ORIGINAL ARTICLE
Identifying nurse practitioners’ required case management competencies in health promotion practice in municipal public primary health care. A two-stage modified Delphi study Virpi Maijala, Kerttu Tossavainen and Hannele Turunen
Aims and objectives. The aims of this study were to identify and reach consensus among municipal primary health care participants on nurse practitioners’ (NPs’) required case management competencies in health promotion practices in eastern Finland. Background. The NP’s role as a case manager of patients with chronic conditions has been found to have positive outcomes in health promotion, such as reduced hospital lengths of stay and readmission rates. However, the challenging work of health promotion requires NPs to have multidimensional competencies in health promotion, including communication, advocacy, assessment, planning, consultation and implementation. Design. A two-stage modified Delphi study. Methods. Round 1 semi-structured interviews were conducted among municipal primary health care participants (n = 42) in 11 health centres from April–July 2009, and the round 2 questionnaire survey was conducted in the same health centres in eastern Finland in January and March 2011. The questionnaire was answered by 64% of those surveyed (n = 56). Content analysis and descriptive statistics were used for data analysis. Results. We identified a total of 18 required case management competencies for NPs’ health promotion practices in municipal primary health care. In 17 of these competencies (such as knowledge, skills and ability to work independently in health promotion), a consensus was reached (51% or over). However, the need to be interested in municipal decision-making (446%) did not reach consensus. Conclusion. Consensus was clearly achieved for 17 competencies that NPs were required to have, and these indicated the knowledge or abilities of health promotion. Nevertheless, there was no agreement on the NPs’ need to be interested in municipal decision-making. Relevance to clinical practice. NPs need a variety of case management skills and abilities to realise health promotion in municipal primary health care and they
Authors: Virpi Maijala, MNSC, PhD Student of Nursing Science, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio; Kerttu Tossavainen, PhD, Professor of Nursing, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Hannele Turunen, PhD, Professor of Nursing, Nurse Director, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12855
What does this paper contribute to the wider global clinical community?
• NPs need a variety of case man-
•
agement competencies in health promotion practice in municipal primary health care. Nevertheless, there was no agreement on NPs’ need to be interested in municipal decisionmaking.
Correspondence: Virpi Maijala, PhD Student of Nursing Science, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Canthia-building, Yliopistonranta 1C, PO. Box. 1627, FI-70211 Kuopio, Finland. Telephone. +358 505742607. E-mail:
[email protected]
1
V Maijala et al.
need to be supported by primary health care leaders to develop health promotion activities. Key words: case management, competencies, health promotion, nurse practitioner Accepted for publication: 25 March 2015
Introduction The role of the nurse practitioner (NP) was established in the USA more than 50 years ago to facilitate the delivery of primary health care in community settings. Since then, this role has been implemented in many countries in a variety of settings (Gardner et al. 2010). The context of primary health care is complex for nurses who work in it and they are required to have an understanding of the multidimensional factors of health and the ability to engage in health promotion activities (Meyer & O’BrienPallas 2010). However, a NP’s role as a case manager of patients with chronic conditions has demonstrated positive outcomes with reduced intensive care unit lengths of stay, hospital lengths of stay and readmission rates (Wilson et al. 2012). In Finland, a new health care law (The New Health Care Act, 30.12.2010/1326) that became effective on 30 December 2010 emphasises the health promotion of the population and the recognition and reduction in health inequalities. Registered nurses (RNs) can work as NPs in health care centres that are responsible for providing primary health care services and health promotion in municipalities (Teperi et al. 2009). In eastern Finland, health promotion is particularly challenging. The population is ageing, with approximately 20% over 65 years of age, and morbidity is higher than anywhere else in Finland. In addition, chronic diseases, mental health problems, obesity, smoking and alcohol consumption are more common in this region than in other Finnish municipalities (National Institute for Health & Welfare 2011). NPs have been found to provide health promotion activities in primary health care, such as chronic disease management treatment, patient education and counselling (McCarthy et al. 2012). This study aimed to identify and reach a consensus among primary health care participants for NPs’ required case management competencies in health promotion practice in eastern Finland.
Background Health promotion emphasises a comprehensive view of health; it not only embraces actions directed at strengthening the skills and capabilities of individuals but also encompasses actions directed towards changing social,
2
environmental, political and economic conditions to enhance their impact on populations and individual health (Baisch 2009). Health promotion activities require nurses to have a wide range of knowledge and skills (Battel-Kirk et al. 2009, Speller et al. 2012). Therefore, for example, the Galway Consensus Statement and the Australian Health Promotion Association (AHPA) have established recommendations of core competencies for health promotion practitioners (AHPA 2009, Speller et al. 2012). Core competencies of health promotion are identified and defined according to the challenges of public health, such as differences in public health and the health-related needs of the ageing population (AHPA 2009, Speller et al. 2012). However, NPs’ competencies are mainly identified in various clinical nursing settings, such as acute, surgical or perioperative nursing care (Gardner et al. 2010, McCarthy et al. 2012). Traditionally, nurses’ health promotion competencies are described as consisting of themes related to knowledge, skills and attitudes (Irvine 2005). However, the health promotion competence of nurses includes attributes such as (1) assessment, planning and consultation; (2) implementation and evaluation of research; (3) values and ethics; (4) communication, policy, advocacy, strategy development, organisation, and management; (5) working with communities, community empowerment, partnership building and collaborative working; and (6) strategic leadership (Speller et al. 2012). The literature of health promotion has mainly focused on presenting completed frameworks of competencies and professionalisation, but their usefulness or other applications to health promotion research have not been specifically addressed (Battel-Kirk et al. 2009). In addition, the health promotion practice of nurses has been found to be embedded into day-to-day nursing care (Runciman 2013). When defining the health promotion competencies of nurses, case management provides an approach to meet the challenges of health promotion. This approach involves a model to coordinate the care of chronically ill patients and community-based health promotion work (Wilson et al. 2012). Case management originated from the social work of the early 1980s and was extended to the outpatient care of the older, becoming a generic concept and finding its way into acute hospital care by the early 1990s (Gray & White 2012). Nurse case management models have been © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Original article
mainly described in various nursing settings as patient-centred and targeting intensive care in high-risk individuals to reduce hospital admissions and improve care coordination (Wilson et al. 2012). For example, nurse case management has been found to significantly reduce re-hospitalisation related to cardiovascular symptoms and morbidity (Berra 2011). However, nurse case management, including monitoring, has been found to improve self-care, disease and medication education, as has counselling in chronically ill older adults, leading to fewer admissions (Schraeder et al. 2008). In addition, in single studies, such as those concerned with women who suffer from depression, nurse case management has been found to improve the patients’ knowledge of medication and mental status (Kneipp et al. 2011). Although there is a great amount of evidence regarding the effectiveness of nurses’ case management in clinical nursing, there remains a lack of knowledge about the case management functions that are undertaken to improve public health promotion. Nurses’ case management competencies that are similar to those of health promotion, including abilities such as patient-centred care, coordination, communication, documentation and patient education, have been found to be the most common case management competencies for nurses (Stanton & Dunkin 2009). However, there is still a need to clarify the health promotion practices of nurses (Goodman et al. 2011).
The study Aim The aims of this study were to identify and reach consensus among municipal primary health care participants on nurse practitioners’ (NPs’) required case management competencies in health promotion practices in eastern Finland. Ethical considerations This study was approved by a hospital district research ethics committee. In addition, senior physicians in all 11 municipal health care centres where this study was performed consented to this research. All the participants gave written consent to participate voluntarily in the research and were given information orally and in written form at the beginning of the study.
Methods In this study, the two-stage modified Delphi technique comprising the qualitative and quantitative approach was applied. The Delphi is a group facilitation technique designed to transform individual opinions into group con© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
NPs’ case management competencies in HP
sensus and it includes two or more rounds of data collection (McKenna 1994, Keeney et al. 2001). The Delphi technique is useful when there is a need to achieve a consensus from geographically dispersed experts (Keeney et al. 2001). There is no one recognised guideline on an appropriate level of consensus. (Keeney et al. 2006). When the goal of the Delphi study is to achieve consensus, a commonly accepted method for determining consensus is to attribute a percentage value to the level of agreement, which has ranged from 51 to 100% (McKenna 1994, Williams & Webb 1994). On the other hand, Keeney et al. (2006) suggested 75% as the minimal level, but there is no obvious scientific rationale for this. In this study, the consensus level was set at 51% agreement.
Procedure Round 1 An informational letter about the study was sent to all 34 municipal health centres in eastern Finland. Eleven of the recipients responded and volunteered to participate in this study. As is recommended for a Delphi study, the participants should be interested in the topic, credible within their field and willing to participate throughout the study (Keeney et al. 2001). Nursing managers of municipal health centres suggested possible participants, and the researcher (VM) asked them for their consent to take part in this study. The inclusion criteria were that the participants had five or more years of experience in primary health care. In addition, they had to have experience of either working independently as a NP or experience working as a pair or team working with a NP. In round 1, 42 individuals participated in this study. Table 1 presents the demographics of the first-round participants. In round 1, questions used in the semi-structured interviews were constructed based on the literature. Focused questions were developed around the following themes: the NPs’ case management abilities, multidimensional knowledge and attitude towards health promotion practices in eastern Finland. The interviews were conducted in a similar manner, performed in the primary health care participants’ work places, tape-recorded and transcribed. A content analysis was used for the data analysis (Weber 1990). The content analysis began by reading through all transcribed interviews and identifying meaningful units of text such as common words, sentences and phrases related to NPs’ case management competencies in health promotion practice. We found 464 meaningful units that identified NPs’ required case management competencies in health promo-
3
V Maijala et al. Table 1 Demographics of municipal primary health care expert panel in Delphi study Participants (n = 42) in round 1 Male 3 Female 39 Age 25–64 years Work experience in primary 5–42 years health care Clinical expert area in primary health care Primary health care leaders 7 ward nurses 6 nursing managers 2 senior physicians 1 education manager Health promotion planning 3 health promotion officers Political decision-maker 3 local councillors General practice 2 general practitioners 18 nurse practitioners Participants (n = 56) in round 2 Male 6 Female 50 Age 25–65 years Work experience in primary 5–42 years health care Clinical expert area in primary health care Nurse practitioners (NPs) 31 Nursing managers 14 Senior physicians 5 Health promotion officers 3 Local councillors 3
tion practice in primary health care. These were classified into eight categories that were developed based on the literature of nurses’ case management competencies (Finkelman 2011, p. 34) as follows: 120 on the skills of providing individual or family education; 98 on the ability to perform patient- or client-centred care; 92 on the ability to implement evidence-based knowledge; 45 on com-
munication skills; 43 on critical thinking, clinical reasoning, and judgment; 23 on the ability to document; 16 on knowledge of community resources; 15 on the ability to evaluate; and 12 on ethical issues. The analysis proceeded by identifying health promotion competencies based on literature (Irvine 2005, AHPA 2009, Speller et al. 2012). An example of the analysis process is presented in Table 2. Round 1 ended with the development of a questionnaire for a quantitative survey in round 2. Statements were drawn up for each competence and the questionnaire included 18 statements, scored on a five-point Likert scale: 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree) and 5 (neither agree nor disagree). The questionnaire was pretested with five NPs in public primary health care who were not involved in the research. Round 2 The questionnaire was sent to a larger group than in round 1, to 87 individuals, including participants from round 1, and also nursing managers, NPs and senior physicians in the same 11 primary health care centres who had not participated in the first Delphi round. Round 2 had a response rate of 64%; 56 participants returned the questionnaire. Table 1 presents demographics of the participants in Delphi round 2 (see Table 1). Data from the second Delphi round were collected in January and March of 2011. The data were analysed with the SPSSâ (v19.0; IBM Corporation, Somers, NY, USA) and descriptive statistics were described as frequencies, percentages, means, standard deviations for each statement and chi-square for each statement comparing the clinical areas of primary health care.
Table 2 Example for data analysis process in round 1
Category (Finkelman 2011)
Examples for meaningful units from interviews
Individual or family education
‘NP must be able to discuss unhealthy issues such as tobacco or overweight with patients.’ (NM 3) ‘. . . NP needs skill to give health counselling.’ (NP 9) ‘NP must be able to give health counselling to various patient groups.’ (NP 10) ‘We must be able to give health education via Internet.’ (NP 11)
Identified competencies of health promotion (Irvine 2005, AHPA 2009, Speller et al. 2012)
Statements in a questionnaire in Delphi round 2
Ability to discuss unhealthy lifestyle
NPs need the ability to discuss unhealthy lifestyle issues with patients
Ability to give face-to-face health education Ability to give group health education
NPs need the ability to provide face-to-face health education NPs need the ability to provide health education to various groups
Ability to give web-based health education
NPs need the ability to provide web-based health education
NM, Nursing manager; NP, Nurse practitioner.
4
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Original article
NPs’ case management competencies in HP
Table 3 Summary of results Level of consensus* NPs’ case management competencies in health promotion practice
n
(%)
Mean†
SD
Pearson’s chi-square
NPs NPs NPs NPs NPs NPs NPs NPs NPs NPs NPs NPs NPs NPs NPs NPs NPs NPs
56 54 53 52 52 51 50 48 47 46 45 44 43 42 41 41 37 25
100 964 946 929 929 911 893 857 839 821 804 786 768 750 732 732 661 446
100 104 105 107 109 111 111 114 116 123 121 121 127 129 132 127 145 179
0000 0187 0227 0260 0345 0366 0312 0353 0371 0539 0456 0414 0522 0530 0575 0447 0761 0929
0196 0685 0205 0604 0225 0555 0272 0472 0732 0616 0674 0433 0965 0859 0429 0670 0359
need need need need need need need need need need need need need need need need need need
the ability to discuss unhealthy lifestyle issues with patients to have a holistic approach to the health promotion of patients to have knowledge about common public health problems skills to communicate with various patient groups the ability to treat all patients equally the ability to create a confidential nursing relationship with the patient to have knowledge about how to prevent diseases the ability to evaluate patients’ individual health promotion needs the ability to provide face-to-face health education knowledge of available health services in their own community the ability to provide health education to various groups the ability to search for information from various databases the ability to consider the patient’s knowledge related to health the ability to provide web-based health education the ability to document health promotion issues in patient records the ability to apply current research results in health promotion practices the ability to make decisions independently to be interested in municipal decision-making
‡
*Completely agree responses. Scale included 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree) and 5 (neither agree nor disagree). ‡ Pearson’s chi-square for each statement comparing clinical expert area in municipal primary health care. †
Results As a result, 18 required case management competencies for NPs in health promotion practice were identified. Of these, 14 reached consensus level 750% or higher, 3 reached consensus levels between 661–732%, while consensus was not reached in the case of one competence among the municipal primary health care participants in eastern Finland. Table 3 presents the summary of the results for NPs’ case management competencies in health promotion.
Discussion Health promotion practices by nurses are associated with the common universal principles of nursing, and nurses are expected to have relevant practical skills, knowledge on health promotion and the ability to apply these skills in various nursing settings in hospitals and primary health care (Aldossary et al. 2012). This two-stage modified Delphi study resulted in consensus on the NPs’ need for ability to discuss unhealthy lifestyle issues with patients (100%) and need to use a holistic approach in patients’ health promotion (964%), which reached the highest levels of consensus. Similarly, studies have found that individual and holistic perspectives, including helping people make health decisions and become engaged in changing unhealthy life© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
styles, are the main health promotion activities in nursing (Povlsen & Borup 2011, Speller et al. 2012, Runciman 2013). Case management competence in health promotion indicated a need to have knowledge of common public health problems, and a level of consensus (946%) was reached in this study. Having multidisciplinary knowledge about public health issues has been found to be the basic premise for health promotion practice in nursing (Irvine 2005). We found that the idea that NPs need skills to communicate with various patient groups reached a consensus level of 929%. Similarly, recent studies revealed that NPs who work with vulnerable groups, such as older persons, need strong communication skills and equal interaction with patients in health promotion practices (Goodman et al. 2011). In addition, the literature has a broader definition for communication skills in health promotion practices that includes an understanding of social and cultural diversity, application of information technology in social media and knowledge of health literacy (AHPA 2009, Speller et al. 2012). Interestingly, our results did not confirm this broader view of communication skills in health promotion practices in primary health care. Among the participants, the level of consensus reached on NPs’ need for ability to treat all patients equally was 929%. This finding confirmed the consensus statement by Speller et al. (2012) who suggested that ethical health promotion practices are based on
5
V Maijala et al.
commitments to health, human rights, respect, dignity, confidentiality, and the worth of individuals, groups and communities. The idea that NPs need ability to create a confidential nursing relationship with patients reached a consensus level of 911% in this study. This finding has been reported in previous studies as competence with respect to attitudes, including factors such as advocacy or encouraging the patient to participate in decision-making (Irvine 2005, Runciman 2013). In this study, the level of consensus as to whether NPs need to have knowledge of how to prevent diseases reached 893%. Traditionally, health promotion practices in nursing have been based on the understanding that preventive interventions for patients with chronic diseases can be delivered in nursing (Richard et al. 2010). In this study, the NPs’ need for ability to evaluate patients’ individual health promotion needs reached an 857% consensus level, which was consistent with a previous study by Irvine (2005) stating that nurses need skills to assess health promotion needs individually. NPs’ need for ability to provide face-to-face health education reached a consensus level of 839% in this study. This level of consensus is surprising, as face-to-face health education has been found to be a major health promotion activity in nursing (Gardner et al. 2010, Chang et al. 2012). This result may perhaps indicate that orientation in health education has gradually moved towards empowerment, which includes collaboration and an equal relationship with patients (Runciman 2013). NPs’ need for knowledge of available health services in their own community showed a consensus level of 821%. Our results support the consensus statement that NPs need the ability to work collaboratively with various sectors of the community (Speller et al. 2012), have knowledge of the availability of interventions in their own area of practice and be involved in health promotion activities in the surrounding community. We found that NPs’ need for ability to provide health education to various patient groups reached a consensus level of 804%. On the basis of recent studies, we may consider that NPs will be increasingly involved in health promotion practices in patient-related groups that have many health promotion needs, such as obesity (Hessler & Siegrist 2012). We found that NPs’ need for ability to search for information from various databases reached a consensus level of 786% among the participants. Similarly, studies have found that in health promotion practice, nurses need the ability to use and search for information from various databases (Irvine 2005, Whitehead 2008). According to our results, NPs’ need for the ability to consider the patient’s knowledge related to health reached a consensus level of 768%. This result indicates that empowerment orientation will be more
6
visible in health promotion practices. However, it has also been found that empowerment was not embedded in the nurses’ health promotion practice (Runciman 2013). We found that NPs’ need for technology skills, such as the ability to provide web-based health education, reached a consensus level of 75%, while the need to have the ability to document health promotion issues in patient records reached 732%. Both of these results demonstrated that NPs also need skills to use information technology and communicate via social media in health promotion practice (Speller et al. 2012). In our study, NPs’ need for the ability to apply current research results to health promotion practices reached a consensus level of 732%. Evidence-based practice has been found to be increasingly important to NPs in clinical nursing (Gerrish et al. 2011, Chang et al. 2012). Therefore, NPs need the ability to collect, review, and appraise relevant information and implement health promotion actions (AHPA 2009, Speller et al. 2012). In this study, NP’s need for ability to make decisions independently reached the level of 661%. A previous study has shown that NPs’ ability to communicate with doctors is associated with multi-professional teamwork, and it serves as a factor that helps NPs perform their work (McElhinney 2010). Only 446% of the participants agreed that NPs need to show an interest in municipal decision-making, and consensus was not reached in this study. However, this result verifies previous studies in which nurses have not demonstrated a clear and obvious political role in health promotion practice (Whitehead 2008).
Limitations of the study Because of the small sample size and data collection from one geographical area, our findings should be generalised with caution. However, the response rate was 100% in round 1 and 64% in round 2. In addition, the high level of consensus among the expert panel in round 2 adds to the validity of the study (Keeney et al. 2006). We conducted a pilot study to test the semi-structured interview and questionnaire, which improved the feasibility and reliability of the results (Jairath & Weinstein 1994). The modified Delphi technique is challenging, and therefore all three researchers (VM, KT and HT) were involved in the research process, which increased scientific accuracy (Jones & Bugge 2006).
Conclusion The two-stage modified Delphi method proved useful in systematically identifying 18 required case management © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Original article
NPs’ case management competencies in HP
competencies in health promotion practice for NPs who work in primary health care in eastern Finland. A consensus was clearly achieved on 17 required competencies that were related to knowledge or abilities regarding health promotion. However, consensus was not reached on the case management competence, the need to be interested in municipal decision-making. Therefore, more research is needed to clarify NPs’ political role in health promotion practice.
Relevance to clinical practice The findings of this study showed that NPs need a variety of case management competencies in health promotion practice in municipal primary health care in eastern Finland. However, the challenges that public primary health care faces in eastern Finland force the leaders to strengthen health promotion practices and support continuing education for NPs who work in public primary health care.
Acknowledgements The authors gratefully thank the participants in this study. Researcher VM acknowledges the support of the Department of Nursing Science at the University of Eastern Finland.
Contributions Study design: VM, KT and HT; data collection and analysis: VM with KT and HT supervising the data collection and analysis process; manuscript preparation: VM with KT and HT making critical revisions to the paper. KT and HT supervised the research process.
Funding This study received a specific grant from The Finnish Foundation for Nurse Education and The Finnish Nurses Association.
References Aldossary A, Barriball L & While A (2012) The perceived health promotion practice of nurses in Saudi Arabia. Health Promotion International 28, 431–441. Australian Health Promotion Association (AHPA) (2009) Core Competencies for Health Promotion Practitioners. University of the Sunshine Coast, Maroochydore, Qld, Australia. Available at: http://www.healthpromotion. org.au/issues/91?task=view (accessed 15 October 2012). Baisch MJ (2009) Community health: an evolutionary concept analysis. Journal of Advanced Nursing 65, 2464–2476. Battel-Kirk B, Barry MM, Taub A & Lysoby L (2009) A review of the international literature on health promotion competencies: identifying frameworks and core competencies. Global Health Promotion 16, 11–20. Berra K (2011) Does nurse case management improve implementation of guidelines for cardiovascular disease risk reduction? Journal of Cardiovascular Nursing 26, 145–167. Chang IW, Shyu YI, Tsay PK & Tang WR (2012) Comparison of nurse practitioners’ perceptions of required competencies and self-evaluated competencies in
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Taiwan. Journal of Clinical Nursing 21, 2679–2689. Finkelman A (2011) Case Management for Nurses. Pearson Education, Inc., Upper Saddle River, NJ. Gardner G, Gardner A, Middleton S, Della P, Kain V & Doubrovsky A (2010) The work of nurse practitioners. Journal of Advanced Nursing 66, 2160– 2169. Gerrish K, McDonnell A, Nolan M, Guillaume L, Kirshbaum M & Tod A (2011) The role of advanced practice nurses in knowledge brokering as a means of promoting evidence-based practice among clinical nurses. Journal of Advanced Nursing 67, 2004– 2014. Goodman C, Davies SL, Dinan S, See TS & Iliffe S (2011) Activity promotion for community-dwelling older people: a survey of the contribution of primary care nurses. British Journal of Community Nursing 16, 12–17. Gray FC & White A (2012) Concept analysis: case management role confusion. Nursing Forum 47, 3–8. Hessler K & Siegrist M (2012) Nurse practitioner attitudes and treatment practices for childhood overweight: how do rural and urban practitioners dif-
fer? Journal of the American Academy of Nurse Practitioners 24, 97–106. Irvine F (2005) Exploring district nursing competencies in health promotion: the use of the Delphi technique. Journal of Clinical Nursing 14, 965–975. Jairath N & Weinstein J (1994) The Delphi methodology (part one): a useful administrative approach. Canadian Journal of Nursing Administration 7, 29–40. Jones A & Bugge C (2006) Improving understanding and rigour through triangulation: an exemplar based on patient participation in interaction. Journal of Advanced Nursing 55, 612–621. Keeney S, Hasson F & McKenna HP (2001) A critical review of the Delphi technique as a research methodology for nursing. International Journal of Nursing Studies 38, 195–200. Keeney S, Hasson F & McKenna HP (2006) Consulting the oracle: ten lessons from using Delphi technique in nursing research. Journal of Advanced Nursing 53, 205–212. Kneipp SM, Kairalla JA, Lutz BJ, Pereira D, Hall AG, Flocks J, Beeber L & Schwartz T (2011) Public health nursing case management for women
7
V Maijala et al. receiving temporary assistance for need families: a randomized controlled trial using community-based participatory research. American Journal of Public Health 101, 1759–1768. McCarthy G, Cornally N, Moran J & Courtney M (2012) Practice nurses and general practitioners: perspectives on the role and future development of practice nursing in Ireland. Journal of Clinical Nursing 21, 2286–2295. McElhinney E (2010) Factors which influence nurse practitioners ability to carry out physical examination skills in the clinical area after degree level module – an electronic Delphi study. Journal of Clinical Nursing 19, 3177– 3187. McKenna HP (1994) The Delphi technique: a worthwhile research approach for nursing? Journal of Advanced Nursing 19, 1221–1225. Meyer RM & O’Brien-Pallas LL (2010) Nursing services delivery theory: an open system approach. Journal of Advanced Nursing 66, 2828–2838. National Institute for Health and Welfare (2011) Available at: http://uusi.sotkanet.fi/portal/page/portal/etusivu (accessed 10 June 2012).
8
Povlsen L & Borup IK (2011) Holism in nursing and health promotion: distinct or related perspectives? - A literature review. Scandinavian Journal of Caring Sciences 25, 798–805. Richard L, Gendron S, Beaudet N, Boisvert N, Sauve MS & Garceau-Brodeeur MH (2010) Health promotion and disease prevention among nurses working in local public health organizations in Montreal, Quebec. Public Health Nursing 27, 450–458. Runciman P (2013) The health promotion work of district nurse: interpreting its embeddedness. Primary Health Care Research & Development 4, 1–11. Schraeder C, Fraser CW, Clark I, Long B, Shelton P, Waldschmidt V, Kucera CL & Lanker WK (2008) Evaluation of primary care nurse case management intervention for chronically ill community dwelling older people. Journal of Clinical Nursing 17, 407–417. Speller V, Parish R, Davison H & Zilnyk A and the CompHP Project Partners (2012) The CompHP Professional Standards for Health Promotion Handbook. IUHPE, Paris, pp. 1–44. Stanton M & Dunkin J (2009) A review of case management functions related to
transitions of care at a rural nurse managed clinic. Professional Case Management 14, 321–327. Teperi J, Porter ME, Vuorenkoski L & Baron JF (2009) The Finnish Health Care System: A Value-Based Perspective. Sitra Reports 82. Edita Prima Ltd., Helsinki. The New Health Care Act 30.12.2010/ 1326. Avaialable at: www.finlex.fi/fi/ laki/kaannokset/. . ./en20101326 (accessed 5 September 2012). Weber RP (1990) Basic Content Analysis, 2nd edn. Sage, Newbury Park, CA. Whitehead D (2008) An international delphi study examining health promotion and health education in nursing practice, education and policy. Journal of Clinical Nursing 17, 891–900. Williams PL & Webb C (1994) The Delphi technique: a methodological discussion. Journal of Advanced Nursing 19, 180–186. Wilson PM, Brooks F, Procter S & Kendall S (2012) The nursing contribution to chronic disease management: a case of public expectation? Qualitative findings from multiple case study design in England and Wales. International Journal of Nursing Studies 49, 2–14.
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
