Editorial

Nursing: Continuity of care and the constant challenge of change

Sue K Armitage
Professor of Nursing; Head, Department of Community and Mental Health Nursing, Faculty of Nursing, University of Sydney, NSW

PP: 119

Article Text

"The times they are a-changing". So sang Bob Dylan in the nineteen sixties. And the times have certainly changed in nursing since these days. Positions were once tenured and nursing was one of those safe occupations that gave a job for life. Change is inevitable, although the pace of change varies, and not all people feel that change is progress. Few people have been cocooned from fast moving changes in their professional lives. The fortunate ones have been able to adapt to inevitable changes in nursing education or clinical practice in a smooth relatively unhurried fashion, and calamitous change has been the thing that has happened in someone else's professional life. The status quo that is comfortable and unthreatening no longer exists and change appears to be happening at an inevitably faster pace. "May you live in interesting times" reputedly goes the Chinese saying. We hear bland admonishments to see the changes in life as an opportunity rather than a threat, and to meet the new challenges head on, and to take control of them before they take control of us.

Nursing has moved far in the past thirty years from where it once was. Unlike many other disciplines, nurses have always been interested in and taken up with an attempt to define what is nursing. Other disciplines as diverse as medicine, sociology, law and accountancy do not concern themselves with the need to define what they do. In their terms, nursing is what nurses do. The nursing that nurses do is not easily circumscribed as once it was in those times of the Bob Dylan song. Many of the essential elements of nursing are indeed the same. Nurses care for patients who are in a variety of settings. From the institutional large tertiary referral metropolitan hospitals to community health centers to people in their own homes and sometimes outside in the bush in outback Australia. In essence the ideology of nursing remains and the issues of concern can span several decades. One such issue that is dear to my heart is that of continuity of care. It is one of the areas that was beginning to be addressed in research carried out by nurses for the first time 20 to 30 years ago. Interestingly, or perhaps sadly, it is still with us.

The care gap

Twenty-five years ago, nurses began to be aware of the care gap that existed for patients between their stay in a hospital and the return to their own homes (Skeet, 1974; Roberts, 1975). Patients stayed in hospitals for many weeks and three weeks as an in-patient following a myocardial infarction was not uncommon. The major surgery of cholecystectomy entailed a two to three week spell in hospital with drips and drains predominating. Studies examining the issues surrounding the referral of patients for discharge from medical wards revealed that a lack of effective and efficient assessment of patients' needs frequently resulted in inadequate or non-existing services for patients requiring community care once they were discharged home (Armitage, 1981; Bowling and Betts, 1984; Armitage, 1991). Deficits in discharge planning were identified leaving the patients at their most vulnerable in the first 24 to 48 hours at home after leaving hospital. Models of discharge planning have been offered (McClelland, Kelly and Buckwalter, 1985) but with little evidence of being used. Subsequent studies have shown that nurses recognise the need for appropriate and adequate referrals for follow up care after a period in hospital (Armitage and Kavanagh, 1995; 1996). That period has, of course, decreased rapidly. Patients stay in hospital two or three days rather than the two or three weeks of 30 years ago. With the changes have come the pressures on nurses to respond to the acuity of patient care and to keep up with the pace of throughput of large numbers of patients. Nurses are aware of the issues about continuity of care. They readily cite the principles of good practice in discharge planning; that it should begin on day one of a patient's admission to hospital and before that if the admission is planned; that a comprehensive nursing assessment should be carried out and the effective communication between all the health professional is important. They also acknowledge that adequate provision of care enable people to stay out of hospital and that discharge planning performed competently uses staff time and the resources of a hospital in an efficient manner. Sadly too, they also say that due to the pressure of time on their work, they give little priority to discharge planning and it becomes an event at the end of a stay in hospital, which has little preparation (Armitage and Kavanagh, 1996).

The demands are great and yet everywhere we look there are examples of innovative and exciting nursing practice. Hospital in the home schemes meet the needs of patients in a way that enable them to receive expert care when they need it and where they need it: in their own homes where most patients prefer to be and where they can feel in control of the care given (Caplan and Brown, 1997; Elliott, 1993).

Complementary therapies

On another front, complementary therapies are increasingly being incorporated into every day nursing care. The Australian public is a high user of a large and increasing variety of natural and complementary therapies that are often the first choice of treatment for many people. Nurses frequently see the use of these therapies as a contributory factor to their ability to deliver holistic nursing care (McCabe, 1996) and older people, for example, often benefit from the use of a combination of such therapies as massage and aromatherapy.

For many years, nurses have claimed to care for the whole person. Increasingly, attention is being paid to the spiritual needs of people (Ronaldson, 1997; Wright, 1995). Spirituality is taking an increasingly important role in our educational curricula as we recognise and acknowledge the body/mind/spirit as one entity without division and the effects of health of this interrelated view of people. The globalisation of the world in which we live by paradox has drawn attention to the indigenous peoples of the world. We realise that the first people of many nations hold sacred their relationship with the land, their history and their heritage in a holistic way, which is often envied by those who live in an ever increasingly paced urban world. The meaning of spirituality as a sense of wholeness and as something that gives meaning to life is constantly being sought. Those who live in the cities often seek the nomadic or alternative ways of living. The 'grey nomads' travel the country on their retirement and urban dwellers seek a return to former meanings with the growth interest in shamanism and a variety of alternative therapies.

The nurse practitioner role

Nurses are responsive to the changing needs of a population and the communities in which they work. The nurses who practice in rural and especially remote areas of Australia provide excellent examples of the versatility and breadth of expertise that is inherent in the discipline of nursing (Bradley, 1998; Handley, 1998). The combination of independent practitioner, trauma specialist, primary health care nurse and member of the community is not containable in one all encompassing definition.

Where does the future of nursing lie? Perhaps the response to this question lies in whatever direction nurses take in the ever-changing world. Let us not confine nursing by trying to define it.

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