Co-Contributor: Katunzi Mutalemwa

The purpose of this blog is to describe a baccalaureate (BSN) prepared nursologist’s, Katunzi Mutalemwa personal lived pre-internship clinical learning experience in primary care at a local community-based non-governmental outpatient clinic run by The Tanzania Doctors with African CUAMM  in collaboration with a local District hospital.

Katunzi’s reflections have been interpreted within the context of nursology discipline-specific knowledge of Neuman’s Systems Model (NSM), and the Theory of Self-Care of Chronic Illness (TSCC), as well as the Expanded Chronic Care Model, a model shared with public health.

Inasmuch as the ECCM is a shared model, the starting point for the interpretation is the nursology discipline-specific conceptual model that is NSM (Villarruel et al., 2001). Whereas the NSM guided the overall understanding of the reflections, the concepts of the TSCC guided some of the specific actions described, as did the ECCM. The NSM provides a nursology conceptual foundation that takes into considerations the multiple levels of client/client system influences – the physiological, psychological, socio-cultural, developmental and spiritual interacting factors and environmental stressors. The model has the potential of advancing the future of nursology in the area of expanded nursing scope of practices and services in response to chronic disease management.

Katunzi’s reflections highlight the role of the BSN-prepared nursologists in the management and prevention of chronic diseases beyond the walls of the acute care settings (i.e., community-based primary health care settings)

The main ideas seen in this blog are consistent with the World Health Organization’s (2020) State of World Nursing publication, the nursology.net blog Primary-care-primary-nursology-and-the-attending-nursologist, the AACN White-Paper on the Vision-Academic-Nursing; the Health Resources & Services Administration (HRSA) 2018 call for Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program as well as several journal articles on the role of the primary care nursologist (e.g. Anderson et al., 2012; Bodenheimer, & Mason, 2016; Borgès Da Silva et al., 2018; Epping-Jordan, 2002; Lipstein, et al., 2016; Norful, et al., 2017).  The description of the roles and responsibilities discussed in this blog acknowledge the varied contextual nursing scope of practices across the globe.

Katunzi’s Nursing Context/Situation

The personal reflections demonstrate how a BSN-prepared nursologist practices within the Tanzania Nursing and Midwifery Council (TNMC) (2014) general nurse full scope of practice. The TNMC’s major role definitions of a general nurse prepared at the baccalaureate level are: 1) Accountability, Ethical and Legal Practice; 2) Care Provision, Health Promotion, Leadership and Management and, 3) Professional, Personal and Quality Development. For instance, the care provisions and leadership definition of the TNMC general scope of practice, the BSN-prepared nurse roles includes, but is not limited to developing practice guidelines, representing nursing at the management meetings, preparing and presenting nursing budgets at management team meetings, participating in nursing research and utilizing research results in provision of nursing care, providing comprehensive nursing care and carrying out nursing management independently, formulating relevant policies about patient and client care, and reviewing performance appraisal for nurses. According to the TNMC, if assigned, a BSN-prepared nurse is also allowed to prescribe medications for persons with some acute, emergency conditions and chronic illnesses and to prescribe physical therapy and other rehabilitative treatments in keeping with existing protocols.

Katunzi’s reflections

Community Resources and Policies and, Health Care System (Concepts of the ECCM)

As a BSN-prepared nurse completing a pre-internship clinical learning opportunity in a private community-based clinic (NSM community as the client system), I was mentored into the primary care role by a team of nurses and other healthcare providers. I was involved in the management of clients living with diabetes and heart diseases (adults and adolescents) (NSM developmental variable) trice a week and also participated in conducting monthly supervisions in satellite health centers. I learned to assure patients/clients maintained a maximum level of wellness by keeping stressors and stress responses at a minimum through effective, efficient care at three levels of prevention (NSM prevention as intervention). Utilizing a holistic approach (NSM physiological, psychological, socio-cultural, development, and spiritual variables), I was exposed in health counseling, medication administration, health teaching, case management and care coordination services (NSM prevention as intervention]. I worked closely with nurses in other satellite health centers within the clinic’s catchment area. The collaboration strengthened patient treatments and improved care. I regularly participated in conducting home visits and tracking down patients who were lost to follow-up care.  I dealt with barriers such as clients’ religious and traditional beliefs that hinder adherence to prescribed regimen (NSM socio-cultural and spiritual variables).

As a part of the learning process, I practiced advocacy and I was able to participate in regular district administrative meetings to negotiate consultation fees and cost of drugs with district authorities (NSM socio-cultural variable). I improved my nursing skills in individual/family and community assessment while fulfilling this role. For instance, I was able to share with the authorities how financial challenges forced clients to take half doses of their prescribed medication and intentionally caused missed follow-up visits. Likewise, I noted that other clients opted to traditional herbal treatments as they were perceived to be cheaper than hospital medications. I was able to see how self-medication practices (Concepts of the TSCC) can harden caring of chronic patients. Some patients opt to buy drugs in stores rather than visit the clinic or hospital. Some of the challenges were attributed to lack of transportation and health illiteracy on disease processes (NSM socio-cultural variable). I called attention to the impact of laxed drug dispensing policies on clients’ lives.  For example, I shared how clients with contraindicated medication can easily procure the drugs from a local drug store, making them at risk of readmissions and possibly death. In addition, as a community health educator, I advised patients and their families to participate in community development projects such as livestock keeping, small scale agricultural that helped them to earn extra money for buying drugs and supporting individual and family their well-being (NSM socio-cultural and spiritual variables ).

Delivery System Design and Self-Management Support(Concepts of the ECCM)

The community clinic was centered at a District Hospital and operated synergically with ten other health centers within our catchment area (NSM community as the client system). I learned to assure the provision of self-care maintenance, self-care monitoring, and self-care management services (Concepts of the TSCC). For instance, I was involved in caring for chronic disease patients especially type 1 diabetic patient by empowering and preparing clients to manage their health through effective and safe self-injection practice. I provided health education on regular testing to control glucose levels as well as insulin-self administration.  Assessing clients’ health literacy levels in the treatment process was a crucial piece of my practice role. I developed peer guided groups with an interpofessional team comprising of a nutritionist and physician. In addition, I conducted monthly supervision at each of the ten assigned health centers. During the supervisory visits, I was involved on assessing the overall patient’s adherence practice to nursing care and follow up (Concepts of the TSCC). I also participated in conducting professional development seminars to nurses on management of patients living with chronic diseases, how to conduct referrals and improve protocols to manage patients with diabetic ketoacidosis and heart failure (NSM variances from wellness). I completed frequent home visits with nurses and other providers to assess the client’s progress, adherence practices and storage of medications (concepts of the TSCC), as well as delivered promotional health messages to patients and families (NSM primary prevention as intervention).

Decision Support and Clinical Information System (Concepts of the ECCM)

I learned how to make clinical decisions in chronic disease management consistent with scientific data and patient preferences. For example, when I saw patients with medical adherence issues, I made sure I educated the clients on possible consequences and let the clients make informed decisions (NSM primary prevention as intervention). I always acknowledged the challenging presence of scientifically unproved treatment plans attributed to the growing number of traditional doctors involved in client’s health care decisions (NSM individual as the client system). I always paid attention to gender-based influences (NSM socio-cultural and spiritual stressors) in medication adherence NMS-. For instance, I was able to determine that men attended treatments when they had severe signs and symptoms of an illness and/or at advanced stage of disease. To address this social determinant among some of the men, I participated in initiating the use of mobile phones to trace patients on monthly basis. This initiative had a positive impact on “no show” clients who had access to mobile phones.

Implications for nursologist scholars

Katunzi’s reflections have implications for advancement of nursology discipline-specific knowledge and future professional transformations. The evolving role of the nursologist  in primary care (Wojnar & Whelan, 2017) calls for a well-rounded RN (Swan, et al, 2006) and, most importantly, a BSN-prepared global nursology  workforce (Wojnar & Whelan, 2017). Use of the ECCM requires ongoing research — or review of existing research – to determine the validity of the model as a shared theory/model (Villarruel et al., 2001) that is useful in new nursing education curricula (Humphrey, 2019),  reimbursement (Funk & Davis, 2015) and regulatory models (Start, 2020) situations that fit BSN-prepared nurses’ full scope of nursologists’ practice and meet clients’ health and social needs in places where people live, learn and play.  

We would like to learn from our nursology.net readers on their perceptions of these questions:

1. What does the future of nursology hold for the role of the BSN-prepared nursologist in primary care, especially in the United States where primary care is regarded as a major role of advanced practice nursologists holding master’s and/or Doctor of Nursing Practice degrees?
2. How can nursologists overcome the barriers and maximize contextual opportunities to fulfill their roles? 
3. What barriers may influence effective adoption of applicable borrowed and shared theories/models in nursology-led chronic disease management interventions?

We welcome nursologists at different levels of practice (i.e., LPN, ADN, BSN, DNP, PhD-prepared) to share their stories of how they provide primary care services (or ambulatory care or community-based care), in private or public health care systems.  Please share your thoughts in comments section below

References

Anderson, D., St. Hilaire, D., Flinter, M., (May, 2012). Primary Care Nursing Role and Care Coordination: An Observational Study of Nursing Work in a Community Health Center OJIN: The Online Journal of Issues in Nursing, 17, 2, http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No2-May-2012/Primary-Care-Nursing-Role-and-Care-Coordination.html

Barr, V, Robinson, S, Marin-Link, B, Underhill, L, Dotts, A, Ravensdale, D, & Salivaras, S. (2003). The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model, Hospital Quarterly, 7(1), 73-82.

Bodenheimer, T., & Mason, D. (June, 2016). Registered nurses: Partners in transforming primary care. In Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation in June. http://64.62.135.154/docs/macy_pubs/Macy_Monograph_Nurses_2016_webPDF.pdf

Borgès Da Silva, R., Brault, I., Pineault, R., Chouinard, M.-C., Prud’homme, A., & D’Amour, D. (2018). Nursing Practice in Primary Care and Patients’ Experience of Care. Journal of Primary Care & Community Health, 9, 1-7 https://doi.org/10.1177/2150131917747186

Epping-Jordan, J., (Ed.) (2002). Innovative care for chronic conditions: building blocks for action: global report (document no. WHO/NMC/CCH/0201). World Health Organization Global Report. https://www.who.int/diabetes/publications/icccreport/en/

Funk, K. A., & Davis, M. (2015). Enhancing the role of the nurse in primary care: the RN “co-visit” model. Journal of general internal medicine, 30(12), 1871-1873.

Health resources & Services Administration (2018).  Nurse Education, Practice, Quality and Retention (NEPQR) – Registered Nurses in Primary Care (RNPC) Training Program. Retrieved from https://www.hrsa.gov/grants/find-funding/hrsa-18-012

Humphrey, B., L., Mixer, S. J., Thompson, K., Davis, S., Elliott, L., Lakin, B., … & Niederhauser, V. (2019). Transforming RN roles in community-based integrated primary care (TRIP): Background and content. Issues in mental health nursing, 40(4), 347-353.

Lipstein, S. H, Kellermann, A. L., Berkowitz, B., Phillips, R., Sklar, D., Steele, G. D., & Thibault, G. E. (September, 2016). Workforce for 21st century health and health care: A vital direction for health and health care. National Academies of Medicine. https://nam.edu/wp-content/uploads/2016/09/Workforce-for-21st-Century-Health-andHealth-Care.pdf.

Norful, A., Martsolf, G., de Jacq, K., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic review. International journal of nursing studies, 74, 15-23.

Start, R., Brown, D. S., May, N., Quinlan, S., Blankson, M., Rodriguez, S. R., & Matlock, A. M. (2020). Strategies for creating a business case that leverages the RN role in care coordination and transition management. Nursing Economics, 38(4), 203-217.

Swan, B. A., Conway-Phillips, R., & Griffin, K. F. (2006). Demonstrating the value of the RN in ambulatory care. Retrieved from https://jdc.jefferson.edu/cgi/viewcontent.cgi? article=1012&context=nursfp

The Tanzania Nursing and Midwifery Council (2014). Scope of Practice for Nursing and Midwives in Tanzania. United Republic of Tanzania.

Wojnar, D. M., & Whelan, E. M. (2017). Preparing nursing students for enhanced roles in primary care: The current state of pre-licensure and RN-to-BSN education. Nursing Outlook, 65(2), 222-232.

Villarruel, A.M., Bishop, T.L., Simpson, E.M., Jemmott, L.S., & Fawcett, J. (2001). Borrowed theories, shared theories, and the advancement of nursing knowledge. Nursing Science Quarterly, 14, 158-163.