Clinical skills and nursing management in community health nursing – A qualitative study / Klinische Skills und Pflegemanagement im Rahmen von Community Health Nursing – Eine qualitative Studie

The expert interviews were conducted with participants selected according to specific inclusion criteria relevant to the Austrian health care context: -

Expertise: We aimed to include experts from the political, educational, healthcare, consultancy, and practice-based sectors, all with specialized knowledge in CHN. Participants were supposed to cover professional functions as different as government employees involved in health regulations, educators and directors of nursing programs, as well as leaders in healthcare advocacy and operational management within the nursing field.

The selection of interview participants was conducted using theoretical sampling as described by Strauss and Corbin (1996) and Glaser and Strauss (2010). This method entails making decisions about the selection and composition of empirical materials concurrently with data collection and analysis (Flick, 2019). The process adopted a cyclic and interactive approach, involving repeated cycles of sampling, interviewing, transcription, coding, and evaluating data until theoretical saturation was reached in each category – either deductively defined through the literature or inductively derived during the analysis – and the theory-building process was completed. Initially, interview partners were selected based on their relevance to the research area, with subsequent participants chosen based on insights gained from earlier interviews. This iterative process continued until additional interviews ceased to yield new information, refining the focus of sampling over time (Misoch, 2019). Furthermore, we adapted the theoretical sampling process by categorizing the interview participants into five groups and interviewing at least two experts from each group, irrespective of whether theoretical saturation had been reached. The groups were defined as follows: -

Politics: Individuals working in government or related agencies who focus on nursing care issues in Austria.

In instances where an interviewee’s assignment to a group was unclear or they could be placed in multiple categories, the assignment was determined through discussion among the research team members, focusing on the best match with one of the five fields.

Access to the study interview participants was facilitated through an initial identification of potential interview partners via websites, press appearances, publications, ResearchGate, and social media profiles. Further participants were recruited using the snowball method, with initial contact typically made through email.

Data collection for this qualitative research involved conducting semi-structured interviews to explore the participants’ contextual knowledge deeply. The chosen method was the problem-centered interview, which adheres to the principles of Grounded Theory as proposed by Glaser and Strauss (2010). This method is designed to explore the subjective perspectives and interpretations of individuals regarding a socially relevant issue (the “problem”) with the final aim of generating theory. Problem-centered interviews emphasize narratives as a central principle and are characterized by their highly communicative nature (Witzel, 2000).

Data were collected during May and June of 2022 through 15 detailed qualitative interviews. On average, each interview lasted about 66 minutes, ranging from 41 to 105 minutes in length. The interviews were conducted entirely in German. The initial outreach to prospective participants was made through email, where the study details were explained, consent for participation was requested, and the appointments for the interviews were arranged. A few days before each interview, an informed consent form allowing for the digital recording of the session was sent to participants for their signature.

The interviews adhered to the guidelines specified by Hermanns (2019) and the procedures for expert interviews outlined by Przyborski and Wohlrab-Sahr (2021). In the development of the interview guide, the SPSS method of Helfferich (2011) was applied (SPSS: German for ‘sammeln, prüfen, sortieren, subsumieren’, i.e., collect, check, sort, prioritize). The interview guide was developed on the background of an extensive literature research and refined after a pilot test conducted with individuals outside the expert groups. It was designed to be flexible, supporting the conversational flow and the elaboration of the interviewees’ narratives rather than enforcing a rigid questionnaire structure. This guide was used to compare interviews and refined throughout the study based on insights gained from the initial four interviews. Once established, the guide remained unchanged as no further modifications were necessary.

The interview guide referred to the main area of interest of the required skills and competencies of CHNs in Austria. The aim was to identify key areas, while establishing a connection to the Public Health Intervention Wheel (Minnesota Department of Health, 2019, p. 11), and addressing the current state of opinion in the literature as well as any peculiarities/special features of the Austrian health and social system. In this respect, the guide represented an overarching orientation framework for the interviews, with the problem area being represented in the form of individual, thematic fields.

The interview process contained a warm-up phase (for example: “When did you first deal with the topic of CHN and in what form/context?”, “What is your current professional activity, how long have you been doing it and in which facets does the topic of CHN play a role?”, “Are you involved in the establishment of the pilot projects on community nursing or in the general introduction of a system of CHN in Austria in any way and if so, what is your contribution in this regard?”), followed by an open question, which allowed the interviewees to build up narrative sequences and initially define their own priorities (“In your opinion, what are the key skills and competencies that a CHN in Austria should have? ... Just tell us, you can set your own priorities - what is important to you!”). If necessary, additional questions followed (for example: “Could you go into more detail in the area of planning/management/collaboration etc.?”, “Do any particularities/specialties/peculiarities of the Austrian health and social system result in further/additional competencies of CHN that differ from other countries?”). As the study progressed, the focus shifted to more specific topics related to the research question. A first focus was the Public Health Intervention Wheel (Minnesota Department of Health, 2019, p. 11) (“Looking at the Public Health Intervention Wheel: What additional skills/competencies - in relation to the Austrian healthcare system - are required for CHNs compared to those currently possessed by qualified nurses trained in Austria? In which areas are additional knowledge or skills required? Please make an assessment.”). The interview guide closed with some final questions on the skills and competencies required of CHNs in Austria (for example: “Suppose you had the opportunity to design a system of CHN for Austria: What central tasks would a CHN take on in this model and what skills and competencies would they need for this?”). At this point, the interview participants were also given the opportunity to add further descriptions and narrative sequences that had not been discussed yet.

Interviews took place over video conferencing platforms and were digitally recorded. In line with the recommendations of Mey and Mruck (2007), no more than one interview was conducted per day to ensure thorough preparation and follow-up. Immediately following each session, extensive field notes were taken to record insights about the process, detail the dynamics of the interview, and note any significant events or behaviors observed during the conversations. Upon the completion of 15 interviews, it became apparent that no additional insights were forthcoming, suggesting that data saturation had been reached.

The interviews were transcribed word-for-word by a specialized transcription agency, adhering to the protocols recommended by Dresing and Pehl (2018). The research team (authors: CM, HL, GM, HS) examined, refined, and anonymized these transcripts to protect participant privacy. To ensure precision, parts of the video recordings were reviewed repeatedly as required. The completed transcripts were then imported into the MAXQDA Plus software for qualitative content analysis (CM, HL).

The data analysis was conducted using the qualitative content analysis method as outlined by Mayring (2015). This approach systematically applies a rule-based and theory-driven examination of textual data with the goal of drawing insights about specific aspects of the communication. It adopts several techniques, particularly emphasizing the use of a categorical system at the heart of the analysis to ensure a structured interpretation of the data (HL, GM, HS).

The process began with initial reading through the interviews, identifying the salient features and elements of each interview. Summaries were created to capture significant sections concisely (CM). This was followed by paraphrasing the relevant content into a focused, descriptive format, stripping away any unnecessary details (HL). These paraphrases were then organized into categories, forming a preliminary categorization system (GM, HS). Both the category definitions and the categorization system were developed deductively from the theoretical background and previous international studies which were included in the scoping review of Lidauer et al. (2022), as well as inductively from the data itself, without referencing pre-existing theoretical constructs (Mayring, 2015). The deductive approach was employed initially, while further along in the process refining and expanding the system based on its application to the empirical data, with subcategories being added as necessary (Mayring, 2015).

Throughout the analysis, the categories were continuously evaluated by CM, HL, and HS regarding their fit and adjusted through a formative reliability check. After analyzing the initial interviews, a provisional category system was established and iteratively refined until theoretical saturation was achieved (CM, HL, GM, HS). The finalized category system was then rigorously applied to all data. To ensure intersubjectivity, the researchers engaged in peer discussions to validate the plausibility of the coding assignments and regularly consulted with a supervisor to review category assignments throughout the research process (CM, HL, HS). The generalization and reduction steps involved multiple rounds of abstracting the data, removing redundant paraphrases, and synthesizing related paraphrases into new formulations, following a cyclical process until the desired material reduction was achieved (Mayring, 2015).

The data analysis was concluded by identifying relevant thematic fields and compiling substantive findings for interpretation concerning the research question, following the recommendations of Green et al. (2007). Additionally, specific evaluative steps for expert interviews as proposed by Meuser and Nagel (2009) were incorporated to enrich the analytical depth.

Experts highlight the competency of being a navigator through the health system. It is essential that CHNs are able to fulfill their role of “guiding the people living in their region and supporting them in navigating the healthcare system and finding the right partners.” To do this, they must know “how providers, whether social or health service providers, are distributed in the region where they work, what they offer, their main tasks, and possibly how they collaborate and interconnect” (Int. 11, Lines 43–51). It is about being able to “properly refer clients and pave the way for them, which is targeted to their needs” (Int. 11, Lines 176–177). The CHN performs a “gatekeeper function” (Int. 9, Line 425). It requires “this interface management” (Int. 12, Line 55), and “this interface and already an individual perspective” (Int. 12, Lines 286–287). The goal is for the CHN’s role is to “also build a network for these people” (Int. 6, Lines 230–231). Part of the guiding function also includes actively making the members of communities aware of existing health and social services (Int. 7, Line 46) and “also thinking about how to support people with subsidies, services, monetary benefits, or in-kind contributions” (Int. 8, Lines 119–121). In various instances, interview participants emphasize the competency of cooperative collaboration with clients. The emphasis is repeatedly on working “together with those affected, with the relatives” (Int. 7, Lines 267–268). One interview partner also uses the term “customer orientation” (Int. 6, Line 180). The CHN must “be able to approach people and be able to build communicative trust” (Int. 7, Lines 57–58). Clients should be “participatively involved” (Int. 13, Line 537). Furthermore, an advisory component is attributed to the Community Health Nurse’s role: “My term for these people is indeed a coach” (Int. 13, Line 530) to guide and advice people. The CHN should not “say: this and that must be changed, but rather [...] really accompany [the clients] in this process-oriented approach, starting from their own strengths and capabilities” (Int. 4, Lines 211– 212). Ultimately, the CHN’s task is to “educate patients so they can make a decision themselves” (Int. 13, Lines 538–539).

Interview participants also focus on the competency of client self-management support during the surveys: “When we look at the demographic change with a majority of multimorbid, chronically ill people, then we need to see how they can learn to manage their illness independently in the long run” (Int. 13, Lines 90–92). An essential pillar in this regard is “teaching health “ (Int. 7, Line 179). There is also a need to “build additional knowledge, know-how” (Int. 13, Line 96), “so that the health literacy of the population improves, so that the sick are more informed about their illness” (Int. 7, Lines 180–182), “so that they learn to cope well with their current living conditions, using their own means or also understanding their limits” (Int. 13, Lines 100–101). In this context, it is also important to “bring people into contact with health education early” (Int. 12, Lines 152–153). It requires “this concept of empowerment” (Int. 12, Line 153). The CHN must be able to “also move more towards self-management and therefore probably empower patients to take care of and manage themselves” (Int. 11, Lines 237–239). In this process, a central guideline is “to educate a patient so that they can make a decision themselves, to inform the patient enough so that they can give informed consent” (Int. 13, Lines 538–542).

Other aspects mentioned in the interviews regard the competency of promoting participation and self-determination of clients, which are closely related to the topics of collaboration and self-management. Again, health education and building additional knowledge and know-how play a central role. Also, the concept of empowerment is mentioned, as well as educating clients with the goal of enabling them to make an autonomous decision. Finally, the topic of identifying the clients’ own resources is addressed: The CHN must ask, “what do people already bring with them, what is their expertise, and then derive the support really only from where they definitely need it” (Int. 4, Lines 375–377).

Furthermore, interviewees emphasize the competency of prescription-related knowledge, desiring an expansion of the current decision-making regarding the prescription of medications, aids, etc. for CHNs in Austria. This extended scope should be accompanied by the appropriate knowledge and skills: “For me, it would be absolutely desirable for the area of personal responsible area to be expanded. (...) I would like them to have the possibility to prescribe in broader areas, or at least to prescribe repeatedly if necessary, and then one must consider based on which parameters - it could be time spans or could be significant deviations of standard values or something else - then one would say, this is too much, now we need a physician again or possibly actually the hospital, it doesn’t matter now, but there, I believe, they must be competent” (Int. 8, Lines 127–140). Another interviewee notes: “It is quite possible, in my view, that a competent CHN can change the dosage of a medication without needing to ask a physician. If it’s a diuretic and the heart failure patient has swollen feet, then they can say they should take an extra pill for a few days (...). Or adjust the dose of a blood pressure medication a bit higher or lower, and such things, yes. So, I think I would give the nurses a bit more competence in this regard” (Int. 7, Lines 278– 284). Subsequently, the competency of implementing care goals is also discussed.

In summary, experts highlight the importance of CHNs as navigators in the healthcare system. They guide clients through the system, connecting them with the right services and supporting them with subsidies or other resources. CHNs also build trust, involve clients in decision-making, and empower them to manage their health independently. Improving health literacy through education is seen as a key aspect, especially for people with chronic or multiple illnesses. Interviewees also advocate expanding CHNs’ ability to prescribe medications and adjust dosages autonomously, within their competencies. In essence, CHNs are regarded as intermediaries who advise, empower, and support clients in becoming more self-reliant.

A core competency of CHNs is case and care management. “Case and care management is also very central” (Int. 10, Lines 43–44). It involves “taking over this case and personalized management” (Int. 13, Lines 242–243), “having this lead, this overview, this oversight in management” (Int. 13, Line 343). “The counseling, support, and consultation, this interface management is a significant area of the CHN” (Int. 12, Lines 54–56), with the goal that they “build a network for these people” (Int. 6, Line 231). An important skill in this context is that the CHN is able to assess situations and recognize complex care situations. They must also be able to “act in an interdisciplinary, multiprofessional team along with case discussions, (...) to be able to design the outcome for the affected as optimally as possible” (Int. 4, Lines 132– 134). For this, it is necessary to “truly grasp situations and then think based on health determinants - knowing who needs to be involved, what needs to be organized” (Int. 4, Lines 692–694). The competence of case and care management is particularly significant in connection with a possible gatekeeper function of the CHN as “the first point of contact in a region, in a neighborhood, in a district, before I even need to go to a physician” (Int. 9, Lines 423–425). Its importance is also highlighted in the context of discharge management after a hospital stay. The interviewed experts focus explicitly on the competency of clinical assessment: The CHN “must be able to assess these people”. That means they must be able to perform assessments or (...) clinical assessment” (Int. 1, Lines 381–383), “make a nursing assessment” (Int. 9, Line 68). Another respondent states: “Through clinical assessment, I can collect data, gather data, and this is ultimately a basis for my further action, for my further decision.” “A CHN should (...) be able to perform these physical examinations, and yes, nursing assessments of course” (Int. 10, Lines 46–50).

Concerning the competency of identifying client groups, it is the task of the CHN “to look at the municipal level, in the communities, where there is a nursing need” (Int. 14, Lines 290–291). “I believe that it really comes down to getting to know, how is my community structured, how are my citizens in the community, where are the problem areas in the various target groups” (Int. 14, Lines 296– 299). In the context of ensuring the care of vulnerable groups of people, it is first necessary to “recognize who in the community is such a person” (Int. 14, Line 155). Often clients present their (health) condition better than it actually is, which CHNs should be able to recognize in the process of identifying client groups: “And what we know, that old people quite like to present themselves better than they are, this is noticeable in all care allowance classifications. And finally, it is also necessary that the CHN is able to quickly get an overview of the overall client situation during a visit – only then client groups can be accurately identified: “I must have learned, when I enter a room - and a good caregiver can do this - they enter the room and immediately have a perception of the overall image of the patient, client, resident, whatever, based on the room conditions and the actual physical and mental state of the resident. And I must; this is a very important basic competence in nursing generally, but for the CHN even more, because in mobile care or in long-term care or even in the hospital, I can go to someone more often, because they are already there or they are already bound in a care contract with me and there I can possibly rectify mistakes the second, third, fourth time. The CHN has the first impression and the first chance and again, if that is botched (…), then maybe I can come again a year later” (Int. 6, Lines 542–552).

The competency management of chronic diseases is brought up as central by some interview participants. A corresponding competence is required so that “the progression of chronic diseases can be slowed down in terms of speed” (Int. 13, Lines 417–418). An interview participant states: “They must also have an understanding of chronic diseases. That means, they should be familiar with diabetes, hypertension, etc., because just those people do many controls at home and certainly questions arise when the CHN comes, from the patients, (...) there they should also have a certain knowledge and competence and should know things like a disease management program ‘Active Therapy’, they must know that, yes. They must know that it is checked every quarter, with labs, etc., because also a task area, from my perspective, is the accompaniment at certain controls” (Int. 7, Lines 77–84).

Finally, also the competency of quality in nursing practice is mentioned, particularly addressing the area of quality management: “A very important aspect would be that they also take on a kind of quality management for caregiving relatives. So there, where caregiving relatives reach their limits or need support. (...) That means, really supporting the people and saying, listen, this is important, this is a particular hazard, possibly also supporting them in care planning, in documentation. So there I see a great need” (Int. 8, Lines 304–312). This can enable caregivers to take better decisions and actions. Quality management is also discussed in relation to other professional groups: “I already see them in this area of teaching (...), especially also in the role that they also enable others. So that they might also support other professional groups that are active there - I don’t know, (...) those not belonging to qualified nursing staff from (...) mobile facilities” (Int. 8, Lines 312–315).

In summary, our research outlines the following key competencies of CHNs that enable them to provide comprehensive community care: -

Case and care management: Overseeing patient care, coordinating with teams, and acting as a community gatekeeper.

Some methodological constraints arise from the selection process of interview participants: To mitigate these limitations, we ensured theoretical saturation and deliberately included multiple expert groups. Even after the theoretical saturation, care was still taken to have at least two interviews from each group.

Given the novelty of this domain within the Austrian healthcare system, the pool of potential interviewees with relevant expertise was limited. As the CHN system unfolds, there may be shifts in required skills and competencies over time. With increased proficiency in this realm, more nuanced insights and prerequisites might emerge. Nevertheless, the skills and competencies outlined in this study should sufficiently underpin the structuring of CHN training.

Lastly, it is not possible to generalize the study findings to other nations due to disparities in their healthcare, social systems, and legal frameworks.