future direction. The study results are particularly relevant to the issues relating to the diversity of community nursing practice, in other words the proliferation of practice areas and possible fragmentation of the work experience and job content of community nurses. While the results do indicate considerable diversity of experience they nonetheless demonstrate bounds to this diversity. Firstly, despite the proliferation of practice areas (22) nominated by nurses, a large majority (70%) worked in only six practice areas (75% if public health and community health are merged). Thus, the fragmentation of community nursing, in an overall numerical context, is not as great as might be otherwise considered. Secondly, while 281 job titles were identified, amply confirming suspicions about confusion in terminology and titles, almost 90% of nurses agreed that the ‘Community Nurse-specialist designation’ e.g. ‘Community Nurse-Maternal and Child Health’ would be an acceptable title. It should be noted that, while this title was specifically proposed to the nurses rather than being the response to an open-ended question, it was done so on the basis of the pilot survey in which the nurses’ own suggestions were sought. Thirdly, while considerable diversity existed in the job contents of the six practice areas (see below) there was a core of activities that were frequently and widely performed by community nurses. (Eighteen of 57 job activities were so identified and with all but four of the 57 being regarded as part of the community nurse’s role.) Some qualifications nevertheless are required in interpreting these job content results. While the same activity (e.g. assessing an individual’s health status) may be performed by nurses in different practice areas, the precise nature of this activity may still vary between practice areas, and indeed between nurses in the same practice area. In addition, some practice areas have job contents more in common than others while one (MCN) is very different to the others. Thus CDVNs and HDVNs were the only areas to frequently perform rehabilitation activities and OHNs and MCHNs were the only groups to perform routine screenings. MCNs, who constitute the largest community nursing practice area, shared very few job activities with the other five large practice areas. Most MCNs work alongside and under the direction of general practitioners, a fact which determines their job activities. This is also true for diagnostic and pathology nurses and other medical clinic nurses working closely with medical specialists. In brief, the different practice areas of community nursing (with the exception of medical clinic nurses) share a sufficiently large number of job activities to make the concept of the generic community nurse a meaningful one. Nevertheless there is clearly a sufficient diversity of activities between practice areas for the concept of separate practice areas to remain meaningful. The educational consequences of this are that postgraduate courses in community nursing should contain compulsory core units relevant to community nursing but also include elective units relevant to particular practice areas. (In Melbourne, this occurs currently in courses such as those offered at La trobe University, Phillip Institute of Technology and the Royal District Nursing Service). There is a strong
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indication however that the group of nurses classified by the Victorian Nursing Council as MCNs (which includes diagnostic and pathology nurses) should be categorized differently to other groups of community nurses and received a different post-basic educational experience.
Conclusion
Community nursing, at least in Victoria, Australia currently consists of a large number of dispersed and relatively isolated groups which nevertheless share many common features in their job activities. A more appropriate model (and set of working conditions) for nurses practising in a community setting depends upon the promotion of the concept, and title, of the community nurse-specialist designation, which recognizes both the common and separate features of the different practice areas. While these conclusions are based on the study of community nursing in one Australian State, they are of relevance for community nursing in other parts of Australia and other countries. Acknowledgements-We acknowledge the helpful advice and direction of the Steering Committee to the study, in particular Miss N. Bryan, Dr M. Bennett and Miss B. Carson. In addition, Dr Bennett gave considerable guidance in regard to developments in post-graduate nursing education. We would like to thank Professor R. Webster and the Department of Community Medicine for their generous financial and secretarial support, Dr E. Khatib for computing advice, Dr S. Wales for editorial assistance and MS L. Pearce for typing. We thank the large number of individuals and special interest groups, for their time and assistance when consulted during the study design stage. Finally, we acknowledge the many community nurses who gave so freely of their time to answer our questions. The study was funded by the Royal Australian Nursing Federation (Victorian Branch).
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