Assessment of Barriers, Supports, and Context to Implement Best Practice Pain Management in the Emergency Department: The IMPAINED Study.

AIM: To assess the emergency department practice context and identify strategies to improve outcomes of patients with acute pain. BACKGROUND: Effective treatment of acute pain in the emergency department depends upon clinicians adopting pain interventions into practice. However, it is well-recognized that acute pain is often undertreated. The local practice context strongly influences clinicians' adoption of interventions into their clinical practice. An assessment of this practice context can inform implementation interventions and strategies to improve outcomes for patients with acute pain. METHODS: Chart audit, staff survey, and staff working groups were conducted from June 2020 to May 2021 Data were analyzed and synthesized across sources informed by assessment elements of the Ottawa model of research use (OMRU) implementation model and expert recommendations for implementing change strategies. RESULTS: The OMRU facilitated contextual assessment of pain treatment practice in the emergency department and the development of implementation strategies. Adoption of evidence-based pain interventions was low in the sample studied. Workflow and workload were the primary barriers to evidence-based pain practices by potential adopters, while positive beliefs and high awareness of evidence-based pain interventions were supportive factors. Implementation strategies were informed by assessment findings and mapped to the Ottawa model and expert recommendations for implementing change elements. CONCLUSION: The adoption of evidence into practice in the emergency department relies upon a comprehensive assessment of the local context. The use of the OMRU assessment process resulted in meaningful engagement with staff and a deeper understanding of local pain management practices. Clinicians view evidence-based pain management as important, however, there are competing priorities within the emergency department, such as patient flow and triage. This study provides an exemplar of utilizing an implementation framework to identify pain practices within the emergency department. CLINICAL IMPLICATIONS: Achieving impactful change in clinical practice to improve patient outcomes should start with the application of implementation methods that enable comprehensive analysis of the local practice context. The assessment should begin with collaboration with local clinicians that persist throughout the life of the study to ensure change is sustainable.

Practice pathways, education, and regulation influencing nurse practitioners' decision to provide primary care: a rapid scoping review.

BACKGROUND/OBJECTIVE: Initially established to improve access to healthcare, particularly for primary care, the full potential of the nurse practitioner role is yet to be realised in most countries. Despite this, most countries are working to meet an ageing population's increasing healthcare needs and reduce healthcare costs and access disparities. Achieving these outcomes requires reform at multiple levels, including nurse practitioner practice pathways, education and regulation, and identifying the barriers and facilitators to optimising their primary care role. METHODS: A rapid scoping review of nurse practitioner practice pathways, education and regulation inclusive of: (1) a systematic search of Medline and CINAHL for peer-reviewed English language articles, including opinion pieces published between January 2015 and February 2022; and (2) a web-based search of nurse practitioner program entry requirements of International Nurse Regulator Collaborative country members with a protected nurse practitioner title and prescribing rights, plus the Netherlands. The individually summarised search data was integrated and synthesised using Popay's narrative approach. RESULTS: Emerging evidence from the included nurse practitioner courses (n = 86) and articles (n = 79) suggests nurse practitioners working in primary care provide safe, effective care and improve healthcare efficiencies. However, different regulatory and educational models are required if the primary care nurse practitioner is to meet growing demand. CONCLUSIONS: International variations in entry criteria, curriculum, and regulation shape the global profile of the nurse practitioner primary care workforce and their practice setting. For countries to grow their primary care nurse practitioner workforce to meet unmet needs, different entry requirements, program content and accredited post-registration transitional programs must be urgently considered.

Leveraging university-industry partnerships to optimise postgraduate nursing education.

BACKGROUND: Industry and higher education sectors devote considerable, but independent resources to deliver postgraduate nursing education. This leads to duplication, uncertainty among students, and critical gaps in nursing education. Establishing and sustaining meaningful partnerships between invested university and industry stakeholders can strengthen workforce capability and improve patient care. METHODS: To evaluate the feasibility and effectiveness of using a University-Industry Integration Framework to develop a postgraduate nursing education program. Prospective mixed methods cohort study (STROBE). A co-design approach, using an established University-Industry Integration Framework, leveraged expert stakeholder partnerships to contextualise knowledge and service need for developing a postgraduate education program for cancer care nurses. RESULTS: All participants (n = 46) were 100% satisfied with the online resources, support, and communication processes applied. Qualitative data generated three major analytical interpretations (reciprocity, flexible adaptations, authentic learning), highlighting the experiences and connections and how the partnership evolved. Program participants (n = 15) undertook a six-week cancer education program with eight responding to the survey with overwhelming satisfaction (100%), increasing their knowledge and skills. While barriers were evident, three quarters (n = 6) indicated these were addressed and enabled progress in the program. However, 63% (n = 5) were not satisfied with the program workload. CONCLUSIONS: University and industry partners can apply the University-Industry Integration Framework and deliver a successful postgraduate education program for cancer care services. Within a co-design partnership it is possible to develop strategies and processes to overcome barriers and deliver a program for mutual benefit. The culmination of this successful education program has enhanced collaborations between partners and likely will sustain the offering of future co-design endeavours.

Are men treated differently in clinical placements during nursing studies? A cross-sectional study.

AIM AND OBJECTIVE: To explore the perceptions of nursing students regarding the treatment of men in nursing during their clinical placement. BACKGROUND: Negative placement experiences of men who are nursing students is a risk factor for student attrition. Hence, exploring gender disparity in treatment during placement from both men and women studying nursing will contribute to improving student experience and reducing attrition. DESIGN: Survey capturing both quantitative and qualitative data. METHODS: Nursing students were surveyed between July and September 2021 across 16 Schools of Nursing in Australia. In addition to the Clinical Learning Environment Inventory (CLEI-19), an open-ended question explored if men received different treatment during clinical placement. RESULTS: Those who expressed difference in treatment of men were less satisfied with their clinical learning experience (p < .001). Of the 486 (39.6%) who responded to the open-ended question, 152 (31%) indicated a difference in the treatment of men, reporting that men received: (a) better (39%); (b) different, not exclusively better or worse (19%); and (c) worse (42%) treatment from either the clinical facilitator or ward staff. While both men and women perceived gender differences in the treatment of men during placement, men were more likely to report worse treatment. CONCLUSION: Despite the advances achieved in recruiting men in nursing, negative experiences during clinical placement are characterised by stereotypes, prejudice and discrimination, adversely impact retention. RELEVANCE TO CLINICAL PRACTICE: Nurse educators need to recognise specific support students require during placement regardless of gender. Our findings reinforce the adverse impacts of inequitable treatment on both men and women nursing students on learning, clinical performance, morale and ultimately on retention in the nursing workforce. Addressing gender stereotyping and discrimination in the undergraduate nursing program is an important step in promoting diversity and inclusivity in the nursing workforce.

Promoting Person-Centered Care for Health Baccalaureate Students: Piloting an Interprofessional Education Approach to Wound Management.

OBJECTIVE: To describe and analyze the implementation of a wound management interprofessional education experience for nursing, podiatry, pharmacy, and exercise and nutrition science health baccalaureate students. The disciplines outside of nursing were invited to join the classes of a wound care elective unit in nursing. METHODS: This study included the development and implementation of a wound care program and observation of all students enrolled in the health disciplines where wound management education was relevant. RESULTS: Results indicated an increase in students' recognition of their roles and the roles of others within an interprofessional healthcare team. Facilitators reported that students learned to share information and work collaboratively to plan care for people with wounds. CONCLUSIONS: The outcomes confirm that the structured wound management program of interprofessional education within a Faculty of Health course promoted student recognition of wound management and the essential shared approach to person-centered care.

Development and psychometric testing of the gender misconceptions of men in nursing (GEMINI) scale among nursing students.

BACKGROUND: Misconceptions about men in nursing may influence recruitment and retention, further perpetuating the gender diversity imbalance in the nursing workforce. Identifying misconceptions and implementing early intervention strategies to address these deep-rooted stereotypes remain challenging but is considered critical to support students who are commencing a nursing career. OBJECTIVE: To develop and evaluate the psychometric properties of the 'Gender Misconceptions of meN in nursIng (GEMINI) Scale. DESIGN: Cross-sectional survey. METHODS: Pre-registration nursing students enrolled in undergraduate nursing programmes across 16 nursing institutions in Australia were surveyed from July to September 2021. The 17-item self-report GEMINI Scale measured the gender misconceptions of men in nursing. RESULTS: Of the 1410 completed surveys, data from 683 (45%) women were used for exploratory factor analysis showing a one factor structure, while data from 727 men (47%) were used for confirmatory factor analysis of the 17-item GEMINI Scale, which showed a good model fit. The scale demonstrated high internal consistency (Cronbach's alpha of 0.892). Men were found to have higher gender misconceptions (p < 0.001) while respondents who: (a) identified nursing as their first career choice (p = 0.002); (b) were in their final year of programme enrolment (p = 0.016); and (c) engaged in health-related paid work (p = 0.002) had lower gender misconceptions. CONCLUSION: The GEMINI Scale is a robust, valid, reliable, and easy to administer tool to assess misconceptions about men in nursing, which may potentially influence academic performance and retention. Identifying and addressing specific elements of misconceptions could inform targeted strategies to support retention and decrease attrition among these students. IMPACT STATEMENT: Genderism harms nursing, as well as the men and women working in the profession. Recruitment and retention of men into nursing is needed to cultivate male role models and diversify the workforce, however this is impeded by negative portrayals in popular culture and misconceptions entrenched in society.

Exploring the observer role and clinical reasoning in simulation: A scoping review.

AIM: This scoping review aimed to explore nursing students experience as simulation observers and their level of engagement in learning through use of clinical decision-making models and learning scaffolds. BACKGROUND: A gap continues to exist between the published empirical literature, the role and experiences of the simulation observer and teaching scaffolds that enhance learning outcomes, despite the increased understanding of simulation and its role in preparing nursing students for practice. Further, little is known about the nursing student's experience of clinical reasoning whilst observing simulation and the impact of scaffolding observations using clinical decision-making models. DESIGN: This scoping review was conducted using the methodological framework of Arksey and O'Malley (2005) and the PRISMA checklist for systematic reviews (Page et al., 2020). METHODS: A comprehensive search of the literature published in Medline and CINAHL databases between 1999 and 2020 was undertaken in May 2019. The studies selected for this review (n = 18) were analyzed thematically. The validated Mixed-Methods Appraisal Tool assessed quality of the quantitative, qualitative and mixed methods studies. RESULTS: The role of the observer in simulation was explored and included observation to transform practice in self and observation to transform practice in others, namely peers in the nurse role in simulation. Application of the MMAT indicated that of the 18 studies included only 6 (33.3%) had a clear research question. Research aims or objectives were found in another six studies (33.3%). In this review 13 studies (72%) included answers to the research question or aim, three (17%) did not and in two (11%) it was impossible to tell. CONCLUSIONS: Results of this review indicate the paucity of research relating to nursing student's experience of clinical reasoning while observing simulation. Further, it highlights the value of nurse educators optimizing the observer role and maximizing learning by scaffolding observer activities within the simulation experience.

Building safety cultures at the frontline: An emancipatory Practice Development approach for strengthening nursing surveillance on an acute care ward.

AIM: To evaluate an emancipatory Practice Development approach for strengthening nursing surveillance on a single medical-surgical ward. BACKGROUND: Registered nurses keep patients safe in acute care settings through the complex process of nursing surveillance. Our interest was understanding how frontline teams can build safety cultures that enable proactive nursing surveillance in acute care wards. DESIGN: A year-long emancipatory Practice Development project. METHODS: A collaborative relationship was established around a shared interest of nursing surveillance capacity and researcher embedded on a medical-surgical ward. Critical analysis of workplace observations and reflection with staff generated key sites for collective action. Ward engagement was supported by creative Practice Development methods including holistic facilitation, critical reflection and action learning. An action learning set was established with a group of clinical nurses, facilitating practitioner-led change initiatives which strengthened nursing surveillance and workplace learning. Evaluation supported an iterative approach, building on what worked in an acute care context. Immersive researcher evaluation, drawing on multiple data sources, generated an analysis of how ward nursing surveillance capacity can be strengthened. COREQ criteria guided reporting. RESULTS: The ward moved through a turbulent and transformative process of resistance and retreat towards a new learning culture where nursing surveillance was visible and valued. Staff developed and sustained innovations including the 'My MET Call series', a 'Shared GCS initiative', an enhanced 'Team Safety Huddle', and staff-led Practice Development workshops. These new practices affirmed nurses' agency, asserted nurses' clinical knowledge, positioned nurses to participate in team decision-making and humanised care. CONCLUSION: Working collaboratively with frontline staff enabled bottom-up sustainable innovation to strengthen nursing surveillance capacity where it mattered most, at the point of care. RELEVANCE TO CLINICAL PRACTICE: Emancipatory Practice Development enables the profound impact of small-scale, microsystem level practice transformation. It is an accessible methodology for clinical teams to develop effective workplace cultures.

Effectiveness of using simulation in the development of clinical reasoning in undergraduate nursing students: A systematic review.

AIM/OBJECTIVE: This systematic review examines the effectiveness of undergraduate nursing students' using simulation to acquire clinical reasoning. BACKGROUND: Use of simulation to positively impact practice outcomes is an established method in nursing education. Clinical reasoning is a graduate capability that contributes to safe practice, so developing clinical reasoning requires explicit scaffolding in undergraduate contexts. While research has primarily evaluated specific clinical reasoning frameworks, variability in clinical reasoning definitions has obscured simulation efficacy for clinical reasoning acquisition. DESIGN: This review uses the Joanna Briggs Institute Systematic Reviews approach. METHODS: An electronic database search was conducted to identify studies published from May 2009 to January 2020 using a three-step search strategy. Selected papers were assessed by at least two independent reviewers for inclusion criteria, methodological validity, and data extraction. Ten studies using quasi-experimental designs involving 1532 students were included. RESULTS: Evidence regarding the effectiveness of simulation for undergraduate nursing students' acquisition of clinical reasoning was limited but of high quality. Review results showed no statistically significant gains in clinical reasoning with a single simulation exposure. Two emerging concepts, situation awareness and teamwork support the enhancement of clinical reasoning within simulation. In order to draw future conclusions on the efficacy of simulation to develop clinical reasoning, more research is warranted. CONCLUSIONS: New insights about team-based simulations and situation awareness were identified as integral for development of clinical reasoning in the context of simulation. More consistent use of terminology in the context of simulation research is also recommended.

Developing a postgraduate professional education framework for emergency nursing: a co-design approach.

BACKGROUND: Hospital and university service providers invest significant but separate resources into preparing registered nurses to work in the emergency department setting. This results in the duplication of both curricula and resource investment in the health and higher education sectors. This paper describes an evidence-based co-designed study with clinical-academic stakeholders from hospital and university settings. METHODS: The study was informed by evidence-based co-design, using emergency nursing as an exemplar. Eighteen hours of co-design workshops were completed with 21 key clinical-academic stakeholders from hospital and university settings. RESULTS: Outcomes were matrices synchronising professional and regulatory imperatives of postgraduate nursing coursework; mutually-shaped curriculum content, teaching approaches and assessment strategies relevant for postgraduate education; a new University-Industry Academic Integration Framework; five agreed guiding principles of postgraduate curriculum development for university-industry curriculum co-design; and a Graduate Certificate of Emergency Nursing curriculum exemplar. CONCLUSION: Industry-academic service provider co-design can increase the relevance of postgraduate specialist courses in nursing, strengthening the nexus between both entities to advance learning and employability. The study developed strategies and exemplars for future use in any mutually determined academic-industry education partnership.

The effectiveness of nurse-initiated interventions in the Emergency Department: A systematic review.

BACKGROUND: Nurse-initiated interventions potentially provide an opportunity for earlier response for time sensitive presentations to the Emergency Department, and may improve time-to-treatment, symptomatic relief and patient flow through the department. OBJECTIVE: To determine the effectiveness of nurse-initiated interventions on patient outcomes in the Emergency Department. METHOD: The review followed the JBI methodology for reviews of quantitative evidence. Each study was assessed by two independent reviewers and data were extracted from included papers using standardized data extraction tools. Outcomes of interest included time-to-treatment, relief of acute symptoms, waiting times and admission rates. RESULTS: Twenty-six studies were included in the final review, with a total of 9144 participants. Nine were randomized control trials, 17 had a quasi-experimental design. Twelve of the studies involved pediatric patients only and 14 included adult patients only. Interventions, protocols and outcomes were heterogeneous across studies. Overall, nurse-initiated interventions were effective in reducing time-to-analgesia, time-to-treatment for acute respiratory distress as well as improved pain relief and decreased admission rates. CONCLUSION: To achieve early intervention and timely relief of acute symptoms, nurses should seek to consistently implement nurse-initiated interventions into their care of patients in the Emergency Department. Several findings are made to inform practice, however future high-quality research with locally specific strategies is required to improve certainty and quality of findings.

Comparison of simulation observer tools on engagement and maximising learning: a pilot study.

OBJECTIVES: This pilot study examined if the Clinical Reasoning Observer Worksheet (CROW) compared to a standard observer worksheet used during simulation, would enhance nursing students active learning behaviours and perceptions of clinical reasoning ability. METHODS: This pilot study was undertaken to test the design and processes for a future larger study and reports on preliminary evidence of efficacy of recruitment procedures and instrumentation in addition to student's learning outcomes. RESULTS: There was little overall difference in outcomes between groups who used either simulation observer worksheet. Overall, participants who used either worksheet perceived their ability to apply clinical reasoning to an episode of patient care increased. CONCLUSIONS: Modifications were identified as necessary for a larger study including changes to instrumentation, method of survey delivery and training of simulation facilitators. A more definitive evaluation will be achievable with a larger group of students in a main study with the suggested modifications.

Effectiveness of nurse-led clinics in the early discharge period after percutaneous coronary intervention: A systematic review.

BACKGROUND: Readmission after percutaneous coronary intervention is common in the early postdischarge period, often linked to limited opportunity for education and preparation for self-care. Attending a nurse-led clinic within 30 d after discharge has the potential to enhance health outcomes. OBJECTIVE: The aim of the study was to synthesise the available literature on the effectiveness of nurse-led clinics, during early discharge (up to 30 d), for patients who have undergone percutaneous coronary intervention. REVIEW METHOD USED: A systematic review of randomised and quasi-randomised controlled trials was undertaken. DATA SOURCES: The databases included PubMed, OVID, CINAHL, EMBASE, the Cochrane Library, SCOPUS, and ProQuest. REVIEW METHODS: Databases were searched up to November 2018. Two independent reviewers assessed studies using the Cochrane risk-of-bias tool. RESULTS: Of 2970 articles screened, only four studies, representing 244 participants, met the review inclusion criteria. Three of these studies had low to moderate risk of bias, with the other study unclear. Interventions comprised physical assessments and individualised education. Reported outcomes included quality of life, medication adherence, cardiac rehabilitation attendance, and psychological symptoms. Statistical pooling was not feasible owing to heterogeneity across interventions, outcome measures, and study reporting. Small improvements in quality of life and some self-management behaviours were reported, but these changes were not sustained over time. CONCLUSIONS: This review has identified an important gap in the research examining the effectiveness of early postdischarge nurse-led support after percutaneous coronary intervention on outcomes for patients and health services. More robust research with sufficiently powered sample sizes and clearly defined interventions, comparison groups, and outcomes is recommended to determine effectiveness of nurse-led clinics in the early discharge period.

Outcomes of a randomised pilot trial of a nurse-led clinic for patients after percutaneous coronary intervention.

BACKGROUND: Hospitalisation for percutaneous coronary intervention (PCI) in Australia is reducing. Patients who undergo PCI may be discharged home without a post-discharge health management plan, referral for secondary prevention, or understand their chronic condition. Subsequently, negative psychological symptoms such as anxiety and depression may be experienced in the post-discharge period. OBJECTIVES: This study assessed the effectiveness of a nurse-led clinic on patients' cardiac self-efficacy and negative psychological symptoms of anxiety and depression 1-week post-PCI discharge. METHODS: One-hundred and eighty-eight potential participants were screened, and 33 participants were block-randomised to study groups. The nurse-led clinic used a person-centred approach and delivered tailored education, health assessment, and post-discharge support. In Phase 1, the Cardiac Self-efficacy Scale and State-Trait Anxiety Inventory measured primary outcomes, while the Cardiac Depression Scale was used to measure secondary outcomes. Phase 2 evaluated participants' experiences and healthcare professionals' perceptions of the intervention through semi-structured interviews. RESULTS: In Phase 1, intervention group participants did not show improvements in mental health indicators compared to standard care group participants, except for a moderate reduction in anxiety levels (d = 0.50). Phase 2 qualitative findings; however, highlighted the benefits of the nurse-led clinic. CONCLUSIONS: Overall, findings suggest that nurse-led clinics may be valuable to reduce anxiety and act as a supportive measure in the early post-discharge period until commencement of a secondary prevention program. Further research with a more powered sample is needed to determine the significance of the findings.

Inquiry-based learning and clinical reasoning scaffolds: An action research project to support undergraduate students' learning to 'think like a nurse'.

A period of re-negotiation is expected when introducing a new teaching and learning approach in a Bachelor of Nursing course. This study, underpinned by a social constructivist framework, used action research to uncover the interactions, challenges and outcomes when implementing an inquiry-based learning approach to support the development of students' clinical reasoning and capability to think like a nurse. Data collection involved non-participant observation of 32 tutorial groups (600 first-year students and 8 teachers) over the first two weeks of semester. Analysis was informed by Charmaz's social constructivist approach. The findings revealed three interconnected constructs: Opting in and out (students), Driving and reframing (teachers) and Creating and realising new understandings (both students and teachers). Introducing a new approach necessitated conscious planning and deliberate behaviour change on behalf of the teacher and student. Use of an inquiry-based learning approach which embedded clinical reasoning, investigative prompts and learning scaffolds in the form of case exemplars assisted students to 'think like a nurse'.

Strengthening nursing surveillance in general wards: A practice development approach.

AIMS AND OBJECTIVES: To explore the context and culture of nursing surveillance on an acute care ward. BACKGROUND: Prevention of patient deterioration is primarily a nursing responsibility in hospital. Registered nurses make judgements and act on emerging threats to patient safety through a process of nursing surveillance. Organisational factors that weaken nursing surveillance capacity on general wards increase the need for patient rescue at the end point of clinical deterioration with poorer outcomes. Yet little is known about cultures that enable and sustain ward nursing surveillance for patient safety. DESIGN: Workplace observations and semistructured interviews using a critical lens as the first stage of a larger emancipatory practice development project. METHODS: Researcher immersion including 96 hr of nonparticipant observation with 12 semistructured interviews during July-August 2017. This study adhered to the COREQ guidelines. RESULTS: We offer a metaphor of nursing surveillance as the threads that support the very fabric of acute care nursing work. These hidden threads enable nurses to weave the tapestry of care that keeps patients safe. This tapestry is vulnerable to internal and external forces, which weaken the structure, putting patients and staff at risk. CONCLUSION: Understanding local context is essential to supporting practice change. This workplace observation challenges us to find ways to creatively engage nurses with the underlying cultural and systems issues that so often remain hidden from view in the deteriorating patient literature. RELEVANCE TO CLINICAL PRACTICE: Building cultural values that strengthen nursing surveillance is a prerequisite for safe and effective hospital care. As such, practice-based research that empowers frontline nurses and teams to develop person-centred workplace cultures can hold the key to unlocking sustainable improvements in patient safety.

Engaging students in a community of learning: Renegotiating the learning environment.

Promoting student engagement in a student led environment can be challenging. This article reports on the process of design, implementation and evaluation of a student led learning approach in a small group tutorial environment in a three year Bachelor of Nursing program at an Australian university. The research employed three phases of data collection. The first phase explored student perceptions of learning and engagement in tutorials. The results informed the development of a web based learning resource. Phase two centred on implementation of a community of learning approach where students were supported to lead tutorial learning with peers. The final phase constituted an evaluation of the new approach. Findings suggest that students have the capacity to lead and engage in a community of learning and to assume greater ownership and responsibility where scaffolding is provided. Nonetheless, an ongoing whole of course approach to pedagogical change would better support this form of teaching and learning innovation.

SUPPORTING CLINICAL FACILITATORS THROUGH PEER REVIEW OF TEACHING.

The QUT School of Nursing is currently trialling peer review of teaching (PRoT) as one strategy to support clinical facilitators working with undergraduate students. Work integrated learning (WIL) relies on collaborative partnerships and clinical facilitators need specific skills and knowledge.

NURSES REPORT FORMAL EDUCATION IMPROVES PRACTICE.

Increased demand for colonoscopy procedures has led to the introduction of nurse endoscopist in Australia. Evidence suggests that nurse endoscopy is safe and effective (Williams et al. 2009).

REIMAGINING A FUTURE FOCUSED BACHELOR OF NURSING CURRICULA.

Higher education providers of nursing education programs are charged with the responsibility to produce 'work ready' graduates to meet the changing demands of healthcare including a shift from acute care to home and community based chronic care (Primary health Care Advisory Group, 2015.