- Email: [email protected]
Promoting healthy communities through neighborhood nursing
Promoting Healthy Communities Through Neighborhood Nursing Reinhard, RN, CS, PhD, FAAN Mary Ann Christopher, RNC, MSN, FAAN Diana J. Mason, RNC, PhD, FAAN Susan
C.
K a t h l e e n McConnell, RN, MPH Patricia Rusca, RN Eileen Toughill, RN, MSN
Neighborhood nursing is grounded in the public health nursing mission of promoting healthy communities by collaborating with consumers where they live, work, and go to school. A pilot project designed by the Visiting Nurse Association of Central Jersey provides an example of the implementation and outcomes of neighborhood nursing and implications for health policy and education.
Forming a relationship with a patient requires establishing a relationship with the patient's community as welt. A great many health concerns that individuals bring to the patient-practitioner relationship have their origins in the community and its institutions, are affected by characteristics of the community, or can best be addressed within the community. In addition, by working to solve community problems not associated with one particular patient, health care practitioners can have a positive impact on the health of many. Pew-Fetzer Task Force on Psychosocial Health Education, 1994 T h e
twentieth century is ending with renewed interest in the populationfocused type of health care delivered by nurses 100 years ago. 1"4National epidemiological studies confirm what community health nurses have known for decades-that major health problems such as infant Nurs Outlook 1996;44:223-8. Copyright © 1996 by Mosby-Year Book, Inc. 0029-6554196/55.00+ 0 3511174420
NURSING OUTLOOK
mortality and AIDS will not be resolved at the individual level but require community action. 5,6 Nurses have a rich history of promoting the publiC's health and are uniquely positioned for this role. 7 Unfortunately, the present structure of health care thwarts community-focused nursing practice. Payment policies and market forces direct community and home c a r e agencies to focus on episodic care of acutely ill individuals. 8,9 Reform is needed at the national level, particularly regarding reimbursement policies. We also need to reorient and reconnect nurses to the communities they serve while fostering changes in the structures and processes of agencies to support community-level nursing practice. In addition, as the education system calls for curricular changes in educating health professionals, m°'Hwe must determine how we can prepare and support the current workforce to broaden its concept of client from the individual to the family and community levels. This article examines a pilot program intended to restore these family and community loci to nursing practice in a large community health nursing agency,
SEPTEMBER/OCTOBER 1996
with emphasis on the implications for health policy and education.
PILOTING NEIGHBORHOOD NURSING Neighborhood nursing is a philosophy that is grounded in the public health nursing mission of promoting healthy communities by collaborating with consumers where they live, work, and go to school32 This philosophy is consistent with nursing's past 13 and preferred future34 As with district nursing, 15'16block nursing, I7 and parish nursing, is the goal of neighborhood nursing is to position the nurse as a central person in the community to improve accessibility of care for consumers; however, neighborhood nursing does not rely on nurses living in the communities they serve, is not focused solely on care of the elderly, and is not based on a spiritual model. To implement their neighborhood nursing philosophy, the Visiting Nurse Association of Central Jersey (VNA-CJ) col-
The goal of neighborhood nursing is to position the nurse as a central person in the community to improve accessibility of care for consumers. laborated with two consultants to design a pilot project that would help the staff reconceptualize the agency's practice from caring for ill individuals referred by hospitals to promoting the health of the entire
Reinhard et al. 223
neighborhoods they serve. Staff nurses, consumers, and agency officials worked together to identify system changes required to support this reconceptualized practice. Moving from a model of caring for individuals in their homes to a community
to implementing this expanded focus. Facilitatory factors included the positive reputation of the VNA-CJ in the community, the strong commitment of management, and the availability of in-house experts to mentor staff. Some of the barriers identified were the lack of time for nurses to develop contacts with their communities and the complexity of VNA-CJ itself. Moving from a model For example, the VNA-CJ home visiting program was separate from its senior of caring for individuals wellness program, and thus within a given in their homes to a neighborhood one nurse saw clients who community partnership were ill in a senior citizen residence and requires structural changes and a fundamental another nurse saw clients who were well in a clinic in the same residence, resulting change in thinking, or a in fragmented care. paradigm shift. To address these barriers, the Steering Committee approved time-saving strategies and a major structural change in the orgapartnership requires structural changes and nization by consolidating programs. For exa fundamental change in thinking, or a ample, a trial use of beepers to contact paradigm shift. If it is to succeed, neigh- nurses in the field resulted in a significant borhood nursing must belong to nurses, not increase in efficiency, and the decision to be imposed upon them; thus the project integrate the VNA-CJ home visiting and design was based on an ownership model. ~2 senior wellness programs gave nurses more A site team committee of staff nurses and opportunities to provide continuity of care supervisors from the pilot sites devised spe- and make community contacts. cific strategies for orienting their peers to The neighborhood nursing concept was the project, developing partnerships with introduced to the staff of the two pilot sites their neighborhoods, and recommending during the last quarter of year 1 through a policy changes to facilitate and support two-day orientation workshop. The first neighborhood nursing practice. A steering day, the group focused on (1) identifying committee of consumer and agency repre- problems relating to individuals and famisentatives provided direction for model lies that fall within the scope of nursing development, implementation, and evalu- practice (even when these problems were ation, as well as support for the necessary not identified in the initial medical treatchanges in the organization's policies, ment plan sent by the hospital or physistructures, and processes to implement and cian) and (2) exploring options for maxiextend the model. mizing financial support for the additional A pre- and post-test group comparison care required to deal with these problems. design was used. Two of the then seven Participants were introduced to aggregatehealth centers of the VNA-CJ served as level nursing practice and given an assignpilot sites, and a third was used as a con- ment: they were asked to conduct a comtrol site. Although both original pilot sites munity assessment of their neighborhoods included suburban and urban neighbor- before the second workshop, which was hoods, one (Center A) was located in the scheduled to take place 6 weeks later. The center of town, whereas the other (Cen- second orientation day was devoted to ter B) was located in a residential area. The identifying recurrent patterns that indicate pilot sites included 35 nurses, and the con- community-level problems, presenting trol site had 32 nurses. Almost half (45 %) potential community-level activities, and of the nurses at each site were at least bac- planning specific strategies to nurture calaureate prepared. neighborhood contacts. Quarterly meetIn two full-day workshops, the Site ings with the Site Team and Steering Team Committee explored strategies to Committees provided opportunities for integrate an individual, family, and com- formative evaluation and led to ideas such munity focus in their daily practice and as providing nurses with business cards identified facilitatory factors and barriers and creating a new VNA-CJ brochure to 224
Reinhard et al.
introduce the nurses to pharmacists, school nurses, pastors, postal workers, and others in their neighborhoods. Posters that included space to write in a nurse's name were created and placed at senior wellness sites. OUTCOMES
The expected outcomes of the pilot project included the following: 1. Increased client satisfaction and nurse satisfaction 2. Increased consumer access to care as measured by referral patterns, health promotion visits, and evaluation visits 3. Increased community-level activities 4. Identification of barriers and facilitators to implementing neighborhood nursing throughout the agency Both quantitative and qualitative methods were used to track these outcomes; however, except for community-level activities, the quantitative data were inconclusive in terms of the summative evaluation. Qualitative data, on the other hand, were often rich and suggested that neighborhood nursing was a worthwhile endeavor that should be developed further. For example, client satisfaction was measured by a seven-item survey tool that was developed by VNA-CJ and mailed (with telephone follow-up on a subsample) to a random sample of 50 discharged clients from each site, but the agency's patient satisfaction ratings were already so high that it
Qualitative data suggested that neighborhood nursing was a worthwhile endeavor that should be developed further.
did not prove to be a sensitive indicator of tile impact of the project. Post-pilot project client satisfaction data showed that the project did not have any adverse effects on client satisfaction. Qualitatively, nurses in the project reported positive responses from community members when the nurses discussed neighborhood nursing. In one community, the neighborhood nurse was called to coordinate the community's response to a major fire in a boarding home. The nurse pro-
VOLUME 44 • NUMBER 5
NURSING OUTLOOK
vided guidance to the boarding home staff, assessed residents, and assisted with preparation and allocation of food and shelter. Such exemplars spoke more powerfully to the success of neighborhood nursing than the quantitative data. Nurse satisfaction was measured with the Index of Work Satisfaction (IW8)19; permission was obtained to modify items that specified "hospital" by substituting the word "community" or "agency." Although important considerations in the selection of this instrument were its established reliability and validity, this index was chosen because it had been used in a statewide evaluation of nurse satisfaction. 2° Nurses at the pilot and control sites completed the IWS before the orientation workshops, 1 year after the pilot program began, and 1 year after the workshops took place. Qualitative data on nurse satisfaction and responses to neighborhood nursing were collected continuously at staff meetings, project director meetings with staff and their supervisors, and site team meetings. The IWS measured no meaningful differences in nurse satisfaction; however , qualitative data from the nurses' discussions of their work have suggested that a more appropriate approach to determining nurse satisfaction would have been to track individual changes in work satisfaction. Neighborhood nursing appeared to be unfamiliar and u n c o m f o r t a b l e for some nurses, who tended to either be recent graduates or had come from an acute care hospital model of nursing. For other nurses, particularly those who had prior experience with or educational exposure to community-level practice, neighborhood nursing provided a context of commitment to health and community that was consistent with their own philosophies of nursing, and this resulted in greater enthusiasm for their work. Several nurses were quickly functioning at a proficient level of practice for a community health nurse generalist. 21 Consumer access to care was measured by referrals from family, neighbors, and friends; visits to evaluate the need for services (evaluation visits); and nonbillable health promotion visits. The reliability of the referral data was limited by discrepancies in coding at the point of intake of the client into the agency. Small numbers and a great deal of variability in the other measures limited the usefulness of the access
NURSING OUTLOOK
% 0.3 0.25 0.2: 0.15 0.1 0.05 0 Q2
Q3 1992
Q4
Q1
Q2 1993
Q3
• Control - - C e n t e r A x C e n t e r B Percentage
of all visits
Figure 1. Evaluation visits.
0.7 %
0.6 0.5
Y
0.4
f
0.3 0.2 0.1
0
Q2
° I
Q3 1992
I
Q4
I
Q1
I
Q2 1993
Q3
• Control -I- Center A • Center B Percentage of all visits Figure 2. Health promotion visits.
data. Nevertheless, Center A showed an overall increasing trend in the number of evaluation visits (Figure 1). Nurses at this center documented more examples of direct consumer contact that resulted in evaluation visits, such as when a concerned neighbor approached the nurse in a housing development or an elderly woman came to a senior wellness clinic to seek nursing assessments for homebound friends. Nurses at Center A attributed their greater visibility to several factors. In two senior citizen buildings, they developed strong working relationships with social workers, who now make lists of residents who require nursing attention. In addition, Center A is located adjacent to a VNA-
SEPTEMBER/OCTOBER 1996
CJ volunteer-run thrift shop that is frequented by area residents, and thrift shop volunteers encourage consumers to walk over to the health center if they need to talk to their neighborhood nurse. Given the drive for reimbursable visits, health promotion visits are usually low in priority and few in number. Nurses at the pilot sites were encouraged to make these visits to consumers who would benefit from support and education. Figure 2 illustrates the predominantly upward trend of health promotion visits at the pilot sites, compared with the low, flat percentage of these visits at the control site. Again, pilot site differences are evident, with Center A demonstrating a consistent positive trend
Reinhard et al.
225
35
Hours
30 25 20 15 10 5
-<
O* -t"- ~P- ~ i it-. w !, w April May June July Aug 8ep Oct Nov Dec Jan Feb MarchApril May June July Aug Sep 93 92 I • Control
-[- C e n t e r A
~ Center B
Figure 3. Community encounters.
• Development of town-specific resource guides for consumer leaders • Participation in town alliances • Initiated volunteer programs with: - - Hispanic Resource Center - - Churches - - Girl Scouts • Presentations to local board of health and community groups • Development and presentation of health education programs • Participation in town days • Participation in development and testing of a town disaster plan • Participation in health fairs
after the workshops and Center B showing initial gains followed by a downward trend. Qualitative analyses indicated that the number of health promotion visits varied with staffing changes and with fluctuations in funding, which came from county grants and donations; these fluctuations in funding at times influenced whether health promotion visits were encouraged by management. In addition, staff members did not always remember to document health promotion visits, particularly when they were of short duration or were seen as an extension of a "therapeutic" billable visit. Aside from these neighborhood nursing outcomes for individuals and families, analysis of community-level activities (see Box 1 for examples) substantiates a growing focus on the aggregate consumer. Community-level activities were tracked in 226
R e i n h a r d et al.
three ways: quantitative tabulation of the number of community activities, nursing logs, and exemplars reported by staff members. Figure 3 graphs monthly reports of the number of hours spent on community-level activities. The control site's limited rise in community activities during the third quarter of year 1 confirms that provision of codes to document community encounters does not change the practice of nurses unless they are provided with education and encouragement to expand the concept of consumer to the community level. After the staff orientation workshops took place in the fall, nurses from both pilot sites began to document more hours spent in community encounters, such as those listed in Box 1. Activities declined at both sites before and during the summer months, with a positive trend re-established in the third quarter of year 2. The fluctuations in
the pattern of community activities and health promotion/evaluation visits were explained through qualitative data from the nurses' log entries, site team meetings, and project director-facilitated weekly meetings. During the spring of year 2, market forces escalated the pace of change in New Jersey, which forced an agency-wide emphasis on increasing nursing productivity as measured by reimbursed visits. Although nurses at the pilot sites were encouraged to continue to participate in activities with a neighborhood nursing emphasis on health promotion, they expressed concern about how their productivity would be measured. Some of the nurses at Center A had been demonstrating a greater commitment to the goals of neighborhood nursing and were extending their work hours as needed to be able to continue to maintain this focus. With concurrent monitoring of the quantitative data, the Steering Committee determined that measures of productivity needed to include neighborhood nursing activities, and thus they set modest goals for each nurse's expected community-level activities and encounters. Staffing changes also had an impact on the staff's ability to meet the neighborhood nursing expectations, as did the extent to which the health center nurse manager actively supported a sustained effort on the part of the staff. The differences between Centers A and B regarding community activities, health promotion visits, and evaluation visits were attributed to the fact that Center a nurses spent more time networking in their neighborhoods with the full support of their managers. A few key staff nurses at Center A became strong proponents of the neighborhood nursing philosophy and effectively role modeled the behaviors for their peers. These nurses quickly incorporated both scheduled and unscheduled visits with school nurses, boarding home managers, postal workers, and community leaders into their work schedule. Although the staff members at Center B made community encounters, several nurses indicated that they were more comfortable making traditional home visits. Qualitative data from the staff indicated that the neighborhood nursing concept improved their ability to connect clients with community services. Nurses were also asked to address community groups on
V O L U M E 44 • N U M B E R 5
NURSING O U T L O O K
health topics, participate in health fairs, and provide caregiver seminars. They were able to identify the community's health needs and became known in the neighborhood as "our nurse." DISCUSSION
Neighborhood nursing represents a paradigm shift from a nursing model of fragmented care and a focus on individuals
Educating nurses for this expanded role at orientations and ongoing in-services is necessary but not sufficient to sustain behavior change. driven by decades of health care financing policies to a model that embraces continuity of care and integrates the individual, family, and community. To help the VNA-CJ and its staff make this shift, neighborhood nursing was developed as a method of providing structural, procedural, and other supports necessary for the philosophy to be operationalized. Exemplars from the neighborhood nurses, other qualitative data, and an agency vision that embraces the community encouraged the Steering Committee of the pilot project to extend the project to the control site, with support from the W K. Kellogg Foundation. As neighborhood nursing has progressed, other health centers have incorporated the concepts into practice on their own and have requested to be included formally in the program earlier than scheduled. The differences between pilot sites can be explained in part by differences in the level of interest of individual nurses in working at the neighborhood level--interest that can be developed and supported by a strong and committed managerial staff. In addition, several of the neighborhoods served by Center A may bei more conducive to neighborhood nursing practice because they have more naturalistic groupings, such as neighborhood centers and housing developments. Educating nurses for this expanded role at orientations and ongoing in-services is necessary but not sufficient to sustain behavior change. Continual socialization of NURSING OUTLOOK
the nurses by clinical specialists in community health nursing, s by nurse managers, or by senior staff nurses is crucial. To encourage and reward individual nurse development at an expert level, the VNA-CJ developed invitational seminars on community-level practice with internal and external experts as presenters. The series targeted the neighborhood nurse who embraced the concept and was eager for more development and mentorship. The first two seminars focused on public speaking and community empowerment. The participants responded with enthusiasm; several of them integrated the content of the seminars into their practice and served as role models for other staff members. The VNA-CJ is evaluating criteria used to hire new staff members. Whereas nurses with acute care experience may do well with the more acutely ill patient in the home, they also need to express some interest in or understanding of the community dimension of the nurse's role. This dimension has been integrated into job descriptions and evaluations. Neighborhood nurses need to know how to develop partnerships with communities to ensure the financial and other resources needed to support outreach and health-promoting activities in the community. The neighborhood nursing pilot project has suggested that some nurses have poor self-efficacy with group activities and public speaking. Nurse educators need to consider whether such skills are being fostered and include traditional core public health functions in curricula. According to the Pew-Fetzer Task Force on Advancing Psychosocial Education, health professionals need knowledge or skills in the following areas to enter into effective community relationships: (1) the meaning of community; (2) the multiple contributors to health and illness within the community; (3) developing and maintaining relationships with the community; and (4) effective community-based care. = It was necessary for the project manager to do a great deal of role modeling to support implementation of an additional key element of neighborhood nursing-the Neighborhood Advisory Committee, or NAC. An N A C was formed at each health center to strengthen the understanding of the c o m m u n i t y and the community's participation in planning and delivering health-promoting services. Each NAC is cofacilitated by the center nurse
SEPTEMBER/OCTOBER 1996
manager and a community member. Key community members are invited to meet monthly to identify community needs, resources, and strategies. The NACs are developing their own goals and action plans. The small numbers of encounter hours in the pilot project were a reflection of financial limits--something that all community health nursing agencies confront. How much of a nurse's time can an agency afford to shift from billable visits to often unfunded community outreach and intervention? Indeed, a small agency could probably not sustain the start-up costs of a neighborhood nursing program. The biggest single factor limiting the potential success of neighborhood nursing is health care financing. The scope of the influence of health care financing on the structure and functioning of a community health nursing agency was illustrated in a variety of ways in this project, from nurses who were uncomfortable with community outreach to productivity definitions driven by reimbursement practices. The ability of an agency to serve a community may become even more limited during the current era of managed care and health care networks. For example, how does the neighborhood nurse serve members of a community who are not part of the health care network in which the agency is a participant? When the NAC identifies a community health problem-- for example, an increase in asthma or breast cancer how does it persuade these managed care entities to negotiate provision of a community-based prevention service that is available to the
The biggest single factor limiting the potential success of neighborhood nursing is health care financing.
entire community? Some hospitals are taking the lead by conducting such negotiations for patient populations served by the insurers, but not for the entire community. Neighborhood nursing would have a greater chance of success if an alliance of managed care entities and health care organizations existed that could negotiate a capitated approach to care of a community or purchase community-level interventions. Reinhard et al.
227
The VNA-CJ is confronting several key questions. How does the agency position neighborhood nursing as the fulcrum of vertically integrated health care in a way that will protect the mission of the agency? How can neighborhood nursing become a marketable commodity in the present businessoriented context? Does the neighborhood nurse need to be an advanced practice nurse who can provide the primary health care that will be valued by the payors? While grappling with these important questions, the VNA-CJ continues to pursue national, state, and local funding for its community service. This was the catalyst for the development of a free-standing, federally qualified health center, entitling it to specialized funding. Although the VNA-CJ has been successful in securing local and state support for special initiatives, government spending cuts limit the likelihood that neighborhood nursing can be sustained through these funding streams. Davis 23points out that cutbacks in federal categorical grant programs and initiatives supported by the Centers for Disease Control could drastically undermine essential public health services for women and children. Other funding mechanisms through corporations, churches, and civic organizations are being explored. In the meantime, the standing of the VNA-CJ in the communities that it serves has increased tremendously as a result of the community outreach and community-level activities that have been initiated and because of the N A C s . From a marketing standpoint, neighborhood nursing has conveyed to its communities, its clients, and insurers that the agency has a vision and is committed to excellence. A strength of neighborhood nursing is its ability to demonstrate a public/private partnership that is increasingly being emphasized by foundations and communities. 24 Neighborhood nursing connects clients to volunteer resources that are not reimbursable. Support for caregivers, whether family members, significant others, or volunteer community members, requires developing community resources to support the self-care that is being expected as health care expenditures are contained and restricted. Neighborhood nursing is invested in the informal networks, support systems, and human services that can maximize the per capita services available to an individual and share the risk involved in developing and provid228
Reinhard et al.
ing a new service with others in the community. W i t h the d e v e l o p m e n t of the NACs, the possibilities for interagency collaboration are exciting. One can argue that the agency's community orientation would be less essential to the communities it serves if local and state government provided strong public health efforts. In fact, the agency does receive state and local funding for contracted services, such as core public health clinics. However, the current emphasis on market forces does not include a public health focus. True health care reform must incorporate methods of financing health promotion and prevention services for individuals, families and communities. The health of our neighborhoods depends on such reforms. • REFERENCES
1. Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988. 2. Shugars DA, O'Neil EH, Badger JD, editors. Healthy America: practitioners for 2005. Durham (NC): The Pew Health Professions Committee, 1991. 3. United States Department of Health & Human Services. Healthy People 2000: summary report. Boston (MA): Jones & Bartlett, 1992. 4. Wall L. The house on Henry Street. New York: Holy, 1915. 5. American Public Health Association. APHA's vision: public health and a reformed health care system.Nation's Health 1993;23(6):9-11. 6. Shea S. Community health, community risks, community action. Am J Public Health 1992;82(6):785-7. 7. Zerwekh JV. Commentary: Going to the people--public health nursing today and tomorrow. Am J Public Health 1993;83(12): 1676-8. 8. Mason DJ, Knight K, Toughill E, DeMaio D, Beck T, Christopher MA. Promoting the community health clinical nurse specialist. Clin Nurse Specialist 1992;6(1):6-13. 9. Phillips EK, Cloonan P, Irvine A, Fisher ME. Nonreimbursed home health care: beyond the Bills. Public Health Nurs 1990;7(2):60-4. 10. de Tornay R. Reconsidering nursing education: the report of the PEW health professions commission. J Nurs Educ 1992;31(7):296301. 11. Selby M, Riportella-Muller R, Salmon M, Legault C, Quade D. Master's degree community health nursing educational needs: a national survey of leaders in service and education. J ProfNurs 1991;7:88-98. 12. Christopher MA, Reinhard S, McConnell K, Mason D. Neighborhood nursing: the community as partner. Caring Mag 1993;12( 1):44-9. 13. ZerwekhJV. Public heahh nursing legacy:historical practical wisdom. Nurs Health Care 1992;13(2):84-91.
14. American Nurses Association. Nursing's agenda for health care reform. Washington, D.C.: The Association, 1992. 15. Dreher M. District nursing: the cost-benefits of a population-based practice. Am J Public Health 1984;74(10):1107-11. 16. Buhler-WilkersonK. Public health nursing: in sickness or in health? Am J Public Health 1985;75(10):1155-6t. 17. Jamieson MK. Block nursing: practicing autonomous professionalnursing in the community. Nurs Health Care 1990;11(5):25-53. 18. Solari-Twadell PA, Djupe AM, McDermott MA. Parish nursing: the developing practice. Park Ridge (IL): National Parish Nurse Resource Center, Lutheran General Health Care System, 1990. 19. Stamps PL, Piedmonte LB. Nurses and work satisfaction: an index for measurement. Lansing [MI]:Health Administration Press, 1986. 20. Knickman J, Kovner C, Hendrickson G, Finkler S, Whittier D, Graf H. An evaluation of the New Jerseynursing incentive reimbursement awardsprogram. New York:The Health Research Program of New York University, 1991. 21. American Nurses Association. Standards of community health nursing. Washington, D.C.: The Association, 1991. 22. Resolini CP and the Pew-Fezter Task Force. Health professions education and relationship-centered care. San Francisco:Pew Health Professions Commission, 1994. 23. Davis K. The federal budget and women's health [editorial].Am J Public Health 1995;85 (8):1051-3. 24. Polivka BJ. A conceptual model for community interagency collaboration. Image J Nurs Sch 1995;27(2):110-5.
SUSAN C. REINHARD is deputy commissioner at the New Jersey Department of Health in Trenton. MARY ANN CHRISTOPHER is executive vice president and chief operating ofricer of the Visiting Nurse Association of Central Jersey in Red Bank, N.J. DIANA J. MASON is a professor and associate dean for graduate studies at Lienhard School of Nursing, Pace University, New York and Pleasantville, N.Y. KATHLEEN MCCONNELL is director of homecare at the Visiting Nurse Association of Central Jersey in Red Bank, N.J.
PATRICIA RUSCA is project director at the Neighborhood nursing Visiting Nurse Association of Central Jersey, Red Bank, N.J. EILEEN TOUGHILL is director of longterm care and ancillary services at the Visiting Nurse Association of Central Jersey, Red Bank, N.J.
V O L U M E 44 • NUMBER 5
NURSING OUTLOOK
C.
K a t h l e e n McConnell, RN, MPH Patricia Rusca, RN Eileen Toughill, RN, MSN
Neighborhood nursing is grounded in the public health nursing mission of promoting healthy communities by collaborating with consumers where they live, work, and go to school. A pilot project designed by the Visiting Nurse Association of Central Jersey provides an example of the implementation and outcomes of neighborhood nursing and implications for health policy and education.
Forming a relationship with a patient requires establishing a relationship with the patient's community as welt. A great many health concerns that individuals bring to the patient-practitioner relationship have their origins in the community and its institutions, are affected by characteristics of the community, or can best be addressed within the community. In addition, by working to solve community problems not associated with one particular patient, health care practitioners can have a positive impact on the health of many. Pew-Fetzer Task Force on Psychosocial Health Education, 1994 T h e
twentieth century is ending with renewed interest in the populationfocused type of health care delivered by nurses 100 years ago. 1"4National epidemiological studies confirm what community health nurses have known for decades-that major health problems such as infant Nurs Outlook 1996;44:223-8. Copyright © 1996 by Mosby-Year Book, Inc. 0029-6554196/55.00+ 0 3511174420
NURSING OUTLOOK
mortality and AIDS will not be resolved at the individual level but require community action. 5,6 Nurses have a rich history of promoting the publiC's health and are uniquely positioned for this role. 7 Unfortunately, the present structure of health care thwarts community-focused nursing practice. Payment policies and market forces direct community and home c a r e agencies to focus on episodic care of acutely ill individuals. 8,9 Reform is needed at the national level, particularly regarding reimbursement policies. We also need to reorient and reconnect nurses to the communities they serve while fostering changes in the structures and processes of agencies to support community-level nursing practice. In addition, as the education system calls for curricular changes in educating health professionals, m°'Hwe must determine how we can prepare and support the current workforce to broaden its concept of client from the individual to the family and community levels. This article examines a pilot program intended to restore these family and community loci to nursing practice in a large community health nursing agency,
SEPTEMBER/OCTOBER 1996
with emphasis on the implications for health policy and education.
PILOTING NEIGHBORHOOD NURSING Neighborhood nursing is a philosophy that is grounded in the public health nursing mission of promoting healthy communities by collaborating with consumers where they live, work, and go to school32 This philosophy is consistent with nursing's past 13 and preferred future34 As with district nursing, 15'16block nursing, I7 and parish nursing, is the goal of neighborhood nursing is to position the nurse as a central person in the community to improve accessibility of care for consumers; however, neighborhood nursing does not rely on nurses living in the communities they serve, is not focused solely on care of the elderly, and is not based on a spiritual model. To implement their neighborhood nursing philosophy, the Visiting Nurse Association of Central Jersey (VNA-CJ) col-
The goal of neighborhood nursing is to position the nurse as a central person in the community to improve accessibility of care for consumers. laborated with two consultants to design a pilot project that would help the staff reconceptualize the agency's practice from caring for ill individuals referred by hospitals to promoting the health of the entire
Reinhard et al. 223
neighborhoods they serve. Staff nurses, consumers, and agency officials worked together to identify system changes required to support this reconceptualized practice. Moving from a model of caring for individuals in their homes to a community
to implementing this expanded focus. Facilitatory factors included the positive reputation of the VNA-CJ in the community, the strong commitment of management, and the availability of in-house experts to mentor staff. Some of the barriers identified were the lack of time for nurses to develop contacts with their communities and the complexity of VNA-CJ itself. Moving from a model For example, the VNA-CJ home visiting program was separate from its senior of caring for individuals wellness program, and thus within a given in their homes to a neighborhood one nurse saw clients who community partnership were ill in a senior citizen residence and requires structural changes and a fundamental another nurse saw clients who were well in a clinic in the same residence, resulting change in thinking, or a in fragmented care. paradigm shift. To address these barriers, the Steering Committee approved time-saving strategies and a major structural change in the orgapartnership requires structural changes and nization by consolidating programs. For exa fundamental change in thinking, or a ample, a trial use of beepers to contact paradigm shift. If it is to succeed, neigh- nurses in the field resulted in a significant borhood nursing must belong to nurses, not increase in efficiency, and the decision to be imposed upon them; thus the project integrate the VNA-CJ home visiting and design was based on an ownership model. ~2 senior wellness programs gave nurses more A site team committee of staff nurses and opportunities to provide continuity of care supervisors from the pilot sites devised spe- and make community contacts. cific strategies for orienting their peers to The neighborhood nursing concept was the project, developing partnerships with introduced to the staff of the two pilot sites their neighborhoods, and recommending during the last quarter of year 1 through a policy changes to facilitate and support two-day orientation workshop. The first neighborhood nursing practice. A steering day, the group focused on (1) identifying committee of consumer and agency repre- problems relating to individuals and famisentatives provided direction for model lies that fall within the scope of nursing development, implementation, and evalu- practice (even when these problems were ation, as well as support for the necessary not identified in the initial medical treatchanges in the organization's policies, ment plan sent by the hospital or physistructures, and processes to implement and cian) and (2) exploring options for maxiextend the model. mizing financial support for the additional A pre- and post-test group comparison care required to deal with these problems. design was used. Two of the then seven Participants were introduced to aggregatehealth centers of the VNA-CJ served as level nursing practice and given an assignpilot sites, and a third was used as a con- ment: they were asked to conduct a comtrol site. Although both original pilot sites munity assessment of their neighborhoods included suburban and urban neighbor- before the second workshop, which was hoods, one (Center A) was located in the scheduled to take place 6 weeks later. The center of town, whereas the other (Cen- second orientation day was devoted to ter B) was located in a residential area. The identifying recurrent patterns that indicate pilot sites included 35 nurses, and the con- community-level problems, presenting trol site had 32 nurses. Almost half (45 %) potential community-level activities, and of the nurses at each site were at least bac- planning specific strategies to nurture calaureate prepared. neighborhood contacts. Quarterly meetIn two full-day workshops, the Site ings with the Site Team and Steering Team Committee explored strategies to Committees provided opportunities for integrate an individual, family, and com- formative evaluation and led to ideas such munity focus in their daily practice and as providing nurses with business cards identified facilitatory factors and barriers and creating a new VNA-CJ brochure to 224
Reinhard et al.
introduce the nurses to pharmacists, school nurses, pastors, postal workers, and others in their neighborhoods. Posters that included space to write in a nurse's name were created and placed at senior wellness sites. OUTCOMES
The expected outcomes of the pilot project included the following: 1. Increased client satisfaction and nurse satisfaction 2. Increased consumer access to care as measured by referral patterns, health promotion visits, and evaluation visits 3. Increased community-level activities 4. Identification of barriers and facilitators to implementing neighborhood nursing throughout the agency Both quantitative and qualitative methods were used to track these outcomes; however, except for community-level activities, the quantitative data were inconclusive in terms of the summative evaluation. Qualitative data, on the other hand, were often rich and suggested that neighborhood nursing was a worthwhile endeavor that should be developed further. For example, client satisfaction was measured by a seven-item survey tool that was developed by VNA-CJ and mailed (with telephone follow-up on a subsample) to a random sample of 50 discharged clients from each site, but the agency's patient satisfaction ratings were already so high that it
Qualitative data suggested that neighborhood nursing was a worthwhile endeavor that should be developed further.
did not prove to be a sensitive indicator of tile impact of the project. Post-pilot project client satisfaction data showed that the project did not have any adverse effects on client satisfaction. Qualitatively, nurses in the project reported positive responses from community members when the nurses discussed neighborhood nursing. In one community, the neighborhood nurse was called to coordinate the community's response to a major fire in a boarding home. The nurse pro-
VOLUME 44 • NUMBER 5
NURSING OUTLOOK
vided guidance to the boarding home staff, assessed residents, and assisted with preparation and allocation of food and shelter. Such exemplars spoke more powerfully to the success of neighborhood nursing than the quantitative data. Nurse satisfaction was measured with the Index of Work Satisfaction (IW8)19; permission was obtained to modify items that specified "hospital" by substituting the word "community" or "agency." Although important considerations in the selection of this instrument were its established reliability and validity, this index was chosen because it had been used in a statewide evaluation of nurse satisfaction. 2° Nurses at the pilot and control sites completed the IWS before the orientation workshops, 1 year after the pilot program began, and 1 year after the workshops took place. Qualitative data on nurse satisfaction and responses to neighborhood nursing were collected continuously at staff meetings, project director meetings with staff and their supervisors, and site team meetings. The IWS measured no meaningful differences in nurse satisfaction; however , qualitative data from the nurses' discussions of their work have suggested that a more appropriate approach to determining nurse satisfaction would have been to track individual changes in work satisfaction. Neighborhood nursing appeared to be unfamiliar and u n c o m f o r t a b l e for some nurses, who tended to either be recent graduates or had come from an acute care hospital model of nursing. For other nurses, particularly those who had prior experience with or educational exposure to community-level practice, neighborhood nursing provided a context of commitment to health and community that was consistent with their own philosophies of nursing, and this resulted in greater enthusiasm for their work. Several nurses were quickly functioning at a proficient level of practice for a community health nurse generalist. 21 Consumer access to care was measured by referrals from family, neighbors, and friends; visits to evaluate the need for services (evaluation visits); and nonbillable health promotion visits. The reliability of the referral data was limited by discrepancies in coding at the point of intake of the client into the agency. Small numbers and a great deal of variability in the other measures limited the usefulness of the access
NURSING OUTLOOK
% 0.3 0.25 0.2: 0.15 0.1 0.05 0 Q2
Q3 1992
Q4
Q1
Q2 1993
Q3
• Control - - C e n t e r A x C e n t e r B Percentage
of all visits
Figure 1. Evaluation visits.
0.7 %
0.6 0.5
Y
0.4
f
0.3 0.2 0.1
0
Q2
° I
Q3 1992
I
Q4
I
Q1
I
Q2 1993
Q3
• Control -I- Center A • Center B Percentage of all visits Figure 2. Health promotion visits.
data. Nevertheless, Center A showed an overall increasing trend in the number of evaluation visits (Figure 1). Nurses at this center documented more examples of direct consumer contact that resulted in evaluation visits, such as when a concerned neighbor approached the nurse in a housing development or an elderly woman came to a senior wellness clinic to seek nursing assessments for homebound friends. Nurses at Center A attributed their greater visibility to several factors. In two senior citizen buildings, they developed strong working relationships with social workers, who now make lists of residents who require nursing attention. In addition, Center A is located adjacent to a VNA-
SEPTEMBER/OCTOBER 1996
CJ volunteer-run thrift shop that is frequented by area residents, and thrift shop volunteers encourage consumers to walk over to the health center if they need to talk to their neighborhood nurse. Given the drive for reimbursable visits, health promotion visits are usually low in priority and few in number. Nurses at the pilot sites were encouraged to make these visits to consumers who would benefit from support and education. Figure 2 illustrates the predominantly upward trend of health promotion visits at the pilot sites, compared with the low, flat percentage of these visits at the control site. Again, pilot site differences are evident, with Center A demonstrating a consistent positive trend
Reinhard et al.
225
35
Hours
30 25 20 15 10 5
-<
O* -t"- ~P- ~ i it-. w !, w April May June July Aug 8ep Oct Nov Dec Jan Feb MarchApril May June July Aug Sep 93 92 I • Control
-[- C e n t e r A
~ Center B
Figure 3. Community encounters.
• Development of town-specific resource guides for consumer leaders • Participation in town alliances • Initiated volunteer programs with: - - Hispanic Resource Center - - Churches - - Girl Scouts • Presentations to local board of health and community groups • Development and presentation of health education programs • Participation in town days • Participation in development and testing of a town disaster plan • Participation in health fairs
after the workshops and Center B showing initial gains followed by a downward trend. Qualitative analyses indicated that the number of health promotion visits varied with staffing changes and with fluctuations in funding, which came from county grants and donations; these fluctuations in funding at times influenced whether health promotion visits were encouraged by management. In addition, staff members did not always remember to document health promotion visits, particularly when they were of short duration or were seen as an extension of a "therapeutic" billable visit. Aside from these neighborhood nursing outcomes for individuals and families, analysis of community-level activities (see Box 1 for examples) substantiates a growing focus on the aggregate consumer. Community-level activities were tracked in 226
R e i n h a r d et al.
three ways: quantitative tabulation of the number of community activities, nursing logs, and exemplars reported by staff members. Figure 3 graphs monthly reports of the number of hours spent on community-level activities. The control site's limited rise in community activities during the third quarter of year 1 confirms that provision of codes to document community encounters does not change the practice of nurses unless they are provided with education and encouragement to expand the concept of consumer to the community level. After the staff orientation workshops took place in the fall, nurses from both pilot sites began to document more hours spent in community encounters, such as those listed in Box 1. Activities declined at both sites before and during the summer months, with a positive trend re-established in the third quarter of year 2. The fluctuations in
the pattern of community activities and health promotion/evaluation visits were explained through qualitative data from the nurses' log entries, site team meetings, and project director-facilitated weekly meetings. During the spring of year 2, market forces escalated the pace of change in New Jersey, which forced an agency-wide emphasis on increasing nursing productivity as measured by reimbursed visits. Although nurses at the pilot sites were encouraged to continue to participate in activities with a neighborhood nursing emphasis on health promotion, they expressed concern about how their productivity would be measured. Some of the nurses at Center A had been demonstrating a greater commitment to the goals of neighborhood nursing and were extending their work hours as needed to be able to continue to maintain this focus. With concurrent monitoring of the quantitative data, the Steering Committee determined that measures of productivity needed to include neighborhood nursing activities, and thus they set modest goals for each nurse's expected community-level activities and encounters. Staffing changes also had an impact on the staff's ability to meet the neighborhood nursing expectations, as did the extent to which the health center nurse manager actively supported a sustained effort on the part of the staff. The differences between Centers A and B regarding community activities, health promotion visits, and evaluation visits were attributed to the fact that Center a nurses spent more time networking in their neighborhoods with the full support of their managers. A few key staff nurses at Center A became strong proponents of the neighborhood nursing philosophy and effectively role modeled the behaviors for their peers. These nurses quickly incorporated both scheduled and unscheduled visits with school nurses, boarding home managers, postal workers, and community leaders into their work schedule. Although the staff members at Center B made community encounters, several nurses indicated that they were more comfortable making traditional home visits. Qualitative data from the staff indicated that the neighborhood nursing concept improved their ability to connect clients with community services. Nurses were also asked to address community groups on
V O L U M E 44 • N U M B E R 5
NURSING O U T L O O K
health topics, participate in health fairs, and provide caregiver seminars. They were able to identify the community's health needs and became known in the neighborhood as "our nurse." DISCUSSION
Neighborhood nursing represents a paradigm shift from a nursing model of fragmented care and a focus on individuals
Educating nurses for this expanded role at orientations and ongoing in-services is necessary but not sufficient to sustain behavior change. driven by decades of health care financing policies to a model that embraces continuity of care and integrates the individual, family, and community. To help the VNA-CJ and its staff make this shift, neighborhood nursing was developed as a method of providing structural, procedural, and other supports necessary for the philosophy to be operationalized. Exemplars from the neighborhood nurses, other qualitative data, and an agency vision that embraces the community encouraged the Steering Committee of the pilot project to extend the project to the control site, with support from the W K. Kellogg Foundation. As neighborhood nursing has progressed, other health centers have incorporated the concepts into practice on their own and have requested to be included formally in the program earlier than scheduled. The differences between pilot sites can be explained in part by differences in the level of interest of individual nurses in working at the neighborhood level--interest that can be developed and supported by a strong and committed managerial staff. In addition, several of the neighborhoods served by Center A may bei more conducive to neighborhood nursing practice because they have more naturalistic groupings, such as neighborhood centers and housing developments. Educating nurses for this expanded role at orientations and ongoing in-services is necessary but not sufficient to sustain behavior change. Continual socialization of NURSING OUTLOOK
the nurses by clinical specialists in community health nursing, s by nurse managers, or by senior staff nurses is crucial. To encourage and reward individual nurse development at an expert level, the VNA-CJ developed invitational seminars on community-level practice with internal and external experts as presenters. The series targeted the neighborhood nurse who embraced the concept and was eager for more development and mentorship. The first two seminars focused on public speaking and community empowerment. The participants responded with enthusiasm; several of them integrated the content of the seminars into their practice and served as role models for other staff members. The VNA-CJ is evaluating criteria used to hire new staff members. Whereas nurses with acute care experience may do well with the more acutely ill patient in the home, they also need to express some interest in or understanding of the community dimension of the nurse's role. This dimension has been integrated into job descriptions and evaluations. Neighborhood nurses need to know how to develop partnerships with communities to ensure the financial and other resources needed to support outreach and health-promoting activities in the community. The neighborhood nursing pilot project has suggested that some nurses have poor self-efficacy with group activities and public speaking. Nurse educators need to consider whether such skills are being fostered and include traditional core public health functions in curricula. According to the Pew-Fetzer Task Force on Advancing Psychosocial Education, health professionals need knowledge or skills in the following areas to enter into effective community relationships: (1) the meaning of community; (2) the multiple contributors to health and illness within the community; (3) developing and maintaining relationships with the community; and (4) effective community-based care. = It was necessary for the project manager to do a great deal of role modeling to support implementation of an additional key element of neighborhood nursing-the Neighborhood Advisory Committee, or NAC. An N A C was formed at each health center to strengthen the understanding of the c o m m u n i t y and the community's participation in planning and delivering health-promoting services. Each NAC is cofacilitated by the center nurse
SEPTEMBER/OCTOBER 1996
manager and a community member. Key community members are invited to meet monthly to identify community needs, resources, and strategies. The NACs are developing their own goals and action plans. The small numbers of encounter hours in the pilot project were a reflection of financial limits--something that all community health nursing agencies confront. How much of a nurse's time can an agency afford to shift from billable visits to often unfunded community outreach and intervention? Indeed, a small agency could probably not sustain the start-up costs of a neighborhood nursing program. The biggest single factor limiting the potential success of neighborhood nursing is health care financing. The scope of the influence of health care financing on the structure and functioning of a community health nursing agency was illustrated in a variety of ways in this project, from nurses who were uncomfortable with community outreach to productivity definitions driven by reimbursement practices. The ability of an agency to serve a community may become even more limited during the current era of managed care and health care networks. For example, how does the neighborhood nurse serve members of a community who are not part of the health care network in which the agency is a participant? When the NAC identifies a community health problem-- for example, an increase in asthma or breast cancer how does it persuade these managed care entities to negotiate provision of a community-based prevention service that is available to the
The biggest single factor limiting the potential success of neighborhood nursing is health care financing.
entire community? Some hospitals are taking the lead by conducting such negotiations for patient populations served by the insurers, but not for the entire community. Neighborhood nursing would have a greater chance of success if an alliance of managed care entities and health care organizations existed that could negotiate a capitated approach to care of a community or purchase community-level interventions. Reinhard et al.
227
The VNA-CJ is confronting several key questions. How does the agency position neighborhood nursing as the fulcrum of vertically integrated health care in a way that will protect the mission of the agency? How can neighborhood nursing become a marketable commodity in the present businessoriented context? Does the neighborhood nurse need to be an advanced practice nurse who can provide the primary health care that will be valued by the payors? While grappling with these important questions, the VNA-CJ continues to pursue national, state, and local funding for its community service. This was the catalyst for the development of a free-standing, federally qualified health center, entitling it to specialized funding. Although the VNA-CJ has been successful in securing local and state support for special initiatives, government spending cuts limit the likelihood that neighborhood nursing can be sustained through these funding streams. Davis 23points out that cutbacks in federal categorical grant programs and initiatives supported by the Centers for Disease Control could drastically undermine essential public health services for women and children. Other funding mechanisms through corporations, churches, and civic organizations are being explored. In the meantime, the standing of the VNA-CJ in the communities that it serves has increased tremendously as a result of the community outreach and community-level activities that have been initiated and because of the N A C s . From a marketing standpoint, neighborhood nursing has conveyed to its communities, its clients, and insurers that the agency has a vision and is committed to excellence. A strength of neighborhood nursing is its ability to demonstrate a public/private partnership that is increasingly being emphasized by foundations and communities. 24 Neighborhood nursing connects clients to volunteer resources that are not reimbursable. Support for caregivers, whether family members, significant others, or volunteer community members, requires developing community resources to support the self-care that is being expected as health care expenditures are contained and restricted. Neighborhood nursing is invested in the informal networks, support systems, and human services that can maximize the per capita services available to an individual and share the risk involved in developing and provid228
Reinhard et al.
ing a new service with others in the community. W i t h the d e v e l o p m e n t of the NACs, the possibilities for interagency collaboration are exciting. One can argue that the agency's community orientation would be less essential to the communities it serves if local and state government provided strong public health efforts. In fact, the agency does receive state and local funding for contracted services, such as core public health clinics. However, the current emphasis on market forces does not include a public health focus. True health care reform must incorporate methods of financing health promotion and prevention services for individuals, families and communities. The health of our neighborhoods depends on such reforms. • REFERENCES
1. Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988. 2. Shugars DA, O'Neil EH, Badger JD, editors. Healthy America: practitioners for 2005. Durham (NC): The Pew Health Professions Committee, 1991. 3. United States Department of Health & Human Services. Healthy People 2000: summary report. Boston (MA): Jones & Bartlett, 1992. 4. Wall L. The house on Henry Street. New York: Holy, 1915. 5. American Public Health Association. APHA's vision: public health and a reformed health care system.Nation's Health 1993;23(6):9-11. 6. Shea S. Community health, community risks, community action. Am J Public Health 1992;82(6):785-7. 7. Zerwekh JV. Commentary: Going to the people--public health nursing today and tomorrow. Am J Public Health 1993;83(12): 1676-8. 8. Mason DJ, Knight K, Toughill E, DeMaio D, Beck T, Christopher MA. Promoting the community health clinical nurse specialist. Clin Nurse Specialist 1992;6(1):6-13. 9. Phillips EK, Cloonan P, Irvine A, Fisher ME. Nonreimbursed home health care: beyond the Bills. Public Health Nurs 1990;7(2):60-4. 10. de Tornay R. Reconsidering nursing education: the report of the PEW health professions commission. J Nurs Educ 1992;31(7):296301. 11. Selby M, Riportella-Muller R, Salmon M, Legault C, Quade D. Master's degree community health nursing educational needs: a national survey of leaders in service and education. J ProfNurs 1991;7:88-98. 12. Christopher MA, Reinhard S, McConnell K, Mason D. Neighborhood nursing: the community as partner. Caring Mag 1993;12( 1):44-9. 13. ZerwekhJV. Public heahh nursing legacy:historical practical wisdom. Nurs Health Care 1992;13(2):84-91.
14. American Nurses Association. Nursing's agenda for health care reform. Washington, D.C.: The Association, 1992. 15. Dreher M. District nursing: the cost-benefits of a population-based practice. Am J Public Health 1984;74(10):1107-11. 16. Buhler-WilkersonK. Public health nursing: in sickness or in health? Am J Public Health 1985;75(10):1155-6t. 17. Jamieson MK. Block nursing: practicing autonomous professionalnursing in the community. Nurs Health Care 1990;11(5):25-53. 18. Solari-Twadell PA, Djupe AM, McDermott MA. Parish nursing: the developing practice. Park Ridge (IL): National Parish Nurse Resource Center, Lutheran General Health Care System, 1990. 19. Stamps PL, Piedmonte LB. Nurses and work satisfaction: an index for measurement. Lansing [MI]:Health Administration Press, 1986. 20. Knickman J, Kovner C, Hendrickson G, Finkler S, Whittier D, Graf H. An evaluation of the New Jerseynursing incentive reimbursement awardsprogram. New York:The Health Research Program of New York University, 1991. 21. American Nurses Association. Standards of community health nursing. Washington, D.C.: The Association, 1991. 22. Resolini CP and the Pew-Fezter Task Force. Health professions education and relationship-centered care. San Francisco:Pew Health Professions Commission, 1994. 23. Davis K. The federal budget and women's health [editorial].Am J Public Health 1995;85 (8):1051-3. 24. Polivka BJ. A conceptual model for community interagency collaboration. Image J Nurs Sch 1995;27(2):110-5.
SUSAN C. REINHARD is deputy commissioner at the New Jersey Department of Health in Trenton. MARY ANN CHRISTOPHER is executive vice president and chief operating ofricer of the Visiting Nurse Association of Central Jersey in Red Bank, N.J. DIANA J. MASON is a professor and associate dean for graduate studies at Lienhard School of Nursing, Pace University, New York and Pleasantville, N.Y. KATHLEEN MCCONNELL is director of homecare at the Visiting Nurse Association of Central Jersey in Red Bank, N.J.
PATRICIA RUSCA is project director at the Neighborhood nursing Visiting Nurse Association of Central Jersey, Red Bank, N.J. EILEEN TOUGHILL is director of longterm care and ancillary services at the Visiting Nurse Association of Central Jersey, Red Bank, N.J.
V O L U M E 44 • NUMBER 5
NURSING OUTLOOK