Professor Patricia Leahy-Warren – Exploring Models of Nursing and Midwifery in the Community: International and National Perspectives

Across the world, primary care is increasingly being embraced as central to healthcare services. Effective delivery requires an efficient and cost-effective community-based model of care. However, no single overarching model of nursing and midwifery practice in the community exists in the literature. A collaboration of experts, headed by Professor Patricia Leahy-Warren from the Catherine McAuley School of Nursing and Midwifery at University College Cork in Ireland, is addressing this complex but critical gap to guide the development of nursing and midwifery in the community in Ireland.

Nursing and Midwifery in the Community

Internationally, primary healthcare is accessed within the community, usually at a GP practice or one’s own home. For many individuals, this is where they first come into contact with healthcare professionals and also where they receive care. In addition to providing treatment, increasing emphasis is also being placed on the promotion of health and well-being, and the prevention of disease within the community. Nurses and midwives are at the forefront of this fundamental provision, constituting the largest group of professionals working in the community context.

The diversity in nursing in the community is reflected in the roles and titles assigned to registered nurses – these can include health visitor, public health nurse, school nurse, practice nurse, clinical specialist nurse, advanced nurse practitioner and generalist nurse. Furthermore, the role of the nurse or midwife varies across individual and population groups. It involves differing emphasis on preventative care, health education, health promotion, case management, and self-management support.

To add to this complexity, the provision of nursing and midwifery in primary healthcare is confronted by a multitude of challenges. Populations and communities are multifarious in their approaches, resources and needs. Globally, ageing populations and chronic ill-health rates are increasing, accompanied by ongoing developments in health, social and welfare provision, all pointing to the need for proactive (rather than reactive) multifaceted service healthcare provision in the community.

The Need for Re-orientation

Given the inherent complexity in existing services and the current challenges these services face, it is argued internationally that healthcare provision, in its current form, requires dramatic change or ‘re-orientation’ in the coming years. More specifically, it is argued that this re-orientation should ensure more effective and efficient provision of services, underpinned by improved partnerships and systems, stronger leadership and governance, and a greater focus on evaluation. In recognition of this, the Department of Health (DoH) in Ireland commissioned a review of evidence on current models of nursing and midwifery practice in the community, with the aim of informing policy development.

The DoH awarded the tender to a consortium of universities (University College Cork, National University of Ireland, Galway, and University College Dublin), led by Professor Patricia Leahy-Warren from the Catherine McAuley School of Nursing and Midwifery, University College Cork.

Reviewing the Literature on Nursing and Midwifery in the Community

Professor Leahy-Warren and her colleagues undertook a rigorous systematic review of empirical and grey literature on nursing and midwifery in the community. They identified 127 empirical and 24 grey literature papers based on searches conducted on multiple databases, which they evaluated and analysed to identify broad categorical themes and associated subthemes.

It is of note, that despite the breadth of literature explored by the team, that not one single overarching model of nursing and midwifery practice in the community was identified. Importantly, however, the team uncovered valuable insights that they synthesised into four core themes to inform the development of a proposed model to overcome this gap in the literature.

Integrated and Collaborative Care

The first theme identified focuses on the need for greater linkage between primary services (day to day healthcare and the first port of call for health advice and treatment) and secondary services as broadly defined, to ensure all sectors are working in tandem. They argue that this is crucial for maintaining the overall well-being of a population, as it represents the link between all sectors of the health service, including nurses, midwives, and specialised practitioners.

The successful integration of all aspects of care would benefit patients with complex needs (such as those with multiple and ongoing conditions) in particular. Professor Leahy-Warren and the team noted that nurse-led care for chronic diseases such as diabetes and continence management compares favourably to physician-led care, and that midwife-led care for low-risk pregnancies is generally cost-effective, safe and well-received by women.

Organisation and Delivery of Nursing and Midwifery Care

The second theme is focused around the organisation and delivery of nursing and midwifery care in the community. Translational care models, such as home-based, telehealth (which utilises electronic information and telecommunication technologies to provide health services), and nurse-led care are associated with positive outcomes for patients as well as higher satisfaction. This kind of approach is especially important for vulnerable or marginalised populations, and Professor Leahy-Warren and her colleagues emphasise the importance of these interventions for a strong primary healthcare system. In support of this, they cite high quality studies demonstrating the use of home-based and nurse-led interventions as having a strongly positive influence and being more cost-effective than usual medical care.

Adjuncts to Nursing and Midwifery

The third theme identified by Professor Leahy-Warren and her colleagues relates to adjuncts to nursing and midwifery in the community. Adjuncts to nursing, such as the support of non-licenced personnel working under the supervision of a nurse, have been shown to have significant positive effects primarily on maternal and child health and emotional well-being. The approach of helping patients help themselves is a hugely important aspect of healthcare, and nurse-led interventions with supporting personnel can help reduce the risk of hospitalisation in young adults with chronic disease.

Within this theme, the importance of embracing technological developments also becomes clear. It has been demonstrated that the delivery of healthcare remotely using telehealth interventions is associated with clinical benefits, including providing support for patients to feel empowered to participate in their own care. This type of approach could be combined with chronic care plans, such as for patients with cystic fibrosis, providing an access point for care almost anywhere and in particular, providing a significant benefit for rural communities.

In the current day and age, and particularly during the current COVID-19 pandemic, adjuncts to nursing are likely to become increasingly important in modernising the ways in which we access healthcare although, so far, their effectiveness has only been evaluated to a limited extent.

A Proposed Model of Nursing and Midwifery in the Community

Professor Leahy-Warren and her colleagues’ extensive review identified key evidence for the core components of community and nursing and midwifery that should underpin any future interventions. These core components of nursing and midwifery are presented within a framework informing how a model might be conceptualised. Through this approach, it can become possible to optimise the full potential of the implementation of evidence-based nurse-led and midwifery-led care.

Of particular importance within this framework is the adoption of a care management, person-centred approach in which patients actively participate in their own care, working in close cooperation with healthcare professionals. Acknowledging the importance of provisions such as home-based interventions and telehealth support is essential if we want to improve the way we care for our communities. However, further research on such interventions is required.

Prior to the work of Professor Leahy-Warren and her colleagues, there had been little attempt to understand the complexity of nursing and midwifery services in the community. Each patients’ lifetime, from birth to death, encompasses a huge range of services, professionals, health conditions and events which would benefit from a strong and integrated approach. Indeed, taking the person-focused perspective turns healthcare into a much more compassionate system which may have more positive outcomes down the line, reducing the burden on healthcare services.

Improving the Lives of People in Ireland and Beyond

The foundations of good care, based on the philosophy of integration and collaboration as outlined by Professor Leahy-Warren and her colleagues now provide the building blocks for a more fluid and responsive nursing and midwifery service in the community, and one that could seamlessly meet the ever-evolving needs of a population. This solid, theoretically and empirically derived basis for nursing and midwifery in the community is critical if we are to balance policy goals with the practical ability to achieve such goals. To sum up, the ambitious and far-reaching work conducted by Professor Leahy-Warren and her team will inform policy development relevant to nursing and midwifery in the community nationally within Ireland and is likely to be of significant interest to policy makers, researchers and practice leaders on an international scale.