case study on community health nursing

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Case Studies in Community Health

• Jo Fairbanks - University of New Mexico, School of Public Administration, Centennial Group, Latin America
• Judith Candelaria - New Mexico Department of Health
• Description

Case Studies in Community Health presents 14 classroom-tested case study scenarios, including background information and discussion questions. Written for students in public health and community health courses, these cases help integrate the basic concepts of public health into an applied setting. The case studies provide an opportunity for students to apply those basic concepts to a "real-life" situation. The overall purpose of the book is to help students understand that public health practice occurs in a social context and therefore is subject to all the complexities of a social environment. The cases explore a broad range of topics in three critical areas of public health: epidemiology, health administration, and health program planning.

This text will be of interest students and professionals in family studies, family therapy, gerontology, health communication, medical sociology, nursing, nursing administration, nursing health, nursing research and theory, patient care, public administration, public health, quantitative research and methods, school counseling, social work, and sociology.

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Handbook of Social Sciences and Global Public Health pp 1–12 Cite as

Community Nursing and Global Health

• Yvonne Parry 2 , 3  
• Living reference work entry
• First Online: 22 December 2022

49 Accesses

Nursing provides the largest direct care and health intervention workforce and as such is a global health resource. Examinations of the International Classification for Nursing Practice (ICNP) have found that community nursing interventions directly address the identified themes related to gaps in healthcare, services, and system’s coverage and continue to support advancements in understanding the complexities of health for individuals, families, and communities. Additionally, nursing in and of itself addresses some global health goals through the provision of meaningful work for mostly women who are provided with income and career opportunities. Thus, nursing can assist in addressing inequities faced by populations with limited access to health and employment. This chapter outlines the role of community health nursing and how community nursing is used to address the global public health agenda. Community health is a nursing speciality that moves healthcare from the acute setting into the community-based health sector. These appropriate and cost-effective responses place community nursing at the forefront of responses to the global health Sustainable Development Goals. Globally, there is a need for more community nurses as they play a critical role in providing quality healthcare in the community. Community nurses enable the public to access best practice and evidence-based healthcare in their community in easy reach of the population. The research illustrated in this chapter uses community nursing services to directly address the global health agenda. Using examples from the Global North and South, the chapter provides evidence of the impact of community nursing on Global Health. The use of nurses in the community to advance health messaging and health access is foundational in addressing the needs of marginalized and vulnerable populations.

• Community health
• Community nursing
• Social determinants of health
• Global health and nursing

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College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia

Yvonne Parry

Research Lead, Better Communities, Caring Futures Institute, Adelaide, SA, Australia

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Pranee Liamputtong

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Parry, Y. (2023). Community Nursing and Global Health. In: Liamputtong, P. (eds) Handbook of Social Sciences and Global Public Health. Springer, Cham. https://doi.org/10.1007/978-3-030-96778-9_12-1

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Community Health Nursing: A Case Study Approach 0th Edition

• ISBN-10 0397554605
• ISBN-13 978-0397554607
• Publisher Lippincott Williams & Wilkins
• Publication date January 1, 1997
• Language English
• Dimensions 6.25 x 0.5 x 9.25 inches
• Print length 311 pages
• See all details

Product details

• Publisher ‏ : ‎ Lippincott Williams & Wilkins; 0 edition (January 1, 1997)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 311 pages
• ISBN-10 ‏ : ‎ 0397554605
• ISBN-13 ‏ : ‎ 978-0397554607
• Item Weight ‏ : ‎ 1.06 pounds
• Dimensions ‏ : ‎ 6.25 x 0.5 x 9.25 inches
• #225 in Home & Community Nursing Care
• #1,065 in Nursing Home & Community Health
• #309,617 in Unknown

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Case studies in community health nursing practice : a problem-based learning approach

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Case Studies in Community Health

• By: Jo Fairbanks & Judith Candelaria
• Publisher: SAGE Publications, Inc.
• Publication year: 1998
• Online pub date: June 19, 2012
• Discipline: Health & Social Care
• Subject: Public Health (general)
• DOI: https:// doi. org/10.4135/9781452243290
• Keywords: community health centers , counties , health centers , health plans , learning objectives , managed care , public health Show all Show less
• Print ISBN: 9780761914051
• Online ISBN: 9781452243290
• Buy the book icon link

Case Studies in Public and Community Health presents 14 classroom-tested case study scenarios, including background information and discussion questions. The overall purpose of the book is to help students understand that public health practice occurs in a social content, and is subject to all the complexities of a social environment. The book can be used as a textbook supplement to Jo Fairbanks William H Wiese's,The Public Health Primer (SAGE, 1997); it can also be used on its own, or as a supplement to other textbooks in the field.

Front Matter

• Introduction

Part I: Epidemiology

• Case Study #1: Basic Terms in Epidemiology
• Case Study #2: Cholera in London, 1850
• Case Study #3: The Hantavirus Outbreak
• Case Study #4: Focus on Violence

Part II: Public Health Administration

• Case Study #5: Why Regulate?
• Case Study #6: Meningococcal Meningitis Outbreak
• Case Study #7: Quality Leadership Process
• Case Study #8: Managed Care: What Role for Public Health?

Part III: Health Program Planning

• Case Study #9: Planning in a Social Context
• Case Study #10: Closure of a Planned Parenthood Clinic
• Case Study #11: Homeless Health Care
• Case Study #12: Planning for School Health Services
• Case Study #13: School Health/Border Issues
• Case Study #14: Health Promotion/Prevention of Diabetes Mellitus
• Case Study #15: Health Promotion Program Evaluation

Back Matter

• About the Authors

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Conceptual framework of the nursing centre for the integration of community health nursing practice, education, and research

Neti juniarti.

1 Community Health Nursing Department, Faculty of Nursing, Universitas Padjadjaran, Indonesia, Jl. Raya Bandung – Sumedang KM. 21 Jatinangor, West Java, Indonesia

Jeffrey Fuller

2 College of Nursing and Health Sciences, Flinders University of South Australia, Sturt Road, Bedford Park 5042, South Australia, Australia

Lana Zannettino

Julian grant.

To develop a conceptual framework that can be used for the integration of community health nursing (CHN) practice, education, and research within a Nursing Centre (NC) model.

Background:

New forms of training and support are needed to equip nurses to manage the complex and costly challenges facing health care systems. The NC model provides scope to address these challenges by integrating nursing practice, education, and research. However, there is little information about how these constructs are integrated or how education is constituted within the model.

This study used an embedded single case study design across three Nursing Centres (NCs) in West Java Indonesia. Semi-structured interviews and a review of relevant documents were conducted. Interview participants were recruited purposively to select stakeholders with rich information, including clients, nurses, nursing students and lecturers who have been using the NC model, as well as the head of the co-located Community Health Centres. Data was analysed using thematic analysis, pattern matching and cross-unit synthesis.

Four components relevant to integration in the NC were identified, namely (1) client-centred care as the shared common ground for integration in the NC; (2) nursing education using a service learning approach; (3) the NC as a model for reviving CHN services; and (4) service improvement through research and community service activities. The service learning approach was identified as appropriate because it links services with the learning process and this serves to address the interests of both practice and education institutions. The conceptual framework identified in this study can be used to improve the functionality of NCs in Indonesia and be considered for use internationally.

Introduction

New forms of training and support are needed to equip nurses to manage the complex and costly challenges facing health care systems. To provide appropriate forms of training and support, strong partnerships through organisational integration are needed between nursing schools and health care organisations (Wilcock, 2011 , p. 242). Inter-organisational integration refers to the quality of collaboration among different organisations and different sectors in the society to improve the quality of service as well as to improve efficiency (Axelsson and Axelsson, 2006 ). This can also extend to the way in which services are delivered and how practices are organised and managed together (Heath et al ., 2013 ). The main types of inter-organisational integration are co-operation and collaboration, although terms such as networks, partnerships, and coalitions are also used to explain different levels of integration (Axelsson and Axelsson, 2006 ). Cooperation and collaboration is a continuous process at both individual and system levels where individuals are required to constantly negotiate boundaries (Wihlman et al ., 2008 , p. 1).

Integration of academic and health care organisations is often difficult to establish due to lack of trust and respect from both parties (Andrew et al ., 2008 ). This can result in gaps between what is taught and what is practised, presenting major challenges for nursing as a profession (Kitson, 2006 ; Maben et al ., 2006 ). Nursing education can then have little immediate or direct impact on achieving goals of quality patient care (Smith and McCarthy, 2010 ). Proposed solutions include integrating academic research in practice settings to enhance the implementation of evidence-based practice throughout nursing (Christie et al ., 2012 ).

Schools of Nursing in the USA established Nursing Centres (NCs) in the previous decade as one approach to bridging the gap between education and practice (King, 2008 ). These centres have a threefold goal to educate student nurses, provide health care services and conduct research that advances health care (Pohl et al ., 2007 ). As a part of community health care and higher education systems, NCs sought to integrate scholarly nursing practice, education and research to provide a comprehensive primary health care service to individuals, families and communities (Boettcher, 1996 ; Shiber and D’Lugoff, 2002 ; Barkauskas et al ., 2006 ). In the USA, the origin of the Nursing centre (NC) was started in the late 19th century (King, 2008 ). The NCs were defined as:

Organisations that give clients and communities direct access to professional nursing services. Professional nurses in these centres diagnose and treat human responses to actual and potential health problems, and promote health and optimal functioning among target populations and communities (American Nurses’ Association, 1995 , p.1).

There are two major approaches to the NC. These include the approach that focusses on integration between nursing and other organisations (Lundeen, 1993 ; 1999 ) and that focusses on integration of health services, research and education (Newman, 2005 ). While most of these papers reported on the integration of nursing practice, education and research, there was little information about the integration frameworks or specific approaches to education. Miller et al . ( 2004 ) proposed that a business plan as a blueprint for the NC should be used to determine the feasibility of clinical services, faculty development requirements, and expected returns on investment of time and resources. However, there has thus far been no subsequent publication that indicates that this blueprint has been implemented and evaluated.

In West Java, Indonesia, an NC model was developed in 2002 by the Faculty of Nursing Universitas Padjadjaran (UNPAD) (Samba, 2002 ). Defined as a nurse-led clinic, the model integrates health care services, education and research through the optimal use of all potential resources in the community health care system (Samba, 2007 ). The NC model in West Java is unique because attachment to the government-owned community health centres is the main integration strategy. It emphasises improving the quality of Community Health Nursing (CHN) services, education, and health outcomes for people in the community. This NC was the first collaborative project between nursing education institutions, local government, provincial health offices, community health centres ( Puskesmas ) and the community in Indonesia. In 2016, there were 26 NCs located in 21 cities and regencies in West Java Province. By 2018, this has increased to 36 NCs.

One of the problems for NCs around the world is sustainability (Barger and Kline, 1993 ; Bell, 2008 ). Thus, organisational partnership between academics and the community is needed to maintain the sustainability of NCs (Krothe et al ., 2000 ). However, there is a lack of a conceptual framework from which to compare what works and the benefits of partnership for stakeholders (Levine-Brill et al ., 2009 ; Funnel and Rogers, 2011 ; Leffers and Mitchell, 2011 ). Also, there are no clear indicators of success and there is also a lack of a blueprint that can be used to measure the effectiveness of the model (Levine-Brill et al ., 2009 ). A lack of clear measurement indicators is quite common in organisations that have a diversity of practice and a wide variety of stakeholders (Davies, 2004 ). As the NC model is increasing in use in Indonesia, it is essential that frameworks are established to measure their success and identify areas for improvement. This paper presents research that identified the core components of the NC in West Java, and proposes a conceptual framework that can be used for the research and evaluation of NCs in Indonesia.

This study used an embedded single case study design (Gomm et al ., 2000 ; Yin, 2014 ). Guided by a constructivist ontology and an interpretivist epistemology, this study used an embedded single case study design as the strategy to conduct the research (Yin, 2014 ). This study used a case study design to investigate the activities and processes of, and the inter-relationships between, the stakeholders in the NC model within its real-life context in Community Health Centres (Puskesmas) in West Java, Indonesia. The findings of this study have informed the process of developing a theory to underpin the NC model.

The model is viewed as the single case because it is a unique and collaborative CHN educational approach in the Indonesian setting. While the NC model is viewed as a single case, the study involved three NC (Puskesmas) sites in West Java as the embedded sub-units of analysis. These sub-units were used as focussed sites for the case study inquiry to obtain sufficient and specific data about the NC model as the larger unit of analysis (Yin, 2014 ). Even though case study findings cannot be used for empirical generalisation, the wider relevance of the findings may be conceptualised as a basis of transferability to other settings (Gomm et al ., 2000 ; Yin, 2014 ). The study was approved by the Flinders University of South Australia’s Social and Behavioural Research Ethics Committee (SBREC) (project number 5887).

Data collection

Data included semi-structured interviews with a range of stakeholders ( n = 41) and a search of evidentiary materials that comprised the original documents about the NC model, two published books about NCs, and policies related to nursing education, CHN practice, and community health centres in Indonesia ( n = 9).

The focus of the study was on the experiences of clients, the nurses, nursing students, and lecturers who have been using the NC, as well as the head of the Community Health Centre. Hence, participants were recruited purposively in this study in order to select cases and stakeholders who could provide rich information for the in-depth study of participants’ opinions, interpretations, and perspectives (Liamputtong and Ezzy, 2005 ). Participants included clients, nurses, nursing students and lecturers using the NC model, as well as the head of the co-located Community Health Centres ( Puskesmas ). The number of participants recruited from each of the three sites was 13. As suggested by Guest et al . ( 2006 ), at least twelve interviews per site is needed to understand common perceptions and experiences. With the founder of the NC and the Provincial Coordinator, the total number of participants was 41. The characteristics of participants who were involved in this study are presented in Table ​ Table1 1 .

Participants characteristics

The semi-structured interviews comprised open-ended questions that encouraged participants to express their perceptions about the NC in a conversational manner, while closely maintaining the case study line of inquiry (Yin, 2014 ). All the interviews were conducted in the Indonesian language by the first author who is an Indonesian native speaker. Interviews ranged from 30 minutes to 1.5 hours in duration and were recorded using a digital audio recorder. Field notes were also taken by the interviewer during the interviews.

The questions asked during the semi-structured interviews were informed by a study conducted by Laplante ( 2009 ) which investigated the meaning of reciprocity in service learning, and also by the Kellogg logic model which consists of examining context, implementation, and outcomes (Kellogg Foundation, 2004 ). The interview questions focussed on the context of the NC model, the activities and implementation of this model, and the perceived outcomes of the NC. Participants were also asked about their understandings of the learning methods involved in the NC model. The matrix of interview questions is presented in Table ​ Table2 2 .

The matrix of interview questions for seven stakeholders

Data analysis

The audio recordings of the interviews were transcribed in the Indonesian language, forward-translated into English, and then back-translated into Indonesian to ensure the rigour of the qualitative data. All authors were involved in identifying and refining the themes of three interviews transcripts in order to ensure that the coding process was comprehensive and to identify the ‘scope’ of what each theme was about. The first author continued the analysis using the same coding process for all interview transcripts. NVIVO version 10 software (QSR International Pty Ltd., 2012 ) was used to store and organise the data. Data analysis was undertaken in two stages. Firstly, inductive thematic analysis was used to identify the experiential issues described by the participants (Braun and Clark, 2012 ). The analysis consisted of the following six phases: becoming familiar with the data, generating the initial codes, searching for themes, reviewing the themes, defining and naming the themes, and producing the report. Pattern matching and cross-case synthesis (Yin, 2014 ) were then employed as a second stage to conceptualise the broad components of the various puskesmas activities, informing the overall NC model. The identification of patterns and consistency in the case study approach is considered the most rigorous technique for case study researchers (Yin, 2014 ). This is because the identified patterns can show how the various parts of the findings fit together (Thomas, 2011 ). The researcher compares the pattern of the data empirically based on the expected pattern of outcomes (Yin, 2014 ). Pattern matching enabled comparison of study findings with the theoretically expected outcomes from the literature and evidentiary materials in order to examine the most suitable educational method to be used in the NC model (Thomas, 2011 ). The pattern of relationships found in the data from the three NCs was then compared to the pattern of possible explanations using the components of adult learning, active learning, and service learning theories, as these are the concepts that are closely related to the NC model in Indonesia. In this way, the findings of this study will reflect the most suitable educational method to be used in, and to improve, the NC model. If the empirical pattern and the possible explanation seem to be congruent, the findings can strengthen the credibility of the study (Yin, 2014 ).

The cross-unit synthesis was used to compare and contrast the three NC sites to draw a broad conclusion about the ideal NC model. Themes were then grouped to identify the similarities and differences in the situation, implementation and outcomes of the NC across the three sites.

To be considered as evidence, a qualitative narrative should consider the rigour or trustworthiness of the interpretive perspective based on its credibility, transferability, confirmability, and dependability (Patton, 2002 ; Altheide and Johnson, 2011 ). Creswell ( 2009 ) suggested the use of triangulation as one way to maintain the credibility and accuracy of the findings. In this study, methodological triangulation was employed by using more than one data collection technique; that is semi-structured interviews and document analysis. Data triangulation was also achieved by using multiple data sources from seven NC stakeholders. Documents were also used as additional sources of evidence. The documents were analysed to identify the original Indonesian NC model, the development of the NC model, the specific activities expected to be conducted by the NC, the history and development of policy for CHN practice in Indonesia, and to understand the underlying reasons for collaboration between nursing education institutions and community health centres.

In terms of transferability, qualitative research seeks to understand, in an in-depth manner, a specific case within a particular context, rather than to generalise. In this study, the NC stakeholders have differing views which need to be explored in order to deeply understand them. Even though these views could not be generalised, the lessons learned from a deep understanding of the stakeholders’ views can be used to inform other models beyond the case study site of investigation (Yin, 2014 ).

To ensure the dependability of this research, steps of analysis were explained, starting from methods, data collection procedures, and data analysis procedures. In terms of confirmability, authors were constantly aware of the possibility of bias in the data collection. Authors worked within the reflexive approach constantly in order to consciously separate personal background from the data, and to analyse the data using an ‘outsider’ perspective. In this way, the personal bias was kept to minimal

The functionality of the Indonesian NCs

Overall, the current condition of the three NCs demonstrates that there is an inadequate functionality of the NCs because the components of the NC model have been understood differently by the various stakeholders. Each of these centres has a different focus, with NC 1 focusing on student placement for CHN and family nursing, for example ‘ The operation of the NC was mostly conducted by the students. […] So far in here, the NC was a place for students to learn to provide nursing services ’ (Lecturer 1 NC1). NC 2 focusing on lecturers’ community service activities, ‘ the NC is used by the lecturers only for community service. We don’t involve students in the NC ’ (Lecturer 1 NC2). NC 3 focusing more on the Community Health Centre agendas that leads to the ineffective nursing education in this NC, as stated by one of the students:

I have done a placement in the community and have heard about the NC from the lecture. However, placement in the NC is not effective because we [male students] have not been given a chance to practice inside the Puskesmas (Student 1 NC3) .

As a result of these three foci, the optimal collaboration between services and learning experience in the NCs was not able to be developed, implemented, monitored or evaluated. In order to improve the integration and hence the functionality of the NC, the data were analysed to identify the ideal components of the NC as perceived by the participants. These components are presented in the following sections.

Main components of the NC

Four main components of the NC were identified as: (1) client-centred care as the shared common ground for integration in the NC; (2) nursing education using a service learning approach; (3) the NC as a model for reviving CHN services; and (4) service improvement through research and community service activities. It is argued that all of these components need to operate in a conducive environment such as the feeling of being valued in order to develop the functionality of the NC.

Client-centred care as the shared common ground for integration in the NC

To improve the functionality of the NC, the one basis for common ground identified in this study was to focus on clients, including individuals, families, and people in the community within a caring environment. Most of the stakeholders viewed that the NC has benefitted clients. The following excerpts are examples of students’ and nurses’ views about this:

The benefit of the NC is very big for people in the community because they can receive free health consultations. People do not have to spend money, but they will know how to manage their illness, such as TB and diabetes mellitus (Student 3 NC1) .

Patients can receive more knowledge in the NC, we can prevent patients from getting worse, […] we explain how to take care of the disease at home so that the patients can be independent in conducting self-care (Nurse 1 NC3) .

Client-centred care is the core requirement that could be used as a starting point and a common ground towards the improvement of health outcomes for individuals, families and people in the community through close collaboration between the nursing education institution and the Puskesmas . This client-centred appraoch had helped to develop a desire for caring among the students:

Before I met the patient, I felt lazy to start it up [give intervention], but once I started [the interaction], I want to give, and want to give again. […] I used the same approach, just starting to give health education. When the client gave a positive response, then I felt good (Student 1 NC1) .

The above quote highlights that students’ capacity for caring was developed through providing care for families and people in the community. The students’ interactions with the clients were useful in developing a desire for caring that can lead to the development of students’ caring behaviours. The NC model is designed to provide a consistent caring environment for students and nurses. Students who have learnt about caring for patients in the classroom can then apply this knowledge consistently in the field.

Nursing education using a service learning approach

In this section, pattern matching analysis was used to analyse the documents and interview data in order to compare this data to the pattern of possible explanations. Analysis of the first publication of the Indonesian NC (Samba, 2007 ; 2012 ) showed that the theoretical basis for the Indonesian NC consisted of six concepts: CHN services as a system, adult learning, professional organisation, caring, nursing research, and community. This finding was different from the interview findings where lecturers identified three roles associated with the NC, being education, research, and community service, summarised in the following quote:

The concepts of the nursing centre are education, in which students take part in community placements; research, in which academics and students conduct research; and community service, in which the academic gives service to the community (Lecturer 2 from NC1) .

In the document, Samba ( 2012 ) also proposed both adult learning and active learning as the learning approaches in the NC. This may have contributed to the confusion of students in applying the appropriate learning approach, as indicated by the following student statement:

The truth is that the placement in the NC is the most unclear work I have ever had (Student 1)

The data suggest that students from the three NC sites were confused about their roles in the NC, which then appears to contribute to the inadequate functionality of the NCs. The findings from the document analysis showed that an effective and active learning approach was the intention of the NC founder:

In order to learn effectively, nursing students need a learning method that is active, integrative, cumulative, and consistent. Active learning demands creativity, independent thinking, collaboration, and learning directed by the student. Integrative learning is needed in order to give real benefit to the community (Samba, 2012 , p.19) .

The concepts of active, integrative, cumulative and consistent learning do not belong exclusively to the concept of adult learning (Merriam and Bierema, 2013 ), but are also embodied in the concepts of active learning (Dewing, 2008 ) and service learning (Whiteet al., 1999 ). In order to identify an educational method that can facilitate integration at an optimal level in the NC, the following Table ​ Table3 3 presents an overview of the pattern matching analysis using the three concepts mentioned above.

Pattern matching analysis of the learning approach in the NC

While there were confusion in the practice and overlapping components of the adult, active and service learning evident in the data, all components of service learning are evident and matched the characteristics of the NC model in West Java, Indonesia.

The NC as a model for invigorating community health nursing services

In addition to educational purposes, the NCs were also used as a venue for invigorating CHN in West Java, Indonesia “ because CHN practice did not exist. […] an idea of NC is to revitalise the Community Health Nursing program” (Suharyati Samba, the founder of NC Indonesia) . The term ‘Nursing Centre’ is used by the founder of the NC and the Provincial Health Office as a strategy to give new meaning, new energy and new activities to CHN practice in Indonesia. Participants from the community health centres, including the Head of the Puskesmas and the nurses, viewed the CHN program, known as Perkesmas (Perawatan Kesehatan Masyarakat) as the basis of the NC model. The NC was perceived as a venue to conduct the Perkesmas program, as stated by a head of Puskesmas:

I think the NC is a place for nurses to conduct Perkesmas programs inside the Puskesmas building. Nurses’ outreach activities are organised by the person-in-charge of the Perkesmas programs (Head of Puskesmas 2) .

Through a CHN ( Perkesmas) program that was integrated into the NC model, nurses had the opportunity to contribute to the wider community:

Through the NC, we have an opportunity to do the follow-up; nurses will assess and determine the priority of patients who need home visits; from there, we can follow-up and the intervention is not only for one patient but also for a whole family (Head of Puskesmas 3) .

The CHN nurses who worked through the NC had the potential to deliver a holistic form of care, which then had a positive impact on the community. The necessity of holistic activities taking place both inside the facilities and through outreach activities as ways of providing care is also found in the NC document analysis (Samba, 2002 ; 2012 ). Hence, the role of the NC is not merely to fulfil nursing education or lecturers’ needs, but also to provide a holistic form of nursing care for individuals, families, and communities.

Service improvement through research and community service activities

The NC was seen as a way of facilitating the three roles of education, research and community service in Indonesian higher education as per the following participant example:

The lecturers’ roles in the NC are related to three obligations of higher education [in Indonesia]. We need to provide services for the students and to anyone who requires the service. Besides education, we also have to do research and community services (Lecturer 2 NC2) .

The importance of research was also expressed by the Heads of Puskesmas to improve services in the NC and the Puskesmas :

I always welcome students and lecturers who want to do research here. It is very important to improve the Puskesmas performance. We [Puskesmas staff] do not have time to do research, so I always ask the students to do research here and give us the reports (Head of Puskesmas 3) .

These findings show that the lecturers, nurses, and the Heads of the Puskesmas recognise the importance of research in the NC. However, participants stated that the research activities by students and staff could not be conducted optimally due to the time constraints on both lecturers and community health centre staff.

The NCs were also used as community service sites for lecturers as stated by one of the lecturers from NC2:

All the lecturers here want to work in the NC as part of their community service activities. I arrange the schedule for the lecturers to work in the NC. Most of the activities are health education and counselling in the NC, but now we have added home visits and school health activities (Lecturer 3 NC2) .

Research and community service activities would reduce the gap between CHN services and education through the process of knowledge-sharing towards best practice in the Community Health Centres. Knowledge-sharing that is related to evidence-based practice and research would also increase the likelihood of these best practices being applied in the NC by students and nurses. Best practice will also increase the quality of CHN service provision for individuals, families, and people in the community, which has the potential to produce better health outcomes overall.

The components identified in the findings section were used to construct a conceptual framework of the NC as shown in Figure ​ Figure1. 1 . These components form a triangle of integration of CHN services, education, and research with client-centred care as the core of the framework in order to clarify the relationships between these three components of the NC that shows the tri-partite relationships between CHN services, education, and research in the NC model. CHN services and education using service learning are at the bottom of the triangle because these are the fundamental activities that support research and community service activities,which are placed at the tip of the triangle. CHN services consist of inside the NC facility as well as outreach activities. The identification of health problems and community needs during the integration of CHN services and education could become a topic of further research and community service activity.

Conceptual framework for the integration in the nursing centre

Figure ​ Figure1 1 shows the interrelationships between the components in the NC model. The integration of nursing services and education in the NC could contribute to service improvement through research and community service activities. The results of research and community service would inform further improvement of nursing services and education. The arrow directions mean that each of the components influences each other. If the integration of CHN services and education improved, then it would likely induce collaboration and partnerships needed to perform the research and the community service program so that new knowledge and innovation can be produced. In a circuitous way, this knowledge and innovation would likely lead back to the improvement of CHN services and education within the NC.

In this conceptual framework, the clients, who consist of individuals, families, and the community, are the core of the NC model as the shared common ground for both nursing education and health service stakeholders to integrate CHN services, education, and research. Shared mission, values, goals, and measurable outcomes are important to maintain a collaborative approach (Berkowitz, 2000 ). In this way, all stakeholders can actively and jointly establish roles, norms, and processes based on contributions from, and the shared common ground of all stakeholders. This shared common ground would help to facilitate effective interaction among the stakeholders and would ultimately produce better outcomes (Foss et al ., 2003 ). A shared common ground is crucial for inter-sectoral collaboration to strengthen primary and community care, as well as to better coordinate care around people’s needs (Walley et al ., 2008 ). This could lead to increased access to comprehensive and high-quality health services (WHO, 2015 ).

This proposed conceptual framework is different from other NC models as it incorporates a service learning approach and the integration of CHN practice, education, and research in the model. The findings show that by using service learning in the NC model, nursing students could learn from the experience of working collaboratively with the community, nurses and other health professionals. Service learning in this study is defined as a structured form of intra-curricular experiential learning that engages students in service and learning through real-life experiences, using reflection and reciprocity as tools to achieve the specified outcomes and benefits for all stakeholders (Juniarti et al ., 2016 ). This conceptual framework is different from the original six concepts proposed by Samba ( 2002 ) for the Indonesian NC model. The original concepts did neither identify a clear shared common ground between the stakeholders nor clarify the responsibilities and roles of nursing education and health service stakeholders. It is argued that service learning is an appropriate educational approach for the NC because this approach is able to support a clear shared common ground and clarify responsibilities and roles between the stakeholders to support collaborative project and reciprocal benefits (Berry and Chrisholm, 1999 ; Voss et al ., 2015 ). This current study shows that service learning is an appropriate and potentially productive learning approach in the NC. This is similar to the findings from other studies (Connolly et al ., 2004 ; Lough, 1999 ; Lutz et al ., 2001 ; Marek et al ., 2004 ; Yeh et al ., 2009 ) which report service learning as a specific approach to student education in the NC alongside service provision for clients and research.

The conceptual framework of the NC is developed for the purposes of reviving CHN services. Through the NC, nurses are encouraged to integrate a range of programs using the CHN approach as well as to conduct family nursing activities. Involving the key stakeholders in collaborative research activities could become a strategy to build on the desire and willingness of the champions in the nursing education institution and Community Health Centre to improve the quality of community nursing care and students’ education in the NC. However, research agendas in the NCs need to be aligned with the needs of people in the community using participatory recruitment strategies and multiple data collection methods to build reciprocity and maintain trusting relationships with the community (Zachariah and Lundeen, 1997 ). Such trusting relationships need to be maintained over the long term to ensure the sustainability of the NC (King, 2008 ). Integrating CHN services, education, and research would overcome the problem of the sustainability of the NC because it helps to build trusting relationships between stakeholders.

This NC framework shows the clear roles of both the nursing education and the health service stakeholders. The role of the nursing education stakeholders is to provide service learning, research, and community service, while the role of the health service stakeholders is to provide family nursing services, CHN services, and other health programs. The roles of these two organisations are integrated through a collaborative approach which is co-located in the NC.

In the NC, students learn to deliver CHN and family nursing care in the Puskesmas coverage area through partnerships and collaboration with the NC stakeholders. The clients receive services in a caring environment. Through interacting with clients, students could develop a sense of caring for their clients in the community as well as in the hospitals when they graduate. These insights into caring develop when students and nurses engage directly with patients, families, and the community (Morse et al ., 2006 ). Caring behaviours also develop when the conditions within the placement setting are supportive of students (Sikma, 2006 ). Students, nurses, and lecturers who work together in the NC engage with clients at the individual, family, and community levels. Through these forms of engagement, students not only learn about the topic matter, but also enhance their understanding of the meaning of being a nurse, a citizen, and a member of the community (Seifer and Vaughn, 2002 ).

The findings from this study have contributed to a new understanding of the components of integration in the NCmodel. These components are: (1) client-centred care as the shared common ground for integration in the NC; (2) nursing education using a service learning approach; (3) the NC as a model for reviving CHN services; and (4) service improvement through research and community service activities. In this framework, there is a link between nursing education and the community health centre stakeholders through integrated care and service learning that enables greater collaboration and integration in the NC. This greater collaboration and integration in the NC will, in turn, lead to the more effective functioning of the NCs. It is argued that all of these components need to operate in a conducive environment within the NC in order to develop the caring insights of nurses and students who are involved in the NC.

This study shows that the service learning approach is suitable for a model that integrates education and health service institutions because it links the services with the students’ learning process. The components that have been reported in this paper can be used as a conceptual framework with clarified relationships between each component as the basis for the development of future evaluation plans for the NC. The implications of this work have the potential to support policies that will improve the health of individuals and communities through the integration of student education, community health service delivery, and research. This study has added new knowledge to the NC and service learning fields by providing a clear understanding of the conceptual framework of the NC as a ‘blueprint’ for the integration of CHN services, education, and research. The proposed framework would provide clarity for other researchers who would like to apply this model to address a specific health issue in the community. The application of the NC model to address specific health issues in the community would strengthen the framework and increase its applicability in different community settings in Indonesia and across the globe. However, there is a need for further research that encompasses the applicability and suitability of the framework in other NC settings

Acknowledgements

This study was conducted as part of a Doctor of Philosophy program at Flinders University South Australia, which was made possible through a Postgraduate Scholarship provided by the Directorate General of Higher Education of Indonesia.

Author ORCIDs

Neti Juniarti 0000-0002-2303-4591

Conflict of Interest

None declared

External Funding

No external funding received

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Published on 18.3.2024 in Vol 8 (2024)

Using Principles of Digital Development for a Smartphone App to Support Data Collection in Patients With Acute Myocardial Infarction and Physical Activity Intolerance: Case Study

Authors of this article:

Original Paper

• Diana Isabel Cáceres Rivera 1 * , MSc, PhD   ; 
• Luz Mileyde Jaimes Rojas 1 * , MSc   ; 
• Lyda Z Rojas 2 * , MSc, PhD   ; 
• Diana Canon Gomez 2 * , MD   ; 
• David Andrés Castro Ruiz 1 * , MSc   ; 
• Luis Alberto López Romero 3 , MSc  

1 Facultad de Enfermería, Universidad Cooperativa de Colombia, Bucaramanga, Colombia

2 Centro de Investigaciones, Fundación Cardiovascular de Colombia, Floridablanca, Colombia

3 Departamento de Pediatría, de Obstetricia y Ginecología y de Medicina Preventiva y Salud Pública, Universidad Autónoma de Barcelona, Barcelona, Spain

*these authors contributed equally

Corresponding Author:

Diana Isabel Cáceres Rivera, MSc, PhD

Facultad de Enfermería

Universidad Cooperativa de Colombia

Torre 2 Apto 203

Bucaramanga, 64000

Phone: 57 3014006658

Email: [email protected]

Background: Advances in health have highlighted the need to implement technologies as a fundamental part of the diagnosis, treatment, and recovery of patients at risk of or with health alterations. For this purpose, digital platforms have demonstrated their applicability in the identification of care needs. Nursing is a fundamental component in the care of patients with cardiovascular disorders and plays a crucial role in diagnosing human responses to these health conditions. Consequently, the validation of nursing diagnoses through ongoing research processes has become a necessity that can significantly impact both patients and health care professionals.

Objective: We aimed to describe the process of developing a mobile app to validate the nursing diagnosis “intolerance to physical activity” in patients with acute myocardial infarction.

Methods: We describe the development and pilot-testing of a mobile system to support data collection for validating the nursing diagnosis of activity intolerance. This was a descriptive study conducted with 11 adults (aged ≥18 years) who attended a health institution for highly complex needs with a suspected diagnosis of coronary syndrome between August and September 2019 in Floridablanca, Colombia. An app for the clinical validation of activity intolerance (North American Nursing Diagnosis Association [NANDA] code 00092) in patients with acute coronary syndrome was developed in two steps: (1) operationalization of the nursing diagnosis and (2) the app development process, which included an evaluation of the initial requirements, development and digitization of the forms, and a pilot test. The agreement level between the 2 evaluating nurses was evaluated with the κ index.

Results: We developed a form that included sociodemographic data, hospital admission data, medical history, current pharmacological treatment, and thrombolysis in myocardial infarction risk score (TIMI-RS) and GRACE (Global Registry of Acute Coronary Events) scores. To identify the defining characteristics, we included official guidelines, physiological measurements, and scales such as the Piper fatigue scale and Borg scale. Participants in the pilot test (n=11) had an average age of 63.2 (SD 4.0) years and were 82% (9/11) men; 18% (2/11) had incomplete primary schooling. The agreement between the evaluators was approximately 80% for most of the defining characteristics. The most prevalent characteristics were exercise discomfort (10/11, 91%), weakness (7/11, 64%), dyspnea (3/11, 27%), abnormal heart rate in response to exercise (2/10, 20%), electrocardiogram abnormalities (1/10, 9%), and abnormal blood pressure in response to activity (1/10, 10%).

Conclusions: We developed a mobile app for validating the diagnosis of “activity intolerance.” Its use will guarantee not only optimal data collection, minimizing errors to perform validation, but will also allow the identification of individual care needs.

Introduction

In recent decades, the ability to produce, collect, and communicate data around the world has increased exponentially with access to technologies such as smartphones. These technologies have improved data storage as well as its handling and analysis [ 1 ]. In the field of health, electronic record systems facilitate data collection that can be used for various purposes, allowing data retrieval that promotes the improvement of research processes such as identification and recruitment of patients for clinical projects [ 2 , 3 ].

In addition to obtaining individual data from each patient, the collection of large amounts of data can be useful to obtain information that more effectively supports the exploration of diseases, treatment, and rehabilitation. This creates the need to develop research platforms that optimize the capacity to conduct informative and innovative research and enable scientific approaches where objective data can be obtained with a minimum of errors and expended resources [ 4 ].

As part of the health staff providing care to cardiovascular patients, nurses can be the first to identify individual needs. To aid this, tools are available such as the NANDA (North American Nursing Diagnosis Association) taxonomy, which identifies the response of a person, family, or community to real health problems and potential vital processes. However, these diagnoses and their respective defining characteristics must be validated according to the context where they will be assessed, which constitutes a challenge in research into the use, implementation, and dissemination of technologies of information [ 5 - 7 ]. For this purpose, the use of digital platforms has demonstrated its applicability from the early stages of research, such as the assessment of care needs [ 8 , 9 ].

Mobile apps in health, education, and work in Colombia are promoting efficient new practices to streamline processes and improve access to information at the national level, with the intention of contributing to the modernization and globalization of different socioeconomic sectors. These technologies are important to innovate in the health sector because they can benefit both patients and health staff. However, the uptake of this type of technological tool is still slow and limited [ 10 ]. Thus, this paper describes the process of developing a mobile app for collecting health research data. Specifically, it is intended that this app will be a tool that allows speeding up the validation of a nursing diagnosis in an objective and practical way.

This was a descriptive study conducted with 11 adults (aged ≥18 years) with a suspected diagnosis of coronary syndrome who attended a health institution for highly complex needs between August and September 2019 in Floridablanca, Colombia. An app for clinical validation of the “activity intolerance” diagnosis (NANDA code 00092) in patients with acute coronary syndrome was developed in three steps, outlined in the following sections.

Step 1: Operationalization of the Nursing Diagnosis

The first step consisted in the operationalization of the defining characteristics of the nursing diagnosis [ 11 ] of activity intolerance (NANDA code 00092), defined by NANDA-I [ 6 ] as “the lack of sufficient physiological or psychological energy to tolerate or complete the required or desired daily activities.” This diagnosis is categorized as “Domain 4: Activity / Rest, Class 4: Cardiovascular / pulmonary responses Need: Move and Pattern Activity-exercise.” It is also related to an imbalance between oxygen supply and demand, a sedentary lifestyle, immobility, and bed rest; it has defined characteristics [ 12 ]. Through an extensive search of the literature, we selected scales or instruments to standardize the measurement of each defining characteristic of this nursing diagnosis [ 11 ]. An interdisciplinary group that included 2 nurses, an epidemiologist, and a cardiologist verified the face validity of the operationalization.

Step 2: App Development Process

Initial requirements evaluation.

Health professionals, along with a systems engineer, carried out the structural design of the data collection forms or case report forms. The digitization process was carried out using CommCare [ 7 ], which is an open source, cloud-based platform that helps researchers develop data capture tools using mobile devices. An open source tool was also used to create an Android-based mobile app for a low-income setting. Mobile apps can be used as a tool to track beneficiaries through a service lifecycle and can also streamline data collection [ 13 ]. Our app used the HTTPS protocol, which made it cryptographically secure. Access to data was password protected. The CommCare [ 7 ] platform was selected because it has been widely used for health projects all over the world and because of its ease of use and compatibility with older versions of Android. CommCare is a platform that works on Android mobile phones from version 2.3, but the platform recommends reviewing the documentation for these older versions because they may have limitations in terms of functionality and compatibility with the latest features developed by CommCare, so it is recommended to have at least Android version 4.0.3 or later, a storage space of at least 100MB, a minimum of 1GB of RAM, and a processor with at least 2 cores for a better user experience.

Finally, we did not use any programming language because we used a platform that prevents us from reaching that level. We worked directly with CommCare, which allowed us to create data collection applications without touching or programming source code ( Figure 1 ).

CommCare requires the use of a password to access the app and the data stored on the platform. This helps to ensure that only authorized users can access information. The platform uses the secure HTTPS communications protocol, uses role-based access, and is in compliance with data security regulations and standards such as the European Union’s General Data Protection Regulation (GDPR). This ensures that the platform follows good practices in terms of privacy and personal data protection.

Development and Digitization of the Forms

The principles of the Scrum methodology for agile software development were applied. This is a regularly applied process that includes a set of best practices to work collaboratively in teams and obtain the best possible outcome of projects. It is characterized by a strategy of incremental development, boosting the quality of the result by getting to know people in self-organized teams and matching the different phases of development, rather than doing one after the other in a sequential or cascading cycle [ 14 ]. Through this methodology, an app was developed to gather data. This phase included the following six steps: (1) specifying the forms to be digitized, which contained the questions or variables to be obtained in the field; (2) dividing the various sections of the form into smaller subforms, depending on the size of the questionnaire or the time of application; (3) defining the variables as the simple question-and-answer type or as more complex ones containing calculations, depending on others, or having a different logical flow; (4) building the form on the CommCare platform; (5) generating app versions (eg, test versions); and (6) testing the app with health professionals who simulated data from possible patients and followed the flow of questions within the app to check if the different flows worked correctly; if errors or possible improvements were found during the process, the entire procedure was repeated from step 4.

Ethical Considerations

The Ethics Committee of Universidad Cooperativa de Colombia thoroughly reviewed and approved the research (report 003; April 16, 2018), as did the Fundación Cardiovascular de Colombia ethics committee (report 450; May 22, 2018). The study was carried out in strict adherence to the established protocol, regulatory requirements, Good Clinical Practice, the Declaration of Helsinki, and the clinical investigation guidelines of Universidad Cooperativa de Colombia. All participants provided their informed consent by signing a form. Participation in this study was entirely voluntary, and no financial compensation or reimbursements were offered to the participants.

The information obtained has been securely stored in the archives of the Universidad Cooperativa de Colombia to safeguard the privacy of individuals. Each patient was assigned a code to ensure that their names or identification did not appear in the database. Access to the collected data was restricted to the researchers, and the data will be used exclusively for the study’s intended purposes. Personal information is being protected in compliance with Colombian Law 1581 of 2012, which pertains to the right of “habeas data.”

After repeatedly performing the entire process and correctly digitizing all the forms proposed in advance, the last version of the app (the production version) was generated. The result of the development process was an app that allowed obtaining information using the forms shown in Table 1 .

Table 2 shows the scales and instruments used for the operationalization of the defining characteristics of nursing.

The resulting app allowed the simultaneous collection, data entry, and follow-up of patients in different stages of investigation. Two previously trained nurses conducted a pilot test with the first 11 patients included in the research. Taking into account the inclusion and exclusion criteria, a cardiologist selected potential patients. Subsequently, the patient received an explanation of the study; if they agreed to participate, they provided informed written consent. The information was filled out on tablet-type mobile device. Once the data were collected, a process of sending or synchronizing the data with the database in the cloud was carried out, for which it was necessary to have an internet connection (Wi-Fi network).

a TIMI-RS: thrombolysis in myocardial infarction risk score.

b GRACE: Global Registry of Acute Coronary Events.

Later, the systems engineer reviewed the database obtained through the web platform CommCare, which allows downloading information as a flat file or in spreadsheet format. In this way, the research team verified the correct operation of the app and its use in the field, obtaining positive results that allowed the continuity of the investigation with more patients. Figures 2 - 4 show 3 screenshots of the app.

The pilot test yielded descriptive data (n=11). The participants had an average age of 63.2 (SD 4.0) years, 82% (9/11) were men, and 18% (2/11) had incomplete primary schooling. We found that 64% (7/11) had a history of hypertension and 73% (8/11) had ever smoked. The defining characteristics present in this group of patients were exercise discomfort in 91% (10/11), electrocardiogram abnormalities in 9% (1/10), abnormal heart rate in response to exercise in 20% (2/10), dyspnea in 27% (3/11), weakness in 64% (7/11) and abnormal blood pressure in response to activity in 10% (9/10) ( Table 3 ). The κ agreement index ranged from 73% to 100%.

Principal Findings

We describe the development process of a mobile app for collecting health research data in an easy, agile, and practical way. This strategy may be used for the complete collection of samples in the process of clinical validation of the nursing diagnosis “activity intolerance.” In addition, a good rate of agreement was found among the evaluators thanks to the standardization used in the app.

In recent years there has been an increase in the use of computer technologies to replace paper records by means of mobile apps, web forms, and specialized software; likewise, it has become evident that these are key tools to improve quality in health care [ 22 ]. However, it is still a challenge to continue implementing new strategies, achieve their efficient use by health professionals, and make their implementation easier and more accessible.

This process enabled us to validate the app’s use for identifying prevalent nursing diagnoses, such as activity intolerance, in patients with acute myocardial infarction. Among the 9 defining characteristics we evaluated, there was an agreement of over 80% among the evaluators for 5 of them. This, in turn, helped us identify the most prevalent characteristics, namely dyspnea on exertion and heart rate alteration in response to activity. It is also noteworthy that none of the evaluators identified fatigue in any of the users.

Mobile Apps

We evaluated this strategy for identifying nursing diagnoses that require an objective definition of their characteristics and clinical judgment [ 23 ]. The precise operationalization of the defining characteristics through a predefined registry structure, as seen in this mobile app, enhances the precision of nursing diagnoses [ 1 ]. In this sense, it enables the evaluation of these characteristics, which can improve documentation for nursing staff, thereby aiding in the inference and evaluation of diagnoses [ 2 ]. Therefore, this app aims not only to enhance the quality and safety of care processes but also to promote the adoption of standardized nursing language, addressing the limitations in its use.

Another possible use of this app is in education, where it would potentially help to strengthen the precision of documentation in nursing diagnoses [ 3 ]. This strategy is adapted to current conditions, in which the use of virtual methods and mobile technologies has been shown to be a new basic input for the teaching process, making it necessary for professionals and trainers to make an adequate use of this type of strategy.

A relationship where nurse and patient can contribute to improving administrative processes that benefit others has been described in settings such as outpatient care [ 5 ]. This is expected to contribute to research scenarios that promote improved caregiving. Apps can assist in the assessment and generation of nursing diagnoses in hospital practice [ 24 ], and they have been used in research studies such as clinical trials for the self-management of angina [ 25 ].

Limitations

This work was limited to a specific nursing diagnosis. Future work should include other prevalent diagnoses in patients with cardiac disease. An evaluation of usability among end users could help improve our strategy, and more data is also needed to better specify the large-scale feasibility and cost of this strategy with other nursing diagnoses.

Other aspects to improve in the design of future research are to include scales and instruments used in health care to measure different variables. These sources of information should be updated according to the context, clinical conditions, and even environmental conditions. An additional challenge is the integration of these types of apps to existing health systems. A recent review with the objective to provide an overview of studies that have collected patient data using an app-based approach indicated that using mobile technologies could help to overcome challenges linked with data collection in epidemiological research. However, further feasibility studies need to be conducted to test the applicability and acceptance of these mobile apps for epidemiological research in various subpopulations [ 26 ].

Conclusions

We developed a mobile app for use in the validation process of the nursing diagnosis activity intolerance. This app enabled the evaluation of defining characteristics, which can enhance documentation for nursing staff, facilitate more effective inference and evaluation of diagnoses, and reduce errors in information recording. One significant potential of this app lies in its impact on education, as it aids in improving the precision of nursing diagnosis documentation and, as a result, enhances the quality of care planning.

Data Availability

The data sets generated during and/or analyzed during this study are available in the Mendeley repository [ 27 ].

Conflicts of Interest

None declared.

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Abbreviations

Edited by A Mavragani; submitted 10.02.23; peer-reviewed by T Behera, J King; comments to author 07.07.23; revised version received 18.10.23; accepted 02.01.24; published 18.03.24.

©Diana Isabel Cáceres Rivera, Luz Mileyde Jaimes Rojas, Lyda Z Rojas, Diana Canon Gomez, David Andrés Castro Ruiz, Luis Alberto López Romero. Originally published in JMIR Formative Research (https://formative.jmir.org), 18.03.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

New Graduate Nurse Transition into Rural Home: A Case Study

Affiliation.

• 1 Laurie Generous MN, BScN, RN, is a Clinical Nurse Specialist, Island Health, Victoria, British Columbia.
• PMID: 38437043
• DOI: 10.1097/NHH.0000000000001241

The global shortage of nurses and high attrition rates for newly graduated nurses along with the shifting demand for home care has created a critical need for retention strategies that address the specific challenges of rural settings. The effectiveness of structured transition or mentoring programs are primarily studied in acute care settings, making it difficult to translate to the unique context of rural home care nursing. The complexities of the independent nature of home care nursing practice and limited resources to address transition shock make it difficult to successfully transition newly graduated nurses to rural home care. A case study supports mentorship facilitation as a readily available, effective strategy that can overcome the challenges of rural home care settings. A comparative analysis will link Duchscher's (2008) transition shock theory to mentorship as an effective strategy for supporting NGNs' transition in home care nursing. Recommendations offer rural care leaders practical strategies bundled with mentorship to optimize the successful transition and retention of newly graduated nurses in their workplaces.

Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.

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The hacking shut down the nation’s biggest health care payment system, causing financial chaos that affected a broad spectrum ranging from large hospitals to single-doctor practices.

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An urgent care chain in Ohio may be forced to stop paying rent and other bills to cover salaries. In Florida, a cancer center is racing to find money for chemotherapy drugs to avoid delaying critical treatments for its patients. And in Pennsylvania, a primary care doctor is slashing expenses and pooling all of her cash — including her personal bank stash — in the hopes of staying afloat for the next two months.

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These are just a few examples of the severe cash squeeze facing medical care providers — from large hospital networks to the smallest of clinics — in the aftermath of a cyberattack two weeks ago that paralyzed the largest U.S. billing and payment system in the country. The attack forced the shutdown of parts of the electronic system operated by Change Healthcare, a sizable unit of UnitedHealth Group, leaving hundreds, if not thousands, of providers without the ability to obtain insurance approval for services ranging from a drug prescription to a mastectomy — or to be paid for those services.

In recent days, the chaotic nature of this sprawling breakdown in daily, often invisible transactions led top lawmakers, powerful hospital industry executives and patient groups to pressure the U.S. government for relief. On Tuesday, the Health and Human Services Department announced that it would take steps to try to alleviate the financial pressures on some of those affected: Hospitals and doctors who receive Medicare reimbursements would mainly benefit from the new measures.

U.S. health officials said they would allow providers to apply to Medicare for accelerated payments, similar to the advanced funding made available during the pandemic, to tide them over. They also urged health insurers to waive or relax the much-criticized rules imposing prior authorization that have become impediments to receiving care. And they recommended that insurers offering private Medicare plans also supply advanced funding.

H.H.S. said it was trying to coordinate efforts to avoid disruptions, but it remained unclear whether these initial government efforts would bridge the gaps left by the still-offline mega-operations of Change Healthcare, which acts as a digital clearinghouse linking doctors, hospitals and pharmacies to insurers. It handles as many as one of every three patient records in the country.

The hospital industry was critical of the response, describing the measures as inadequate.

Beyond the news of the damage caused by another health care cyberattack, the shutdown of parts of Change Healthcare cast renewed attention on the consolidation of medical companies, doctors’ groups and other entities under UnitedHealth Group. The acquisition of Change by United in a $13 billion deal in 2022 was initially challenged by federal prosecutors but went through after the government lost its case.

So far, United has not provided any timetable for reconnecting this critical network. “Patient care is our top priority, and we have multiple workarounds to ensure people have access to the medications and the care they need,” United said in an update on its website .

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The shutdown of some of Change’s operations has severed its digital role connecting providers with insurers in submitting bills and receiving payments. That has delayed tens of millions of dollars in insurance payments to providers. Pharmacies were initially unable to fill many patients’ medications because they could not verify their insurance, and providers have amassed large sums of unpaid claims in the two weeks since the cyberattack occurred.

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The hospital industry has labeled the infiltration of Change “the most significant cyberattack on the U.S. health care system in American history,” and urged the federal government and United to provide emergency funding. The American Hospital Association, a trade group, has been sharply critical of United’s efforts so far and the latest initiative that offered a loan program.

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The loan program has not been well received out in the country.

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Florida Cancer Specialists and Research Institute in Gainesville resorted to new contracts with two competing clearinghouses because it spends $300 million a month on chemotherapy and other drugs for patients whose treatments cannot be delayed.

“We don’t have that sort of money sitting around in a bank,” said Dr. Lucio Gordan, the institute’s president. “We’re not sure how we’re going to retrieve or collect the double expenses we’re going to have by having multiple clearinghouses.”

Dr. Christine Meyer, who owns and operates a primary care practice with 20 clinicians in Exton, Pa., west of Philadelphia, has piled “hundreds and hundreds” of pages of Medicare claims in a FedEx box and sent them to the agency. Dr. Meyer said she was weighing how to conserve cash by cutting expenses, such as possibly reducing the supply of vaccines the clinic has on hand. She said if she pulled together all of her cash and her line of credit, her practice could survive for about two and a half months.

Through Optum’s temporary funding assistance program, Dr. Meyer said she received a loan of $4,000, compared with the roughly half-million dollars she typically submits through Change. “That is less than 1 percent of my monthly claims and, adding insult to injury, the notice came with this big red font that said, you have to pay all of this back when this is resolved,” Dr. Meyer said. “It is all a joke.”

The hospital industry has been pushing Medicare officials and lawmakers to address the situation by freeing up cash to hospitals. Senator Chuck Schumer, Democrat of New York and the chamber’s majority leader, wrote a letter on Friday, urging federal health officials to make accelerated payments available. “The longer this disruption persists, the more difficult it will be for hospitals to continue to provide comprehensive health care services to patients,” he said.

In a statement, Senator Schumer said he was pleased by the H.H.S. announcement because it “will get cash flowing to providers as our health care system continues to reel from this cyberattack.” He added, “The work cannot stop until all affected providers have sufficient financial stability to weather this storm and continue serving their patients.”

Audio produced by Jack D’Isidoro .

Reed Abelson covers the business of health care, focusing on how financial incentives are affecting the delivery of care, from the costs to consumers to the profits to providers. More about Reed Abelson

Julie Creswell is a business reporter covering the food industry for The TImes, writing about all aspects of food, including farming, food inflation, supply-chain disruptions and climate change. More about Julie Creswell