Integration of the primary health care approach into a community nursing science curriculum

The purpose of this article is to explore and describe guide­ lines for integration of the primary health care approach into a Community Nursing Science Curriculum in a Nurs­ ing College in Gauteng. A qualitative, exploratory, de­ scriptive and contextual research design was utilized. The focus group interviews were conducted with community nurses and nurse educators as respondents. Data were analysed by a qualitative descriptive method of analysis as described in Creswell (1994:155). Respondents in both groups held similar perceptions regarding integration of primary health care approach into a Community Nursing Science Curriculum. Five categories, which are in line with the curriculum cycle, were identified as follows: situ­ ation analysis, selection and organisation of objectives/ goals, content, teaching methods and evaluation. Guide­ lines and recommendations for the integration of the pri­ mary health care approach into a Community Nursing Science Curriculum were described. Uittreksel Die doel van hierdie artikel is om riglyne te bepaal en te besk ry f v ir in tegrasie van die prim êre gesondheidso rgbenadering in ‘n G em eenskapsverp leegkundekurrikulum in ‘n Verplegingskollege in Gauteng, ‘n Kwalitatiewe, verkennende, beskrywende en kontekstuele navorsingsontwerp is gebruik. Die fokusgroeponderhoude is m et gem eenskapsverp leegkundiges en dosente in verpleegkunde as respondente gevoer. Data is ontleed deur middel van ‘n kwalitatiewe, beskrywende metode soos beskryf deur Creswell (1994:155). Respondente in beide groepe het soortgelyke persepsies betreffende integrasie van d ie p rim êre g e so n d h e id so rg b en ad e rin g in ‘n Gemeenskapsverpleegkunde-kurrikulum. Vyf kategorieë, in ooreen-stemming met die kurrikulumsiklus, is as volg geïdentifiseer: situasie-analise, keuse en organisering van o b jek tiew e /d o e lw itte , inhoud , o n d errigm etodes en evaluering. Riglyne en aanbevelings vir die integrasie van d ie p rim êre g e so n d h e id so rg b e n a d e rin g in ‘n Gemeenskapsverpleegkunde-kurrikulum is beskryf.


Introduction
According to the South African Government and community health requirements, a nurse on training must be com prehen sively prepared to function independently in the primary health care setting (W hite Paper, 1997:60-63).The existing nurse training for a com prehensive basic diploma, is based on cura tive services rather than on the community.This creates a gap in that the primary health care approach is not adequately integrated into a Community Nursing Science Curriculum.
From the observations made by the researcher, the existing nurses' training in a Nursing College in Gauteng, does not prepare the nurses to be functional in the primary health care setting.A ccording to the A N C 's N ational H ealth Plan (1994:79) the training o f the health workers has been inap propriate with regard to health needs.As a result o f this inappropriateness, the need exists for change in the basic train ing and development o f new categories of health personnel.The health care system dem ands m ore relevant and com pe tent nurses to im plem ent the primary health care approach.
In view of the above concerns and facts, it is necessary to describe guidelines for the integration o f the primary health care approach into a Community Nursing Science Curricu lum in a Nursing College in Gauteng.This raises the ques tion: How can the prim ary health care approach be inte grated into a Community Nursing Science Curriculum?Hence the purpose o f the study was to explore and describe guide lines for the integration of the primary health care approach into a community nursing science curriculum.This purpose is realised by the following objectives:

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To explore and describe the perceptions o f community nurses regarding the integration of the primary health care approach into a Community Nursing Science Curriculum in a Nursing College in Gauteng.

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To explore and describe the perceptions o f nurse edu cators regarding the integration o f the primary health care approach into a Community Nursing Science Curriculum in a Nursing College in Gauteng.

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To describe guidelines for the integration o f primary health care approach into a Com m unity N ursing Science Curriculum in a Nursing College in Gauteng.

Terminology Integration
In this article, integration means organisation of the com m u nity nursing science content into a close relationship with the primary health care approach concepts, skills and values to constitute an integrated curriculum.

C urriculum
In the context o f this article, curriculum means a Community Nursing Science Educational Programme developed to inte grate primary health care in the education and training of the student nurse.

Stude nt nurse
The student nurse is an adult learner who has been selected for a four year basic diploma course leading to registration as a nurse (General, Psychiatric, Community) and M idwife at a Nursing College.

Com m unity nurse
A community nurse is a professional nurse who is registered with the South African Nursing Council to render health care services in the com munity/primary health care setting.

Nurse educator
A nurse educator is a professional nurse who is registered with the South African Nursing Council.He/she is prepared to educate, train and guide student nurses to become inde pendent practitioners.

Com m unity Nursing Science
Community Nursing Science is a speciality field in nursing practice which synthesizes knowledge and skills from nurs ing and community health and applies them toward the pro motion o f optimal health.

Prim ary H ealth Care
Primary Health Care "is essential care based on practical, sci entifically sound, acceptable methods and technology made universally accessible to individuals and families in the com munity through their full participation and at the cost that the community and the country can afford to maintain at every stage o f their developm ent in the spirit o f self-reliance and self-determination.It forms an integral part of both the coun try's health systems, o f which it is the central function and main focus, and of the overall social and economic develop ment of the com m unity" (WHO, 1975:16).

Research design and method
A qualitative, exploratory, descriptive and contextual research design was utilized (M outon, 1996:107;Woods & Catanzaro, 1998:150).The research m ethod was divided into three phases.The focus group interviews were used to collect data from community nurses (Group A) and nurse educators (Group B).In phase 1, ten community nurses participating in train ing of four year basic diplom a student nurses, in the primary h ealth care settin g for a m inim um o f th ree years w ere purposively selected from the District Health Authority in Western Vaal Metropolitan Substructure.In phase 2, ten nurse educators having community nursing science qualification, teaching four year basic diplom a student nurses in a West Rand Region Nursing College in Gauteng Province for a mini mum o f three years were purposively selected.In phase 3, the guidelines based on the conclusions deduced from the re sults o f phase 1 , phase 2 and literature control were described.Conclusions and recommendations were also made.The in terviews were conducted following explanation of the pur pose and process of the study.Respondents in both groups were asked the same two questions: (I) W hat are your per ceptions regarding integration of the primary health care ap proach into a Community Nursing Science Curriculum for student nurses following a four year basic comprehensive di ploma course?(ii) How can the primary health care approach be integrated into a Com m unity Nursing Science Curricu lum?To explore the perceptions following two questions, subsequent questions were dependent on responses of both group A and group B respondents.A tape recorder was used with the permission of both groups o f respondents while the researcher took field notes to validate data collected.
A suitable, unused, noise free room was used to facilitate pri vacy, confidentiality and protection from discomfort and harm.Consent to participate in the research was obtained from par ticipants.Follow-up interviews were conducted with three respondents from each group to validate some aspects o f the data that was collected.D ata collected w ere analysed using T ech's m ethods (in Creswell, 1994:155).The eight steps of this method were followed.A qualified data analysis specialist and an inde pendent coder was employed.Consensus on categories was reached between the independent coder and researcher re garding the categories to ensure trustworthiness of data analy sis and the coding of data collected.Comparison o f the analy sis was done and consensus was reached about the categories of units of analysis.The themes were then based on the simi lar ideas as perceived by respondents in phase 1 and phase 2 of the study.
The model of Guba (in Lincoln and Guba, 1985:289-300) was used throughout the study to ensure trustworthiness.The four strategies for trustworthiness namely transferability for applicability, credibility for truth value, dependability for con sistency and confirmability for ensuring neutrality were ap plied.The researcher accomplished the transferability o f this study by means o f purposive sampling o f both community nurses and nurse educators.The dense description o f data provides the basic information to other researchers if needed to prove transferability.Credibility was achieved by prolonged engagem ent, triangulation, m em ber checking, peer exam i nation and authority of the researcher.Prolonged engage ment was ensured by spending one hour per focus group in terview.The respondents were given all necessary informa tion related to the study.Triangulation o f data collection and data control was executed.An independent coder was used to analyse data and to validate data gathered in this study.Experts in qualitative research were also used in discussing the process and results of the study.M ember checking oc curred by conducting follow-up interviews with a view to verify data interpretation.To ensure dependability a complete de scription o f methodology, including verbatim transcription o f data was also given.The audit trial technique was used to establish confirmability through an inquiry audit, to ensure truth and accuracy of the study.

Findings
The findings were deduced from the response made by both community nurses and nurse educators during the focus group interviews.Both respondents held similar perceptions with regard to integration o f the primary health care approach into a Community Nursing Science Curriculum.Five categories which are in line with curriculum cycle (Nicholls and Nicholls, 1972:21) were identified as follows: Situation analysis, selection and organisation o f the objec tives/goals, selection and organisation o f content, selection and organisation o f methods and evaluation (see Table 1).

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Situation analysis as the first step in the integra tion o f the primary health care approach into a Comm u nity Nursing Science Curriculum Information which will contribute towards development and implem entation o f an integrated curriculum gathered from both respondents included: philosophy, students, nurse edu cators/ community nurses and community involvement.

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Philosophy o f the integration o f the primary health care approach into a Community Nursing Science Curricu lum The respondents indicated that the philosophy of an integrated Community Nursing Science Curriculum should be based on the following beliefs: -Health is a basic human right.Each individual has to take responsibility for his or her own health though vulnerable groups in the community should be taken care of by com m u nity nurses with m aximum com m unity involvem ent.It is necessary to integrate the primary health care approach into a Community Nursing Science Curriculum because it is an essential service that must be made equitable, accessible, ac ceptable and affordable to the communities throughout the country.
-A paradigm shift in nursing education from curative care towards promotive health is necessary.This means a shift towards comprehensive health care approach.The implica tion o f this paradigm shift from institutionalised care to a community based care, means that the education and train ing o f student nurses in Community Nursing Science need to move from the curative situation to a situation where more emphasis is placed on community based education.The per ceptions of the respondents in this regard is evidenced by the following quotations: "Integrating primary health care approach into a Community Nursing Science Curriculum is acceptable.This means mov ing away from the curative services approach towards a pro motive health.""The integrated Com m unity Nursing Science Curriculum must make provision for services that are equitable, afford able, acceptable and available to all m embers.""Primary health care approach must be integrated into com munity nursing science because it is a basic human right, each individual must take responsibility to look after his own health in totality, but on the other hand vulnerable groups in the community should be taken care o f by the community nurses and trained health care workers.Hills and Lindsey (1994:222) states that there is a need to shift from the medical paradigm to the primary health care approach in order to train and educate students for primary health care practice.On the other hand the National Health Plan for South Africa (ANC, 1994:2) states that primary health care is an essential service that must be made accessible, ac

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Situation analysis as the first step in integration of the primary health care approach into a Community Nursing Science Curriculum.

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Philosophy of an integrated Community Nursing Science Curriculum.
• Students as the recipients of an integrated Community Nursing Science Curriculum.
• Nurse educators/com m unity nurses as learning facilitators o f the student nurses in an integrated Community Nursing Science Curriculum.
• Community involvement in an integrated Community Nursing Science Curriculum.

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Selection and organisation of objectives/goals of an integrated Community Nursing Science Curriculum.

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Selection and organisation of content o f an integrated Community Nursing Science Curriculum.

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Selection and organisation of methods in an integrated Community Nursing Science Curriculum.

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Evaluation in an integrated Community Nursing Science Curriculum.
ceptable, available and affordable to the community through out the country.
It is concluded that the philosophy o f the integrated Com m u nity Nursing Science Curriculum has to be based on the be lief that health is a basic human right.Health has to be equi table, available and affordable to communities throughout the country.Each individual needs to take responsibility for his or her own health although vulnerable groups in the commu nity should be taken care o f by the community nurses with maximum involvement.* Student nurses as recipients of an integrated Com m u nity Nursing Science Curriculum The respondents indicated that student nurses need to be pre pared holistically in order to function independently in the primary health care setting and must have the ability to com municate effectively with families.The respondents are quoted as saying: "The integration of the primary health care ap p ro ach in a co m p re h e n siv e co u rse w ill equip students holistically.They will be able to nurse patients in totality, taking into consideration the culture values and norms of the comm unity."Spradley (1990:192) indicates that clinical nursing is holis tic in nature but in reality patients are viewed as a larger system in terms of a family or group, therefore they must be cared for in totality by comprehensively trained nurses.Knowles (1980:43) perceives student nurses as adult learners who have qualities of positive self-concept, experience, learn ing readiness and positive orientation to learning.Long (1993:240) andReed Procter (1993:31) also reiterate the abovementioned perception.
It is therefore necessary that student nurses as recipients of an integrated Community Nursing Science Curriculum pos sess a positive self-concept in order to be self directed, self controlled, responsible and to determine own learning needs.

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N u rse e d u c a to rs/c o m m u n ity n u rse s as lea rn in g facilitators o f student nurses in an integrated Com m unity Nursing Science Curriculum The respondents indicated that the community nurses/nurse educators need to be knowledgeable and clinically skilful.This means that community nurses/nurse educators must be ex perts in an integrated Community Nursing Science Curricu lum , b o th th e o re tic a lly and p ra c tic a lly .
As lea rn in g facilitators, expertise in health promotion, health assessment, treatm ent and care, and com m unity-based education is es sential in order to guide the student nurses to become inde pendent practitioners in the primary health care setting.This is evidenced by the quotations: "A ll community nurses should be knowledgeable and clinically com petent o f what the stu dent should be equipped with when they complete the course." "College tutors and community nurses should have a way o f communicating, discuss what is to be done fo r the students." "A s a fa cilitator in the integration o f the prim ary health care approach into a Community Nursing Science Curriculum, the nurse educator should provide some opportunities fo r the stu dent to think critically." Mellish and Brink (1998:7) mention that to be an effective teacher, one needs to be a subject expert and have teaching skills as well as good relations with students.
It is important that the learning facilitators o f student nurses need to be Community Nursing science experts both theoreti cally and clinically.Learning facilitators need expert skills in health promotion, health assessment, treatment and care, effective communication and collaboration with the m ulti disciplinary health team in order to develop the capacity of student nurses to become independent practitioners.

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Community involvement in an integrated Community Nursing Science Curriculum The respondents maintain that com m unity involvem ent in an integrated Com m unity N ursing Science C urriculum is necessary since the members of the community are consum ers o f the primary health care services and can realise their health care needs.In reality members of the community need to participate in the curriculum development committee re sponsible for developing the integrated curriculum.This in cludes the involvem ent o f traditional healers, com plem en tary healers and all other stakeholders in the implementation of the integrated curriculum.The respondents were quoted as saying: "Community nurses must involve the community in finding ways o f meeting their needs.This approach will make community to own the clinic and look after it." "Tra ditional healers and spiritual healers are to be included in the syllabus as many patients still prefer their support in ill ness." "The Government also approves the contributions they make in health promotion." The respondents further indicated that the community involve ment will facilitate mobilisation and availability of com m u nity resources that are needed in the primary health care set ting to meet the students learning needs.Respondents were quoted as saying: "Because whatever we prescribe in the curriculum, must go hand in hand with the resources.There is no point in telling the students to do this, and when they go to the actual situation you 'II fin d that the resources are not shaping with the students needs." "If primary health care is integrated into a community nurs ing science you are looking at expanding the resources that are available so that the resources can be accessible and feasi ble to everybody." The National Health Plan (ANC, 1994:21) em phasizes ac countability and com m unity participation as an im portant principle in primary health care approach.Fairley (1993:224) reiterates this idea.Troskie (1997:24) indicates that tradi tional healers have been a central component of African medi cine.Edelstein and Sanders (1998:21) found that more spe cific issues relevant to community partnership, such as rela tionships with traditional healers, should be included in the curricula.
The researcher perceives that it is necessary to involve the com m unity in the developm ent and im plem entation o f an integrated curriculum.Since it is a process of consultation and collaboration.The members of the community need to participate in the integrated curriculum developm ent com mittee to ensure community and practice driven curricula.

• Selection and organisation of goals/objectives of an integrated Com m unity Nursing Science Curriculum
The respondents indicated that the goals o f an integrated Community Nursing Science Curriculum need to aim at prepa ration of student nurses to become independent practitioners in promotive and preventive health care services, to move away from curative to promotive health care, to develop life long learners, who are self-directed, reflective and critical thinkers.
in health assessment, treatment and care to enable them to perform family health assessment, and to provide treatment and care.Respondents were quoted as saying: "Students should be educated on health assessment and identification o f common diseases in the com munity and they should do related practica.

" "Students m ust know how to diagnose prevalent diseases in the community, including m inor ail ments, health hazards and problem s as well as the needs o f young people. "
This was evidenced by the following quotations: "Student nurses should know from the beginning that they are going to be independent practitioners.Students m ust know how to assess, diagnose and treat patients on their own." "Integrat ing prim ary health care approach into a Community Nursing Science Curriculum, means moving away from curative serv ices to preventive and promotive health care.We are moving towards providing comprehensive health s e r v ic e ...... is na tionally acceptable according to the National Health Policy." Beddone and Budgen (1995:14) recom mend that the gradu ates o f the curriculum are to be independent, self-directed, self-motivated and must have the ability to make clinical judge ments based on reflective thinking.It is deduced from the discussion and philosophy that the goals of an integrated Community Nursing Science Curriculum are to enable students to become independent practitioners who are self-directed and self-motivated.Therefore, there is need to move from curative to prom otive health.

* Selection and organisation o f content o f an inte grated Community Nursing Science Curriculum
The respondents revealed similarities in the perceived con tent of the integrated Community Nursing Science Curricu lum as follows:

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Health promotion The respondents indicated that students should be equipped with health promotion skills in order to promote health in the community.They further mentioned that students should come in contact with a healthy person before com ing in contact with a person who has health problems.Respondents were quoted as saying: "The students should be equipped with health promotion skills.They must exactly know what to do, in order to provide health care in the community.They must be taught how to identify problem s in the community .... so that throughout their training career, they m ust..... apply these skills." "The other thing should b e .....to put students in fa m ilie s...... so that they will learn normal family life before you bring them in contact with the ill person."Bestard and Courtenay (1990:24-25) suggest that, during the first year o f training, student nurses should be placed in the clinical area where the nursing focus will be on the prom o tion o f health and development.Thus student nurses need to be equipped with health prom otion skills such as health as sessment skills, communication skills, interactive skills, health education skills and problem-solving skills.

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Health assessment, treatment and care Respondents pointed out that student nurses should be trained The American Association of College of Nursing (AACN, 1993(AACN, in O erm ann, 1994:219) :219) recom m ended that student nurses should be empowered with health assessment skills, treatment skills, health care and education skills, to prepare them for their role as independent practitioners.It is then necessary to teach student nurses health assessment, treat ment and care o f common health problems prevalent in the community.

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Epidemiology Education and training of student nurses to acquire epide miological skills, amongst others to be able to gather statis tics on health needs/problems and factors influencing health patterns and practices in the primary health care setting was perceived essential by the respondents.
The respondents indicated the following: "Epidemiology need to be integrated in the curriculum as it helps to assess, diag nose, plan and evaluate interventions in the community." Respondents further m entioned that: "Keeping health infor mation plays an important role in the delivery o f prim ary health care, statistics on mortality, morbidity, births and death rates; information on violence, road accidents, environmen tal hazards, good nutrition, prevention o f communicable dis eases, especially endemic diseases including sexually trans mitted diseases, A ID S and H IV infections.Immunization o f children, treatment o f m inor ailments, health education and communication skills and insect control should be part o f the integrated curriculum." Clark (1996:99) andDryer et. al (1993:63) indicate the im portance of epidemiology at all levels of primary health care.Community nurses use epidemiology principles to assess, plan, evaluate interventions and to promote health.The epidemio logical skills, especially statistics on health profiles, patterns and practices are a problem in South Africa (W hite Paper, 1997:78).This epidemiological skills such as the gathering o f statistics, health practices/patterns and health problem pro files are necessary.

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Transcultural health issues Respondents indicated the importance o f preparing student nurses in respect of transcultural health issues in order to equip them with skills to deal with multicultural health prob lems in the varied primary health care setting.Respondents were quoted as saying: "Student nurses on training m ust be educated to be sensitive towards the norms, values, customs, beliefs and practices o f patients and people they are working with." "The transcultural issues that exist in the community play an important role in caring o f patients, thus students m ust be taught how to deal with multicultural problems and needs o f the p a tients." Andrews (1995:4) maintains that the transcultural nursing is an influential force in transform ing contem porary nursing education as students learn to function in a multicultural world in which people expect their cultural values and life styles to be respected and understood.Student nurses need to be pre pared to respect the transcultural health issues.They need to be equipped with skills to assess multicultural health prob lems and how these problems are resolved.

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Health related legislation The respondents mentioned that student nurses need to be educated and trained about the laws, regulations and health related legislation which provide a legal framework for prac tising independently as com m unity nurses in the primary health care setting.This is evidenced by the following quota tions: "In the prim ary health care delivery system, students are to be educated about the laws and regulations which con trol the scope o f their practice, health legislation and health related laws in the country.

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Intersectoral and interdisciplinary collaboration The respondents indicated that student nurses need to be pre pared to acquire skills in intersectoral collaboration to enable them to form a network with health related sectors with a view to consultation and referral in the provision o f primary health care in the community.Respondents were quoted as saying: "Syllabus should integrate all those health related services and community organisations that played a role in the provision o f prim ary health care services, fo r example: water supply, basic sanitation, electrification, housing, nu trition, generation o f em ploym ent sm all business develop ment, transport and education because i f a patient is having a problem with one or more o f the above-m entioned services, he may present with a constant health problem thus he will need appropriate referral." "Students m ust receive adequate knowledge on the referral system, fo r example social work ers, physiotherapist and other organisations that are health related." The N ational H ealth Plan (A N C , 1994:21) em phasizes intersectoral collaboration with the sectors that have a bear ing on the integration of the primary health care approach into a Community Nursing Science Curriculum.It is deduced that the Community Nursing Science Curriculum for educa tion and training of student nurses does not adequately inte grate the services o f other health related sectors.It is there fore necessary that the intersectoral collaboration be included in the core content of an integrated Community Nursing Sci ence Curriculum in order to prepare student nurses to acquire skills in intersectoral collaboration.

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Selection and organisation of methods to be followed in an integrated Community Nursing Science Curriculum Respondents indicated the learning opportunities/methods that need to be utilized in the implementation o f the integrated curriculum as follows: *.......... Interactive learning opportunities/methods Respondents indicated a need for placement o f the student nurse in the primary health care setting, with some guide lines to direct her/him.This will enable the student nurse to interact with healthy persons while doing family studies be fore placement in a curative health care situation.The place ment o f the student in the primary health care setting at this level of training prepares the student to acquire skills in health assessment and family involvement which are necessary for health promotion.Respondents were quoted as saying: "Stu dents should be placed in the community first, before they can be allocated in the hospital situation.Each student should be placed in a fam ily with some guidelines on what to look f o r .....a sort o f a workbook." Respondents further emphasized the use o f fewer lectures in the im plem entation o f an integrated Com m unity Nursing Science Curriculum emphasis must be on the utilization of reflective teaching, learning methods, such as fieldwork, semi nars and interactive group discussions.Respondents were quoted as saying: "It is essential that less lectures should be given and experiential and reflective teaching methods should be used such as fieldwork, group discussions, brainstorming and seminars.These methods provide opportunities fo r newlylearned skills and thus promote reflective learning and re flective thinking." Fuszard (1995:81) mentions that family studies as a method o f teaching and learning facilitate the application o f theory to real-life situations.Eshleman and Davidhizar (1997:27) in dicate that the im plem entation o f the curriculum involves actual community experiences for the students.It is concluded that student nurses as adult learners with adult characteris tics need to be placed in the community first, prior to expo sure in the curative health care situation.

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Extensive integrated community clinical experiences Respondents mentioned that students should do more practi cal work in the primary health care setting.Primary health care experiences should be integrated throughout community nursing science practicals.Clinical experiences should pro vide learning opportunities for development of skills in health promotion in various settings.Extensive community prac tice helps the students to develop knowledge and skills in providing care to patients in the community and in the man-agement of acute and chronic health problems.Respondents were quoted as saying: "Students have to do more practica at the prim ary health care setting, i f we want to come out with nurses who are good in practica." "P rim ary health care experiences sh o u ld be integrated throughout their practice and should provide learning op portunities fo r developm ent o f skills in health promotion, pre vention o f illness and m anagement o f both acute and chronic illnesses, as well as m inor ailments." "Out o f the total number o f hours that are allocated fo r their practice .... they should be given something like 60% to spend in the community and 25% at the clinic from the fir s t year until the last year o f their training." "I f possible it would be advisable that students should be accom panied ... so that i f theory is needed, the tutors are there to facilitate with their knowledge, i f possible, especially on the fir st day, they should be accom panied by a tutor." Oermann (1994:216) maintains that clinical learning experi ences in the community provide an opportunity for students to participate in health prom otion in various settings.De Tornyay (1993:302 -306) states that students need to be ac companied in the community clinical situation.
It is necessary that the placem ent o f student nurses in the primary health care setting should be increased from the first year to the last year of their training.Student nurses need to be accompanied by learning facilitators in the primary health care setting.Student nurses will benefit more because the learning facilitators will be able to orientate them to provide the necessary guidance on how to acquire meaningful inte grated learning experiences in health promotion.

• Evaluation in an integrated Com m unity Nursing Science Curriculum
The perceptions of the respondents regarding evaluation in an integrated Com munity Nursing Science Curriculum are based on student-orientated and curriculum -orientated evalu ation.

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Student-orientated evaluation The respondents indicated that: Students should be given a chance to evaluate themselves and formative and summative evaluation should be done because both m ethods assist in determining students progress.They further pointed out that both tutors and com m unity nurses who participated in the training and education o f student nurses should participate in the evaluation of the practical component o f an integrated Comm unity Nursing Science Curriculum .They also indi cated that it would be ideal if continuous clinical evaluation and clinical examination took place in the actual community clinical situation, that is at the clinics where the students have clinical learning experiences.Evaluation should take place immediately following clinical exposure to establish student competence.This is evidence by the following quotations: "Students should be given a chance to evaluate...... them selves.""Both tutors and community nurses who participated in the training and education of students should participate in the evaluation o f the practical com ponent o f the integrated curriculum to determ ine the skills acquired in respect o f each level of training.""It will be ideal if the clinical examina-tion and continuous evaluation should take place in the ac tual community clinical situation, that is the clinics where students receive clinical experiences.The evaluation should take place immediately following clinical exposure to estab lish student com petence.""Formative and summative evalu ation should be done because both evaluations assist to deter mine whether the students are ready to progress to the next level or course of training and education.Summative evalu ation should be in a form of a project."Fuszard (1995:7) states that an educator must provide guid ance on self-evaluation regardless of the learning skills re quired.Van der Horst and McDonald (1997:194) mentioned that there is a need for a record in which some detail about what learners have accomplished as a result of their experi ences in the learning situation can be docum ented.Such records are portfolios which provide evidence o f learners knowledge, skills, attitudes and academic development.It is important that student nurses need to be given an opportunity to perform self-evaluation against a given criteria.There is also a need for portfolios as they involve both the learning facilitators and student nurses in the primary health care set ting in an integrated Community Nursing Science Curricu lum.It is important that both nurse educators and com m u nity nurses who participate in the education and training of student nurses, take part in the clinical evaluation of an inte grated Community Nursing Science Curriculum.

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Curriculum -orientated evaluation Respondents mentioned that research needs to be done after four years following im plementation of the integrated cur riculum, in order to evaluate the entire integration process of the curriculum.They further indicated that the community as the recipient of primary health care services needs to be involved in the evaluation o f an integrated Community Nurs ing Science Curriculum.The respondents were quoted as saying: "We can do research after fo u r years to evaluate the whole integration process." "Consider also checking with the very recipient o f the s e rv ic e ..... the com m unity."Carl (1995:119) em phasizes curriculum orientated evaluation as it seeks to determine the extent to which the objectives of the curriculum have been achieved.It is therefore essential to do continuous evaluation of the integrated curriculum, based on the objectives, so as to evaluate whether the integration of the primary health care approach into a Community Nursing Science Curriculum has really materialized.

Guidelines
The guidelines are described for nurse educators and com munity nurses on integration o f the primary health care ap proach into a Community Nursing Science Curriculum for a four year com prehensive basic diploma course (General, Psy chiatric, Com m unity) and M idwife based on the following categories: situation analysis, goals/objectives, content, meth ods/learning opportunities and evaluation (see Table 2).

Conclusion and recommendations
The purpose o f this article was to describe guidelines for the integration of the primary health care approach into a Com-munity Nursing Science Curriculum in a Nursing College in Gauteng Province.The recom m endations made are based on the results o f this study and the application thereof in nursing education, nursing practice and nursing research.
The recomm endation are that: • The guidelines described in this study could be used to implem ent an integrated Com munity Nursing Science C ur riculum in the primary health care setting.

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The nurse educators/com m unity nurses could use the guidelines described in this study to improve the practice in primary health care setting.

•
The guidelines describe for integration of the primary health care approach into a Com m unity N ursing Science Curriculum could be used to generate hypotheses to be tested in the future with a view to improve health care practice.

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A model to enhance integration o f primary health care approach into a Com m unity Nursing Science Curriculum, be developed using the described concepts for deriving the con ceptual framework in Nursing Education in South Africa.

Conclusion
Based on the above discussions, it is recom m ended that the described recommendations and guidelines be applied in Nurs ing Education to improve primary health care.
T A B L E 2 : Guidelines for integration of the primary health care approach into a com m unity nursing science curriculum

CATEGORIES GUIDELINES
1. Situation analysis as the first step in integration of the primary health care approach into a Com munity N ursing Science Curricu lum.

1.1
Philosophy o f the integrated curriculum.W hen the philosophy about the integrated curriculum is developed, community nurs ing science educators should ensure that:

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Emphasis is placed in the philosophy that health is a basic human right that must be equitable, affordable, accountable and available to all members o f the com m u nity.

•
Individuals are expected to take responsibility for their own health and that • priority should be given by community nurses to vulnerable groups, such as the aged, the poor, the under served, women and children.

1.2
Student nurses' characteristics desirable for the integrated curriculum Nurse educators should ensure that prospective student nurses who enter an integrated Community Nursing Science Curriculum possess the essential characteristics o f an adult learner which should enable nurses to function holistically and independently in the primary health care setting.These characteristics are:

•
Self-concept Since student nurses are expected to function independently in the primary health care setting a positive self-concept should enable them to be self-directed, self-regulated and responsible for their own learning.Student nurses should demonstrate willing ness and receptiveness to acquire new learning experiences in the primary health care setting.

•
Experience As an adult learner, student nurses should bring to the primary health care situation a wide and diverse source o f experience.They should link experiences to knew knowl edge in the primary health care setting.

•
Learner readiness Student nurses' readiness to learn relates to their real-life concerns in terms o f knowl edge, skills, attitudes and values which an adult learner should possess and apply in the primary health care setting.Student nurses should participate actively in their own learning.They should appreciate the learning experiences in the primary health care setting.

•
Learner orientation As adult learners, student nurses are expected to have a problem -solving and task orientated approach to learning, they need to apply the know ledge acquired in the learning situation immediately.

1.3
Nurse educators/com m unity nurses as learning facilitators • Nurse managers in community nursing Science education should ensure that nurse educators/community nurses responsible for education and training o f student nurses possess the following characteristics: Skills in health promotion, health assessment, treatm ent and care and com m u nity based education, in order to guide student nurses to becom e independent practi tioners in primary health care setting.
Effective com m unication with student nurses is essential to facilitate student centred learning.
They m ust collaborate with intersectoral/m ulti-disciplinary health team s to develop the capacity o f students to become independent practitioners in the primary health care setting.
Nurse educators/com m unity nurses should possess reflective thinking skills to guide student nurses in their clinical practice, and be self-confident, flexible, openminded and non-judgmental in facilitating learning in primary health care setting.

1.4
Com m unity involvem ent • All stake holders involved in the developm ent o f an integrated Community T A B L E 2 : Guidelines for integration of the primary health care approach into a com m unity nursing science curriculum

1.
Situation analysis as the first step in integration o f the primary health care approach into a Com m unity N ursing Science C urricu lum.

1.1
Philosophy o f the integrated curriculum.W hen the philosophy about the integrated curriculum is developed, community nurs ing science educators should ensure that:

•
Emphasis is placed in the philosophy that health is a basic human right that must be equitable, affordable, accountable and available to all members o f the com m u nity.

•
Individuals are expected to take responsibility for their own health and that • priority should be given by community nurses to vulnerable groups, such as the aged, the poor, the under served, women and children.

1.2
Student nurses' characteristics desirable for the integrated curriculum Nurse educators should ensure that prospective student nurses who enter an integrated Com munity Nursing Science Curriculum possess the essential characteristics of an adult learner which should enable nurses to function holistically and independently in the primary health care setting.These characteristics are:

•
Self-concept Since student nurses are expected to function independently in the primary health care setting a positive self-concept should enable them to be self-directed, self-regulated and responsible for their own learning.Student nurses should demonstrate willing ness and receptiveness to acquire new learning experiences in the primary health care setting.

•
Experience As an adult learner, student nurses should bring to the primary health care situation a wide and diverse source of experience.They should link experiences to knew knowl edge in the primary health care setting.

•
Learner readiness Student nurses' readiness to learn relates to their real-life concerns in terms o f knowl edge, skills, attitudes and values which an adult learner should possess and apply in the primary health care setting.Student nurses should participate actively in their own learning.They should appreciate the learning experiences in the primary health care setting.

•
Learner orientation As adult learners, student nurses are expected to have a problem -solving and task orientated approach to learning, they need to apply the knowledge acquired in the learning situation immediately.

1.3
Nurse educators/com m unity nurses as learning facilitators • Nurse managers in community nursing Science education should ensure that nurse educators/com m unity nurses responsible for education and training o f student nurses possess the following characteristics: Skills in health promotion, health assessment, treatment and care and com m u nity based education, in order to guide student nurses to become independent practi tioners in primary health care setting.
Effective communication with student nurses is essential to facilitate student centred learning.
They m ust collaborate with intersectoral/m ulti-disciplinary health teams to develop the capacity o f students to become independent practitioners in the primary health care setting.
Nurse educators/com m unity nurses should possess reflective thinking skills to guide student nurses in their clinical practice, and be self-confident, flexible, openminded and non-judgmental in facilitating learning in primary health care setting.

1.4
Comm unity involvem ent • All stake holders involved in the developm ent o f an integrated Com m unity

CATEGORIES G UIDELINES
Nursing Science Curriculum should form part of the curriculum committee, that is community representatives, and alternative traditional healers.
• All those involved in the development of the integrated curriculum should iden tify community health needs problems and assist in the planning of student nurses' educational programmes.• They should identify community resources for student placement in the clinical area, for example voluntary organisations, facilities for the aged and people with health problems.

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They must also point out the existence of transcultural health practices and ex pectations that should be integrated in the curriculum and create self-reliance and mo tivation in the community to participate in responsible and accountable decision-making and in the provision of primary health care services.

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A true partnership must be established between community nurses and com m u nity members in order to create a common ground to discuss different points o f view in health practices and cultural health patterns in the community.

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Community resources must be mobilised and made available, accessible and feasible to those involved in developing the integrated curriculum within the primary health care setting.

Selection and organisation o f g o a ls/o b jectives o f an in te grated Com m unity Nursing Sci ence Curriculum
The goals of an integrated curriculum should be: • to prepare student nurses to become independent practitioners who are self directed and self-motivated.

•
to move from curative to promotive health.In order to achieve these goals, nurse educators/community nurses should set appropriate objectives regarding the fol lowing: H ealth prom otion, health assessm ent, treatm ent and care, epidem iology, transcultural health issues, health related legislation, interdisciplinary and intersectoral collaboration, com m unication and health supportive skills.

Selection and organisation of content of an integrated Com munity Nursing Science Curricu lum
The content related to the primary health care approach should include the following:

3.1
Health promotion

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Nurse educators/community nurses should educate and train student nurses in health promotion.Health promotion education should include knowledge and skills in health assessment, communication, interaction, health education, problem-solving, the study of healthy person and identification of common health problems in the primary health care setting.

•
Health education should be provided on common health problems and treatment of minor injuries at clinics, schools, work places and family environment.

3.2
Health assessment, treatm ent and care Education and training of student nurses by nurse educators/community nurses should include: • Assessment of individuals with common health problems and provision o f treat ment and care, for example in the case o f headache, stomachache, diarrhoea and vom iting.

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Identification o f traditional health patterns and practices and including them in health care plans, for example acupuncture, enemas, herbal treatment, herbal tea.

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Involvement o f members o f the community to develop the capacity to assess their own health needs, problems and to identify appropriate intervention actions.

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Encouragement o f individuals to carry out self-care and treatment, for example administration of medication, dressing of minor wounds, urine testing and administra tion of insulin.

3.3
Epidemiology Nurse educators/community nurses should educate and train student nurses to acquire skills in epidemiology in order to: • G ather common health problem profiles by keeping records of people who visit

CATEGORIES G UIDELINES
• Provide knowledge and skills in respect of the role of the following intersectoral service in the provision of primary health care in the community: nutritional services which provide adequate and proper food supplies to prevent nutrition related health problems; w ater supply services which provide adequate safe water for consumption, hy giene and industrial purposes; sanitation services for adequate and safe waste disposal in preventing health problems.

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Hold Community Nursing Science Committee meeting with community nurs ing experts, experts in health-related sectors and student nurses.

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M embers o f the Community Nursing Science Curriculum Committee must be encouraged to provide input and feedback on primary health care areas that should be improved and on identified community needs/problems.

4.
Selection and organisation of methods/learning opportunities o f an in te g r a te d C o m m u n ity Nursing Science Curriculum.
These methods should include the following: • Family studies, seminars, workshops, fieldwork, interactive group discussions, portfolios, problem-solving, workbooks, community awareness campaigns, film and video shows, brainstorming and community development projects and dialogue.

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Group discussions and seminars should be held with student nurses, health re lated sectors, professionals, community representatives, w om en's organisations, com munity leaders, church leaders and youth groups in the com m unity health centres, clinics, schools, workplaces and non-governmental health care centres.

•
Involvement of community members in identification of their own health needs and development of the capacity to plan how to meet those needs.

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Experts in health related sectors must be involved to guide student nurses in their fields of specialisation, for example, affordable technology in dealing with com mon health problems, such as protection against malaria mosquitoes, life-skills to ap ply in common health emergencies in the community.

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Involvement o f learning facilitators in accompaniment programmes for student nurses in the primary health care setting.The necessary orientation and guidance program m es on integrated Community Nursing Science Curriculum should be pro vided.

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Student nurses should be placed in the primary health care setting from the first year to the last year o f their training, following theoretical learning experiences, in order to correlate and apply theory to practice.

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Student nurses must also be allocated to clinics, families, schools, creches, nurs eries, workplaces and prisons.

E v a lu a tio n in an in t e grated Community Nursing Sci ence Curriculum
Evaluation of the curriculum should be both student and curriculum orientated and should include both the theoretical and clinical learning experiences.

•
Student orientated evaluation should include the following: continuous evaluation, self-evaluation, peer group evaluation, use of portfolios, formative and summative evaluation; student nurses should be given the opportunity to evaluate their own perform ance at different levels of training and education to recognise their limitations to im prove their learning skills; both nurse educators and community nurses who participated in the education and training of student nurses should take part in the clinical examination of an inte grated Community Nursing Science Curriculum; evaluation should be formative and summative in nature, i.e. continuous clini cal evaluation and clinical examination.Evaluation should be conducted immediately after student's exposure to the practica area.

•
Curriculum-orientated evaluation should include continuous evaluation in or der to determine the extent to which the primary health care approach has been inte grated into the Community Nursing Science Curriculum.Each phase o f the integrated Community Nursing Science Curriculum must be evaluated continuously.Research should be conducted four years after implementation of the integrated curriculum to determine if primary health care approach had, in fact, been integrated into the Com- " "The related legislation should include, the Nursing Am endm ent A ct 5 o f 1995, Regulation fo r the Scope o f Practice R2676 o f 1990, the Termination o f Pregnancy Act, Regulations fo r Registration as a Commu nity Nurse, the M edicine a nd related Substance Control Am endm ent A ct 90 o f 1997, which allows nurses to prescribe medicine, the National Health Policy and Labour Relations Am endm ent A ct 42 o f 1996, which improves the industrial relationships." Berman and M uller (1994:32) recom m end that the princi ples o f reading and interpreting health care legislation should be included in all health care professional education pro grammes.Edelstein and Sanders (1998:15) reiterate this idea.In view o f the above discussion, the legal framework for com munity nurses practising primary health care appeared inad equately covered in the education and training o f student nurses.It is necessary to include health related legislation such as the Termination of Pregnancy Act (Act 92 o f 1996), the SA Constitution (Act 108 o f 1996), the National Health Policy, the Nursing A m endm ent Act (Act 5 o f 1995), the Medicine and Related Substance Control Amendment Act (Act 90 o f 1997) and the Labour Relations Amendment Act (Act 42 of 1996) in the education and training programme of stu dent nurses.