Advancing nursing practice through fundamental care delivery
1 INTRODUCTION
There is growing awareness that there needs to be a reorientation of the nursing profession towards the fundamentals of care (Feo et al., 2019). These fundamentals often receive a low priority in clinical practice settings (Feo et al., 2019), and gaps in fundamental care provision are being exposed in nursing care internationally (McSherry et al., 2018). The concern is significant worldwide, and for this reason, many initiatives are developing to tackle the issue. The International Learning Collaborative (ILC) (2021), a global social learning and lobbying network, is leading the way on this. This network is committed to improving the delivery of person-centred and safe fundamental care, promoting excellence of fundamental care through the integration of clinical practice, research and education, and share the best evidence of Fundamentals of Care (FoC) (ILC, 2021; Kitson, 2018).
2 BACKGROUND
The fundamentals of care are conceptualized within three distinct dimensions of care: (1) the relationship, (2) the integration of care and (3) the care context (ILC, 2021). The relationship involves five core elements: developing and maintaining trust, focusing on the patient being cared for, anticipating the patients' needs, getting to know the patient and how best to provide care for them and evaluating the quality progress and outcomes of the relationship (ILC, 2021). The integration of care provides detailed outline of the physical psychosocial and relational aspects of the fundamentals of care (Table 1).Fundamental care involves actions on the part of the nurse that respect and focus on a person's essential needs to ensure their physical and psychosocial wellbeing. These needs are met by developing a positive and trusting relationship with the person being cared for as well as their family/carers
| Physical fundamentals of care (care recipient's needs and outcomes) |
| • Personal cleansing (including oral/mouth care) and dressing |
| • Toileting needs |
| • Eating and drinking |
| • Mobility, Rest and sleep |
| • Comfort (e.g., pain management, breathing easily, temperature control) |
| • Safety (e.g., risk assessment & management, infection prevention, minimizing complications) |
| • Medication management. |
| Psychosocial fundamentals of care (care recipient's needs and outcomes) |
| • Communication (verbal and non-verbal) |
| • Being kept involved and informed |
| • Privacy, Dignity, Respect |
| • Education and information |
| • Emotional wellbeing |
| • Having values and beliefs considered and respected |
| Relational fundamentals of care (care provider's actions) |
| • Active listening, Being empathetic |
| • Engaging with patients |
| • Being compassionate |
| • Being present and with patients |
| • Supporting and involving families and carers |
| • Helping patients to cope |
| • Working with patients to set, achieve, and evaluate progression of goals |
| • Helping patients to stay calm |
However, fundamentals of care are very frequently overlooked (Bagnasco et al., 2019), especially where resources are low (Aiken et al., 2014; Blackman et al., 2020; Kim et al., 2017). The reasons for these gaps vary and are the subject of much debate in the literature (Kitson, 2016), and there is often a limited perception of importance of such (fundamental) activities by nurses (Bentzen et al., 2013). As most human daily and social activities revolve around activities such as eating, drinking, washing, and eliminating, when any health change occurs, or unfamiliar circumstances arise (hospitalization, for example), these activities are often the first to be compromised (Kitson et al., 2010). Nurses do not always consider fundamental care as part of their role because health care assistants often carry out these activities (HSE, 2018; Kalisch, 2006; RCN, 2021). Interviews with nurses, for example, reveal that their role is perceived by care assistants as “paperwork and pills” with nurses increasingly “moving away from the bedside” leaving the fundamental care to care assistants (McGuire, 2019). Fundamental aspects of care that are particularly important are safety, dignity (Zahran et al., 2016) and communication/person-centred care (Dickson et al., 2017).
3 WHERE IS FUNDAMENTAL CARE POSITIONED WITHIN ADVANCED PRACTICE?
One such area that could be accused of moving away from acknowledging the importance of getting fundamental care right for patients is advanced nursing practice. The ever-growing global population of nurses prepared to advanced level, to provide for advanced care of patients across the health care continuum. While core nursing competencies (and particularly those related to high quality fundamental care delivery) remain implicit, advanced practice competencies usually focus on developing higher order skills including skills of critical thinking, research, leadership in addition to advanced clinical skills. By default, the fact that as a profession we do not actually know what critical thinking, research and leadership skills are necessary to deliver (and manage the delivery) of fundamental care means we do not have the conceptual scaffolding to make this happen in practice. With the growing impetus on fundamental care, we wonder whether the concept of contemporary advanced nursing practice by its very nature opposes this concept? Can one be at the same time at the forefront of, and advancing nursing practice and also have a role in championing the further understanding of the fundamentals of care?
“Nursing research and scholarship have never been more important than it is today in developing the global profession and ensuring we provide the best, evidence-based care to our patients and communities. The most important aspect of high-quality nursing research is that it has impact—on patient care, service delivery, policy or the science of nursing” (Hayter, 2020, p. e6),
4 CONCLUSION
It is our view that the advancement of nursing practice for the future is reliant on an acknowledgement and indeed a reorientation towards fundamental care delivery. Some of our team's experiences as advanced practitioners reveals that while these nurses are frequently occupied with physical aspects of fundamental of care, such as medication management, infection control and safety, they are invariably presented with other aspects of fundamental care that require attention. Thus the higher order competencies such as critical thinking, research and leadership that shape advanced practice competencies need greater discussion to explore their contribution to supporting effective fundamental care delivery. These fundamentals also need to be viewed as central and core to all nursing practice. Without such dialogue advanced practitioners skills may become subsumed by the requirements for technical competence in advanced clinical skills and diagnostics, which do not necessarily highlight the requirements for continued attention to the fundamentals of care. Moreover, if limited attention is paid to these, as is the case in many parts of healthcare practice, then priority needs may go unrecognized leading to reduced patient satisfaction and lapses in care. In is important to note that many such lapses do not have immediate effect, such as inattention to relational aspects of care, comfort or dignity, but rather these have longer term effects on patient and family satisfaction with hospital care, perceptions of healthcare experiences and also engagement with health care services. Ultimately managers within the nursing profession need to consider the possible effect of subtle inattention to the fundamentals of care in the context of advancements and provision of high level of advanced nursing services. Managers need to lobby for increased awareness of the need to focus on these fundamentals, but also to begin to develop a more expansive evidence base to underpin their delivery.
ETHICS STATEMENT
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Open Research
DATA AVAILABILITY STATEMENT
Author elects to not share data.
